My Lords, I am glad to be able to respond to these amendments relating, in their several ways, to the NHS England mandate. I will cover each in turn.
I begin with my noble friend Lord Lansley’s Amendment 4. I confess that I am not in the least surprised that he, of all noble Lords, should have
reminded us of the key importance of the NHS outcomes framework. Amendment 4 would require the Secretary of State to specify objectives that will help NHS England achieve improvements in the outcomes provided for in the NHS outcomes framework. As he and I remember clearly, the NHS outcomes framework is a set of indicators that provide for national-level accountability for the health outcomes that the NHS delivers. The first version was published in 2010 to inform the first mandate to what was then still known as the NHS Commissioning Board. In essence, it looks at long-term health trends across various domains, including quality of care and patient experience. It is a valuable resource and, as my noble friend knows, remains an important tool for measuring the NHS’s contribution to improving outcomes over the long term.
I quite agree with my noble friend that progress against outcomes is vital. That is why we have included Clause 3 in the Bill. One of the main advantages of a longer-term mandate is that it will allow us to take a longer-term view of progress against outcomes that can be measured meaningfully only across a number of years.
The noble Lord, Lord Patel, asked who will be responsible for improving outcomes. The answer is that NHS England and ICBs have duties in relation to improving the quality of services. I can assure him that we will hold them to account for doing so. Having said that, we are moving now to a system-wide approach. That entails the need to measure shared outcomes across health and the wider social care and public health system. Some of these outcomes are led by the NHS but many are system-wide, so the business of measuring patient and service-user outcomes will inevitably become more sophisticated.
We want to ensure that our system is flexible and able to adapt as those system approaches develop and mature. I hope my noble friend therefore appreciates why we would not want to enshrine the NHS outcomes framework in the mandate in statute, in a way that might limit or compromise our ability to explore broader system approaches as we go forward. However, I seek to reassure him that the NHS outcomes framework will continue to be a vital tool to look at long-term trends in health outcomes and the NHS’s role in supporting health outcomes. That basic role for the NHS outcomes framework will not change.
I fully understand the concern of the noble Baroness, Lady Thornton, in her Amendment 7 that the mandate should not be revised unnecessarily and without good reason. I completely agree with that sentiment; again, it lies behind our desire to look at the mandate over a longer timeframe than has hitherto been possible. My concern is that her amendment goes much further than, I suspect, she intended, because it would prevent the mandate being revised at all in anything other than an urgent or unforeseen situation. That would be unhelpful, because it would wholly prevent planned changes to reflect, for example, evolving strategic priorities, emerging evidence of need or even a planned general election.
The purpose of Clause 3 is to strengthen the role of the mandate by enabling the Government, where appropriate, to set a mandate that can endure, rather
than having an annual use-by date. Looking back to our debates on the Health and Social Care Bill in 2011, the noble Baroness will remember that it was always the intention that the Government should set a multiyear mandate, and Parliament agreed. In practice, that intention has been hampered by the inevitability of an annual review of the mandate to a fixed deadline—a deadline that does not neatly align to a number of events and strategic processes, including the Budget, spending reviews and general elections. Clause 3 addresses this. I seek to reassure the noble Baroness that there is no intention to revise mandates unnecessarily at the drop of a hat, as it makes no sense to do so.
I am grateful to the noble Baroness, Lady Walmsley, for highlighting a similar set of issues to those raised by the noble Baroness, Lady Thornton. Her Amendment 8 would prevent the Government revising our mandate for NHS England more than once in the same financial year, for any reason. As I said to the noble Baroness, Lady Thornton, I completely understand her concern that the mandate should not be revised so frequently that NHS England is unable to plan for or deliver government priorities effectively. This is why I reassure her that this will not happen, except in the most exceptional of circumstances. I hope she accepts that reassurance, because it cannot be in the interests of any Government, or of patients and service users, to set a mandate that changes NHS priorities too frequently. I expect any such revisions to be very rare. As I have indicated, though, one can imagine that they may be necessary to respond to unforeseen events, to reflect the result of a general election or to signal future shifts in priorities at a point when the NHS is planning ahead. The Government need the necessary mechanism to deal with these and other similar eventualities.
The noble Baroness will see that Clause 3 already contains an explicit safeguard in respect of reasonableness: NHS England will not be obliged to revisit a business plan that it has already published, should the Government revise the mandate within a year of its issue. The Government will also have a continuing duty to consult NHS England before making any revision. I believe that, in combination, these two safeguards work together to fully answer the point that the noble Baroness made.
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Amendment 9 would require the provision to Parliament of an independent financial assessment of the mandate to NHS England, to allow financial scrutiny of issues including sources of funding and value for money. Once again, I am grateful to the noble Baroness, Lady Thornton, for opening up this discussion. I fully agree with her that public spending should be thoroughly scrutinised and constitute effective value for money. However, I do not think that the proposed amendment is necessary to bring this about.
As part of this Bill, we are ensuring that the financial directions which accompany the mandate are laid before Parliament. These directions confirm that the resource and capital limits for the NHS are consistent with the outcome of the spending review. The department works closely with NHS England as part of the spending review, to ensure that its funding is sufficient to fulfil its mandate obligations. The mandate also sets NHS England financial objectives, including on balancing
its budget, and expectations on efficiency. Progress against mandate objectives is assessed annually and reported to Parliament, and that will continue to be the case under this Bill.
The mandate is also guided by the principles in Managing Public Money, and existing mechanisms are in place to ensure robust financial scrutiny of NHS finances beyond those of the spending review, including oversight from the Health and Social Care Select Committee and the Public Accounts Committee. The National Audit Office plays a key role as an independent parliamentary body, auditing NHS England’s annual report. It also examines and reports on the value for money of different areas of NHS spending. Parliament therefore already has significant oversight of NHS spending; adding an additional independent assessment when other mechanisms are already in place does not, I suggest, in itself provide value for money for the taxpayer.
Finally, I am grateful to my noble friend Lord Lansley for Amendment 10, which would reinstate Section 13B(5) of the National Health Service Act 2006, which has been removed by this Bill. That provision makes clear that if the Secretary of State revises the mandate, he must publish the revised mandate and lay it in Parliament, along with an explanation of the reasons for it. Clause 3 already provides for the Secretary of State to both publish and lay in Parliament any and all revisions made to the mandate. I therefore believe that, as currently worded, the clause wholly meets my noble friend’s concern in that regard.
This amendment would also reinstate the requirement to provide an explanation to Parliament of the reasons for revising the mandate, and this would apply to all mandate revisions. In response to my noble friend, I would just say that my colleagues have already provided assurances in the other place that the Government will, in practice, continue to lay a Written Ministerial Statement in both Houses of Parliament alongside any mandate document. I will now reinforce that assurance by repeating the commitment that this practice will continue. Furthermore, such Statements will always clearly explain the reasons for any mandate revisions, whether these are routine or arise from specific and unusual circumstances. That is entirely appropriate, and so I am very happy to make that commitment.
I hope I have been able to give your Lordships some reassurance of our intentions regarding the mandate. I therefore hope that my noble friend will feel comfortable withdrawing his amendment.