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Revisions to NHS Mandate cause 'concern'

Numerous revisions to NHS England's mandate have 'concerned' and 'disappointed' NHS leaders and ignored previous commitments to keep changes between mandates to a minimum, the NHS Confederation said in response to a consultation to refresh the Mandate.

Responding to the Department of Health's (DH) consultation on refreshing the mandate to NHS England for 2014-15, the NHS Confederation said proposed additions risk 'diluting' the Mandate's core objectives and diverting attention from NHS England's core role of 'enabling, supporting and delivering effective commissioning.'

'Minimum necessary'

The 2013-15 Mandate, published in November last year, stated that the Government would 'strive to keep changes between mandates to the minimum necessary' and 'exercise discipline by not seeking to introduce new objectives for the Board between one mandate and the next'.

Processes rather than outcomes

But the number of proposed additions, many of which are based on processes rather than focusing on outcomes for patients, has 'concerned' and 'disappointed' NHS Confederation members.

Members provided considerable feedback on the proposals to inform the Confederation's response, covering issues including the Mandate overall, urgent care pressures, parity of esteem between physical and mental health, integrated care and a fair playing field.


The organisation cautioned against replicating the 'old way of working', which did not support leaders to plan for the long term, and raised the need for a 'stable environment' so the NHS can concentrate on strategic challenges to remain sustainable in the future.


The proposed additions reflect the specifics of several existing commitments and plans in development, and expectations previously articulated by ministers.

The consultation follows a requirement in the Health Act to review – 'refresh' – the Mandate on a yearly basis.

High-level and strategic

The NHS Confederation's response relayed members' desire for a mandate that provides a high-level and strategic approach and supports a new way of working, focussed on improving patient and population outcomes over the long term.

It urged the DH to adopt a set of principles – developed in consultation with members – against which current and future mandates should be assessed.

The Mandate should:

  • empower clinicians to lead, and patients to influence, commissioning
  • be based on a manageable number of objectives which:
    • focus mainly on long-term outcomes for patients and populations rather than measures of how services are delivered
    • encourage collective responsibility for patient outcomes rather than silo working – particularly the expected outcomes from integrated care
    • are easily measurable, specific and realistic to enable accountability across NHS England, commissioners, providers, patients and the public
    • can be implemented efficiently rather than imposing unnecessary or disproportionate cost and burden
    • align with the requirements on the other national bodies; and
    • are in language which is accessible to patients and the public.
  • retain a focus on enabling, supporting and delivering effective commissioning and avoid diverting NHS England's efforts into areas that other organisations (whether local or national) are better placed to address. 

Addressing strategic issues

The organisation also challenged the DH to do more to address strategic issues, including: acknowledging funding pressures; developing a whole-system approach; strengthening working relationships; and bringing together leaders from across the system.

Plans for vulnerable older people

The Confederation welcomed the Mandate's focus on improving care for vulnerable older people, but used the opportunity to warn against the DH's vulnerable older people's plan (VOPP) focussing solely on primary care, making a number of recommendations for the DH and NHS England.

The organisation also welcomed the emphasis on achieving parity of esteem between mental and physical health.

Find out more

Download the full response to the Department of Health's consultation.

Access the current Mandate from the Department of Health's website.

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