Amendment 4

Health and Care Bill - Committee (Day 1) – in the House of Lords at 4:30 pm on 11th January 2022.

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Lord Lansley:

Moved by Lord Lansley

4: Clause 3, page 2, line 8, at end insert “and insert “, including in achieving improvements in the outcomes recorded in the NHS Outcomes Framework””

Photo of Lord Lansley Lord Lansley Conservative

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.

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.

Photo of Baroness Cumberlege Baroness Cumberlege Conservative 4:45 pm, 11th January 2022

My Lords, I will make a rather simple point. I listened very carefully to what the noble Lord, Lord Lansley, said, and a lot of it makes an awful lot of sense—of course it does. He is a very experienced politician and he led the NHS in an outstanding way. I have to say that some of us very much supported what was in the 2012 Act and we are finding it quite difficult now to try to discard that—although throughout the Bill points are made that bring it back in, which is to be welcomed.

Outcomes are extremely difficult. In the National Health Service, we have two sorts of outcomes: PROMs and PREMs. PROMs are patient-reported outcome measures, and we work hard to try to achieve that. At one time we used to take soundings from people on hospital wards on how they were getting on, and it did not quite work. Now we are trying to ensure that the patient-reported outcome measures are set out quite clearly, so that people can relate to them, and they have to be patient driven—it must be the patients who say what is important to them as outcomes. PREMs—patient-reported experience measures—are equally important, and are also extremely difficult to collect.

At the moment we are trying still to implement the report First Do No Harm; I chaired the group that led it. We spent two and a half years listening to patients—that is virtually all we did. Out of that report we have set up centres to address the issue of mesh that was inserted into women, which has proved very unsatisfactory, certainly in the majority of cases that we listened to. We have said what has to happen in these centres before they are fully functioning. We now have sites and staff and are going forward on them, but they will not be any use until we have these outcome measures. This is how we will have to judge things in the NHS in the future.

Of course we have clinicians who are extremely well trained and are very good and well-motivated people. But sometimes they can miss the obvious which is transparent to patients. They are the people we should listen to, because they are the people who receive the service and who, like all of us, pay for it. It is important that these outcome measures are taken much more seriously and that we put a lot more work into ensuring that they will work for patients and for clinicians. It is important that the staff in the NHS also understand that what they are doing is valued—or not. On the whole, of course it is valued, but on occasions it is not, as we heard in our report First Do No Harm. I just wanted to make that quite simple point.

Photo of Lord Patel Lord Patel Chair, Science and Technology Committee (Lords), Chair, Science and Technology Committee (Lords)

My Lords, my knee-jerk reaction was going to be, “I don’t agree with what Lord Lansley says”. However, I have put my knee hammer back in my pocket, because I do agree with him about the importance of using outcomes indicators as a measure of the performance of health in patients. In that respect the outcomes framework has always been a good development. Although Clause 4 focuses on cancer—and I hope we do not change that—it is an example of how it can be used for other conditions to improve healthcare.

The noble Lord has also identified one key omission in this Bill, which I hope we can find a way to fill: who will be responsible for making sure that there is continuous improvement and development in healthcare that measures the outcomes? That is not in the Bill. I hope we might find a way to do that, whether through the mandate or other ways. That is all I have to say.

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Deputy Chairman of Committees, Deputy Speaker (Lords)

My Lords, I must declare an interest, because a lot of the outcome measures that are now used are in place at Cardiff University. I will expand a little on and support what my noble friend Lord Patel said about outcome measures, particularly for something such as cancer. That is in part because the disease process itself is marching on all the time. It is different from many other diseases, where there might be a chronic condition and other things happen as a result of it. If you do not intervene rapidly with some cancers, you miss the boat and go from being able to cure it to a situation where you certainly will not be able to.

The other group of outcome measures that I do not think we should forget has just now been developed: family-reported outcome measures. That is the impact on the family. We know about the number of carers that there are. There are child carers and many unpaid carers. Having somebody in the family with a disease process, waiting for something to happen and seeing that disease process getting worse and worse in front of their eyes, has a major impact on the health of others and stacks up problems for the future in the health service.

That is why, when I was on the All-Party Parliamentary Group on Cancer, I strongly supported John Baron in all his efforts to look at the one-year survival times in cancer. Looking at outcomes can be far more informative than looking simply at process targets, which is what we have been looking at too much to date rather than looking at the overall impact of disease.

Photo of Baroness Thornton Baroness Thornton Shadow Spokesperson (Equalities and Women's Issues), Shadow Spokesperson (Health)

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.

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.

Photo of Baroness Walmsley Baroness Walmsley Co-Deputy Leader of the Liberal Democrat Peers 5:00 pm, 11th January 2022

My Lords, I am certainly with the noble Baroness, Lady Finlay, on the issue of outcomes. Like her, I am a member of the All-Party Group on Cancer, and I was right behind our former chairman John Baron’s attempt to get a clear focus on outcomes. I am delighted to see how successful that has been.

My Amendment 8 is very simple. It would prevent the Secretary of State tinkering too often with the mandate. As others have said, the mandate is the primary instrument through which the Secretary of State provides the Government’s direction to the NHS. He is right to do so, since the NHS uses the most enormous amount of our money and is of vital concern to every voter and taxpayer—those whom the Government represent.

However, the NHS is a little like the “QE2” in that it is absolutely enormous and takes quite a while to change direction. Indeed, a great many levers have to be pulled for it to do so. Chief executives, boards and professional staff need time to set new plans, targets and employment policies—to say nothing of moving the money around—to comply, as they must, with changes to these mandatory directions from on high. It is therefore highly undesirable for a Secretary of State to change the mandate too frequently. As the noble Baroness, Lady Thornton, said, even when it happens, adequate notice and reasons must be given.

Other amendments in this group deal with other aspects of the mandate, but I want to be fully assured that, given the difficult tasks we set our NHS, its outline instructions and targets are not unfairly changed too often. I feel justified in having this concern, because the evidence of clauses later in the Bill indicates to me a tendency by the Government to want to meddle where meddling is inappropriate and could have negative effects. I refer, of course, to the Secretary of State’s attempted power grab, which we will discuss later in Committee.

Can the Minister assure me that there is already some effective measure that would prevent the mandate being changed more than once in any financial year, which would make it very difficult for the NHS to comply?

Photo of Earl Howe Earl Howe Deputy Leader of the House of Lords

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.

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.

Photo of Lord Lansley Lord Lansley Conservative 5:15 pm, 11th January 2022

I am most grateful to my noble friend for that response and to all those who contributed to this short debate. It was a helpful opportunity to reinforce the desirability of the mandate itself being used positively as a mechanism for accountability, particularly where outcomes are concerned.

I entirely take my noble friend’s point that what we are looking for should not be confined to the parameters of the NHS outcomes framework. As time goes on, the possibility of developing what are effectively population health outcomes is exactly where we need to go. My worry is that, if the mandate shifts too much towards population health outcomes, we will be trying to express it in terms of outcomes which the NHS does not control the means of delivering. That goes back to the point the noble Lord, Lord Patel, made earlier about who is responsible for what. As my noble friend said, in essence, the NHS is responsible for delivering the outcomes in relation to healthcare, but the Government are responsible for delivering outcomes in relation to population health, so we cannot confine this to the NHS. The mandate certainly needs to extend into that territory but, in doing so, it should not lose track of continuous improvement in those things that are measured through the NHS outcomes framework, and its development as we go along.

I also take the point about the timeframe. We have learned that we need the NHS to be planning long term, and it is doing that—not least through its development of the 10-year long-term plan. That extends even beyond the Government’s funding commitment, which has a different timeframe. Neither of those are very easily reconciled directly with the annual funding settlement. The mandate could be developed as a very effective way to enable the NHS and the Government to show, in a way that is accountable to public and Parliament, how the plans of the NHS and the funding commitments from the Government can be reconciled into measurable changes, targets, objectives and outcomes in the lifetime of a Parliament, because that is what Ministers will inevitably be looking for. We want the NHS to feel that it has some degree of certainty for the longer term; we want Ministers to feel that they have some degree of accountability and control in the year ahead, or two or three years ahead. That is what the mandate should be used to enable them to do.

My last word on the mandate is: please could Parliament actually scrutinise it? It was always intended that there would be annual debates in this House and the other place on the mandate. There never were. I thought it was shocking that the Government did not devote a day in each House each year to looking at, understanding and scrutinising the mandate as a mechanism for us to look at our most important public service—you can always argue about that, but I think it is—and know what we are trying to achieve in the year ahead, even if the mandate extends further beyond that.

I thank my noble friend, not least for his point on Amendment 10 and his reassurance that Ministers will always explain their reasons for revisions to the mandate and, indeed, that such revisions, as we all agree, should not be too frequent or too detailed; they need to be strategic in their nature. I am glad for his reassurance on that point. With those thoughts, I beg leave to withdraw the amendment.

Amendment 4 withdrawn.

Photo of Lord Brougham and Vaux Lord Brougham and Vaux Deputy Chairman of Committees, Deputy Speaker (Lords)

My Lords, before I call Amendment 5, I advise the Committee that the noble Lord, Lord Howarth of Newport, will be speaking remotely.