Policy paper

The government's 2023 mandate to NHS England

Updated 26 March 2024

Applies to England

Presented to Parliament pursuant to Section 13A of the National Health Service Act 2006.

Foreword from the Secretary of State for Health and Social Care

The government has promised to cut NHS waiting lists, meaning that people can get the care they need more quickly. That promise is at the very heart of this year’s mandate, which will help us deliver for patients - and we are delivering. To support delivery, the government has made up to £14.1 billion available for health and social care over the next 2 years, on top of record funding to improve elective, urgent and emergency, and primary care performance.

We need to enable the health service to deliver and recover in 2 key ways: through supporting innovation and the adoption of the right digital health technologies, and through ensuring the workforce is well supported to continue to deliver the excellent care they provide. On the former, we know, for example, that digitally mature trusts operate with approximately 10% improved efficiency compared with their less digitally mature peers. We also know that it helps to reduce length of stay in hospital, which is of critical importance. A key priority is supporting health and care systems to ‘level-up’ their digital maturity and ensure they have a core level of infrastructure, digitisation and skills by March 2025. I have also seen and been inspired by the use of new artificial intelligence (AI) technology to support clinicians to diagnose skin cancer, lung cancer and strokes, in some instances almost halving the time it takes for patients to leave hospital following a stroke and tripling their chances of being able to live independently. I want to challenge the NHS to go even further to adopt safe, ethical and effective AI tools to improve outcomes for patients in other clinical areas, making the most of the opportunities that this revolutionary new technology creates for improving public services. There is also great potential for better care, and better patient experience, through the transformation of the NHS App as the digital front door of the NHS and in May 2023, we announced plans to increase patient choice via the NHS App to help continue reducing hospital waiting times.

This mandate to the NHS looks different to previous years. The health system has asked for fewer targets, and this is what I have set out. It is a shorter document than the previous mandate - a deliberate choice which both emphasises the government’s commitment to deliver on the key concerns of the public and recognises the importance of allowing integrated care systems the freedom to deliver effectively. The NHS provides a comprehensive health service, and by focusing on these priorities, we can help to make sure everyone gets the treatment they need.

Steve Barclay
Secretary of State for Health and Social Care

Introduction

The new structures and responsibilities across the NHS, introduced by the Health and Care Act 2022, mean NHS England has taken on new responsibilities to support integrated care boards (ICBs) and NHS providers and hold them to account for the delivery of services. The transfer of functions from NHS Improvement, Health Education England and NHS Digital to NHS England has brought together responsibility for health services with central digital and data delivery and health care education and training. NHS England is undergoing a period of transformation to reflect these changes, with a commitment to be at least 30 and up to 40 per cent smaller by April 2024.

There are significant challenges for the NHS ahead: cutting waiting lists, reducing A&E and ambulance waiting times, and improving patient access to primary care. We are focused on delivering these and their enablers, in the form of a well-trained and well supported workforce, adopting the latest innovation and technologies, and investing in the vital digital infrastructure needed to deliver health services.

The NHS’s staff are its greatest asset, and they went above and beyond to provide patients with the best possible care throughout the pandemic. Unavoidably, the impact of COVID-19 led to pressures building up in the system - meaning that many patients are now waiting longer for tests and treatment than they were before the pandemic began. It has reduced the number of people who are able to get timely access to other important services, increased demand for mental health services, and has impacted on access to services for people with learning disabilities and autistic people, as well as those living with dementia. The inability for people to access care also has wider impacts including on the economy and employment market.

In February 2022, NHS England published its delivery plan for tackling the COVID-19 backlog of elective care. This set out a clear vision for how the NHS will recover and expand elective care and cancer services in the next 3 years in a way that addresses disparities in provision. Since its publication, the NHS has made great progress in recovering elective care despite ongoing high levels of COVID-19 throughout 2022, succeeded in meeting the ambition to virtually eliminate waits of 2 years or more for elective procedures in July 2022, and significantly reduced the number of patients waiting 78 weeks or more by April 2023.

In January 2023, the elective plan was followed by the delivery plan for recovering urgent and emergency care services, setting out the commitment to reduce A&E waiting times and ambulance response times. And in May, the delivery plan for recovering access to primary care was published, committing to empowering patients, expanding pharmacy services, tackling the 8am rush and making it easier and quicker for patients to get the help they need from primary care. The government is supporting the NHS with record funding, including investing an additional £3.3 billion in each of 2023 to 2024 and 2024 to 2025 to enable rapid action to improve emergency, elective and primary care performance towards pre-pandemic levels - bringing the NHS resource budget to £165.9 billion in 2024 to 2025.

Taking account of the views of patients and the public

As required by the NHS Act 2006, the government has consulted Healthwatch England on the objectives set in this mandate. This consultation helps to ensure that the mandate is informed by the needs, experiences and concerns of people who use health and social care services, based on insights gathered from national projects and local Healthwatch networks throughout England.

NHS England works with people and communities and engages them on the development of national policies and strategies. ICBs and NHS England need to engage with patients, carers and the public as they discharge their functions, both in relation to clinical and wider commissioning decisions. Furthermore, they should continue to consult as required with staff and the public on service changes or reconfigurations.

Holding NHS England to account for progress in taking forward the mandate

This mandate is intended to apply from 15 June 2023 until a new mandate is published. NHS England has a duty to seek to achieve the objectives in the mandate. The Secretary of State keeps progress against the mandate under review, setting out his views in an annual assessment which is laid in Parliament and published. The government will agree with NHS England how it should report on overall progress against the mandate to support the Secretary of State in keeping this under review. This will include reporting at agreed intervals on other delivery expectations listed beneath the objectives. Reporting for the purposes of reviewing progress against the mandate is in addition to any reports and information that the government may reasonably require to support wider governance for health and care, accountability to Parliament, and effective policy development.

In seeking to meet the objectives set out below, NHS England will need to comply with its delegated responsibilities as set out in Managing public money and its framework document with the department, which will be published on GOV.UK and sets out how it and the government will work together. The framework document will be replaced this year. NHS England’s statutory obligations under the NHS Act 2006 and other legislation also apply.

Mandate objectives

Priority 1: cut NHS waiting lists and recover performance

NHS England will need to lead the NHS in recovering services for patients. Delivery should include:

• continuing to deliver the NHS’ delivery plan for tackling the COVID-19 backlog of elective care. In particular: delivering more planned hospital activity to tackle the elective backlog and build on the success of the delivery of the recovery plan to date. This will include working towards the future ambitions on long waits set out in the plan over the coming years, and will be supported by a focus on increasing outpatient productivity and transforming outpatient pathways to enable the 80% of the patients who are waiting for non-admitted care to be seen more quickly. By March 2025, 95% of patients needing a diagnostic test should receive it within 6 weeks. This will be aided by the continued roll out of community diagnostic centres to increase diagnostic capacity

• improving cancer outcomes, including:

  • improving 1 year and 5 year survival for all cancers, and the NHS Long Term Plan ambition that 55,000 more people diagnosed in 2028 will survive for 5 years or more
  • increasing early diagnosis and making progress against the NHS Long Term Plan ambition to diagnose 75% of cancers at stages 1 and 2 by 2028
  • continuing work to expand diagnostic capacity including through community diagnostic centres, and give priority to people with suspected cancer, so that at least 75% of people referred urgently receive a diagnosis within 28 days
  • ensuring cancer patients can access high quality personalised care that meets their needs during their treatment and follow up, and continuing to track the quality of life of people who are living with the disease

As required by Section 13A(2A) of the NHS Act 2006, these outcome objectives are to be treated by NHS England as having priority over any other objectives set in this mandate relating specifically to cancer. These objectives should be achieved by working towards the recovery of cancer services and continuing to maintain and improve performance against the 62 and 31 day standards.

• building on the existing patient rights to choice, and further to the work of the Elective Recovery Taskforce, information and processes will be strengthened to ensure that patients are able to access all providers of NHS healthcare as part of those options, where providers meet NHS costs and standards. Patients should be given more information, so they can easily compare providers based on waiting times, distance and quality. Patients should be offered a minimum of 5 providers to choose from, where possible. For those already on the waiting list, from October 2023, NHS England should ensure systems support our longest waiting patients to request to move to a different provider to receive earlier treatment where it is clinically appropriate and should they choose to move

• improving A&E and ambulance performance by delivering the urgent and emergency care recovery plan, including 76% of patients being admitted, transferred or discharged within 4 hours by March 2024 and improved ambulance response times for Category 2 incidents to 30 minutes on average over 2023 to 2024, with further improvement against both of these measures towards pre-pandemic levels in 2024 to 2025. This will also include increasing capacity, with 5,000 more beds as part of the permanent bed base for next winter and 800 new ambulances on the road, including specialist mental health ambulances; and expanding services in the community, with greater use of urgent community response to reduce avoidable admissions and over 10,000 virtual ward beds in place by this autumn, as well as ensuring urgent mental health support through 111 is universally accessible. This will be aided by increasing the size and flexibility of the workforce. The publication of data on 12 hour delays from time of arrival in A&E will support the prioritisation of long waits as part of delivery. Hospital flow, as well as improved outcomes for patients, will also be aided by reducing delayed discharges. The NHS should continue to improve hospital discharge processes. It should also work in an integrated way with local government to improve joint discharge processes for patients with more complex discharge needs, including making sure every system has an effective care transfer hub. Working through the Better Care Fund, the NHS together with local authorities should scale up capacity for intermediate care, supported by additional discharge funding of £600 million in 2023 to 2024 and £1 billion in 2024 to 2025, of which half will be issued via the NHS and half through local authorities

• improving GP access by delivering the primary care access recovery plan. In particular, ensuring that patients who need an appointment get one within 2 weeks, and those with urgent needs are seen on the same day or next. Modern General Practice Access should be implemented by moving practices to digital telephony, procuring new digital tools and providing care navigation training and transformation support to all practices that require it. We would expect all practices to have been offered procurement support and asked to sign up for digital telephony by July 2023, with 1,000 transitioned before the end of 2023, and all practices to have new digital tools made available to them by the end of 2023. NHS England should develop and deliver the service specifications and patient group directions for the common condition service in community pharmacy and the necessary underpinning IT improvements. It should also support the Department of Health and Social Care (DHSC) in negotiating funding arrangements with the sector and drive take up and delivery of the common condition service and expansion of the blood pressure and contraception services by community pharmacy. Work is also underway on recovering services in dentistry, particularly in areas of need, and reform of the system. This work aims to increase service provision, increase the attractiveness of NHS work and also build capacity across the dental workforce

Priority 2: support the workforce through training, retention and modernising the way staff work

The health and care workforces are central to the provision of high quality patient care. NHS England will continue to build on the work of Health Education England to deliver for the health workforce, including on education and training. Working with DHSC, ICBs and other partners, NHS England should lead implementation of the actions in the NHS Long Term Workforce Plan, which will set out actions to put the NHS workforce on a sustainable footing and ensure that it has the workforce to meet the changing needs of patients over the next 15 years.

Priority 3: deliver recovery through the use of data and technology

It is also crucial that the NHS makes progress in adopting the latest innovation and technology to digitally transform the NHS and help to ensure its long-term sustainability. The system must utilise the power of technology and the skills, leadership and culture that underpins it, to drive a new era of digital transformation. This will allow the health and care system to thrive long into the future, delivering vast benefits for patients - such as using AI to give better treatment, the latest screening techniques to detect illness sooner and equipment that allows more people to be treated at home. We know that there is significant variation in performance on electives, urgent and emergency care, and primary care. NHS England should continue to prioritise tackling variation, supporting digital transformation in areas where there is greatest challenge. To support digital transformation, it is vital that staff have the skills and resources to implement and utilise new digital tools effectively to deliver high quality services for patients. Delivery should include:

• ensuring innovative, safe and effective delivery of live services, following transfer of functions from NHS Digital. 90% of NHS trusts and foundation trusts should have electronic health records by December 2023, and 95% by March 2025, and 80% of Care Quality Commission (CQC) registered adult social care providers should have digital social care records in place by March 2024. By March 2024, all trusts should adopt barcode scanning of high risk medical devices and submission to the national, mandatory Medical Device Outcome Registry (either directly or via a supporting electronic health record (EHR) or inventory management system that can support registry data submission). The registry will be used to improve patient safety and outcomes in procedures that use high risk medical devices. Implementing the national cyber strategy for health and social care and deliver the cyber improvement programme
• developing and delivering the federated data platform and maximising trust and ICB take up of the platforms and national use case tools. Optimising the use of health and social care data to deliver better services and outcomes for patients, maintaining the highest standards of data protection and ensuring cyber resilience to maintain and build public trust in our protection of people’s data
• transforming the NHS App as the digital front door of the NHS, including increasing its use for booking and managing appointments, ordering repeat prescriptions, accessing patient records and access digital health therapeutics. The aim is for 75% of all adults in England to be registered on the NHS App by March 2024. Increasing the uptake of AI tools to support the NHS workforce in applying best practice

Continue work to deliver the NHS Long Term Plan to transform services and improve outcomes

Alongside the above objectives, we expect NHS England to continue their wider work to deliver the key NHS Long Term Plan ambitions to transform the NHS for the future, in line with NHS England’s operational planning guidance and its wider duty to promote a comprehensive health service. As part of this, they should continue to work with the NHS and other partners on improving patient safety, quality of care and health outcomes, including through specific NHS programmes. This includes:

• the 3-year delivery plan for maternity and neonatal services to deliver safer, more personalised, and more equitable care, including mental health care, for women, babies and families
• delivering the children and young people’s transformation programme
• improving access to mental health support for children, young people and adults, increasing the number of adults and older adults accessing talking therapies, and supporting systems to improve the quality of mental health care
• continuing to shift towards community-based health care, including enabling more people to benefit from proactive and personalised care, strengthen timely access to community services, and streamline direct access and set up local pathways for direct referral
• improving access to and quality of services for people with a learning disability and autistic people
• taking forward the updated Accessible Information Standard when published
• preventing ill health through the delivery of NHS services, and supporting integrated care systems (ICSs) to tackle inequalities in access to healthcare at a local level; to fulfil their legal duties on health inequalities, including the delivery of 5 strategic priorities for system action on health inequalities; and to embed the Core20PLUS5 approach for adults and children and young people
• working with government to support delivery of the Long Term Plan through developing and delivering a major conditions strategy to tackle the main causes of ill health and ensure care is patient-focused

Funding

In exercise of the powers conferred by sections 223D, 223E and 223O of the National Health Service Act 2006, the Secretary of State has issued financial directions to NHS England setting revenue and capital resource limits for 2023 to 2024. The government expects that NHS England will ensure that overall financial balance is delivered for the NHS each and every year.

It is essential that public money for the NHS continues to be spent with care, which includes ensuring that financial risk to the overall health and care system is robustly managed, and that any financial interventions, especially regarding the delivery of key objectives, are targeted, timely, and measurable. To achieve this, NHS England must continue to manage risks and pressures within their resource limits and continue to demonstrate effective financial and risk management planning, working with government to adjust plans if necessary. We expect NHS England to continue to share data and provide monthly updates on both capital and revenue spending, including data on the outcomes that are delivered, capital deployment, and detail on a full range of NHS budgets (including any central funding and contingencies or risks), to support oversight activities and assurance that funding is being utilised effectively.

Financial tests

NHS England should continue to work with DHSC and HM Treasury, using the appropriate financial metrics and controls, to manage, monitor and track the delivery of expected outcomes. The overall aims of NHS England’s Long Term Plan and 5 financial tests remain the right ones and important to government and the mandate objectives reflect these aims while supporting current priorities:

• the NHS will deliver overall revenue and capital financial balance every year
• NHS England will ensure that all ICBs exercise their functions with a view to delivering financial balance. Where deficits occur an agreed recovery plan will be in place to return to financial balance over time
• the NHS should make cash releasing efficiency savings of at least 2.2% in 2023 to 2024. Productivity should continue to be improved back towards pre-COVID-19 levels consistent with commitments to recover patient services, including the elective recovery plan. Ongoing productivity improvement is also an integral part of long-term workforce planning

Annex A: education outcomes framework

The education outcomes framework is published pursuant to Section 100(2) of the Care Act 2014. It sets out the educational outcomes that NHS England must seek to achieve in meeting its workforce, education and training responsibilities and the outcomes have been developed with partners across the health and education landscape. The educational outcomes support improvements in education and training that have a real impact on the quality of care delivered to patients and service users. 

Excellent education

Education and training are commissioned and provided to the highest standards, ensuring learners have an excellent experience and that all elements of education and training are delivered in a safe environment for patients, staff and learners.

Competent and capable staff

There are sufficient health staff educated and trained, aligned to service and changing care needs, to ensure that people:

• are cared for by staff who are reflective of the changing demography of the population they serve
• are properly inducted, trained and qualified
• have the required knowledge and skills to do the jobs to meet service needs, while working effectively in a team

Flexible workforce, receptive to research and innovation

The workforce is educated to be responsive to changing service models and to innovation and new technologies, with knowledge about best practice, research and innovation, that promotes adoption and dissemination of better quality service delivery to reduce variability and poor practice.

Widening participation

Sourcing talent and providing leadership that flourishes, free from discrimination and with fair opportunities to access careers, progress and fulfil potential, recognising individual as well as group differences, treating people as individuals, placing positive value on diversity in the workforce and promoting and encouraging role models. This will include opportunities to progress across the 5 leadership framework domains.

Volunteering

Following the production of the Health Education England volunteering strategy in 2021, deliver proposed products to support the recruitment and enhanced experience of volunteers across the NHS. Additionally, encourage and support NHS staff themselves to take advantage of volunteering opportunities within health and social care, and ensure senior clinical and managerial leadership value the vital contribution volunteers make to the service.

NHS values and behaviours

Healthcare staff have the necessary compassion, values and behaviours (including supporting colleagues) to provide person centred care and enhance the quality of the patient experience through education, training and regular continuing personal and professional development, that instils respect for patients.