My Lords, I am very glad to have this opportunity to contribute to the Committee’s discussions. We turn to the mandate, which noble Lords will recall is the means by which the Secretary
of State principally holds NHS England to account for the delivery of its functions and responsibilities in relation to the NHS.
This becomes more important as time goes on, for two reasons: first, because NHS England will incorporate within its own activities more of the functions pertaining to the NHS, particularly the powers and responsibilities of NHS Improvement; secondly, because in the past there was a sense in which some transparency was associated with the bodies across the NHS. NHS Improvement represented the interests of NHS service providers and NHS England represented the interests of the commissioning of services—that is, the public interest and the population health interest. These are to be incorporated in one organisation; that is the essence of the integration that NHS England and NHS bodies have sought to achieve, contrary to the structures of the 2012 legislation. I wish them success with it, but it does not enhance accountability, either to Parliament or the public. Therefore, the mechanisms for accountability must be as clear as we can make them.
As it happens, since 2013 I do not think Secretaries of State or Parliament have used the mandate in the way it was intended they should. On a number of occasions, the Secretary of State has not used the mandate on an annual basis but has run it on, and we therefore have before us—as we will see in many places in this legislation—an acceptance of how practice has developed and that the legislation should come into line with it.
On a number of occasions, I will simply throw up my hands and say, “Fine, if that is how the NHS wants to do things, let us put the legislation into that structure to enable the NHS to do its job in the way it wishes to.” Indeed, I suspect that those outside this House who are looking at the current situation in the NHS are saying, “What is the relevance of us engaging in all this legislative activity at this moment?” Part of the answer is that legislation impacts on the day-to-day activities of people in the NHS much less than they might imagine. Secondly, one of the things we can do sensibly is to say that, even before the pandemic and the additional extreme pressures that the NHS has had to face, it had developed its own way of working, it wants the legislation to fit with that and I think it is probably helpful to the NHS to do that.
There will be other places, and we will come to them later, some of which I mentioned in my Second Reading speech, where I think the Government are looking to go beyond and to change what the NHS has done by way of practical integration, practical implementation and practical decision-making. I think we should resist some of those. I do not think it helps the NHS, at a time of such extreme pressures, for there to be some of these innovations, and maybe we need to call a halt to some of them.
One of the things, however, that the Government are not intending to do is to dispense with the mandate. The mandate is, in my view, more important for the future, for reasons of the importance of the transparency of accountability for the NHS for the performance of its functions. Since we went into recess before Christmas, NHS England and NHS Improvement have published their operational guidance for 2022-23. I think they
have actually set out a pretty admirable and comprehensive set of objectives, but only a minority of those objectives are outcomes related. Many of them are, quite understandably under current circumstances, very focused on the volume of activity and the targeting therewith—in particular, for example, that the level of elective activity should rise to 110% of the pre-pandemic level and that diagnostics should increase to 120% of the pre-pandemic level. This is absolutely instrumental if we are to deliver on or get back to remotely the kind of waiting time figures we experienced in the earlier part of the last decade—I might say back to 2012-13, when we reduced waiting times to their lowest level.
The point is that there is a great danger, which we have seen in the way Secretaries of State have structured the mandate in recent years to focus on process, on targets and on volume and to devote insufficient continuing attention to the outcomes that are achieved. I gladly make clear that, while I move this amendment, I do not think it is the way the legislation should be framed. What I am looking for from my noble friend is the Government’s acknowledgement that, even as they focus on waiting times, targets, productivity, volumes and the mechanisms by which the volumes of activity in the NHS can be increased in the years ahead, we must not lose sight of outcomes.
What I mean by that is that we have seen a number of examples in the past of how the pursuit of waiting time targets led to significant problems in terms of hospital-acquired infections, which really threw the NHS off course for more than one or two years. So, in the NHS outcomes framework there is a domain relating to safe care, which I think enables us to focus on things like hospital-acquired infections and continuously to measure the outcomes we are achieving in relation to that.
The same is true in relation to preventing premature mortality. This, happily, is an area where, by focusing on outcomes, we can demonstrate that we are meeting internationally comparative high levels of performance. Of course, that does not relate only to cancer, but it is one of the reasons why we do not have a separate debate for Clause 4. I was prompted to put this amendment forward partly because of Clause 4, however. I am glad that it is in the Bill—it was part of a debate we had more than 15 years ago, when John Baron was with me on the shadow health team in another place—but the point is that we were always focused on one and five-year survival rates for outcomes in relation to cancer. What Clause 4 does is enable us to focus on outcomes in that respect.
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However, it would be a serious mistake for us to focus on one set of outcomes and not a broader set of outcomes. I look back on our development of the NHS outcomes framework; it is one of the things we have done in the past decade or more that I am very pleased about. We should focus on that and use it. It is not something that managers can necessarily navigate by on a day-to-day basis, but it is something for which we should hold the NHS accountable. Are we preventing people dying prematurely? For example, what is our ability to prevent mortality from stroke within 30 days —and likewise with cancer outcomes? What is our ability
to ensure that people recover when they have treatments? As I mentioned, do we have safe care? Are we avoiding hospital-acquired infections? Are we improving quality of life for people with long-term conditions, taking the whole population with long-term conditions into account? Are we making sure that we have a positive experience of care? In the past decade, we have developed things like the friends and family test; we should be able to look at it and use it as a mechanism for understanding whether we are continuously improving the performance of the National Health Service.
The NHS cannot and should not be defined by the number of beds it has or the number of staff it employs, nor by the fact that people’s waiting times have been brought back down and are lower than they are now—that is, that people are not waiting a long time for treatment. All those things are important but, fundamentally, we aim to have an NHS that delivers the best population health and in which, when they are ill, people get good care and recover with good outcomes. What I am therefore looking for by virtue of my Amendment 4 is that the mandate should include a continuous programme of looking at the outcomes achieved by the NHS and understanding whether we are making continuous improvements in those outcomes.
In this group, I also have Amendment 10. It serves only a small, particular purpose: to put a question to my noble friend the Minister. The Government are putting into Section 13A of the 2006 NHS Act a power for the Secretary of State to revise the mandate and lay it before Parliament, but they are taking out the provision, in what was Section 13B, that, when the Secretary of State revises the mandate, he should
“lay it before Parliament, together with an explanation of the reasons for making the revision.”
I do not understand why the Government have left that out. The point of my Amendment 10, therefore, is to ask this question: when the Secretary of State revises the mandate, should we not require the Secretary of State not only to lay it before Parliament but to explain the reasons for the revisions—all part of transparency and accountability?
In that context, it may not be necessary but Amendment 7, in the name of the noble Baroness, Lady Thornton, which is also in this group, makes perfectly good sense to me. It may not be necessary in the sense that there is a power to revise the mandate—clearly, that must extend to when there is an emergency—but I rather agree with the benefit of stating that at this stage and perhaps stating it in the Bill.
I hope that I have explained Amendment 4. It would enable this group not least to look at the mandate and, indeed, at Clause 4 in anticipation of the fact that we will not have a separate debate on it. I beg to move.