Are they restricting Public Involvement in the STP* in your area?

The local STPs – (*now called ‘Local Plans to Improve Health & Care’) – are NOT letting local people know what’s being planned, or to say what they think about it. The STP people should be involving ALL of us in ‘shaping’ our local services. IT’S THE LAW!



What are we talking about?

  • England has been split into 44 areas each had to write an STP, Sustainability & Transformation Plan, to reorganise local NHS & care services
  • The STP has to deliver NHS & care services more cheaply (to save money) and also to make them more effective and safer and they have to do all this very quickly
  • (The STPs have to SAVE money as the Treasury refuses to give the NHS more money to meet the growing need for its services – so we are to have CHEAPER NHS services)
  • The local organisations responsible for planning local services are Clinical Commissioning Groups (CCGs) there are 209 of these in England
  • BUT CCGs have had to come together, in the 44 new areas, to plan these changes

Please be patient – it is very complicated

  • Each CCG has a LEGAL DUTY to involve the public in their area in any plans to change how services are made available to them
  • The Act (Health & Social Care Act 2012) says they ‘must make arrangements to secure that individuals to whom the services are being or may be provided are involved (a) in the planning of the commissioning arrangements by the group (b) in the development and consideration of proposals by the group for change in the  commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them,
  • By ‘commissioning arrangements’ the Act means that ‘CCGs must arrange for the provision of the services and facilities …. as they consider necessary to meet the reasonable requirements of the persons for whom they have responsibility‘ (Explanatory Notes of the Act)

So when we say it is THE LAW – we mean that the law requires that:

  • All CCGs  MUST involve the public in their decisions about OUR local NHS services
  • That means each CCG – working in each STP – MUST involve the public in their decisions about the ‘development and consideration‘ of the STP ‘proposals
  • And that they MUST be involving ‘individuals to whom the services are being or may be provided’  
  • That does NOT mean a chosen few who are not accountable to the rest of us

The Patient Activists in Barnsley Save Our NHS (BSONHS) have shared with us how involved the Barnsley public have been, so far, in the South Yorkshire & Bassetlaw (SY&B) STP:

BSONHS asked Barnsley CCG, last summer, how the South Yorkshire & Bassetlaw (SY&B) STP was going to involve the public – according to the CCG’s legal duty to involve the public in decisions about changing services.

We were told that the local Healthwatch would represent the public in developing the plans.

In November 2016 we were told there would be a big conversation with staff and the public – to be done by partners, by voluntary organisations and by Healthwatch.  And that it would include a number of face to face discussions with people.

In February 2017 BSONHS were contacted by the SY&BSTP to say that ‘conversations’ with the public, run by the local Healthwatch, would start on 13th February and end at the end of March.  We were told any feedback, from the public, would go to the Collaborative Partnership Board (STP) to be discussed before taking the (STP) plans any further.

They also sent us a link to a simple online survey that had an introduction giving some basic STP information.

A visit to a BSONHS meeting was offered, to discuss the STP and ‘capture’ our views.  We asked if they could visit an open meeting, with our wider membership, but were told no, it would be a focus group, that would be repeated if many members wished to attend.

So BSONHS decided to send an email to the STP officer saying we would not want a focus group but would welcome a visit to our meeting, for a discussion.

In the email we reminded them of national guidance and the legal duty to involve the public in plans to make service changes.

The email is lengthy – but includes links to, and quotes from, the LAW and the many NHS documents that state clearly that the public MUST be involved in STPs ‘at the early stages’

  • CCGs and Trusts, and NHS England are ignoring their duty to involve us
  • Challenging bad practice needs to give reasons why it is bad practice (evidence)

We share two extracts from this email.  

Both extracts include information about public involvement rights that may be useful to others: 

First Extract:

“BSONHS members discussed the offer of ‘conversations’ with the public at our meeting on Monday, 27th February, and have agreed the following response:

BSONHS members are not aware of any arrangements for such ‘conversations’ that have been made in Barnsley to involve the general public and are concerned that it is now two weeks into the seven week period.


  • We are aware that individual VCS (Voulntary and Community Sector) organisations may have put arrangements in place for the people who use the services they provide – but not for the general public
  • We are also aware that Healthwatch Barnsley, as a local healthwatch service, is required to act as a social enterprise, and therefore to abide by Regulation 36 (1) (b) (that is included in the Statutory Instrument 2012 No 3094) which states they are unable to act in any way that can be interpreted as ‘the promotion of, or opposition (including the promotion of changes) to, the policy which any governmental or public authority proposes to adopt in relation to any matter;’
  • We feel this requirement will limit their (HwBarnsley’s) ability to formally report the genuine concerns of the public about the STP and the significant restructure of services it proposes, or that our members may have about the decision by HM Treasury not to increase the funds to meet the growing need for both the NHS and Social Care services, in effect cutting the resources available
  • We also have concerns that Healthwatch Barnsley is not accountable to the people of Barnsley, nor representing more than about 2% of them – (we expand on this below*)
  • We note that you offer to run numerous focus groups for the people in Barnsley we are in touch with, but we do not feel a focus group enables meaningful public involvement
  • We feel that focus groups are recognised tools for market research, academic research and for pollsters, but not as a participation or involvement technique
  • We are very aware of the general lack of understanding lately, within the NHS, of the recognised skills and techniques for enabling and faciltating meaningful and inclusive public involvement in decisions about services in the NHS
  • We are also aware that all guidance documentation about New Models of Care and STPs from NHS England and NHS Improvement require meaningful involvement of the public, and that recent publications by the Kings Fund (Delivering STPs proposals to plans – Ps 31 & 32) and the House of Commons Public Accounts Committee ( Financial Sustainability of the NHS – Recommendation 4.) both say this is not happening
  • We remember discussing with you, in September 2016, the newly published NHS England guidance about public involvement in the STPs called  Engaging Local People, which clearly states on P8 that: ‘All footprints should be engaging with local people via Healthwatch and other patient and public groups, to discuss and shape their proposals’ – it doesn’t say to just work with Healthwatch who have been the only ones involved so far, by the SY&B STP Collaborative Partnership Board, to ‘represent’ the public – but without involving or informing the public
  • BSONHS, is a ‘public group’, and is in touch with other public groups that exist across the STP area, and further afield; and we have also been represented at a number of national events about the STPs and the New Models of Care and we keep ourselves informed about the central NHS bodies’ current thinking
  • We note that the Engaging Local People document repeatedly refers to terms such as ‘ongoing dialogue‘ and ‘ongoing involvement‘  saying that ‘ jargon free and accessible language that is appropriate to the audience will be essential to ensuring that people can participate meaningfully’  and that ‘ Effective communication and involvement throughout the process will help to build ownership and support for proposals to transform health and care and will also help identify potential areas of concern’
  • We are aware that the initial engagement (in February and June 2016) was NOT jargon free; that the general public have been excluded from the process since; that the people of Barnsley feel no ‘ownership’ in the SY&B STP and that they feel that these changes are being imposed on them, with none of their concerns and fears being heard or taken account of
  • We are also conscious that the Engaging Local People guidance warns that ‘Service change must be evidence-based, and this evidence should be publicly available during the …… decision-making stages’; that ‘public bodies with responsibility for STPs have a variety of legal duties including to involve the public in the exercise of their statutory functions’  and not ‘doing so effectively is likely to cause legal challenge and lengthy delay’; and also that  ‘failure to appropriately involve patients and the public in plans may lead to judicial review and criticism’ , and ‘could lead to proposals that do not adequately meet the needs of the local community’
  • We are very aware that the Collaborative Partnership Board is not a legally constituted organisation with powers to make decisions about service change, but that each constituent CCG carries the legal duty for public involvement, under the Health & Social Care Act 2012 Section 26 14Z2 Public involvement and consultation by clinical commissioning groups, which states:

(2)  The clinical commissioning group must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways)— 

(a) in the planning of the commissioning arrangements by the group,

 (b) in the development and consideration of proposals by the group for changes in the  commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them,


(c) in decisions of the group affecting the operation of the commissioning arrangements

where the implementation of the decisions would (if made) have such an impact. 


(6) The reference in subsection (2)(b) to the delivery of services is a reference to their delivery at the point when they are received by users.”


Second Extract:

“In a seven week period there is only 4 hours of public information/conversation offered by Healthwatch Barnsley, which is the statutory service with the sole purpose to gather the views of patients and the public around the health and social care services available to them, but in Barnsley they reach less than 2% of the local population.

A local healthwatch service is also required to be accountable to the population it serves – this is not the case in Barnsley as they have repeatedly withheld any information about their involvement in the SY&B STP development, and have told us that what they say ‘on our behalf’ is confidential.

We note that:

Healthwatch England produced a summary of the five key things that communities should expect in getting involved in decisions that affect them, particularly about service changes –  These are not happening in Barnsley.

The Local Government Association describes the purpose of healthwatch as: ‘    The aim of local Healthwatch is to give citizens and communities a stronger voice to influence and challenge how health and social care services are provided within their locality.’  (Delivering Effective local Healthwatch – Key Success Factors 2013 P8 – Local Healthwatch purpose – engagement and relationships) This is not happening in Barnsley.

NHS England says that ‘ It is important that there is an ‘intelligent customer’ in the STP communications and engagement team who has skills and experience in public involvement and the associated legal duties’ on P 13  in their Engaging Local People document refered to above.

We do not feel that the apparent delegation of the required public involvement function to Healthwatch Barnsley, and other local healthwatches, ensures that the STP Collaborative Partnership Board is giving due regard to the guidance provided, or the expectations of them and of their constituent statutory bodies, regarding patient and public involvement.

We are aware that this email is lengthy and contains a substantial amount of material but this signifies the seriousness of our concerns about the level of public involvement that has been offered so far in the development of the SY&B STP, and that is proposed to be offered in its future development, its governance, any commissioning arrangements and, in particular, the accountability to the public it is intended to serve.

We would therefore like to invite you, and/or other representatives of the Collaborative Partnership Board, to come to our next BSONHS open meeting, that will be open to our wider membership, in the week commencing 27th March 2017.  We usually meet on a Monday in the evening but will confirm the time and venue to allow some flexibility, as we really do hope it is possible for yourself, or team members to join us.

  • We will be chairing the meeting, but you are welcome to give a brief, Plain English explanation of the STP’s purpose, content and decision making structures
  • We will then invite you to hear the concerns of our membership and to answer their questions.
  • We will ensure that the dialogue is respectful and around the issues, and not the people or personalities involved in the Collaborative Partnership”


BSONHS has now received a reply – which we share below.

From the SY&B STP Associate Director of Engagement and Communication to BSONHS:

Many thanks for your email and your comments on the current public and staff engagement exercise underway to gather views on the ambition and ideas in the South Yorkshire and Bassetlaw’s Sustainability and Transformation Plan.

We are in the very early stages of looking at how we can achieve our ambitions of improving our health and care services and are beginning to explore what is possible. At this stage, we are taking account of public and staff views on the STP’s direction of travel and see this very much as the start of ongoing involvement in discussions to shape the future of services. There are currently no plans to change any services, other than those that existed pre-STP – which are hyper acute stroke services and children’s surgery and anaesthesia services and on which we recently consulted the public.

Our methodology to take account of views looks at gathering feedback from both quantitative and qualitative approaches. This includes:

  • Commissioning Healthwatch and the voluntary sector across SYB to engage with groups and communities, with a particular emphasis on the seldom heard to capture and report their feedback on the plans. They are doing this through a variety of methods, of which focus groups are one. Their role is to put the plans forward as they stand and gather feedback, it is not to promote the plan. Their strong links into communities and with patient groups will help to ensure we reach audiences with an interest in the Plan and also those who are less likely to be heard
  • Media release distributed at the launch – we will also send a ‘two weeks to go’ media release  – signposting people to how they can get involved
  • Social media activity via CWT account, amounting to more than 1,700 reached via Twitter and almost 600 people have so far clicked onto the survey via social media. STP partners are also carrying out social media activity which we will include in the final report on the exercise
  • E-bulletin to all those who signed up to the Commissioners Working Together distribution list
  • Between 13-20 March, all bus tickets across all journeys in South Yorkshire and Bassetlaw will alert people to the opportunity to have their say
  • STP partners are also raising awareness of the survey and holding discussions in their organisations to gather qualitative feedback

At the end of the exercise, we will analyse the survey responses, along with themes that develop from conversations, and report these back to the Collaborative Partnership Board. The Board is very keen to hear the findings and will discuss them before any next steps are agreed.

I note your comments about Healthwatch. The team at Healthwatch Barnsley is aware that the conversations need to encompass as many view points as is possible and are visiting groups individually to gather feedback, as well as holding two focus groups on March 21 in partnership with Voluntary Action Barnsley. To ensure accessibility, one is being held in the morning and in the evening and the team is also providing access support such as care cover where it is requested.  In addition to the two focus groups arranged, they are also facilitating discussion sessions for the following groups:

  • Carers workshop
  • Buckingham House care home, Penistone
  • Springvale Community Gardens, Penistone
  • Barnsley Independent Alzheimer’s and Dementia Support
  • Supporting safe and independent living in Barnsley
  • Barnsley MIND – LBGT group
  • Wednesday Voice – learning disabilities group
  • Parkinson’s District Branch Meeting
  • Goldthorpe Development Group
  • Wombwell cricket club
  • ROMERO coffee morning – the group provides many forms of support for local people marginalized by social inequality
  • Salvation Army, Goldthorpe
  • Conversation Club

They are also attending a Core tenant’s breakfast meeting where the following organisations are represented:

  • Plus Me
  • TADS
  • Creative Recovery
  • Barnsley Sexual Abuse & Rape Crisis Services
  • 360 Engagement
  • The Well
  • Care2Care
  • Academics

I understand Healthwatch has had some technical issues with their website, which have now been resolved and the information is available.  See The team has also been using social media to raise awareness of the opportunities for Barnsley people to have their say, as well as adverts in the Barnsley Chronicle.

Thank you too for your offer to attend the next Barnsley Save Our NHS meeting, which will be held in the week of 27 March. Unfortunately, I am on leave for much of this week and have commitments on the evening I am not. Can I therefore suggest that myself and the STP Programme Director arrange to meet a delegation of Barnsley Save Our NHS the week after. This would allow us to hear the group’s concerns and address questions. I would also encourage your members to complete the online survey (hard copies and alternative formats of the survey are also available) so that we can ensure their views are captured. Dates and times we could make are:” – (possible dates were given)


BSONHS are arranging to meet with them in April –

(if it is confirmed that issues we raise in the ‘conversation’ issues will be included in the feedback to the Board.)  

We have two main concerns about how this ‘involvement’ is happening:  

Firstly that having a few targeted ‘conversations’ excludes ‘individuals’ within the wider general public, and prevents a collective, and informed, public voice.  

Secondly that the ‘conversations’, and the survey, ONLY focus on the information provided, which is ONLY telling people that the STP aims to improve services.

  • There is NO public information about changes to where, when or how services will be available to patients and the public in the future.  
  • There is NOTHING explaining to the public about how the ‘commissioning arrangements’ are changing, including the governance and accountability of local commissioning and how the decisions about services will NOW be made.

By not telling the public ALL the information means that any public involvement is not fully informed nor is it about ‘commissioning arrangements’ – as the LAW  requires.


National NHS Public Voice (N-NHS-PV) is keen to hear how other areas are experiencing ‘public involvement’ in their local STP – general comments welcome too.

Please share with us either:

  • VIA our contact page
  • OR as a comment on this post (we don’t put these online straight away)
  • OR by email to

We will ONLY post your information online if you ASK us to – however you send it to us.


STPs – What are they all about? Why are we being kept in the dark?

The public haven’t been given any information about the STPs – the new area plans for changing NHS services. We have a legal right to be involved in, and able to influence, any major plans for the future of Our NHS services. Why are we kept in the dark?


National NHS Public Voice campaign is challenging the decision by NHS England and other NHS organisations to keep the wider public out of discussions and decisions about the future of Our NHS.

There are NO leaflets to explain what the Sustainable & Transformation Plans are all about.

There IS a page on the NHS England website that tells us a bit about why they are happening.  Here’s what they say:

  • “We are now able to treat people with new drugs and clinical care that wasn’t available in the past.”
  • “As life expectancy increases, so do the ailments of old age and there are now more people with chronic conditions like heart failure and arthritis.”
  • “There are also big opportunities to improve care by making common-sense changes to how the NHS works.”
  • “Improvements that matter, like making it easier to see a GP, speeding up cancer diagnosis and offering help faster to people with mental ill health.”
  • “With services feeling the strain, collaboration between organisations will give nurses, doctors and care staff the best chance of success.”

BUT they don’t mention that the money is the problem.  It’s all because the Treasury has refused to increase the money needed by the NHS to help meet the increasing need and the new technology for diagnosis and treatments.

Nor do they mention that the Plans require all services to find ‘efficiency savings’ out of their smaller budgets.

They also leave out the fact that the average annual increase of NHS funding of 4% over 60 years since the 1950s was reduced after 2010 to an average annual increase of less than 1%.

The crisis in the NHS has been a political choice.

SO in the absence of clear information for the public from NHS sources about the STPs we, the National NHS Public Voice campaign, N-NHS-PV, have written a basic STP information sheet.  stps-what-are-they-all-about


And here it is (with some links at the end):


Sustainability & Transformation Plans (STPs) – What Are They All About?

STPs are the NHS establishment’s answer to the Treasury’s refusal to increase the money for the health, and social care, services we need – with more people, and more needing care, in 2017 than ever before.  But it’s all being done on the quiet, in a rush, with no details and no democratic accountability – no legal back up so that we know who is responsible if things go wrong!


Why are STPs happening?

The last two Governments since 2010 reduced/cut the annual increase in NHS funding to less than 1%, after inflation, from an average of 4% over the lifetime of the NHS[1].

  • At the same time  training places for doctors & nurses have been reduced
  • And Bursaries for nurses have been turned into loans
  • All staff have had changes to their working conditions, including added workloads

BUT managers responsible for NHS services have to cope with:

  • Meeting the same quality and safety targets
  • With more people to treat & more treatments available to them
  • BUT with not enough money & not enough staff

They have asked for more money so services can still run – but the Treasury has refused


What have NHS leaders done to fix this?

In July 2013 Sir David Nicholson, the NHS boss, made a ‘Call for Action’ asking the public, professionals and politicians to say how could the NHS change to do the NHS cheaper

  • As the NHS had ‘increasing demand’ with ‘new technology’ but ‘flat funding’ (no more £s)
  • & if it doesn’t change, it’ll get a £30 billion ‘funding gap’ from 2013/14 to 2020/21 (7 years)

In October 2014, the new boss, Simon Stevens published his Five Year Forward View[2]

  • He said the same – but the £30 billion ‘funding gap’ was from 2015/16 to 2020/21 (5 years)
  • He suggested new ways of delivering services called ‘New Models of Care’

In January 2015 groups of NHS service providers were selected to start trying out some New Models of Care[3] – e.g. emergency services, community services, etc.

In December 2015 a new Planning Guidance[4] introduced the idea of the STPs

In 2016 local NHS planners, CCGs[5], had to work together in 44 areas across England to plan services for the next 5 years (till 2021) across bigger populations, extra work

BUT all NHS services have to make large ‘efficiency savings’ to help fill the ‘funding gap’


What is an STP?  (Sustainability & Transformation Plan)

  • It’s a PLAN to TRANSFORM health & care to be SUSTAINABLE for the next 5 years
  • England has been split into 44 areas, of up to 3 million people, for NHS & care decisions.
  • Each area has to SAVE money by making ‘efficiency savings’ with target sums to save
  • Local NHS planners, CCGs, joined up to PLAN health & care for a bigger area = the STP
  • A ‘Local Place Based Plan’ describes how services will look in each CCG’s local borough

BUT the joined up CCGs ‘committees’ have NO legal status to decide all our services & are NOT accountable, NO-ONE knows yet who WILL BE accountable if things go wrong!


What services will be in this STP?

  • Each STP covers NHS services, Social Care and Public Health
  • Each STP includes services provided by many organisations in the area it covers
  • NHS – GPs, Hospitals, Community nurses, Mental Health, Dentists, Opticians, Chemists..
  • Others – Councils ( Social Care & Public Health), Charities, AND the Private sector

Such as a South Yorkshire & Bassetlaw STP (of 5 CCGS working across 5 boroughs) it has a target sum to find, £571million savings before 2021


What will they mean for hospital services?

  • There won’t be enough money to keep things as they are – so things will have to change
  • To meet quality & safety targets services are being centralised – local services will close
  • This will put pressure on the centralised services – more people to treat – who are more ill
  • This will mean their mortality rates are likely to go up = more people will die
  • Nationally the plan is to reduce staffing and reduce hospital beds – to save money
  • So more hospitals will have to close to new patients – they will become full more quickly
  • This will ‘clog’ the system as the space & staffing will be overstretched – more often
  • Many medical staff are retiring early or leaving because their workload is impossible


What will they mean for community services?

  • There isn’t enough money to keep things as they are – so they won’t set up more services
  • As hospitals take fewer patients there will be more people needing community services
  • Services will have to see more people & still meet quality & safety targets – no extra cash
  • Rather than increase waiting lists, it’s likely they’ll change who can use the services
  • There is no more money for more services so existing services will be overstretched
  • Many smaller services that help keep people well may not continue to be funded
  • Many smaller services that help people when they are unwell may not be funded
  • Mental health service support will only offer time limited services, open access will go
  • People may not have the mental services they trust available when they are reaching crisis
  • Many medical staff are retiring early or leaving because their workload is impossible


What will they mean for patients & the public?

  • We will lose many of our local services that we trust, we rely on and we know the staff
  • We will have to travel further for treatment, even in an emergency – with greater risks
  • Our families will have to travel further to visit us or be with us in an emergency
  • This is at a time when public transport is less subsidised, less available & more expensive
  • Centralised hospital services will be very busy, we’ll wait longer and we may not get a bed
  • Evidence finds that centralised emergency services admit more patients who are more ill
  • Evidence finds a need for more beds in trauma centres – but bed numbers are being cut
  • Evidence finds more inpatients die in centralised hospitals near A&Es that have closed



NOTES – to explain some of the information 

[1] See the Kings Fund’s article on historical increases & analysis of figures on NHS budgets for last two decades

[2] See the Five Year Forward View which includes information about the New Models of Care

[3] See the New Care Models pages of the NHS England website

[4] See the Planning Guidance that introduced the STPs (Sustainability & Transformation Plans)

[5] CCGs=Clinical Commissioning Groups – they receive NHS funds to pay for services needed in their Local Authority area



NHS England’s broken promise & forgotten legal duty – to involve us, the public, in decisions about NHS services.

N-NHS-PV (National NHS Public Voice) has seen how NHS England has broken its promise to involve the public in all decisions about services – and is now treating their legal duty to do so as ‘optional’. We’ve also seen how we, the public, are now excluded from influencing any decisions about services and the future of OUR NHS.


In 2013 NHS England created NHS Citizen as a way of involving the public in decisions about our NHS.  BUT in 2016 they decided to redesign it.  They closed it without telling us. They didn’t share their planned new design with us.  They took it straight to the Board for approval without us knowing what was in their new design.  They are NOT involving us in decisions – not even about NHS Citizen – which is supposed to be a ‘service’ to ‘enable’ us to be involved in NHS England’s decisions about services!

NHS England was created in 2013 by the Health & Social Care Act 2012, but first called the NHS Commissioning Board, to take responsibility for the arrangements of NHS services in England.

The NHS in Scotland, Northern Ireland and Wales is run by their own ‘devolved’ parliament or assemblies.

The Act also says they must involve the public in their decisions about NHS service planning – a legal duty to involve us.  At first, NHS England (NHSE) made a number of commitments to work with patients and the public to make sure we were involved in planning NHS services.

Commitments, or promises, such as:

  1. The NHS Constitution which gave us rights and NHSE made some pledges
  2. NHSE Patient & Public Voice – legal duty to involve us in decisions about services
  3. NHSE to be held to account –  by a Patient & Public Participation Oversight Group?
  4. NHS Citizen & Assemblies – to enable us to be involved & have influence

BUT – things started changing during 2014 and changed completely in 2016

A.   NHS Citizen Workshop – didn’t work with us, to improve NHS Citizen – did it ‘for us’

B.    NHS England Board decided a ‘new approach’ for NHS Citizen – no public involved

C.   NHS Citizen Programme Board created – but the public was not involved or even told

1. NHS CONSTITUTION:   nhsconstitution

The NHS Constitution is a Department of Health pledge to the people, updated every ten years. It says “The NHS belongs to the people” and NHS England promised to abide by its principles and values.

What NHS ENGLAND promised:

  • To follow “[Principle] 7. The NHS is accountable to the public, communities and patients that it serves.” …..  “The system of responsibility and accountability for taking decisions in the NHS should be transparent and clear to the public, patients and staff.
  • to provide you with the information and support you need to influence and scrutinise the planning and delivery of NHS services (pledge);

What we got:

The ‘responsibility and accountability for taking decisions in the NHS’  is NEITHER transparent NOR clear to us:

  • We don’t know who represents us – the patients & public – in decisions
  • We don’t know what they say and do ‘on our behalf’
  • We can’t share our views with them – and they give us no feedback
  • Records of decisions they make ‘on our behalf’ are NOT in the public domain

2. NHS ENGLAND Patient & Public Voice:

What NHS ENGLAND promised:

  • To meet their legal duty to involve individuals who use services (patients), or who may use them (the public), in service decisions and NHS planning – as stated in the Health & Social Care Act 2012 Section 23. 13H & 13Q.
  • To have regular progress ‘Patient & Public Voice’ reports at all Board meetings on how these legal duties are met

What we got:

  • NHS England started to involve us via NHS Citizen ‘Gather’ (see 4. below)  – but now does NOT involve individual members of the wider public at all
  • NHS England now ‘engages’ stakeholders such as voluntary sector service providers, social enterprises (e.g. Healthwatch), patient groups (e.g.the ‘seldom heard’) but NOT with the public
  • NHS England selects and pays people (who are NOT accountable to the public) to act ‘on our behalf’ – as Non-Executive Directors or as Patient & Public Representatives
  • The ‘Patient & Public Voice’ regular progress report at each NHS England Board meeting only happened between December 2012 & May 2014 –  then it was STOPPED


What NHS ENGLAND promised:

  • To show that it DOES involve the public in decisions about planning services by a having a ‘Patient and Public Participation Oversight Group’ check that they do
  • This group includes patient & public representatives
  • It reports to the NHS England board to reassure them the public ARE involved in service planning decisions, and in the development of any proposals to change services

What we got:

NHS ENGLAND’s Patient & Public Participation Oversight Group does NOT:

  • Meet in public
  • Make their meeting agendas or minutes public (for us to see what they say)
  • Tell the public who the patient & public representatives are on this group
  • Report to NHS England’s Board Public Sessions so their findings are on public record
  • Add their ‘assurance’ on public involvement to the NHS England Annual Reports
  • EXIST – maybe not – there’s no public record of its existence, except in the Policy document ‘Statement of Arrangements and Guidance on Patient and Public Participation in Commissioning’ (on P25 Point 4.5)

(APOLOGIES – This document has been moved or deleted from NHS England’s website)


NHS CITIZEN – was created in 2013 by NHS England to involve members of the public in their work.  An NHS Citizen website was set up with some ‘Gather’ pages that allowed public conversations online about people’s NHS concerns and ideas for improvements. NHS England regularly made promises to develop NHS citizen by working with the public.

What NHS ENGLAND promised:

  • To ‘enable’ public involvement ‘without seeking to control’ (6/11/14 NHSE Board report P8,point 14)
  • To allow public influence by posting and discussing concerns/ideas on ‘Gather’
  • Issues would be voted on and a few discussed fully at an NHS Citizen Assembly of members of the public and members of NHSE Board
  • To be held to account by holding  NHS Citizen Assemblies each year for ‘citizens’ (the public) and Board members to agree actions for the Board to take
  • The Board would give feedback on the agreed actions taken
  • To evaluate the NHS Citizen programme by working with the public
  • To continue to develop public involvement online via NHS Citizen‘Gather’

What we got:

  • NHS Citizen became ‘controlled’ by staff who were NOT ‘facilitating’ or ‘enabling’
  • Few decisions were influenced and ‘Gather’ was very tightly controlled – ‘top down’
  • Public votes selected a number of issues – but the staff selected a shortlist and a citizen panel to choose the final five to go to the NHS Citizen Assembly
  • NHSE Board FAILED to report actions taken after the LAST NHS Citizen Assembly held in November 2015, despite discussing five issues in full with ‘citizens’
  • The NHS Citizen website & ‘Gather’ was CLOSED, with NO warning in May 2016
  • The Participation Team REFUSED to meet with concerned ‘Gather’ contributors
  • The NHS Citizen Learning Report was written by staff, NO public contributors to NHS Citizen were involved in either the analysis or the recommendations
  • There is now NO public forum for ‘citizens’ to discuss NHS matters together

In 2016 things changed – more control – less involvement


This was planned for September 2016, after some contributors to NHS Citizen ‘Gather’ contacted the Participation Team when the site had been closed with no warning in May 2016.  We were told the workshop would be staff working together with people involved in NHS Citizen so far, to look, together, at how to improve NHS Citizen. 

This Workshop is discussed in full in our recent post What really happened at the NHS Citizen Workshop – September 2016.  However the key points are repeated briefly below.

What NHS ENGLAND promised:

  • To concerned ‘citizens’ they’d only invite NHS Citizen contributors to the workshop
  • To plan the workshop with NHS Citizen contributors able to say how it should be run
  • To share ideas staff had already shared with NHS England and add any ‘citizen’ ideas
  • To work collaboratively with those attending to agree the future of NHS Citizen
  • To give written feedback from the workshop to people attending
  • To create a steering group with the public to plan the future of NHS Citizen
  • To give feedback from the Sep. 2016 NHS England Board on the plans for NHS Citizen

What we got:

  • They invited providers & commissioners taking up places so some public couldn’t go
  • The workshop was NOT planned jointly with NHS Citizen contributors
  • Only a BIT of the Participation Team’s NHS Citizen plan shared with the workshop
  • We ASKED for nhsc-workshop-slides-handout – got it, incomplete & very much later
  • The workshop was VERY controlled and ‘citizen’ ideas were not discussed openly
  • The workshop was NOT asked for decisions or if they agreed with what they were told
  • NO written feedback from the workshop was sent out to people who attended it
  • NO steering group was set up – or if it has been it’s a SECRET
  • NO feedback was sent out about the Plan discussed at the 29/09/16 Board meeting
  • The NHS Citizen Plan presented to the Board was NOT shared with the public  (unless you know to look on the NHS England website Board pages for the agenda item document)


A plan was presented to the NHS England Board meeting in September 2016, written by the Participation Team, and didn’t include any suggestions from people involved in NHS Citizen.  They described it as a ‘new approach’ for improving the quality of customer insight through NHS CITIZEN.

The Board Paper is discussed in more detail in our recent post The last NHS England Board agreed a new ‘NHS Citizen plan’- to involve the public – that didn’t involve us in deciding what was in it!

The content of the NHS Citizen Programme is discussed in another recent post Will the New NHS Citizen Programme involve citizens (people)?

However the key points of both are repeated briefly below.

What NHS ENGLAND promised:

  • The workshop was told a ‘skeleton idea’ was shared with the NHSE Board early in 2016
  • There was ‘NO DONE DEAL’
  • The Board Paper would be shared with ‘citizens’ at the workshop – once written
  • A steering group would be set up to help decide how NHS Citizen develops

What we got:

  • It was NOT a ‘skeleton idea’ – we were NOT told of the ‘revised model’ of NHS Citizen developed in 2015/16 – see the Board paper  P2 point 5
  • The workshop was NOT given detail of the ‘new approach’ for NHS Citizen
  • They were NOT asked to support any of it
  • There is NO written record of the workshop to prove this
  • The Board Paper WAS a ‘done deal’ – a new NHS Citizen service is imposed on ‘citizens’ who had no say in its content
  • NHSE Board members were misled – the workshop was NOT asked to support a plan
  • They were misled again – NO suggestions in the Board paper are from NHS ‘citizens’
  • And misled again – they were NOT told the learning report recommendations were NOT agreed with the public
  • This ‘new approach’ for NHS Citizen has NOT been shared with the public
  • It has still NOT been sent to the people who were at the workshop
  • The steering group (see P 5 of the Board Paper, point 18.iii) has still NOT happened
  • OR if it has – it’s a BIG SECRET


This was mentioned in the Board paper but was news to everyone who had been involved in NHS Citizen over the last three years or more.  It was not mentioned at the September workshop.

Invitations to the public to apply to be an Expert Patient Adviser Board Member were circulated to ‘citizens’ via the In Touch emailing, and advertised on the NHS England Involvement Hub.

But there was only three weeks to apply, and if you didn’t have strategic experienced you were put off applying. (see the application pack including the new Board Terms of Reference – citizen-prog-board-info-pack.)

We discussed this in a recent post New Public NHS national Board members will be accountable to an NHS England manager – and NOT to Patients or the Public and our conclusions are repeated below.


  • The existence of this Programme Board is news to us
  • It has been imposed on us and we cannot influence it in any way
  • The Expert Patient Adviser Board members are not accountable to us
  • They are ‘managed’ by the Director of Patient & Public Voice & Insight
  • We do not know who they are, or if they understand meaningful involvement
  • The meetings are not in public – we do not know when they met
  • The minutes and agendas of the meetings are not shared with us

OUR CONCERNS (from the recent post on this subject) ARE:

This is not acceptable!  It is not honest – and it is disrespectful to the public.

  • The invitation to apply  to be an Expert Patient Advisor misleads people
  • The members of the public on the Board are not accountable to the wider public.
  • They are not required to be experienced in patient and public involvement.
  • These public Board members are not able to act independently in their roles.
  • The Director of Patient & Public Voice & Insight (PPV&I) selects them and manages their performance and how they carry out their duties.
  • The Director of PPPV&I has total control over patient and public involvement.
  • There is no collective, independent, inclusive and representative NHS Public Voice.

We now have no say in the future of our Public Voice.

We now have no Voice in OUR NHS.






New Public NHS national Board members will be accountable to an NHS England manager – and NOT to Patients or the Public.

The Expert Patient Adviser Board Members on the new NHS Citizen Programme Board will have no contact with, or accountability to, patients or the public. They will have to report to a Senior NHS England Officer instead.


The September NHS England Board approved the recruitment of members of the public as Expert Patient Advisors to sit on the new NHS Citizen Programme Board.  They are to bring public voices to the Board and to have an advisory role in the future of public involvement in the NHS in England.

On 19th October 2016 applications were invited for these roles via the NHS England website with a closing date on 10th November 2016.  The invites were on a page on NHS England’s website.  The intended ‘audience’ lists ‘patients’, ‘carers’ and ‘service users’. But the list doesn’t include members of the public.

The invitation says:

“The NHS Citizen Programme Board is looking for three Patient and Public Participation Expert Advisers. One of the candidates will serve as the Programme Board Chair and will be responsible for the administration of the Board and ensuring an objective and impartial approach.”

It goes on to describe the people they want to apply:

“The ideal candidates will bring significant board level experience, with a strategic healthcare focus, strong intellect, commercial and political astuteness, and a willingness to challenge.”

And also says that: “There will be payments of £150 per day (for those people not representing or supported by an organisation) for an estimated time commitment of 10 days per year. This is in line with the NHS England Patient and Public Voice Expenses policy. Membership of the group is for 12 months initially, at which point membership will be reviewed.”

It ends with saying – “NHS England wants to ensure that its Patient and Public Participation Expert Advisers are representative of the population and that a wide range of people are appointed to these roles.

What this webpage does NOT say is that all representatives or ‘patient and public expert advisors’ are SELECTED by NHS England managers and REPORT to THEM – NOT to patients or the public as they are given no contact with the wider public.

So how can these Board members be representative of the population?

Why are they excluding the public in a Programme that it says is intended “to meet the requirements of the duty to involve”.

(This refers to the legal duty to involve the public – as in Section 13Q of the Health & Social Care Act 2012 !)

How can we trust that NHS England  – when they say one thing and do another?


The role description and the Terms of Reference of the new NHS Citizen Programme Board are described in the NHS Citizen Programme Board Expert Patient Advisor information pack and it becomes clear that:

  • “Patient and Public Participation Expert Advisers are appointed by NHS England’s Senior Responsible Officer (SRO) for the NHS Citizen programme, and will be accountable to the SRO for carrying out their duties and for their performance.” **
  • “All lay members of the NHS Citizen Programme Board must undergo mandatory induction training approved by NHS England in order to undertake the role.”
  • They willManage the public’s expectation around where their feedback will lead;”
  • “The NHSC-PB will be jointly chaired by the National Director for Patient, Public Participation and Insight and a member of the public who will be recruited in an open and transparent fashion*** for an initial period of 12 months.” ***

Did you remember that the webpage inviting people to apply told us that “One of the candidates will serve as the Programme Board Chair” ?  

Well that’s not really the case is it?

This person will be appointed by her and accountable to her, as it says in the Terms of Reference.(**above).  So much for an “open and transparent fashion”, as it also says in the Terms of Reference (*** above)

This is not acceptable!  It is not honest – and it is disrespectful to the public.

  • The invitation to apply to be an NHS Citizen Programme Board member misleads.
  • The members of the public on the Board are not accountable to the wider public.
  • They are not required to be experienced in patient and public involvement.
  • These public Board members are not able to act independently in their roles.
  • The Director of Patient & Public Voice & Insight (PPV&I) selects  them and manages their performance and how they carry out their duties.
  • The Director of PPPV&I has total control over patient and public involvement.
  • There is no collective, independent, inclusive and representative NHS Public Voice.

We have no say in the future of our Public Voice.

We have no Voice in the future of OUR NHS.



PLEASE share this information – and tell us what you think about it.

The last NHS England Board agreed a new ‘NHS Citizen plan’- to involve the public – that didn’t involve us in deciding what was in it!

September’s NHS England Board agreed a new public involvement plan without telling the public what was in it


On September 29th 2016 the NHS England Board discussed and approved a ‘paper’ proposing a new NHS Citizen plan for the future involvement of patients and the public in the work of NHS England.

This Board Paper ‘Improving the quality of customer insight through NHS Citizen’ was presented by Jane Cummings, the Chief Nursing Officer, one of the six National Directors at NHS England. She leads the Nursing Directorate which includes all the work around patient and public participation.

The document describes the brief history of NHS Citizen, an involvement service designed jointly, during 2013 and 2014, by staff and ‘citizens’ – an Amercian term the NHS establishment uses to describe ‘people’.  It was facilitated by four agencies one of which described it’s purpose as:

“NHS Citizen aimed to bring voices from diverse communities into decision-making processes and to hold the Board of NHS England to account.”

However the joint approach was soon discarded with new people taking charge of NHS Citizen at NHS England during 2015, and rather than working together it became ‘managed’ and controlled.  The participation became arranged ‘for us – not with us,’ and just a way of gathering individual ‘feedback’ with no transparency about which ideas in this ‘feedback’ were accepted and which were rejected – or why.

The ‘paper’, in describing its purpose, includes the following words that make it clear it is not about working together anymore, or about public involvement, but about ‘efficiency’ and ‘customer insight’:

“This paper provides a summary of the changes to NHS Citizen since the November 2015 Citizens Assembly, and the proposed new approach for delivery. The programme objective is to improve the quality of customer insight within our business plan priority areas. The new approach will ensure we use a much more comprehensive picture of citizen insight than previously. In line with meeting the triple aim set up in the Five Year Forward View, this will support efficient and effective business planning and policy development.”

How can a manager improve the ‘quality of customer insight’ – within ‘business plan priority areas’?  Are they implying that they know best whether our views are important or relevant?  Or – are they implying that they intend to just ‘note’ those views that agree with their ‘business plan priority areas’?  Or is it both?

The four agencies contracted to deliver the NHS Citizen programme between 2013 and 2016 were asked to write a ‘learning report’ describing the ‘feedback’ from some of the people involved in NHS Citizen and drawing their own conclusions about what worked, what didn’t and how it could work better.  ‘Citizens’ were NOT involved at all in the analysis, nor the writing, of the NHS Citizen Learning Report.

the-tavistock-institute     Public-imapiq7nf_400x400    logo_involve     logo4

The Board paper also describes the NHS Citizen Workshop held two weeks before the Board meeting and implies that the new plans were discussed and supported by saying:

“On 12 September 2016 an event was held to present the proposed new approach to a group of c80 citizens, organisations, partners, and NHS England staff to ensure that it meets both the engagement needs of NHS England, and the requirements of citizens. Many more also engaged with the event through a live webcast and twitter feed. There was a lot of support for the refresh of NHS Citizen and for working with system partner stakeholders. Linking in with existing insight and activity was also strongly supported.”

This was NOT the case.  See the recent post  describing what really happened. Also two people who attended the workshop, and one webcast watcher, wrote to Lord Victor Adebowale before the Board meeting to tell him so.  He, Lord VA, is the NHS England Director who will be overseeing the changes to NHS Citizen, and the emails were from members of our campaign the N-NHS-PV (National NHS Public Voice campaign).

He reported our correspondence at the Board meeting suggesting that people needed to be listened to, even if what they say is not comfortable listening.  You can watch the board’s discussion and hear Lord Adebowale’s contribution here – see the video for Item 7 . (He speaks towards the end of the discussion).

The new plan also included a new NHS Citizen Programme Board. We will be discussing this in a new post shortly.  It will include three Patient representatives that will be selected by NHS England to ‘act’ in our interest, but with no way of hearing what we think or of reporting back to us what they say and do on our behalf.

Please – tell us what you think about all this – by adding a comment or contacting us – and share this information with your friends.


We look forward to hearing from you and starting some good discussions.

What really happened at the NHS Citizen Workshop – held in London on 12th September 2016.

The NHS England EVENTS PAGE said:
“This workshop will explore the next steps for the NHS Citizen programme, ensuring that the programme is co-produced with citizens and ensuring learning from past events and reports.”

The reality was that:

  • There was no full & open discussion on the future of NHS Citizen at any point
  • We were expected to listen to invited ‘experts’ with only our questions invited
  • We were expected to listen to staff commenting on all our own contributions – why?
  • We were not allowed to openly discuss anyone else’s concerns, comments or ideas
  • All our comments were effectively dismissed by staff who didn’t enable discussion

How well did the NHS Citizen workshop manage – “ensuring the programme is co-produced with citizens”?  

Not well at all – it was completely ‘staff-led’, by NHS England’s Patient & Public Participation Team, (PPPT) with no co-production (which is joint & equal decision-making following an open discussion and with any conclusions made by both the organisation and the ‘citizens’ together).

This is how it was:

  • A brief slide show described the staff team’s 2 digital ‘developments’ for NHS Citizen
  • We had no handouts of the slides shown, asked for some and they came hours later
  • The handouts left out a flow chart showing feedback flow and NHS Citizen contacts
  • We were not asked if we agreed with the 2 digital developments for NHS Citizen
  • We were not asked if we thought these digital developments were a good idea or not
  • We were not shown the plans for NHS Citizen discussed to the Board – 2 weeks later
  • We were not asked to comment on these plans before they went on the NHSE website
  • We have never been asked about what are actually the PPPT’s own NHS Citizen plans

See for yourself – these links cover the five hour workshop:

NHS Citizen workshop – morning session

NHS Citizen workshop – afternoon session

NHS Citizen – feedback session

Who attended the workshop?

About 60 people attended with about 20 people who were ‘facilitating’ the day as NHS England staff or external associates supporting the technology of the webcast. There were at least 1 ‘facilitator’ for every 3 attendees.  The 60+ people who attended had applied to attend via the NHS Events pages.  There was no ‘invitee only’ restriction, which is often the case for events involving clinicians.

In June 2016, members of National NHS Public Voice had asked to meet with the PPPT after the NHS Citizen ‘Gather’ blog site had been closed overnight at the end of May with no warning or explanation.  The PPPT said a workshop in September would be arranged just for people who had been involved in NHS Citizen during the three years it had existed to discuss, with the PPPT, how NHS Citizen could be improved.

However those actually attending the NHS Citizen Workshop in September, far from the ‘citizens’ only, included commissioners, voluntary sector providers, and training consultants.  Those attending as ordinary members of the public who had been involved in NHS Citizen only numbered about 30 people.

People from National NHS Public Voice were there, and also watched the workshop webcast.

We were particularly disappointed as, in the spirit of the Workshop’s purpose, we had spoken with over 250 people at NHS events during the week before the Workshop.

We asked all these people how they would like a new NHS Citizen programme to work, and shared their views with all those at the workshop in a contribution from the floor – only to have all these people’s voices ignored.

These people had told us they wanted a collective democratic voice that was independent from service commissioners or providers, that was also inclusive and respectful. But they said the most important thing to them was that any ‘patient representative’ should be accountable to, and elected by, the rest of us.  They felt it was unacceptable that NHS England selected the patient representatives and that NHS England provided no system to enable them to actually represent the views, experience and knowledge of the wider public, or to give feedback on what was said or done on everyone’s behalf.

People had also told us that NHS England is not engaging with mental health service users and that they had no contact with the STP Footprints – which was very worrying.

The conclusions from the workshop:

There was little time left and no real discussion about what should happen next.  We were basically told that:

  • the PPPT staff would write a report for the NHS England Board on 29/10/16
  • a steering group would be set up to take the development of NHS Citizen forward
  • and that this steering group would include members of the public
  • and we would receive a copy of the staff ‘write up’ from the workshop

However there has been no ‘write up’ sent as yet, nor a copy of the report they took to the NHS England Board.  We have had one email thanking us for coming, giving web-links to the web-cast, an evaluation form and another promise of more information. That’s all.

National NHS Public Voice feels that this workshop was not facilitated in a professional and inclusive way nor did it demonstrate co-production.

We also feel that the NHS England Patient and Public Participation Team did not demonstrate that they have knowledge, experience, or even an understanding of best practice in facilitating an inclusive public involvement event. Nor do we feel that they showed any understanding of how co-production is actually supposed to work.

We were told repeatedly  ‘nothing is a done deal’  but the Board paper proved that the opposite is true.

Look out for our next post – explaining our concerns about the plans.

Why not look at a ‘Ladder of Participation’ to see what level of influence you are being allowed?

Sherry Arnstein created a Ladder of Participation in America in 1969 describing the different levels of control over their lives that those who hold the power allow ‘citizens’ to have.

 The original Ladder of Participation devised by Sherry Arnstein in 1969

Some of you may know that, in 1969, Sherry Arnstein looked at citizen control and how citizen participation helps people achieve it.  As she worked in America she used the word ‘citizen’ – an American term for our ‘general public’ or ‘people’. The word ‘citizen’ has now been adopted in the NHS.

Sherry studied different citizen campaigns in different parts of the USA and published her conclusions in an academic paper.  Her work shook up both the political thinking of the time and its comfortable democratic principles.

She talked about the ‘have nots’, as citizens/people without power, and about how citizen participation was a means for them to gain some influence over the affluent society they lived in, and a share in some of its benefits.  Her Ladder shows the different levels of citizen participation that measure how much control people are allowed to have over aspects of their lives.

She also described how, the closer the ‘have nots’ got to achieving full citizen control, the more barriers and excuses were introduced by those holding the power to make the decisions that affected their lives.  And, how these barriers and excuses showed the discrimination that existed at the time.

Sherry was working on this at the end of the ’60s, a time when there was the American civil rights movement, the anti-Vietnam War movement and student unrest everywhere. screen-shot-2013-10-11-at-12-13-29-amA poster she saw created by French students in the 1968 Paris uprising particularly inspired her.

‘I participate, You participate, He participates, We participate, You participate, They Profit’

It’s uncanny how relevant the words from her paper are today – nearly half a century later.

“The heated controversy over “citizen participation”, “citizen control”, and “maximum feasible involvement of the poor”, has been waged largely in terms of exacerbated rhetoric and misleading euphemisms.”

 “The idea of citizen participation is a little like eating spinach: no one is against it in principle because it is good for you. Participation of the governed in their government is, in theory, the cornerstone of democracy-a revered idea that is vigorously applauded by virtually everyone.”

“And when the have-nots define participation as redistribution of power, the American consensus on the fundamental principle explodes into many shades of outright racial, ethnic, ideological, and political opposition.”

This version of her Ladder of Participation clearly summarises her analysis: slide_6

Only a decade ago people in many places across the country experienced participation in the NHS at rungs 6 and 7 of the Ladder of Participation which Arnstein describes as Citizen Power.

Whereas in today’s NHS in England ‘citizens’ are allowed no more than rungs 3, 4 and 5 of the Ladder of Participation, which Arnstein describes as Tokenism.

But the NHS, in England, is now introducing the two lowest levels of Arnstein’s Ladder of Participation (1 ‘manipulation’ &  2 ‘therapy’) by encouraging people to manage their own health.  As part of the Sustainability and Transformation Plans and New Models of Care we are now expected to change our lifestyles and to ‘self-manage’ any long term conditions we may live with.  The NHS describes this new expectation as ‘patient involvement, or participation, in their care’ but Arnstein describes it very clearly as Nonparticipation.

Even worse – only a few weeks ago – NHS England’s Patient and Public Participation Team introduced their new, supposedly improved, ‘Citizen’ Participation programme.  But this will only work at levels 1 – 5 of the Ladder – which is ‘Nonparticipation‘ and ‘Tokenism‘.

The people’s voice in the NHS has been taken away – why?

 A decade ago the NHS was proud of working with patients, and the public, to improve services which then began to work better than they had for a long time.  Why are the ideas and suggestions of the people using the NHS now considered so dangerous that they need to be silenced? It is really disappointing that the level of Participation in the NHS has sunk so low in such a relatively short time.

Why is this necessary – why is the public voice so dangerous?  

The Ladder below describes a modern version of Arnstein’s Ladder of Participation created by a French student in 2009 showing how ‘citizen control’ is seen as dangerous by those holding the power and control. The 1968 Paris student slogan is included (top right), and the spelling is interesting but the message is perfectly clear.


Arnstein’s Ladder, created to describe how people could gain power and control over their lives, has been ‘diluted’ over the years by those holding the power.

downloadEach time her Ladder is simplified its meaning is diluted as there is no reference to her clear analysis.  The very simplified version shown here is often used to show Arnstein’s Ladder.

But when compared to the detailed one shown earlier it tells us very little.

The one the right is a New Economics Foundation version, many ‘co-‘ words, but no clear escreen-shot-2014-03-10-at-5-12-46-pm-278x300xplanation or analysis!

N.B. It was included, on P20, in the Northern Ireland Health Minister’s 10 year plan to save their health service ‘Health & Wellbeing 2026, Delivering Together’ that was published last Tuesday (25/10/16).

coproduction-tree-660This is produced  by Governance International, a consultancy set up in the ’00s, one of the new Involvement Industry.  They help public services to ‘focus on smart savings and innovations to achieve better citizen outcomes‘!

Well they have a tree surrounded by all the ‘co-‘ words – so they must be good!

Finally – Arnstein’s Ladder of Participation, created to describe how people could gain power and control over their lives, has now been adopted by big business.

There is now a Ladder of Participation for On-line Customers.


Another about Loyalty to a Brand, for the marketing department.crm-strategy-20-638

There is even a ‘success’ Ladder for all those ambitious middle managers!!