But the GPC and NHS managers said it was welcome that ministers had not used the report to set a long list of specific, prescriptive targets that would limit the freedom of the NHS Commissioning Board (NCB) and clinical commissioning groups (CCGs).
The 37-page draft document, out for consultation ahead of a 1 April 2013 implementation date, sets out 22 ‘care objectives’ that the NCB will be held to account against, drawing on standards in the NHS Outcomes Framework.
The framework spans five overarching domains:
- Preventing people from dying prematurely.
- Enhancing quality of life for people with long-term conditions.
- Helping people to recover from episodes of ill health or following injury.
- Ensuring people have a positive experience of care.
- Treating and caring for people in a safe environment and protecting them from avoidable harm.
Broad care objectives relating to improving care have been set in each of these areas. The mandate also sets out broad requirements for the NCB around cutting health inequalities, improving services and incentivising commissioners and providers, integrating care and delivering efficiency savings under the £20bn quality, improvement, productivity and prevention (QIPP) savings programme.
The document says there ‘should be incentives for commissioners, through a quality premium’ developed by the NCB, and that this will come from within ‘the overall administration costs limit set in directions for the NHS commissioning system’.
But GPC deputy chairman Dr Richard Vautrey said the document had not addressed the profession’s concerns about the premium.
‘It’s part of the core funding for CCGs, which was already small, so CCGs will be desperate to do whatever it takes to get this funding.
‘If it is linked to achieving financial balance to get that payment, the risk is practices will be under pressure to prescribe and refer less to ensure the CCG gets its quality payment.’
He said withholding part of CCGs’ funding meant they would be unable to plan effectively, and may end up spending the money hastily and inappropriately at the end of each financial year.
He said the quality premium could work against the DH aim of cutting inequalities, because it would be easier for well-off areas to achieve targets to obtain the premium.
Responding to the mandate, NHS Confederation chief executive Mike Farrar said: ‘Encouragingly, this mandate broadly ticks the main box - it keeps things relatively simple and consistent. Unlike documents that have gone before it, the mandate does not seek to develop an ever growing "wish list" of objectives. It rightly encourages commissioners to exercise their knowledge of the needs of their local communities to plan and deliver the best care.
‘Achieving the right balance of national direction and local control is a key aim of this mandate.’
Dr Vautrey said that over the next two years ‘we will see the reality – there is still a risk CCGs will be squashed between a controlling NCB and commissioning support services’.