My Lords, I will speak to Amendments 7 and 9 in my name. I thank the noble Lord, Lord Lansley, for introducing this debate and I look forward to supporting the noble Baroness, Lady Walmsley. I think we are about to see harmony breaking out between the four walls of the Chamber. The noble Lord, Lord Lansley, and I are I think in accord over these amendments.
Historically, the mandate is part of the attempted change—I think that is probably the right way to put it—to distance the role of government and Ministers from the sound of bedpans dropping, if I might put it like that. Unfortunately, as the noble Lord, Lord Lansley, said, despite the mandate’s intentions, recent Ministers have still tried to micromanage and otherwise interfere with NHS managers. During the passage of the 2012 Bill, the Government had to concede that the Secretary of State remained politically responsible to Parliament for the NHS.
I think it would be fair to say that laying the mandate before Parliament in each year, as was intended, has not brought about energetic debates and wise reflections in either House of Parliament. But the mandate is not without merit. It is good that the NHS knows what is expected of it and should be free from sudden announcements and other surprises. Without something of this nature, it is wholly unclear how accountability works. So we accept that, at least until the next reorganisation happens, there has to be a mandate, and the important thing is to get this right.
For that reason, we support the two amendments from the noble Lord, Lord Lansley. If anybody knows how the mandate ought to be used, it is definitely him. Trying to have clearly stated objectives in the outcomes framework, or some equivalent, and ensuring that the mandate is objective, evidence-based and publicly accountable must be correct.
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What most experts have suggested to us is that the NHS would benefit from a more stable background so that it can plan for three to five years or more ahead without lurches in policy and, perhaps more importantly, with the certainty of proper funding to match requirements. We now have the NHS management setting out long-term plans and then taking the bowl to Treasury as and when it can. This is especially relevant in the area of workforce, which is currently a huge challenge and a matter to which we will return later in the Bill. With the NHS so dependent on staff who have to have many years of training, everything points to long-term planning and not to an annual round of moving the deckchairs.
Before the mandate concept entered the jargon, the NHS had to make use of other means to try to work out what was expected. There are still echoes of this in the NHS. It would be valuable for Ministers to reflect on what those who run the NHS think about the mandate and how effective it is, or, more honestly, about how it can be made an effective part of governance and accountability in the new world of collaboration and co-operation. The idea of the mandate being for a longer period and for it to be amended only when something serious happens, perhaps on the scale of a financial crash or a pandemic, certainly has some merit. We certainly favour long-term planning and political stability to assist the NHS to recover from its current parlous state.
I therefore ask the Minister to reflect especially on the two matters raised in our amendments. First, a change in a mandate during its natural term would be hugely disruptive, so there should be some requirement on the Secretary of State to do this only in genuinely urgent circumstances, and he should be able to justify the action to Parliament and to show that the need outweighed the disruption costs.
Secondly, any mandate without a proper financial analysis is always open to question. The setting of the mandate must be tightly linked to the allocation of funding and not entirely divorced from it, as appears to be the case now. That requires a better relationship between the Secretary of State for the department and the Chancellor, but we have to travel in hope. Evidence provided to us and widely published suggests that in the year before the pandemic the NHS had an effective deficit of at least £5 billion. That is the gap between the cost of delivering what Ministers and Her Majesty’s Government want and what they are paying for. That is against an entirely unambitious scenario where the NHS was not reducing waiting times and not making serious improvements.
The Commonwealth Fund has shown the impact of inadequate funding as the NHS slides down the table. Just about everyone agreed that this is an inevitable consequence of the chosen approach of austerity in the previous years. There are credible estimates of even larger gaps if the NHS is robustly to tackle lengthening waits and to try to improve the less-than-enviable record on outcomes: almost certainly well over £10 billion per annum. Time and again, we have heard from various parts of the NHS that they are asked to do things that have not been funded. It is an old trick of blame-shifting: provide inadequate funding
but deflect the blame when delivery does not happen. We need to move away from the suspicion of blame-shifting when we discuss the ICBs.
That all points to the need to restore some credibility in a system which asks for things it cannot pay for. Adding a requirement for something like an OBR analysis of affordability looks to us like a sensible step. After all, we have to assume that plans and mandates are costed out, so most of the actual work is already done, so why not get some assurance of the costings and publish it to build confidence? I await the Minister’s reply on these matters with interest.