The Consultations Coordinator
Department of Health
3E48 Quarry House
Leeds
LS2 7UE
Victoria House
Capital Park
Fulbourn
Cambridge
CB21 5XB
Tel: 01223 597792
Fax: 01223 597712
Web: www.sdu.nhs.uk
August 15th 2012
Consultation on the Department of Health’s draft mandate to the NHS Commissioning Board
The NHS Sustainable Development Unit (SDU) welcomes the opportunity to respond to the
consultation on the Department of Health’s draft Mandate to the NHS Commissioning Board.
The NHS SDU provides leadership, expert support, and technical guidance across the health and
care system in relation to sustainable development. Financially, socially and environmentally
sustainable healthcare meets the health and social needs of today without compromising the needs
of tomorrow, this approach is referred to as triple bottom line healthcare (see appendix 1 for
examples). Sustainable development is an integral dimension of quality in health care: it is a
fundamental principle for the delivery of an affordable, world class and future proof healthcare
service.
The NHS SDU fully supports the broad aims of the mandate to improve health outcomes and
reduce health inequalities. Within these aims the Mandate, in order to align the values in the NHS
Constitution with the guidance in the Mandate, should specifically refer to sustainability. A Mandate
that referred to the sustainability of the system in the goods and services commissioned would
reinforce the NHS Constitution’s declared aim for the NHS to commit to the “fair and sustainable use
of finite resources”, and would provide robust scrutiny in line with HMG’s statutory approach to
deliver everything necessary to guarantee in line with legislation (The Climate Change Act 2008i).
Firstly, the NHS Commissioning Board requires a mandate that gives a clear steer in line with
Government legislation that can then be operationalised within the governance and delivery
frameworks of the NHS. The Mandate is an important opportunity to ensure the principles of the
NHS Constitution are embedded within the frameworks that will stimulate and legitimise practical
action through those NHS organisations providing services. Reference to sustainability would
legitimise and systematise the pioneering work already being delivered in many parts of the NHS
and would provide an important sign that this is an increasingly important duty of care. Ignoring the
opportunity to make any reference to sustainability in the mandate would be to ignore the future,
which would be unsafe, unaffordable and unethical. The NHS is already seen as a leader on the
global stage in this area so legitimising and codifying current practices is an important part of
maintaining this momentum.
Secondly, there is strong evidence for multiple co-benefits to health from environmental
sustainability (for instance through improving nutrition, physical activity, and many other lifestyle and
societal induced preventable causes of ill health), meaning that sustainability should reduce the
preventable disease burden on the NHS, again reinforcing the spirit of the Constitution within the
Mandate. The UK Government’s own estimates show sustainability measures already save the
government £60-70 million every year. The NHS SDU has calculated and helped deliver savings of
The NHS Sustainable Development Unit develops organisations, people, tools, policy and research
to help the NHS in England fulfil its potential as a leading sustainable and low carbon organisation.
many millions of pounds each year within health economies across England. These savings can
continue and increase if a clear message is maintained by direction and diffusion through the health
system from Government legislation to Constitution to Mandate to operational frameworks and
related mechanisms.
The principles of environmental, social and economic sustainability are so aligned with the broad
aims of the mandate and that ultimately it will be impossible to achieve the mandate’s objectives
without developing health services in a sustainable manner. Below we have responded to the
consultation questions and at the end of this letter we have outlined areas where the concepts of
sustainability could be easily and concisely incorporated into this mandate.
Dr David Pencheon
Director
Responses to the consultation questions
Question 1: Will the mandate drive a culture which puts patients at the heart of everything
the NHS does?
Possibly: A future proof health service will deliver the highest possible quality of service that is
equitable, delivered within financial and environmental limits, and socially sustainable. Patients
need to be at the centre of a health service that delivers care in a sustainable manner that will not
prejudice our ability to deliver healthcare in the future of an equivalent or increased quality.
Question 2: Do you agree with the overall approach to the draft mandate and the way the
mandate is structured.
We would wish to see a concise Mandate, well aligned with the NHS Constitution and based on the
principles of an affordable, ethical and sustainable model of public service. The message should be
that services need to be commissioned and services purchased with long term, effective, and
affordable actions included.
Question 3: Are the objectives right? Could they be simplified and/or reduced in number, are
there objectives missing? Do they reflect the over-arching goals of NHS commissioning?
We strongly recommend that the Mandate does not stimulate short term, seemingly positive actions
that have longer term consequences that are financially, socially or environmental unsustainable,
We believe that it is important that the Mandate has an objective that sends out a very clear signal
that we need to design, deliver and develop a sustainable health care system within a sustainable
society. This should be aligned with the Government’s stated aim for the NHS (via the Constitution),
its 2005 strategy for Sustainability,ii the Climate Change Act 20081 and governmental strategies to
develop strong and sustainable communities.iiiiv
Question 4: What are the best ways of assessing progress against the mandate and how can
other organisations best contribute towards this?
One clear principle of measuring success is to ensure that organisations are not commissioning or
delivering services that are unfit for the future i.e. are not doing more long term harm than short term
good.
Suggested measures of progress:
- increases in patient and population health outcomes
The NHS Sustainable Development Unit develops organisations, people, tools, policy and research
to help the NHS in England fulfil its potential as a leading sustainable and low carbon organisation.
-
Improvement in patients, staff, visitor, and partner experience scores.
Compliance with predefined financial and environmental limits (i.e. future proof)
Compliance with the trajectory needed to comply with the Climate Change Act, 2008.
(already calculated with wide engagement and dissemination process within NHS)
Clear governance processes for future proof healthcare: risk registers and compliance with
existing and emerging national/European law, for instance: the Social Value Act, 2011.v
Question 5: Do you have views now about how the mandate should be developed in future
years?
We would expect the Mandate to be reviewed regularly, but not changed substantially - the
mandate should be strongly based on principles and values that are relatively timeless. As new
technologies and models of care are developed, and resources become more expensive and
scarce, some technologies and models of care will become much more acceptable and cost
efficient, the NHS mandate should reflect this. However, the role of the Mandate should be to alert
commissioners that these are fundamental principles to consider in changing times, not to specify
operational mechanisms regarding how these opportunities are grasped or threats avoided. A well
principled Mandate should stimulate the commissioning of flexible, adaptable and future proof
models of care from a set of high performing organisations.
Question 6: Do you agree that the mandate should be based around the NHS Outcomes
Framework and therefore avoid setting separate objectives for individual clinical conditions?
We do not believe the mandate should go into detail about individual clinical areas, instead it should
stay at the level of principles and purpose, giving examples of quantitative/non-quantitative ways to
measure success. Ensuring a future proof way to reap the co-benefits (benefits now and benefits
later) of sustainable policy and practice should be one of the principles of the Mandate.
Questions 7: Is this the right way to set objectives for improving outcomes and tackling
inequalities?
Focus should be applied to devising principles taken from the NHS Constitution for the Mandate that
send out a clear message that the health system should measure progress in ways that are valid,
consistent, and suggest clear courses of action in order to improve the public’s health. An example
would be to encourage the integration health and social services, and supporting those with chronic
illnesses to live independently. A Mandate that mandates and supports the operational frameworks
to deliver these objectives would improve the health of the public and reduce need for healthcare,
thus reducing economic and environmental costs
However, it is impossible to consider improving the health outcomes and reducing health
inequalities without considering climate change. Climate change is a significant threat to healthvi and
it is likely that climate change will disproportionately affect the poorest in society.vii In England the
NHS contributes a significant proportion of all CO2 emissions (in 2004 an estimated 3% of total
English CO2 emissions)viii. Therefore, any Mandate that aims to improve outcomes and reduce
health inequalities should as one of its core principles include reference to the environment. In
addition, as a publically funded health service with a core value of non-maleficence, the NHS has a
responsibility to ensure that delivery of today’s health services should not be at the expense of
tomorrow’s quality of care.
Question 8: How could this approach develop in future mandates?
As already outlined in our answers to questions 5 and 7, as the need for resilience and sustainability
increases, it will become increasingly important to consider environmental sustainability in NHS
Mandates. However, it is already impossible to address health outcomes and health inequalities
without also addressing environmental sustainability and therefore the first mandate should allude to
this principle. We have outlined areas where we consider that sustainability could easily be included
within the mandate at the end of this response.
The NHS Sustainable Development Unit develops organisations, people, tools, policy and research
to help the NHS in England fulfil its potential as a leading sustainable and low carbon organisation.
Question 9: Is this the right way to mandate to support shared decision making, integrated
care and support for carers?
The SDU considers it essential that the need for shared decision making, integrated care and
support for carers is strongly mandated. Healthcare is a route to better health, not an end in itself.
We need better health through better (not necessarily more) healthcare. Improvements in these
areas will also improve patient outcomes and environmental, economic and financial sustainability.
It is also paramount that the Mandate allows the NHS sufficient flexibility and resilience to take
appropriate risks to innovate, but crucially also requires the NHS to understand what works and
what does not for a resilient future.
Question 10: Do you support the idea of publishing a “Choice Framework “ for patients
alongside the mandate?
The NHS SDU supports all proven measures that genuinely improve the information given to
patients and increase engagement with patients and the public. Indeed, the public strongly support
and expect the health service to be mandated to behave responsibly: 92% of the public interviewed
by Ipsos MORI said they wanted the NHS to be more sustainable.ix
Question 11: Does the draft mandate properly reflect the role of the NHS in supporting
broader social and economic objectives?
Social, environmental and economic sustainability are irrevocably interlinked, and are vital principles
of the NHS if it is truly committed to work towards improving health outcomes, reducing health
inequalities, and increasing social capital and wellbeing today and in the future.
Conclusions
In summary it is clear that respecting and protecting the environment has both immediate and long
term positive consequences for human health. It also reduces unnecessary need and demand for
health and social care. Financial and environmental sustainability are mutually supportive; indeed,
we simply cannot afford to allow any large, exemplary system to be visibly environmentally
unsustainable when the need for financial, environmental and resource stewardship has never been
greater. It is therefore essential that the NHS commissioning board is clearly mandated to improve
environmental, financial and economic sustainability. Below we have outlined areas of the mandate
where the concepts of sustainability could be easily incorporated into the NHS care objective.
Suggested amended wording:
 Objective 22 (page 32)
Suggested amendment to the objective in bold:
Ensure the delivery of efficiency savings in an environmental and financially sustainable
manner to maintain and improve quality in the current spending review and beyond.
Suggested amendment to the body of the text in bold:
The board will be accountable for ensuring delivery of sustainable QIPP savings in a way
that supports the current spending review period and beyond”.
 Objective 19 (pages 29-30)
Suggested amendment to the body of the text in bold:
- (5.8) The Board and CCGs will only be able to drive better outcomes if they are
working within a financial framework that promotes quality, value for money and
sustainability.
- (5.9) The Board will need to work closely with Monitor and other partners, including
the Department, in the process of developing tariffs which promote better outcomes
for patients and improve sustainability.
 In addition: All organisations that provide services on behalf of the NHS should comply with
legislation that compels organisations to fulfil the NHS’s duty of care to be a good corporate
citizen. Namely, the need to reduce and monitor its carbon emissions (and pay the requisite
taxes) e.g. via the CRC Energy Efficiency Scheme, and to comply with other related
legislation such as the Climate Change Act 2008 and the Social Value Bill 2011.
The NHS Sustainable Development Unit develops organisations, people, tools, policy and research
to help the NHS in England fulfil its potential as a leading sustainable and low carbon organisation.
Appendices:
Triple bottom line healthcare is financially, socially and environmentally sustainable, and therefore
can deliver improved health outcomes at a reduced environmental and economic cost. Ultimately
triple bottom line healthcare allows for more empowered and informed public, patients and
professionals using better technology within stronger families and communities to improve health
outcomes within financial and environmental limits.
Examples of triple bottom line healthcare:
- Integrated cross sector working to empower the public to improve their health. It is
self evident that in a healthy population, with less need for healthcare, delivering healthcare
would be less polluting and less financially costly
- Earlier intervention for well identified, high risk groups. Many studies have shown
improved health outcomes and reduced financial costs associated with well delivered early
intervention programmes (for example the Partnership for Older People Project)x. Reducing
hospital admissions also reduces the environmental impact of hospital care.
- Less wasteful purchasing, procurement, commissioning, use and disposal. For
example reducing pharmaceutical waste and inappropriate prescribing could save money,
improve health outcomes and reduce the healthcare associated greenhouse gas emissions
(associated with the production, delivery storage and disposal of the pharmaceuticals).
- Care closer to home. Encouraging the default place for diagnosis, treatment, care and
rehabilitation to be in the community with in-reach to hospitals (rather than outreach from
hospitals) only when necessary
- More integrated care vertically and with other agencies using shared vision and
shared budgets. More collaboration across agencies that deliver health and care is more
appropriate, more affordable, more sustainable and has higher quality outcomes when there
are real incentives to collaborate – everything from shared leadership, shared culture,
shared budgets and shared outcomes. This happens in more formally integrated systems of
prevention and care both horizontally (with partner agencies) and vertically (ensuring the
outcomes are ultimately better health outcomes, not just more healthcare).
i
The Climate Act 2008. See: http://www.legislation.gov.uk/ukpga/2008/27/contents
HM Government. The UK Government Sustainable Development Strategy, 2005. Available at:
http://archive.defra.gov.uk/sustainable/government/publications/uk-strategy/documents/SecFut_complete.pdf
iii
The Office of the Deputy Prime Minister. Sustainable Communities: Building for the Future, 2003. Available at:
http://www.communities.gov.uk/documents/communities/pdf/146289.pdf
iv The Department for Communities and Local Government, Strong and Prosperous Communities White Paper, 2006.
Available at: http://www.communities.gov.uk/documents/localgovernment/pdf/152456.pdf
v Public Services (Social Value) Act (2012). See: http://www.legislation.gov.uk/ukpga/2012/3/enacted
vi A. Costello, M. Abbas, A. Allen, S. Ball, S. Bell, R. Bellamy, S. Friel, N. Groce, A. Johnson, M. Kett, M. Lee, C. Levy, M.
Maslin, D. McCoy, B. McGuire, H. Montgomery, D. Napier, C. Pagel, J. Patel, J. A. de Oliveira, N. Redclift, H. Rees, D.
Rogger, J. Scott, J. Stephenson, J. Twigg, J. Wolff, and C. Patterson. Managing the health effects of climate change.
Lancet 373 (9676):1693-1733, 2009
vii M Marmot. Marmot Review - Fair Society, Healthy Lives. Strategic Review of Health Inequalities in England Post-2010.
2012. http://www.marmotreview.org
viii The NHS Sustainable Development Unit. Carbon Reduction Strategy, SDU, 2009. Available at:
http://www.sdu.nhs.uk/publications-resources/3/NHS-Carbon-Reduction-Strategy/
ix The NHS Sustainable Development Unit. Health Check 2012. Available at: http://www.sdu.nhs.uk/healthcheck2012
xThe Department of Health. National Evaluation of Partnerships for Older People Projects: final report, 2010. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111240
ii
The NHS Sustainable Development Unit develops organisations, people, tools, policy and research
to help the NHS in England fulfil its potential as a leading sustainable and low carbon organisation.