Skip to main content

NHS Commissioning Board (Mandate)

Volume 553: debated on Tuesday 13 November 2012

With permission, Mr Speaker, I would like to make a statement regarding the publication of the Government’s first mandate to the NHS Commissioning Board.

The NHS is the country’s most precious creation. We are all immensely proud of the NHS and the people who make it what it is—a service that last year delivered half a million more outpatient appointments, nearly 1 million more A and E attendances and 1.5 million more diagnostic tests than the year this Government came into office; and it is doing so while meeting waiting time targets, reducing hospital-acquired infections and virtually eliminating mixed-sex wards. The essence of the NHS is its values: universal and comprehensive health care that is free and based on need and not the ability to pay.

Today I am proud to publish the first ever mandate to the NHS Commissioning Board. From now on, Ministers will set the priorities for the NHS, but for the first time, local doctors and clinical staff will have the operational freedom to implement those priorities using their own judgment as to the best way to improve health outcomes for the people they look after. That independence comes with a responsibility to work with colleagues in local authorities and beyond, to engage with local communities to create a genuinely integrated system across health and social care that is built around the needs of individual people.

The mandate makes clear my responsibility, as Secretary of State for Health, to uphold and defend the enduring values that make the NHS part of what it is to be British. It also sets out my priorities for the NHS Commissioning Board over the next two years and beyond, linked closely to the NHS outcomes framework, the latest version of which I am also publishing today.

The priorities set out in the mandate closely reflect the four key priorities I have identified to Parliament as my own. Let me take each of them in turn. My first priority is to reduce avoidable mortality rates for the major killer diseases, where despite increases in life expectancy our survival rates are still below the European average in too many areas. If our mortality rates were level with the best in Europe, we could save as many as 20,000 lives every year—20,000 personal tragedies that could be avoided, but are not. It cannot be right that we are below average for cancer survival rates, that for respiratory diseases we are the worst in the EU 15, or that our performance on liver disease is getting worse, not better. Today I call on the NHS Commissioning Board, working with Public Health England, local government, clinical commissioning groups and others, to begin a concerted effort to bring down avoidable mortality rates in this country.

The mandate asks the board to make measurable progress to improve early diagnosis, giving more people quicker access to the right drugs and treatment where they need it; to reduce the wide and unacceptable variation between different parts of the country, both in terms of inequality of health outcomes and variability of performance by NHS trusts; and to support a renewed focus on prevention, working with local authority partners to help people quit smoking, drink less, eat better and exercise more.

My second priority is to build a health and care system where the quality of a person’s care is valued as highly as the quality of their treatment. When we place ourselves in the hands of others, we should be confident that we will be treated well, our dignity respected and that that will be the case regardless of our age or mental state, or whether we are in a hospital, a care home or our own home. For most people, most of the time, that is already the case, but too often it is not. The appalling revelations from places such as Mid Staffs and Winterbourne View bring home the desperate need for change. We must go beyond the enforcement of minimum standards. We must raise our game so that the NHS is recognised globally for its commitment to the highest standards of care for all, just as it is recognised for its commitment to the highest standards of treatment for all.

The mandate asks the NHS Commissioning Board to ensure that GP-led commissioning groups work with others so that vulnerable people, particularly those with dementia, learning disabilities and autism, receive safe, appropriate, high-quality care. It also asks the board to improve standards of care during pregnancy and in the early years of children’s lives. This will include offering women the greatest possible choice over how they give birth, giving every woman a named midwife who will be responsible for them both before and after the birth, to reduce the incidence and impact of post-natal depression through early diagnosis and better intervention and support.

The mandate asks the board to measure and understand how people really feel about their care through the new friends and family test, asking patients whether they would recommend the care they receive to their friends or family. The test will cover hospital and maternity services in 2013, with other parts of the NHS following soon after. The mandate also asks the board to drive up standards of care by championing a transparency revolution within the NHS. This will make us the first country in the world to publish comparative information on performance throughout the health-care system, including on clinical commissioning groups, local councils, providers of care and consultant-led teams. Mental health, long the poor relation, must have parity with physical health. The mandate asks the board to make clear progress in rectifying that, particularly by looking at waiting times and rolling out the programme of improved access to psychological therapies.

My third priority is to improve dramatically care for the third of people in England who live with a long-term condition such as asthma, diabetes or epilepsy. As a group, they account for more than half of GP appointments and nearly three quarters of hospital admissions. That has a huge impact on the individuals concerned—an impact that can be compounded by the way in which they are dealt with by the NHS. We need to do better.

The mandate therefore asks the board to help those who rely heavily on the NHS by harnessing the power of the technology revolution. Labour’s NHS IT projects failed, wasting billions, but we must not allow that failure to blind us to how technology can transform treatment and care throughout the system. I am today asking the board to ensure, by 2015, that all NHS patients in England can access their GP records online; that, in at least parts of the country, those records are integrated with other medical records across the health and social care system, so that a single record can follow a patient seamlessly from ambulance to hospital, to GP clinic and to their own home; and that everyone can book GP appointments and order repeat prescriptions online, as well as contact their GP by e-mail. I am also asking that significant progress be made towards ensuring that 3 million people with long-term conditions benefit from telehealth and telecare by 2017.

With respect to people with long-term conditions, the mandate also asks the board to ensure, by 2015, that more people have the knowledge and skills to control their own care, and that carers have the information and advice that they need about the support that is available to them, including respite care.

My final priority is care for older people, specifically those with dementia. Already, one in three people over the age of 65 lives with dementia. Shockingly, even though the right medicines can make a huge difference to people’s quality of life and that of their families, we diagnose fewer than half of those with the condition. I want the diagnosis, treatment and care for people with dementia to be world-leading. The mandate therefore asks the NHS Commissioning Board to make significant progress in improving dementia diagnosis rates and to ensure that the best treatment and care is available to everyone, wherever they live. We also want hospitals, and indeed all NHS organisations, to make significant progress in becoming dementia-aware and dementia-friendly environments.

The mandate covers other important areas of NHS performance, including research, partnership working, the armed forces covenant and better health services for those in prison, especially at the point when they are integrated back into the community. The mandate also sets the NHS Commissioning Board’s annual revenue budget, which for 2013-14 will be £95.6 billion, with a capital budget of £200 million. An important objective for the board is therefore to ensure good financial management, as well as unprecedented and sustainable improvements in value for money across the NHS.

We are the first country in the world to set out our ambitions for our health service in a short, concise document that is centred around patients. Its clarity and brevity will help bring accountability, transparency and stability to the NHS. The last Government sent endless instructions to strategic health authorities and primary care trusts, constantly bombarding them with new targets, new directions and new priorities, and drowning the NHS in red tape and bureaucracy. In stark contrast, the mandate is just 28 pages long. It signals the end of top-down political micro-management of the NHS—an approach that failed to get the best treatment for patients and the best value for taxpayers. The mandate demands much closer integration between secondary and primary care, and between the NHS and social care. It requires a new style of leadership from the NHS, with local doctors and nurses free to innovate in the way that they commission care. I look to the board to develop their leadership skills so that they can do that. The mandate will make it easier for Ministers to hold the health and care system to account, and easier for Parliament to hold Ministers to account for their stewardship of the system. It is a historic step for the NHS, and I commend the statement to the House.

The Secretary of State has just reeled off an impressive wish list, but people across the NHS will be asking a simple question: how on earth can he ask the NHS to do more, when we learn today that 61,000 jobs have been lost or are at risk in the NHS? His statements are dangerously at odds with the reality on the ground and risk raising unrealistic expectations. Across England, services are under severe pressure with ambulances queuing outside A and E, patients left on trolleys in corridors for hours on end, and increasing numbers of A and E and ward closures. No wonder nurses’ leaders today warn that the NHS is “sleepwalking into a crisis.” To listen to the Secretary of State, however, it is as if none of that is happening.

A toxic mix of reorganisation and real-terms cuts risks plunging the NHS into a tailspin. Today, people will have been hoping for a mandate for common sense to restore sanity to an NHS that is in danger of losing the plot, and for instructions to protect the front line. Well, they will have been disappointed.

The Secretary of State glosses over finance, but let me give the House the facts. He and his predecessor promised to reinvest all efficiency savings in the NHS front line—[Interruption.] Yes, they say, yet we learn that £3 billion of NHS money has been swiped back by the Treasury. When will the Secretary of State stand up to the Treasury and keep promises that the Government have made to the NHS? While the NHS front line takes a battering, the Government keep throwing money at a back-office reorganisation that nobody wanted. A full £1 billion has been spent on redundancy packages for managers, more than 1,000 of whom have received six-figure payouts while 6,000 nurses get P45s. That is the scandalous reality of the coalition Government NHS.

Will the Secretary of State confirm that a single payoff of £324,000 was made to the former chief executive of NHS Bolton? How would he care to justify that to NHS staff in Bolton who are losing their jobs? There could be no clearer illustration of a Government whose priorities are completely wrong.

Let me turn to some of the specific points set out by the Secretary of State. First, he makes welcome commitments on care for older people. If that is his priority, however, why are there no instructions in this mandate to stop commissioners from imposing restrictions on essential operations for older people? Last year, there were 12,000 fewer cataract operations than in 2009-10. Older people were told that they could have an operation in one eye but not in two. The Government boast about shorter waiting lists, but that is because people cannot get on those lists in the first place. A postcode lottery is running riot and there is nothing in this mandate to stop it.

The Secretary of State’s promises on dementia will be nothing more than hollow words until he faces up to the crisis in council budgets for adult social care. Across England, older people and carers are facing a desperate struggle as council services such as home helps are cut to the bone. Millions of people are facing ever higher care charges—cruel coalition dementia taxes—as councils are forced to put up the cost of meals on wheels and other services. If the Secretary of State really wants to help people with dementia, when will he act to stop this scandal?

Let me turn to mortality rates. Over the past decade, the deaths from heart attacks fell by 50% in men and 53% in women, and the NHS achieved the biggest drop in cancer deaths among the 10 most developed nations. It is widely accepted that the clinical networks established by the previous Government played a significant role in that success. Indeed, the NHS medical director, Professor Sir Bruce Keogh, called them “an NHS success story”. Why, then, is the Secretary of State proceeding with brutal cuts to cancer, heart and stroke networks? Surely the best way to meet the ambitions he has set out is to build on that track record of success, not destroy it.

The Secretary of State promises to implement the Labour amendment to the Health and Social Care Act 2012 to ensure “parity of esteem” between physical and mental health. However, the opposite is happening as the NHS reverts to its default position and places mental health services first in line for cuts. Will he confirm that mental health spending was cut in real terms last year, and what will he do to reverse that? He says he wants a transparency revolution, but across the country local people are being shut out of crucial decisions affecting local NHS services. If he believes in “No decision about me without me,” will he today commit to consult Greater Manchester patients with long-term conditions on whether they want ambulance services to be run by a bus company? Will he act to stop details of contracts under his “any qualified provider” regime from being kept secret from local people under “commercial confidentiality”? The truth is that patients are being shut out as his friends in the private sector fill their boots.

In the weekend’s papers, this mandate was called the first contract with the NHS—the new language of the coalition NHS, in which competition and contracts replace care and compassion. Yes, the Secretary of State has today published a new mandate, but we needed a change of direction. The Government have put the NHS on a fast track to fragmentation. Today, they have unfairly and unrealistically raised expectations on a battered NHS, thinking they have cleverly contracted out responsibility to the national Commissioning Board. I have news for them. The chaos in the NHS starts and ends with the guilty men and women on the Government Benches. We will hound them and hold them to account for the damage they are doing.

This is an incredibly important document for the NHS, and I think that we were all expecting a bit more than the same old hollow rhetoric from the right hon. Gentleman.

There could be no greater commitment to the NHS than to protect its budget at a time of unprecedented austerity. This Government have protected the NHS budget; the right hon. Gentleman said that that would be irresponsible. The Government take action; he uses words. The picture he paints of the NHS in crisis is not the picture recognised by thousands of doctors and nurses up and down the country. Of course, with an ageing population, the NHS is doing more than ever before. Nearly 1 million more people every year are in A and E than when he was Health Secretary, but it is meeting all its waiting times targets and has virtually eliminated mixed-sex wards, and hospital-acquired infections are going down. This NHS is performing exceptionally well.

Let me address some of the points that the right hon. Gentleman made. On finance, in the figures he gave, I think he was alluding to the fact that, in the first year the coalition was in power, it worked to Labour’s NHS budgets. There was an underspend in that year, as there was in each of the last four years that Labour was in control. In three of those four years, the underspend was higher than it was when my right hon. Friend the Leader of the House was Health Secretary. Let us talk about redundancy payments. The reforms introduced by my right hon. Friend will save the NHS—[Interruption.]

Order. I appreciate that there are very strong feelings on these matters, but Opposition Front Benchers must not shout at the Secretary of State as he is responding to questions. He must be heard. Everybody will have a chance—Members can rely upon me to ensure that—but the Secretary of State must be heard.

The redundancies in management and administration will save the NHS £1.5 billion every year—£1.5 billion that can be spent on the front line. We should compare that with the £1.6 billion the NHS must spend every year to deal with the right hon. Gentleman’s disastrous private finance initiative policies that left the NHS with £73 billion of debt overhang.

Let us talk about clinical networks, which are extremely important. We have four clinical networks—for cardio, cancer, maternity and mental health—and they will continue. The budget that the networks are using is increasing and not decreasing under the Commissioning Board.

The right hon. Gentleman said that ambulance services in Manchester would be run by a private bus company. I am sure the House will be interested to know who the Health Minister was when the guidelines that allow private bus companies to bid to run ambulance services were drawn up. It was the right hon. Gentleman. He was in post when that happened.

The right hon. Gentleman describes the mandate as a wish list. He should tell that to the 570,000 people who have dementia, for whom Government Members want to do a better job. He should tell it to people who suffer from cancer. They have below-average European survival rates, but we want them to have the best survival rates in Europe. He should tell it to the families and carers of people who are worried about the level of care they receive in certain parts of the system.

Government Members are determined to aim high for our NHS, because we believe in it. We believe it is doing incredibly well in difficult circumstances, but it can do even better. The right hon. Gentleman should also want an ambitious NHS. Just because he did not have those ambitions when he was Health Secretary does not mean that the Government should not aim high to make our NHS the best in the world.

I apologise to you, Mr Speaker, and to the House for my inability to control modern technology.

Does my right hon. Friend think it striking that, when he presents the first mandate of the NHS Commissioning Board to the House of Commons, we hear a lot of synthetic rhetoric from the Opposition Front Bench, but not a single disagreement with any one of his propositions from the Dispatch Box or in the mandate? Does that not demonstrate—this has always been the Conservative case—that there is a shared commitment to the ideals of the NHS, and that the difference is our ability to deliver it effectively?

I hope my right hon. Friend is right that there is agreement on the goals in the mandate, because they have been drawn up after extensive consultation with the people of this country and are important priorities, particularly as we grapple with an ageing society. I agree with him that it does not the help the NHS to descend to the rhetoric we heard from the right hon. Member for Leigh (Andy Burnham). There is a very important and legitimate debate about the right way to achieve shared goals. Government Members do not believe the right way is through performance management from the Department of Health and trying to echo out every part of the system. We believe the right way is to empower local GP-led groups to make changes on the ground. That is at the heart of the reforms.

I can understand the Secretary of State’s desire to give operational freedom to people in each locality, and his desire, as he says in his document, to reduce the inequalities of treatment between one area and another, but how does he intend to reconcile those two objectives?

The approach the reforms take is this: when there are inequalities in treatment, and when one hospital is particularly good at certain operations and another hospital is not as good, the best way to drive up performance is to make that information available in a way that has never happened before. More than anything, peer review drives the NHS. A very important part of the programme will be to roll out plans similar to those we have rolled out for cardiothoracic surgery, for which a performance comparison by consultant team, not just by hospital, has led to a dramatic improvement in survival rates from heart operations. We need to roll that out across many other disciplines. We also need to be able to compare local GP-led group with local GP-led group, and local authority with local authority. That will be a far more effective way of driving change than the old top-down way. That was tried under different Governments many times and in many ways, but it was never as successful as it was meant to be.

I welcome the statement, and particularly the actions that are being taken to deliver parity of esteem between physical and mental health, and to drive improvements on dementia. Those two things are linked by the common frustration of family carers, who feel that their voices are not always heard or understood within the NHS, and that there is too much variation in this country when it comes to identifying carers and ensuring that they get access to the breaks they so often need. Can the Secretary of State assure us that the mandate will ensure that people who need breaks get them before they have a breakdown?

I thank my right hon. Friend for the work he did at the Department, which is widely recognised on both sides of the House. He is right to talk about the critical role of carers. We have spoken a lot today about dementia. Dementia puts huge pressure on partners of the people affected. Very often, because we do not give the support we need to give at an early stage, people with dementia end up having to go to residential homes, whereas with that support, they would be able to stay at home happily for much longer. It is a critical issue. I hope he will be pleased to see in the section on long-term conditions explicit mention of the role of carers. We will follow the matter closely as the NHS Board implements at a local level the support he mentions.

My constituent Michael Wade was wrongly refused surgery for a life-threatening condition. What in the mandate improves patients’ rights, or will they have to continue to have to rely on MPs and campaigning local newspapers?

Any such examples are totally unacceptable. The rights that people have to the treatment they need clinically are enshrined in the NHS constitution. There will always be a need for MPs and other campaigners to highlight problems in the system, but we hope to make it much easier by exposing unacceptably low levels of clinical care much earlier than happens currently. As a result of the changes in the next two years we will see the NHS becoming the most transparent health care system of any in the world, which we hope will enable us to identify failures before they lead to the kind of tragedy the right hon. Gentleman mentions.

I understand that the Government are adding the one and five-year indicators for all cancers to existing indicators in the NHS outcomes framework. That is very welcome. It will particularly help those with rarer cancers, and the all-party group on cancer has long lobbied for it. Will the Government work towards ensuring that the commissioning outcomes framework, which measures clinical commissioning groups, mirrors those one and five-year indicators, which are terribly important in encouraging earlier diagnosis so that we have coherent policies at the national and local level?

May I thank my hon. Friend for his work campaigning on cancer? He is absolutely right. We want to make sure that we pick up rarer cancers, so we are moving towards a composite indicator for cancers with the one and five-year measures. He is absolutely right that, properly to drive improvement, we need to compare not just hospital and consultant-led teams, but local GP-led commissioning groups, so that where there are successful outcomes everyone knows that. To get that comparison to work, we have to ensure that we compare the demographics. Part of the work we are doing is to understand how we can meaningfully compare CCGs, so that the public can truly understand who is doing best and who needs to do better.

The Secretary of State talks about operational independence on the ground for doctors and CCGs. He did not mention anything in his statement about sexual health care. One issue that we have been struggling with for some time in Walthamstow is the limitations of doctors who have decided to deny women even the most basic contraceptive services. We are still struggling with how the new mandate and new services will deliver them. Will the Secretary of State meet me and women from Walthamstow to discuss the issue, so that we can be confident that the changes will not lead to a further deterioration in sexual health care services across the country?

We will publish a sexual health strategy at the end of this year that will look at variation in services across the country and at the kind of problems the hon. Lady raises. It will be led by the public health Minister, my hon. Friend the Member for Broxtowe (Anna Soubry), who will be happy to meet the hon. Lady to discuss the issue further.

My right hon. Friend’s statement will be widely welcomed, especially his emphasis on an integrated system based on the needs of people. Does he not agree, however, that there is far too little use of complementary medicine outside private health care, and that greater use of herbal medicine, acupuncture and the much under-utilised resource in this country of homeopathic medicine, homeopathic doctors and the Society of Homeopaths, would be a good thing? Seventy per cent. of pregnant women in France use homeopathic medicine.

There are parts of the country where acupuncture is available on the NHS. This will be clinically led. It needs to be driven by the science, but where there is evidence, and where local doctors think that it would be the best clinical outcome for their patients, that is what they are able to do.

As a customer of the national health service, I was lucky enough to have cancer treatment and a heart bypass in those days—halcyon days, almost, by comparison—when 80,000 nurses and 20,000 doctors were recruited, and the money increased from £33 billion to well over £100 billion. Does the Secretary of State know that the optimistic outlook that existed in those days has now been replaced by a climate of fear? That is what I find at the sharp end in hospitals when I go to see the same people I met at the end of the last century. What I say to you is that the figures might sound grand and all the rest of it, but when you start sacking 60,000 people in the national health service, set against a background of elderly people living longer—people like me who need the treatment—the net result will be a catastrophe and not those halcyon days of yesteryear.

Let me say to the hon. Gentleman that we have 17,000 fewer managers than when his party was in power. We also have 3,500 more doctors and there are more clinical staff in the NHS today than when his party left office, so I think the record speaks for itself. There is not a climate of fear—I reject that. There is an understanding that the NHS is under a lot of pressure, with an ageing population and more people using and needing its services every year. That is why today’s package is so important to support the NHS in delivering what the public need.

At long last, the NHS will be operationally independent, and genuinely clinically led. I welcome the mandate: it is an excellent and ambitious target for the NHS. Will the Secretary of State reassure the House that, in these challenging times, efficiencies made in the NHS will be genuinely reinvested in patient services?

My hon. Friend, as a GP, will recognise from the mandate that a lot of the improvements that we need in the NHS are in primary care. The budget for the NHS is protected, but demand for services is going up, so we need to make these changes. I will give her one example where I think that this is particularly important. The number of hours it will save GPs if the majority of prescriptions are ordered online, which does not happen at the moment, could transform life for more than 8,000 GP surgeries up and down the country.

One of the great problems the NHS has is the millstone of private finance initiative costs that are so damaging to so many hospitals. The other millstone is the huge profit made by the private sector on contracted out and privatised services. Is it not time for the Government to give a clear directive to the NHS to employ its staff to deliver its services and borrow money in the traditional way to build new facilities, so that public money goes into a public service and the public are not lining the pockets of the banks and private health providers instead?

I hope we can move beyond the debate about public good, private bad and private good, public bad that has dogged the NHS for many years. I believe there is a role for the independent sector and the voluntary sector. Of course, the primary role will be for the traditional NHS. However, when the private and voluntary sectors are used will not be a matter not for politicians or parties; but for local doctors on the ground. I think that in the vast majority of cases, they will want to use and contract with traditional NHS services, but it is important that they have the choice to do what is in the interests of the patients for whom they are responsible.

For too many years in my Crawley constituency health decisions were made by people who were nowhere near that location. I am delighted that under this Government decisions are being returned to local clinicians and local people. We have seen results already—the local CCG has started a dementia pilot with money from the Department of Health. Will my right hon. Friend join me in congratulating that kind of vision, both in Crawley and elsewhere?

I am more than happy to do that, because when it comes to conditions such as dementia there is no one right solution, and doctors’ surgeries and hospitals will have different approaches in different parts of the country. We want everyone to take ownership of the problem. I hope that what is happening in Crawley will be noticed by other parts of the country, so that we can spread best practice everywhere. That is the point—we want to allow innovation to happen in a way that has never happened before.

This is a hugely significant occasion. It is the one opportunity that Parliament will have to call the Secretary of State to account for the priorities that he sets for the NHS Commissioning Board, so may I refer him to his pledge to improve cancer outcomes? Given that he made a pledge to the House on 23 October to make available to anybody who required it innovative radiotherapy, how does that square with giving back to the Treasury £3,000 million that could otherwise be used to buy advanced and innovative radiotherapy equipment?

Let me remind the hon. Gentleman, as I reminded the right hon. Member for Leigh, that for the four years that preceded this Government, there were underspends, including when the right hon. Gentleman was Health Secretary, and in three of those four years the underspend was higher than it was in our first year in office. But we do want innovative cancer treatments to be available. That is why we introduced, among other things, the cancer drugs fund, which was not introduced by his Government and which has transformed the lives of thousands of cancer sufferers.

I welcome the statement, particularly the use of IT and online resources, but how will we avoid the previous errors of Connecting for Health and its huge costs?

That is a very important question. We are going to avoid that because I will not be signing any big national IT contracts. The initiative will be locally led and locally driven. Guidelines will be laid down to make sure that all the systems developed in different parts of the country are inter-operable. That is very important, but we will not have any grand plans nor will there be a big single database, so we can thereby avoid some of the problems. We must none the less be prepared to grasp what technology changes can mean for the NHS, just as they do for the rest of society.

On 23 October I raised with the Secretary of State unacceptable delays of two and a half hours for the transfer of patients from ambulances to James Cook University hospital accident and emergency in Middlesbrough on 27 September. Last Thursday night for one hour and last Friday morning for one hour, owing to bed pressures, patients in ambulances were diverted from James Cook to North Tees hospital, and 14 planned operations were cancelled the same Friday and the following Saturday. Is not the mandate completely dependent on whether the Secretary of State is in control of the remit of his Department?

The mandate makes it clear that waiting times targets must be met. That is a very important part of the mandate. I continue to be extremely concerned by what the hon. Gentleman tells me about what is happening in his constituency, and I look to his local NHS to come up with a sustainable, rapid solution.

As the Secretary of State saw for himself when he visited Kettering general hospital recently, the NHS is very good at treating people but perhaps is not quite as good at preventing people from getting ill. Given that prevention is better than cure and often less expensive, what is there in this mandate that will encourage up-front health care before patients are admitted to hospital?

There is something critically important in the mandate that will do that, which is that by making the NHS operationally independent we are giving commissioning responsibilities to local GP-led groups for the first time, and GPs understand the importance not just of primary care but of prevention. So I think we will see much more innovation, along with the co-operation that the NHS has with local authorities and the new health and wellbeing boards, to make sure that there is a much bigger focus on prevention than there has been in the past.

Will the Secretary of State confirm that if there is an underspend in the NHS Commissioning Board financial allocation, that will stay in the NHS and not go back to the Treasury?

As the hon. Lady knows, we manage our finances extremely carefully but we do have underspends. We try to minimise them and there has been a real-terms growth in spending—actual money spent in the NHS, compared with Labour’s plans. In the first year of the review there was a real-terms increase and we will continue to manage NHS finances with a commitment to protecting the budget, which did not ever happen when the right hon. Member for Leigh was in post.

I welcome the Secretary of State’s priority to reduce the disparity in health outcomes, not just across the country but across local areas. Will he reassure me that the mandate, delivered in partnership with local health and wellbeing boards and local GPs, will end the scandal—Labour’s legacy—that from the west of the borough of Enfield to the east, the age mortality rates decrease by more than 10 years?

My hon. Friend is right. That is why, at the heart of the mandate, is an information revolution so that the public can understand exactly how well different parts of the system work, and so that we create the right pressures on the system to improve where performance is poor. I agree that the central, top-down structures that we had before did not allow that to happen. If we had cut the budget, as the Opposition wanted, it would have been even more difficult now.

Tomorrow, as the Secretary of State knows, is world diabetes day. I discovered that I had diabetes only because of a chance visit to my local GP. I welcome what the right hon. Gentleman said about including diabetes in his mandate, but will he mandate the local health authority to test all its patients? Today marks the start of the Hindu new year—Diwali. In this new year statement that he is making today, will he ensure that everyone is tested for diabetes in their local practice?

As the right hon. Gentleman will know, we are losing 24,000 people unnecessarily every year by not properly recognising the symptoms of diabetes. That is incredibly important. We have made it clear that reducing mortality rates—preventing avoidable mortality—is a major priority of this Government, so I expect this to be a key priority for GP practices and for local authorities throughout the country.

I welcome my right hon. Friend’s statement today and the mandate, and note that it is based on the NHS constitution, which states that it is founded on a common set of principles and values. So in a week when GPs have become millionaires by selling off their interests in parts of the NHS, may I suggest a further test, beyond the friends and family test—a patients before profit test? Will that be introduced?

The outcome that we want is for more patients to live longer and more healthily than ever before. The right thing for me to specify in the mandate is that we want the NHS to deliver improved patient outcomes. Sometimes that will involve using the independent sector and the voluntary sector, but in the vast majority of cases it will mean working within the traditional NHS. If we deliver those improved outcomes, we will be doing the right thing by patients throughout the country.

Minister, may I thank you for your statement on the mandate and in particular your reference to the armed forces covenant? Mental health has been the poor relation for too long. The statement says that mental health will be elevated to parity with physical health. Can the Minister explain how those who have fought in the wars in Iraq and Afghanistan in particular and who have seen the awfulness and the brutality of war will be helped through the mandate?

Order. I always listen extremely carefully to the hon. Gentleman, who has asked a very serious question. I hope he will take it in the right spirit if I say that my medium-term ambition is to persuade him to cease to use the word “you” in asking questions in the House. But his question has been heard and it will now be answered.

The hon. Member for Strangford (Jim Shannon) may know that there is a mental health helpline specifically for veterans because we recognise the importance of this decision. He will also have seen from the mandate that mental health is mentioned in virtually every part of it, whether in the context of avoiding mortality from extreme mental illness or helping people with long-term conditions, which would also cover post-traumatic stress disorder.

The Secretary of State rightly places survival rates at the top of his agenda and identifies the importance of early diagnosis. When it comes to breast screening, the switch to digital is critical in spotting cancer early. Does he agree that the NHS must move faster in making that switch to digital?

I absolutely agree. That can be hugely transformational in terms of patient outcomes. Many patients would be astonished to know that a full medical record is not available to consultants in hospitals before they operate on them. We need to put that right because it could transform the decisions that surgeons take in extreme cases. So my hon. Friend is right, and we must press on with this very fast.

The Secretary of State and the whole Government are keen to deliver public services using the internet and online. He mentioned in particular people with long-term conditions being able to communicate with their doctors online. The Department for Work and Pensions has found that 6.5 million people who will be entitled to universal credit have never used a computer. Has he any knowledge at all of how many of those with long-term conditions are computer literate?

Some will be, some won’t be, but the hon. Lady should not underestimate the computer literacy of people who are adopting the internet at breakneck speed, including the 40% of pensioners who now do their banking online.

I welcome my right hon. Friend’s objectives, particularly on the quality of care and—I would add—patient safety, which is so important. With an ageing population—a 50% increase in the number of over-60s by 2045 has been predicted—equality of access will require most clinical services to be close at hand. How does he expect to hold the board to account over its duty to reduce inequalities of access?

The waiting time targets are among the board’s responsibilities under the mandate. Having care close to home is a key priority for many patients, often because they think that the quality of care will be better, if it is at a local hospital or—even better—in their own home. One major change resulting from the increased role for GPs under the mandate will be much better support for domiciliary care, which will enable people to live at home for longer.

The tension between the postcode lottery and local commissioning has been discussed, but of paramount importance is how the budgets filter down to the various groups. The Secretary of State just said that funding to the cancer, stroke and heart networks will increase, yet a paper from the NHS Commissioning Board talks about funding cuts from £18 million to £10 million. I am afraid that the veracity of his figures is often challenged. Would he like to put the record straight on the figures?

I will happily look into the matter the hon. Lady raises, but my information is clear that the budget through which the clinical networks are funded is increasing.

In priority 4—dementia—the Secretary of State states that the NHS Commissioning Board is mandated to ensure that the best treatment and care are available to everyone, wherever they live. Can he guarantee that there will be no postcode lottery, and that people with dementia in Liverpool will get the same treatment as the best in the rest of the country?

There is an element of postcode lottery now—there is a huge and unacceptable variation in treatment throughout the country—but the structures we are putting in place have a much better chance of reducing that variation than what went before, which failed to reduce it.

I think we can all welcome the four stated priorities of the new mandate, not least in respect of cancer, mental health and dementia, and I recognise that the statement will have predictive implications for devolved policy making as well. Is the Secretary of State confident that the means and methodology are there to fulfil this mandate? Are resources sufficient and responsibilities sufficiently clear? Will this be workable in practice, or just a worthy presentation from a Minister?

The mandate sets some very high ambitions in challenging times, but those ambitions can help to reduce costs and make the NHS more sustainable. Embracing the technology revolution should mean that we give people better care, as should allowing clinicians more time to spend with patients and allowing nurses to spend more time with the people they are responsible for, but those things should also save the system money. There is not an either/or, but I accept the hon. Gentleman’s point that this is very ambitious.

Does the Secretary of State’s commitment to parity of esteem for mental health services include a promise that under his watch spending on mental health services will not decline in proportion to spending on physical health services?

The hon. Gentleman will understand that the purpose of such a mandate is not to set specific financial objectives but to set outcomes for patients, and then to let local professionals on the ground—doctors and nurses—decide how best to deliver them. The mandate is clear, however, that we want parity of esteem for mental health and to improve equality of access, which at the moment is much better for physical health than for mental health.

The stroke networks have been hugely successful at reducing mortality and inequalities of treatment in this country, yet their future is now in doubt, staff are being lost and their funding is not guaranteed. What can the Secretary of State do to assure those involved in stroke care that his mandate will ensure that they are properly funded and resourced?

I can only repeat what I said earlier: those clinical networks are extremely important and will continue.