Annex heavy Mandate is “Involvement lite”

PPI – what’s in a name?  Think you know what it means?  Don’t be so sure.  We don’t mean “Proton Pump Inhibitor” or “Payment Protection Insurance” – or even “Pirate Parties International” which is causing a stir in some EU member state elections.  it appears that those “PPIs” have more weight in the grand scheme of things – if you go by occurrences in the media –  that the “other PPI” – patient and public involvement.   That’s by way of an introduction to talking about the draft Mandate released by the Secretary of State on 4th July.  It is pretty light (make that “lite”?) on the kind of PPI that matters to patients, carers, citizens and communities.

We should be worried.   The Mandate’s predecessor, the 2012-2013 Operating Framework, sold out real involvement to a “do once” centrally-driven communications initiative without the Big Beast at the centre even blinking an eye.  And I am always suspicious of a document like this one (37pp) which comes with four annexes (42pp) which are bigger than it is.

Mandating outcomes

The Mandate is the new-fangled way of saying what the English NHS should be focusing on and delivering.  Mr Lansley talks about it here  – “motherhood and apple pie.”  It is open for comments online until late September.

The Mandate comes from the SoS to the NHS Commissioning Board (England) and when it emerges in a final form should have a big impact on what the English NHS spends its time doing from 2013-2015 with our tax money.  It is supposed to reflect priorities in the NHS Outcomes Framework which set indicators for healthcare performance which NHS bodies have to provide evidence of meeting.

There are 22 key objectives for the first two years and “ambitions” identified for the coming 5-10 years.  Neat idea, but hard to do with so many local, vested interests fighting over money and pulling in different directions.  In a cold climate, this scrap will get worse. Just look at the struggle escalating over A&E and maternity department rationalisation in West London hospitals.

Domain 4 looks promising

The first question in the consultation on the Mandate is the killer:  “will the Mandate drive a culture which puts patients at the heart of everything the NHS does?”

To which the answer is “maybe yes, but maybe no.”  As Florence Nightingale observed “no report is self-executive”.   The Mandate will be no different.  How the question turns out all depends on how seriously the local NHS takes all of this and how vigilant local people and Councils are about making sure they know what good care is, demanding that their communities receive it and doing something that makes a difference if it doesn’t happen.  That’s a big part of the role of Local Healthwatch from April 2013.

Domain 4 of the Mandate has potential.  It is about patient experience. Here’s what it says:

“Ensuring that people have a positive experience of care Objective 4:

i) Increase the proportion of NHS patients in England who would rate their experience as “good” (an additional X patients by 2015);

ii) increase the proportion of patients who would recommend their hospital to a family member or friend as a high-quality place to receive treatment and care;

iii) increase the proportion of doctors, nurses and other staff who would recommend their place of work to a family member or friend as a high-quality place to receive treatment and care; and

iv) provide evidence that poor performance is being tackled where patients and/or staff say they would not recommend their hospital to family members or friends as a high-quality place to receive treatment and care.

But it isn’t enough

This sounds superficially attractive.  But it is not strong enough as it stands. I agree with the potential importance of the “family and friends” recommendation test.  But it is not all that needs to be done. Providers must be required to produce concrete evidence which users verify – that’s the missing bit and possibly a role for Local Healthwatch  – that they have not only understood the intelligence but done something with it that matters to users and which users recognise as an improvement.

That is how the circle needs to be closed.  Otherwise the intelligence just piles up for compliance purposes to keep the Commissioning Board and CQC happy and does not get into the NHS bloodstream as improvements.  And it won’t stop another Mid Staffs scandal from blowing up.

My litmus test 

When the Mandate was being compiled, the prevailing advice was to avoid trying to get included into it every clinical condition or sectional interest because local commissioners needed room to operate.  I approve of flexibility to reflect local conditions, but the danger in that is that it can mean letting groups who are neglected already continue to fall through the gaps.

The Mandate’s litmus test for me is whether long term neurological conditions are taken seriously and not just submerged in general blandness about long term conditions. The scandalous shortcomings in neurological services highlighted by the Public Accounts Committee and the National Audit Office have to be addressed. If the mandate ignores the specifics of long term conditions with bland generalities, we all know what that means – some groups will remain stuck underneath the train and not on it as it roars ahead. From my reading of it, it looks like people with Long Term Neurological Conditions will be bumping along underneath the Mandate express.

“Nothing about Us”

Colin Adamson mined Nick Timmins’ expose about the Health and Social Care Act 2o012 for our July newsletter.  He found it to be excellently written stuff about how government works (machinations aplenty), but searching for references about  patient engagement, involvement etc produced zero references. Not even in any discussion of the Future Forum.

Maybe this suggests the diagnosis for the Mandate: PPI – the real kind – isn’t in the Mandate because it isn’t in the DNA of government.  To use Colin’s apt phrase:  “So much for Nothing About Us Without Us – we can shorten that slogan to ‘Nothing About Us.’


The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.


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