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NHS Commissioning Board: Mandate

Volume 740: debated on Tuesday 13 November 2012


My Lords, I shall now repeat a Statement given in another place earlier today by my right honourable friend the Secretary of State for Health on the subject of the mandate to the NHS Commissioning Board. The Statement is as follows.

“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 this 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&E attendances and 1.5 million more diagnostic tests than the year that this Government came into office, and 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 healthcare that is free and based on need and not 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, and 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.

This 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 that I have identified to Parliament as my own as Health Secretary. Let me take each 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; and that our performance on liver disease is getting worse, not better. So today I call on the NHS Commissioning Board, working with Public Health England, local government, local commissioning groups and others to begin a concerted effort to bring down avoidable mortality rates in this country.

The mandate asks the NHS Commissioning Board to make measurable progress to improve early diagnosis, giving more people quicker access to the right drugs and treatment when 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 to 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, with our dignity respected and that this 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, this is already the case. But too often it is not. The appalling revelations from places like Mid Staffordshire and Winterbourne View bring home the desperate need for change. So 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 the highest standards of treatment for all.

The mandate asks the NHS Commissioning Board to ensure that local GP-led commissioning groups work with local authorities and others so that vulnerable people, particularly those with dementia, learning disabilities and autism, receive safe, appropriate, high quality care. The mandate 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, responsible for them both before and after their birth, and by reducing the incidence and impact of postnatal 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 that they receive to their friends or family. This test will cover hospital and maternity services in 2013, with other parts of the NHS following soon after.

It 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 healthcare system, including between clinical commissioning groups, local councils, providers of care and consultant-led teams. Mental health, which has long been the poor relation, must have parity with physical health. This mandate asks the board to make clear progress in rectifying this, particularly by looking at waiting times and by rolling out the programme of improved access to psychological therapies.

My third priority is to dramatically improve care for the one-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. This has a huge impact on the individuals concerned, an impact that can be compounded by the way that they are dealt with by the NHS. We need to do much better. So this mandate asks the NHS Commissioning Board to help those who rely heavily on the NHS by harnessing the power of the revolution in technology. 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.

So today I am asking the board to make sure that by 2015 all patients in England will be able to access their GP records online. In at least parts of the country, those records will be 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.

By 2015 everyone will be able to book GP appointments and order repeat prescriptions online, as well as contact their GP by e-mail. Significant progress will also have been 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 NHS Commissioning Board to ensure that by 2015 more people have the knowledge and skills to control their own care and that carers have the information and advice they need about the support available to them, including respite care.

My final priority is care for older people, specifically for those with dementia. Already one in three people over the age of 65 live with dementia, but, shockingly, even though the right medicines can make a huge difference to people’s quality of life and those 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, so the mandate asks the NHS Commissioning Board to make significant progress in improving dementia diagnosis rates and to ensure that the best treatment and care are available to everyone wherever they live. We also want to see progress in ensuring that hospitals and, indeed, all NHS organisations make significant progress in becoming dementia-aware and dementia-friendly environments.

The mandate also 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 people are integrated back into the community.

The mandate also sets the NHS Commissioning Board’s annual revenue budget. For 2013-14, this is £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 centred around patients. Its clarity and brevity will help to bring accountability, transparency and stability to the NHS. The previous Government sent endless instructions to SHAs and PCTs, constantly bombarding them with new targets, new directions and new priorities and drowning the NHS in red tape and bureaucracy. In stark contrast, this 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.

This 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 in which they commission care. I look to the board to develop their leadership skills so that they can discharge their duties in the best interests of their patients. The mandate will make it easier for Ministers to hold the health and care system to account, and it will make it easier for Parliament to hold Ministers to account for their stewardship of the system. This is a historic step for the NHS, and I commend this Statement to the House”.

My Lords, that concludes this Statement.

My Lords, first, I thank the Minister for repeating the Statement and for the briefing that he gave me earlier today. I also refer noble Lords to my interest in health, contained in the register.

This morning I had the great privilege of hosting a ministerial visit to Birmingham Heartlands Hospital by the Minister’s honourable friend, Mr Norman Lamb. He came to see the Birmingham and Solihull Rapid Assessment, Interface and Discharge service—RAID—which essentially is a partnership that has placed mental health professionals inside the emergency department of my local hospital to give people a holistic physical and mental health response. In that context, I very much welcome the emphasis in the mandate on mental health priority and the promise to implement the amendment that we tabled in your Lordships’ House in relation to parity of esteem between physical and mental health.

But—and there is a but—the problem at the moment in the National Health Service is that mental health has been first in line for reductions in expenditure. Is the Minister in a position to confirm that mental health spending was cut in real terms last year, and to say what the Government intend to do to reverse that? Will he also confirm, in relation to mental health, that he is determined to see that primary care plays its role and that we will see more mental health specialists working in teams with GPs, nurses and carers? Will personal health budgets be extended to enable patients with mental health issues to select the best combination of services and treatments for themselves? Furthermore, does the Minister agree that good mental health does not start in the hospital or treatment room but in our workplaces, schools and communities? For example, poor mental health in the workplace costs the UK an estimated £26 billion a year. Does the Minister accept that this requires a cross-government approach, and is he as disappointed as I am at the news of the apparent demise of the Cabinet Sub-Committee on Public Health—due, it is said, to a lack of interest from other government departments?

The mandate contains a number of welcome references to helping to improve people’s health. I would be grateful if the Minister could tell me what the Government are doing to reawaken interest across Whitehall. The whole architecture of the NHS that the Minister brought to your Lordships’ House in the Health and Social Care Act was about the Department of Health passing over day-to-day concerns about the NHS to the national Commissioning Board, giving itself time to work on wider public health issues—and, I have always assumed, to seek to influence the rest of Whitehall. Would he accept that the demise of this Cabinet sub-committee is a very disappointing signal?

I have three fundamental questions concerning the mandate, which relate to funding, the measurement of performance and the role of Ministers. As the Minister has intimated, this is a multiyear document, setting objectives for the period April 2013 to March 2015 but subject to revision at the end of each year—or, in other special circumstances, including a general election. We can only hope that we might be coming back to this mandate sooner than the Government perhaps would wish. I have noted that the mandate has been restructured around the outcomes framework, which is to be welcomed, and that some of the specific levels of ambition that were placed in the consultation on the mandate have now been replaced by what the Minister described as stretched levels of ambition. Has the mandate been costed out? I could not help but contrast the optimistic claims of Ministers with the everyday financial realities of life in the NHS. Is the mandate a realistic document about what the public can expect to happen or is it little more than a Christmas shopping list which is unlikely to be realised in full?

The noble Earl will have seen the RCN’s warning today of thousands of job losses among clinical staff. That appears to be the reality of life in the NHS. Emergency services are under pressure and a toxic mix of reorganisation and real-terms cuts risks plunging the NHS into a very difficult situation. There has been a great deal of publicity and concern about the decision of the BBC in relation to the retirement package, as it were, of the former director-general. However, the Government stand accused of wasting a full £1 billion on redundancy packages for health service managers as a result of the recent reforms. That money could have been spent on patient care.

I note that most of the time the Statement seeks to create a consensus but every so often it descends into political rhetoric, which I regret. I was pained to hear the noble Earl say that the previous Government sent endless instructions to the health service and constantly bombarded it with new targets. However, those targets, which focused on reducing waiting times and improving clinical performance, were absolutely pivotal to improving the performance of the National Health Service. We will, of course, always find ways to make further improvements, but there is no doubt whatever that between 1997 and 2010 the NHS was vastly improved.

The new architecture which the Government have set in place feels very bureaucratic to those working in the National Health Service. Instead of clear departmental direction, three major agencies have been created, which often row in different directions. Monitor, the economic regulator, has conflicting roles. It is unsure about how to incentivise integration but is stuck with the mantra of the market and enforced competition. The CQC lacks confidence and credibility and awaits the Francis verdict, although the appointment of the new chief executive, David Behan, is a very good step forward. The national Commissioning Board is all-powerful and talks the talk of devolution but I am afraid to report that it displays some centralist tendencies. Indeed, I have heard that “aggressive commissioning” is the buzzword around the national Commissioning Board. I certainly hope that it can do better than that. I do not think that the frail elderly, who comprise the patient group that makes the most demands on the health service, need aggressive commissioning. They need an integrationist approach whereby the architecture and the key national players—the department, Monitor, the CQC and the NCB—work together to get the conditions right for an integrationist approach.

I urge the national Commissioning Board to focus its attention on primary care, community care and adult social care. Does the noble Earl agree with that? We are seeing in the health service the development of seven-day working in acute hospitals. I welcome the mandate’s emphasis on mental health playing its full part, but it requires the same commitment from GPs, community services and adult social services. The contrast between what is happening in some parts of the NHS with the desperate struggle that local authorities are facing to keep council social care services for adults going could not be wider. Indeed, millions of people face higher care charges as councils are forced to put up the cost of meals on wheels and other services. The response from local government to the need for a seven-day service is extremely patchy and very worrying.

I would like also to refer to the comment made in the Statement about the performance of the NHS in relation to certain clinical services. If the Government are so concerned, why on earth are they proceeding with cuts to the cancer, heart and stroke networks? Surely that needs to be reconsidered.

Turning to the performance of the national Commissioning Board and how it is to be measured, the mandate contains a long list of improvement areas —as they are called—and says that it is the Government’s ambition,

“for England to become one of the most successful countries in Europe at preventing premature deaths, and our objective for the NHS Commissioning Board is to make measurable progress towards this outcome by 2016”.

What do the Government mean by “measurable progress”? Are there going to be some numbers or is this going to be a vague promise by the national Commissioning Board? What will happen if the national Commissioning Board does not meet those objectives and ambitions? Will there be any sanction placed on it?

The noble Earl repeated the mantra that the NHS is being liberated from day-to-day, top-down interference in its operational management. The mandate seems to have issued an uncosted wish list and is hoping to contract out responsibility to the national Commissioning Board, but it does not absolve Ministers of their accountability for giving Parliament as much information as possible and, ultimately, accepting their responsibility to Parliament for the performance of this great public service.

My Lords, I am grateful to the noble Lord for the welcome he was able to give to aspects of the mandate, not least in the area of mental health where, as he will have noted, the original version of the mandate has been considerably strengthened in a number of places to emphasise the parity of mental health with physical health in a number of ways. I am glad he thinks that that is a positive step and I agree that it is a necessary one if we are to achieve the higher standards in the care of those with mental health problems which we all want to see.

The noble Lord also welcomed the focus on outcomes and the fact that the mandate has been restructured around the five domains of the outcomes framework. We thought it was logical and sensible to hold the board to account for objectives which related directly to indicators within the outcomes framework. That has been warmly welcomed by the board itself.

The noble Lord asked a number of specific questions. First, on personal budgets in mental health, I can tell him that, subject to the results of the current trials in personal health budgets which we expect to announce very soon, we expect that mental health will be one of the areas where patients will be able to exercise direct control over the services they receive. As the noble Lord well knows, patient empowerment in the area of mental health is, in itself, therapeutic. If we can encourage that, we should.

The noble Lord also mentioned mental health in the workplace and I completely agree with what he said about that. I recently mentioned, in your Lordships’ House, the network which Dame Carol Black and I chair in the department looking at health in the workplace and the pledges that have been devised and which businesses can sign up to. One of those pledges indeed relates to mental health. We hope that we can recruit willing enthusiasts from among the business community to sign up to as many of those pledges as they can.

The noble Lord referred to public health, and I agree with him that it is not a matter simply for the department; all government departments need to engage in it. I should say to him that the creation of Public Health England will provide an immediate opportunity for that body to work with other government departments, but also much more widely to ensure that we genuinely have a joined-up approach to public health objectives. He will know that the public health outcomes framework, which has been drawn up to align itself as far as possible with the NHS outcomes framework, will be a powerful driver for improvement across the field of public health.

The noble Lord characterised the mandate as an uncosted wish list. I can tell him that it has been costed, and the NHS Commissioning Board itself was fully consulted before the mandate was drawn up, because it would clearly not be in anyone’s interests to task the board with delivering the unachievable. The board is aware that it will receive real-terms increases in the budget for the NHS—increases the NHS has received during every year of this Parliament. He referred to cuts. I want to emphasise to him that while we are aware that there are significant constraints at a local level, particularly at provider level, the overall budget to the NHS is not being cut; it is increasing, year by year.

The redundancy payments that unfortunately have been necessary of course represent ongoing annual savings from now on. It is always painful to make people redundant, but we deemed that it was absolutely necessary if we were to retain a sustainable health service. Every pound that we save will go straight back into front-line care.

The noble Lord mentioned the performance of the previous Government, and I am the first to pay tribute to the improvement in the health service that took place under that Administration—not least in waiting times. It is why we have explicitly said in the mandate that waiting times continue to matter. They matter to patients, they are clinically a valid measure of patient experience, and we have no intention of abandoning that metric.

The noble Lord also spoke about enforced competition. I should correct him on that because, as he will know from our debates on the Health and Social Care Bill, we believe that competition can sometimes be a tool for commissioners. We do not believe that it should be shoved down anybody’s throat. Competition, as Sir David Nicholson pointed out the other day, should be regarded as a rifle shot, rather than a carpet-bombing exercise. It should be used only where it is in the interests of patients, which is why the first duty of Monitor, the economic regulator of the health service, is to serve the interests of patients.

The noble Lord referred to partnership working, and I was absolutely in agreement with him that there needs to be partnership, not only at a local level between GPs, social care, secondary care providers, but at the level of the arm’s-length bodies. Chapter 7.3 of the mandate covers the latter aspect comprehensively. However, in Chapter 2, we also place great stress on integration of services, which was the subject of a number of debates in your Lordships’ House during the passage of the Bill. Primary care is covered in Chapter 9.2, which is one of the main areas that the board will be commissioning.

The noble Lord asked me about networks, which we debated a few days ago. They can take various forms. The strategic clinical networks, about which he asked me in his Oral Question the other day, embrace, as he knows, four major clinical areas where we believe that considerable change is required if we are to see services improved to the extent that they should be. However, that does not preclude other networks forming at a local level—for example, at provider level—to ensure that services are joined up. I am sure that we shall encourage those networks, wherever they are appropriate, but we are not mandating them.

The noble Lord asked me about measurable progress. Today, we are publishing an updated version of the NHS outcomes framework, which includes an appendix that sets out the detailed definitions for the majority of indicators. We will have robust metrics which we shall be able to use to measure health outcomes. Over the past few months, the Health and Social Care Information Centre has been publishing many of the data as they have become available. Publishing data for the indicators will, in itself, show whether outcomes are improving. In order to interpret progress, we will work with the NHS Commissioning Board and experts to develop a methodology for measuring progress. There is time enough to do that and I will happily keep the noble Lord informed as that work rolls forward.

My Lords, perhaps I may remind noble Lords that contributions and questions should be brief so that as many noble Lords as possible can participate. I also remind noble Lords that contributions will come from around the House so Members other than those in the Labour Party need to speak now. Maybe we could hear from the Cross Benches.

My Lords, I shall speak briefly, not least because before I knew about this Statement, I made an appointment to meet some major professional visitors at four o’clock this afternoon. I make my apologies to the noble Earl.

The general terms of this mandate are to be greatly welcomed. Its structure is attractive and its relationship to the future of the outcomes framework is very welcome indeed. I welcome the concentration on long-term conditions and their management, although it is important to mention that, whereas diabetes, hypertension and mental health are highlighted in the document, there are many other long-term conditions that need special attention, many of them neurological, such as Parkinson’s disease, multiple sclerosis, neuro-muscular diseases, and so on. I also welcome the emphasis on innovation.

My one major question relates to the very paragraph to which the noble Lord referred. Paragraph 9.2 states:

“The NHS Commissioning Board will be directly commissioning NHS services provided by GPs, dentists, community pharmacists and community opticians; specialised care; health services for people in custody; and military health”.

There are the two words, “specialised care”. We have had discussions about this before and my understanding is that the NHS Commissioning Board will commission directly highly specialised services but more general specialised services will be commissioned by the clinical commissioning groups. Indeed, paragraph 9.3 states:

“The Department will hold the Board to account for the quality of its direct commissioning, and how well it is working with clinical commissioners … An objective is to ensure that, whether NHS care is commissioned nationally by the Board or locally by clinical commissioning groups, the results—the quality and value of the services—should be measured”.

Therefore, is there not an incompatibility between these two paragraphs, one saying that all care will be commissioned by the NHS Commissioning Board, and the next paragraph modifying and qualifying that? I think that is a matter for clarification as the mandate goes forward.

My Lords, I am grateful to the noble Lord for his welcome to the overall structure of the mandate and its content. I do not believe that there is an inconsistency between those two paragraphs. We have had a number of debates about specialised healthcare. I can confirm to him what I have said in the past: it will be the responsibility of the NHS Commissioning Board to commission services in relation to highly specialised conditions and, on top of that, those specialised conditions that are currently commissioned by the regional specialised commissioning groups. It is services for not only very rare conditions but slightly less rare conditions that the board will commission. That is a positive step that has been welcomed by the specialised healthcare community. We will spell out in regulations exactly what conditions are specialised conditions.

Paragraph 9.3 states that the way in which the board is held to account should be directly analogous to the way in which other commissioners in the health service are held to account. In other words, the board cannot expect not to be held to account by the department in a similar fashion. I hope that with that clarification, the noble Lord will be reassured.

My Lords, I note that the mandate no longer sets quantifiable levels of ambition. The Minister explained how progress might be measured. There will be overarching indicators and improvement areas that will all match or mirror the five parts of the outcomes framework. Will my noble friend the Minister explain to the House how frequently progress is likely to be reported, and how it will be monitored by parliamentarians?

I am grateful to my noble friend. The board will have to publish its progress against the objectives in the mandate. The Government will publish an annual assessment of its progress. We have set an objective for the board to demonstrate progress against all the indicators in the NHS outcomes framework. We will use a range of evidence to assess the board’s performance, including asking CCGs and other stakeholders for their feedback. This will be important, because it will provide the board and everybody else with a much more rounded view of how the health service is doing. The information will be publicly available, so everyone will be able to judge for themselves whether the NHS has achieved these stretching goals. In year, Ministers will hold the board to account. In particular, the Secretary of State will hold formal accountability meetings with the chair of the board every two months. Minutes of those meetings will be published. The meetings will be an opportunity to review performance and discuss issues as they arise, and as is right and proper.

My Lords, there is much to welcome in this mandate, especially the points that the Minister made about mental health. Perhaps I may gently remind him that he and his Government will be able to send this patient information whizzing round the system and the country only as a result of the much maligned national spine that the previous Government put in place, along with a central contract. It is worth bearing in mind a little history.

The Minister said that this had been a masterly and costed exercise and that the NHS Commissioning Board had said that it could deliver the mandate within the finances available. Will he confirm that this means that the NHS Commissioning Board’s chief executive has accepted that he will have to deliver, through his new role, £20 billion in savings over four years—the so-called Nicholson challenge? We would like to know whether the Nicholson challenge includes that money.

Finally, I will follow up the point about specialist and specialised services made by the noble Lord, Lord Walton. The Minister may recall that in July the new president of the Academy of Medical Royal Colleges make the powerful point that we have far too many 24/7 acute centres. Will it be part of the Commissioning Board’s responsibility, with the money it uses to directly commission specialist and specialised services, to start to make progress on Professor Terence Stephenson’s suggestions that we need fewer specialised centres of a larger size?

My Lords, I pay tribute to the noble Lord’s role in the NHS IT programme. He is right: we have a great deal to be thankful for in much of the IT that was rolled out under the previous Administration. It failed at a local level rather than a national level—it perhaps failed for honourable reasons—but that is history now and we need to move forward and find other ways of delivering the benefits which his Government identified and we are determined should be delivered at provider and commissioning levels. That is why there is emphasis in the mandate, in chapter 2.6, around technology because it is important that we have inter-operative systems at every level.

The noble Lord asked about the costing of the mandate and, in particular, the quality, innovation, productivity and prevention programme—or the Nicholson challenge as it is sometimes known. We refer to that on at least two occasions in the mandate, at chapter 6.4 and chapter 8.1. The NHS Commissioning Board has confirmed that it will continue to implement the Nicholson challenge and we will work with it to ensure that that happens.

As regards service configuration, the noble Lord will note that in chapter 3.4 we draw attention to that issue and, in particular, to the four tests that need to be met before service configuration can be considered acceptable. Those four tests must be determined locally and there must be a clinical buy-in to any reconfiguration of services. That is one of the most important features of the framework surrounding that area. We may well see fewer centres for a number of conditions but, if we do, it will not be through a top-down edict but because doctors and other health professionals think that it is the right thing to do for patients.

My Lords, there was an agreement between the usual channels that it is the Government Benches, then the Opposition and then the Cross Benches. The noble Baroness is seeking to reinterpret what has already been agreed.

My Lords, I, too, congratulate the Government on the mandate. When we were debating the Bill, I requested that the mandate should be short, precise and well-focused, and it is all of those things. I particularly welcome the focus on the importance given to improving standards in maternity services. The mother’s experience and the start of life are very important and have a huge impact on the long-term well-being of children.

I wish to link the outcomes framework with the mandate. On the outcomes framework, at page 11 under “Trauma” we are told that this is an area for further improvement. It states:

“As part of the development of the placeholder ...‘improving recovery from injuries and trauma’ the indicator has now been defined as ‘Proportion of people who recover from major trauma’”.

That links very much with what my noble friend was saying earlier about expertise. The point I want to make on the mandate is that we are told that the objectives in the mandate can be realised only through local empowerment. The board’s role in the new system will require it to consider how best to balance different ways of enabling local and national delivery. These may include the duties and capabilities for engaging and mobilising patients, professionals and communities in the shaping of local services.

My concern is on A&E and the emergency services. With the NHS Commissioning Board having now appointed Tim Kelsey to look at communications, how can we get public leadership to understand that expertise in certain areas is very important for survival? The footballer Fabrice Muamba collapsed on the football field and passed several A&E departments to get to the one that saved his life because the expertise was there. Is there a requirement in the mandate that there should be a mobilising and further education of the community so that it understands what expertise is needed in order to save lives?

My noble friend makes a series of extremely important points and I agree with everything she said about maternity services. Emergency services will be commissioned at a local level by clinical commissioning groups but that cannot be the end of the story. She rightly implied that paramedics and trauma care doctors require skills in sometimes very sophisticated techniques of maintaining life at the scene of an accident, for example, and hospital procedures. These skills must be maintained and improved. The short answer to her question is quite consciously missing from this mandate. This is the need for Health Education England to work very closely with the board because the Centre for Workforce Intelligence and Health Education England will have to ensure that we have not only the right numbers in the NHS workforce but those with the right skills and the right level of skills. As she rightly said, we also need to educate the public that the health service does not consist of a series of buildings; it consists of a network of services. We will have advanced considerably if the public can understand rather better than they generally do that the continuation and improvement of services matter, rather than bricks and mortar.

My Lords, I declare my interest as Professor of Surgery at University College London Hospitals NHS Foundation Trust. I very much welcome the noble Earl’s indication that the five objectives of the mandate are now clearly linked to the five parts of the outcomes framework. However, successful and meaningful commissioning decisions will critically place intense focus on the development of metrics in the outcomes framework. Local commissioning will be completely meaningless without objective metrics set as part of the commissioning process at a local level and without the ability to measure those outcomes. With specific emphasis on chronic conditions, what progress has been made on integrated care pathway metrics for integrated care both in the community and in the hospital? If there is little progress, when will we ensure that we have integrated care pathway metrics available to ensure that we drive forward meaningful local commissioning decisions?

The noble Lord has alighted on an extremely important area. We have been very careful in constructing the outcomes framework to make sure that we define deliverable outcome indicators. The NHS Commissioning Board is satisfied that the indicators are realistic but I have to be candid with him. This represents work in progress as the precise way in which the board will demonstrate that it has made progress against each of the indicators has not been defined in every case. I can assure him that it will be. It will be up to the board, however, to construct a system of local accountability to ensure that the clinical commissioning groups are held to account against realistic demonstrable indicators which match those of the NHS outcomes framework, not least in the area of chronic conditions. The patient pathway is work in progress, too, but much of its quality can be measured by reference to the patient experience. That is one of the central domains of the outcomes framework, on which a lot of work has been done. I would be happy to write to him on that.

My Lords, perhaps I may press the noble Earl a little further on the part about IT in the mandate. My noble friend Lord Warner also referred to it. Would he develop a little the expectation in the mandate about developing the electronic patient record, which I feel is an aspiration rather than a practical reality if it is going to take place within two years? Can he help me by describing the way in which progress can be measured, and how is this to be achieved in a period when the pressure is on local resources and there is a dispersal to local responsibility which earlier he described as being a problem?

There are several objectives around our wish to see more patients having access to their records, not only to enable them to order repeat prescriptions and make appointments with their GPs online, which many practices already enable, but also to access their own personal health records where they wish to do so. This, too, is a work in progress. Noble Lords do not need me to tell them that there are clear confidentiality issues involved in this area. What we cannot have is a system that is open to breaches of security. However, work is going on with the Royal College of General Practitioners and the British Medical Association on that point. We have said that it is our ambition that everyone should be able to access their GP records online by 2015. That is the ambition and we think that it is achievable. However, once again I would be happy to keep the noble Baroness updated as work continues.

I thank the noble Earl for the imaginative and humane part he has played in producing this mandate and say that it adds even further to what is already a remarkable record. I want to put two questions to him about the fourth objective in the mandate which in a sense will complement what he has already said about new technology, as well as what the noble Baroness, Lady Jay, has said about it. I want to ask him about two more specifically human aspects that fall under the fourth objective.

The first is the great importance of training health assistants to meet some of the responsibilities of their role in terms of communicating with patients. We are now putting a heavy burden of responsibility on health assistants who, of course, are not fully trained nurses and therefore are not trained in communicating with patients. Secondly, perhaps I may draw his attention to a specific area of what I think is serious failure in the NHS and its relationship with local government, and that is the field of rehabilitation, which is now probably one of the weakest areas in terms of trying to assist patients and give them a good experience of the NHS.

My noble friend is absolutely right to raise both of those issues. On healthcare assistants, I can confirm that the work by Skills for Health and Skills for Care is proceeding in a very encouraging way. We are still on track to deliver a system that will enable healthcare assistants to become accredited on a voluntary basis to a register, and that is obviously a welcome step in the direction of ensuring that we can upskill the workforce both in secondary care settings and in social care. However, much will still depend on nurses in those settings to supervise healthcare assistants, and we look to the management of hospitals and care homes to ensure that proper supervision is conducted and, indeed, that there is proper training at the bedside and in the care homes of elderly people. Again, this is work in progress, but I am glad to say that the progress is real and encouraging.

On rehabilitation, my noble friend is absolutely right to say that we need to ensure that NHS continuing care and social care recognise the importance of ensuring that patients recover quickly. It is our ambition that the patient experience should be published and a measure of the quality of the service that is being delivered. Over the past two years we have made available considerable additional resources to local authorities and we will continue to do that so as to ensure that their budgets are not put under as much strain as they would otherwise be, and thus enable them to deliver these very important services.