How much public accountability is there in OUR NHS?

All those responsible for health policy and the running of our NHS are accountable to the public through the Nolan Principles of Public Life and duties laid down in law to account for their decisions and actions.



BUT – the word ‘accountable’ is being used to describe many new structures being created in the NHS – these do not follow the legal duties or, always, mention the Nolan Principles .

What do we mean by public accountability?

It’s about whether the people who make the big decisions that affect our lives are  ‘accountable’ to us – the ‘public’ – or not!  It has been defined as follows:

What is PUBLIC ACCOUNTABILITY? definition of PUBLIC ACCOUNTABILITY (Black’s Law Dictionary) – which says it’s:

The obligations of agencies and public enterprises who have been trusted with the public resources, to be answerable to the fiscal and the social responsibilities that have been assigned to them. These companies and agencies need to be accountable to the public at large and carry out the duties asked of them responsibly.”

So – Accountability must be:

  • all about the decision-makers being answerable to us for the decisions they make.
  • and all about the public trusting that the decision-makers are making decisions in ‘our’ best interest.

Who are the people making decisions about OUR NHS?

The NHS is a public service and is funded by public money. But who decides what it looks like?

Health policy is decided by government politicians, who decide how our NHS will work and how much public money will be put into it.

  • the government then puts this policy into the law – that NHS managers have to abide by
  • the government also decides how much public money goes into the NHS – giving NHS managers budgets that they have to keep to

At least it was!

  • But in 2013 NHS England was created to run the NHS on behalf of the Government, as stated in the Health & Social Care Act 2012.

The government still decides what money the NHS has to work with, but has frozen NHS funding since 2010.

  • This frozen NHS budget means that there is not enough money to fund the increased costs of the NHS year on year
  • These increased costs are because of using more technology (in treatments and diagnostics) and for the growing population and increased need for services

So now NHS England uses this funding ‘gap’ as a reason to reorganise NHS service delivery, and to provide us with cheaper NHS services with fewer staff and in fewer places – as a way of making ends meet.

How are all these NHS decision-makers actually accountable to us – the public?

Our UK government and politicians are held accountable to the public by our democratic vote every few years – apparently:

  • so we can vote out the government politicians if we don’t like their health policies
  • but we can’t vote out NHS England managers if we don’t like what they’re doing

The NHS England and NHS Trusts akk have a Board of Directors which include Non-Executive members of the Board who are appointed to protect the public interest, paid for their time, and are supposed to act in the interests of the public.   NHS Non-Executive Directors have patient involvement and public accountability within their responsibility – but the appointment process has no requirement that they have either knowledge or expertise in these areas.

We can write to the Non Executive Directors on the NHS England and NHS Trust Boards, and to the Lay members of Clinical Commission Group Governing Bodies.  And they may reply to us. But they don’t have to take any notice of what we say!

Non Executive Directors at NHS England and NHS Trusts, and the CCG Lay members, are NOT accountable to the public in any way! 

And what about Senior NHS managers in the NHS, whether at NHS England or at all the other NHS bodies?

Well – the reality is that NHS senior managers are appointed by other senior managers and approved by the Directors of the relevant NHS body’s Board of Directors.  They are paid very large salaries but are only accountable directly to the people who appointed them.  Only these people can decide if they are not right for the senior responsibilities they have. Only they can sack them.

NHS senior managers are NOT accountable to the public!

NHS Trusts also have a Board of Governors, some of which are elected by members of the public – but they have to sign up to be a ‘member’ of the Trust to get a vote.  The NHS Trust Board of Governors can appoint, and can deselect, a Non-Executive Director and are supposed to check that they act in the public interest in their role.  The Governor meetings are partly held in public, but the public cannot remove an unsatisfactory Trust Governor.

NHS Trust Governors are not accountable to the public either!

What about the NHS Annual Reports that are Presented in Public?

It is a legal requirement for all Trusts and all Commissioners to publish an Annual Report, which is presented to the public each year at a publically advertised event. This Annual Report has to show the meeting attendance of Trust Directors and CCG Governing Body Members and what payments they received.

Commissioners (NHS England and CCGs) also have to say in their Annual Report exactly how they involved the public in their work that year, again as a legal requirement.

Well.  Is this real public accountability? It’s just saying what they did last year.  There’s nothing that allows the public to influence what they do next year.

What about the health scrutiny function of local authorities?

A local authority has statutory (legal) powers to scrutinise a particular matter about the planning, provision or operation of health services in their area.  These powers include:

  • inviting interested parties to comment on the matter
  • taking account of relevant information available to it
  • making reports and recommendations to the responsible person in the relevant NHS body, including detail and explanation of the scrutiny process
  • creating joint health scrutiny committees to share their powers to scrutinise health service matters that affect more than one local authority area
  • requiring to be consulted by the relevant NHS body on any proposal for substantial change in health service provision in their area
  • reporting to the Secretary of State if they are not satisfied that the consultation was adequate in content or in time allowed

A local authority also has a statutory duty to scrutinise any particular matters about the planning, provision or operation of health services in their area that has been referred to them by the local Healthwatch.

Unfortunately the scrutiny functions of local authorities are not always carried out very rigorously having become a bureaucratic exercise rather that an exercise in meaningful public accountability.

What about Healthwatch?

In 2013 there was a local Healthwatch created in each local authority area, with the local authority responsible for the contract and its establishment.  There are 152 of these with each being required to:

  • Gather the views of local people about local health and care services, where these need improving and where any gaps are
  • Build a picture of how the local health and care services are performing and collect evidence to clarify specific concerns
  • Attend the local Health & Wellbeing Board to feed in the local overview of local health and social care services which is based on the views of local people
  • Carry out ‘Enter and View’ visits to inspect services giving concern and send a report to the service provider which may include recommendations for improvement
  • Alert local commissioners, Healthwatch England and/or the Care Quality Commission of any particular concerns about local health and care services
  • Signpost local people to information about local health and care services and how
    to access them
  • Provide people with information about their choices and what to do when things
    go wrong, such as how to get support from the Independent Advocacy Service
  • Act as an independent social enterprise with the power to recruit its own staff and to make its own workplans
  • Produce an annual report  demonstrating it is inclusive and enables the local population to lead in its work and are directly involved in its governance

However Healthwatch nationally only works with about 6,000 volunteers and about 300,000 individual views.  But there are at least 55,000,000 people in England, so only a few were actually involved with Healthwatch, with on average:

  • 0.01% of local people as Healthwatch volunteers
  • 0.5% of local people with their views about services gathered by Healthwatch

Many Healthwatch representatives on their local Health & Wellbeing Board say little or nothing at all, certainly not having a local overview of local health and care services to feed into discussions.

 Healthwatch cannot be said to represent the public and are only accountable to a very small percentage of their local population


What about the Seven Nolan Principles of Public Life?

All elected representatives in local and national government, and all the senior managers, directors and board members of ‘public bodies’, including Councils and the NHS, have to act within the Seven Nolan Principles of Public Life.

These are listed in full on the last page of the Nolan Report – The First Report of the Committee for Standards in Public Life, that was Chaired by Lord Nolan and presented to the UK Parliament in 1995.

These Seven Principles expect all those in public service to behave in a way that shows:

  • selflessness – not acting for personal or financial benefit
  • integrity – not being beholden to outside influence
  • objectivity – making any choices their role requires on merit
  • accountability – answering to the public for their decisions and actions
  • openness – being open and transparent in their decisions and actions
  • honesty – declaring and addressing any conflicts of interest
  • leadership – leading and promoting the principles by example

But – as none of these people acting as public servants are directly answerable to us – for either how they behave – or for their decisions and actions they take – how can they be considered be directly accountable to the public?

How can we trust that they always act in the public interest when we don’t know what they do – in our name – as they are not directly accountable to us?

How can we trust that what they do with our public money is always carried out according to the seven Nolan Principles of Public Life when they are not directly accountable to us?

Well then – Is there any Public Accountability in OUR NHS?

At the beginning of this post a definition described accountability in public services, including in the NHS, being all about:

  • decision-makers being answerable to us for the decisions they make – they are not!
  • the public trusting the decision-makers are acting in our interest – well we don’t!


When trust becomes broken it is time to CHALLENGE!



The NHS belongs to the PEOPLE!

What do you think?

We will look at the new, and very secretive, ACCOUNTABLE CARE SYSTEMS next – are these partnerships to integrate services accountable to the public?

We will also look at the ACCOUNTABLE CARE ORGANISATIONS too – supposed to manage the budgets and contracts for integrated services in each local area – do they serve the people and give us safe and effective services – or do they just save money, and take decisionb-making further away from public, and political, accountability?

There are two legal challenges already to the content of the Accountable Care Organisation version of the NHS Standard Contract.

Please share your thoughts about all this with us.

“The NHS belongs to the PEOPLE” – so why can’t the PEOPLE change how it’s run?

It’s our NHS. We pay for it in our taxes. The law says that people should be directly involved in all decisions about NHS services, but we don’t have any real influence on decisions about OUR NHS. Why not – and how do we change that?




We own the NHS, and have some choices.

We can:

  1. Challenge the system (The Government, which makes NHS policy)
  2. Challenge the people running the system (NHS England)
  3. Challenge the people arranging local services (CCGs, STPs)
  4. Use the system to challenge & change the system

Here’s how:

OUR NHS has been altered in the last couple of decades in a number of ways – so we need to know how NHS decisions are made – what about – and who by!

In 1999 the responsibilities for their own NHS services were handed over to Scotland, Wales and Northern Ireland and they are allocated funds to manage their own NHS.

We are talking about the NHS in England here.

What is The System?  The UK government’s laws and its Department of Health continue to set the NHS overall policy, and decide what the overall funding will be, for NHS services in England.


Who are the People Running the System?  In 2013 the responsibility for running the day-to-day NHS service delivery, in England, was given to a new organisation called NHS ENGLAND – which has to make sure the services we all need are available to us.  They need to meet annual targets and to do all this using the money the UK government decides to give them.


Who are the People Arranging Local Services?  Also, in 2013, a number of CLINICAL COMMISSIONING GROUPS (CCGs) were created across England and allocated money, that was paid to them by NHS England, to plan and buy local services for their local population, usually the area of a local authority, or Council.

This began the transfer of NHS decisions about services from a National level to a local level – as the CCGs are legally responsible for planning local NHS services.


Or is it really as simple as that?

In 2015 NHS England invited different areas across England to test out new ways of delivering NHS services.  These are called VANGUARDS and are mainly made up of some NHS Trusts working together.  NHS Trusts are responsible for providing NHS services, planned and paid for by the CCGs under a contract.

This introduces some words you really need to know about:

‘Commissioners’ = organisations that plan the services needed by the people who live in the area they cover, and ensure that these services are available – usually by paying for them.  (CCGs and NHS England are commissioners)

‘Providers’ = organisations that provide the services people need, such as care and support services – usually planned, and paid for, by commissioners under a contract. (NHS Trusts and GP Practices are providers)

Having the Vanguards plan new ways of delivering services was a BIG change as the ‘future’ of services was now being planned locally – not Nationally anymore – and by providers, not commissioners – and not even the UK government, or Department of Health.

 Was this NHS policy – was it NHS service planning – or was it NHS service delivery?

In 2016 – NHS England instructed CCGs to come together to plan NHS services for a larger local area, to deliver the STPs, building on the ‘new models of care’ developed by the Vanguards in their area.

STP originally stood for a Sustainability and Transformation Plan in which each collection of CCGs had to show how NHS services could be delivered more cheaply over the next few years, until 2021, to give a TOTAL saving of £22 billion across England.

It is claimed that the CCGs are still individually, legally responsible for the planning, services, and the decisions made by the STPs.

That’s because these partnerships of CCGs have no legal powers to make joint decisions about NHS services, only the individual CCGs can do that.

HOWEVER – it is becoming increasingly clear that decisions ARE going to be made by the STPs, and influenced by the Vanguards.


It looks like a mess.




I think we are meant to be – so we are less likely to know who to challenge – about bad decisions – and when things go wrong!

So – back to our choices.

REMEMBER – Commissioners MUST involve the public DIRECTLY in their plans and decisions about NHS services.

You need to know that CCGs each cover a population of around a quarter of a million, that the STPs each cover a population of well over a million people, and also to know that NHS England covers a population of around 55 million people.

See the Statutory Guidance (about the public involvement duty for commissioners) & our last blog post STPs must INVOLVE the public in their decisions – it’s the LAW

The law gives us legal rights from the legal duties that the commissioners have to meet.

If we know about our rights and their duties – in the law – we can challenge them in public at their Board meetings when these are ignored.  We can also challenge them in other ways – such as formal complaints, Freedom of Information requests and, if all else fails, by taking them to court.



Here’s how it can work:

1. CHALLENGE THE SYSTEM (The Government which makes NHS policy)

  • There’s a General Election – so make sure you use your vote to protect the NHS and the accountability to the public of any national policy decisions affecting OUR NHS.
  • After the General Election – make sure your MP is accountable to you and your neighbours for any speeches, votes and committee contributions they make about matters that affect OUR NHS – and – that they protect and promote direct public involvement in all NHS decisions.



The Board – each member of the NHS England Board takes responsibility for the policies and the statutory duties of NHS England – which includes public involvement in commissioning. It is possible to send public questions in to NHS England by email (see this page) before a Board meeting and a written response is promised.  (But responses are not always sent.)

Individuals – senior officers and Board Members (see this page) – who often put blog posts on NHS England’s website which invite public comments.

  • Why not post a comment on why they don’t involve us in decisions about our services?
  • We can give you some suggestion about things to write if this is new to you.

Complaints – NHS England has a complaints system (see this page).  There are the usual statements in the complaints policy about treating complaints seriously and in a timely manner.  As a commissioner, NHS England has to involve us in their commissioning decisions for specialist services and for primary care.

  • NHS England involves ‘us’, now, via selected representatives in a national public involvement process called the NHS Citizen Programme and run by its Patient and Public Participation Team.
  • But this is all done ‘in secret’ and definitely doesn’t meet the new Statutory Guidance. (see many of our recent blog posts about national involvement).

Freedom of Information (FoI) requests – (see this page). Any FoI request needs to be clearly stated, and asking for short and very precise answers or there will be an excuse given that a response is not possible as the total cost of investigating an answer is over the statutory maximum cost limit.

This is a fairly new process to us but again if you’d like help please contact us.



This looks more difficult – as a Complaint and a Freedom of Information request both apply – but only to the individual CCGs.

It is still possible to ask public questions, and to attend CCG, and other NHS, Board meetings, which should meet in public and be advertised on their websites and in the local press.

  • Get a small group together and go to a meeting to see how they’re run.
  • Go again, so you can see what they do and they know you’re watching them!
  • Then start asking questions – awkward questions.

Such as asking them to say EXACTLY how they will involve the public directly, and EXACTLY how they can be sure their chosen public representatives can TRULY represent all our views.

If their answers to such public questions at ANY of these meetings of CCGs are not clear – then ask the same question again at the next meeting.  If it still isn’t answered – then ask it again at the next meeting – and if needed at the meeting after that ……..



Public questions at Board meetings held in public

Above we describe our right to attend Board meetings, to ask public questions at most Board meetings, of most NHS Boards.  You can attend every meeting and ask a question every time.  Some people do this.

  • The meetings are ‘in public’ – with no restriction on how many people can attend
  • The agenda should state ‘Questions from the public’ – again no restrictions
  • Every member of the public has an equal right to attend and to ask a question ………
  • It could be that many people have similar questions about the same issues ……..


Complaints and Freedom Of Information (FoI) Requests

Again we describe above our right to make a complaint and to ask one or more Freedom of Information requests.

  • Every member of the public has an equal right to complain and make an FoI request
  • It could be that many people choose to complain, or to make an FoI request, about the same issues, it’s a good tactic


Legal challenges when commissioners ignore their legal duties and powers

We all have the right to challenge a decision made by a public body which we feel was not made according to the law by applying to make a claim for a Judicial Review of the ‘lawfulness’ of their decision.

Public Bodies act within the duties and powers given to them in Public Law.

NHS commissioners, the CCGs and NHS England, are ‘public bodies‘ and they were both given their duties and powers in the Health & Social Care Act 2012, which is ‘public law‘.

So this means we all have a right to challenge, in the high court, any ‘illegal decision’ by commissioners to ignore their legal duty for public involvement in commissioning and to exclude us from any one of their commissioning decisions.

(The lawyers will be only too happy to take on such cases as a number of recent changes to the legal system have affected their business, and win or lose they will get paid.)

To apply to put in a claim for a Judicial Review you, or your group, has to:

  • Apply within 3 months of the decision that is being challenged was made – some challenges have shorter deadlines
  • Make it on a point of law about legal duties required or legal powers used
  • Have tried other ‘remedies’ first, only use the High Court as a ‘last resort
  • Pay an ‘application’ fee and be able to cover all the costs – it is not cheap
  • Be prepared to pay the public body’s costs if the judge rules against you
  • Expect to use a lawyer as the law is very complex – not wasting court time

Once an application to take a claim is accepted a Judicial Review hearing is arranged.

A judge then reviews the way the decision was made, but not what was decided.

In other words if the judge finds the decision was made unlawfully then they will tell the public body to do their decision-making again – and to do it properly (within the law).

But the judge will not tell them to make a different decision.


HOWEVER:  An application for a Judicial Review is a serious move that has consequences for ALL of us – and should not be taken lightly – or rushed into on a whim:

  • Most Judicial Reviews are unsuccessful – but you still pay the fee and costs
  • So if you ‘crowdfund’ and lose – others may struggle to get public support
  • It must have strong evidence to support the case – able to ‘stand up to scrutiny’
  • A judge’s ruling becomes ‘case law’ = ‘judicial precedent’ in English Law
  • That means the judge’s ruling becomes law  = latest interpretation of the law
  • Future cases will be judged by the latest judge’s ruling on a similar case

Historically the NHS establishment has ignored its legal obligations about involving the public.  But this is partly because they don’t keep up with the latest law and any statutory guidance that explains the law.

We, at National NHS Public Voice, are finding that CCGs, and even NHS England, are unaware of the different wording in the sections of the Act dealing with the public involvement duty that is in the Health & Social Care Act 2012 when compared with the earlier 2006 Act.

There are two key differences:

  1. Who to involve:
  • The 2006 Act says ‘users of those[health] services‘ – which implies patients only
  • The 2012 Act says ‘individuals to whom services are being or may be provided‘ – which implies everyone (all of us)
  1. How to involve:
  • The 2006 Act says ‘whether directly or through representatives
  • The 2012 Act does NOT include this wording

Most CCGs and NHS England still use selected representatives that do NOT represent the public’s views, and they concentrate on patients, not the public.  These approaches are NOT within the current (2012) law.

Commissioners, campaigners, and their legal representatives – need to be aware of these differences – and the differences between the 2017 Statutory Guidance which is much clearer and stronger than the 2013 version (which is no longer valid).


Some campaigners are already taking legal action

We can only hope that they are fully up to date with all relevant detail in the law and the relevant statutory guidance.

Also that they have carefully considered any implications their case may have for all future applications for Judicial Review around commissioning decisions that other campaigners may wish to make.

Time will tell!


What do YOU think?

What success have YOU had with challenging the CCGs?

When do you think the courts should be used?


STPs must INVOLVE the Public in their decisions – it’s the LAW!

A new Statutory Guidance for CCGs and NHS England makes it clear that they must INVOLVE the public DIRECTLY in their commissioning decisions – and not just CONSULT us after they’ve made their decisions.


Some of you may have read National NHS Public Voice’s recent blog post, on this site, (see  Shhh! it’s a secret……). about the draft of the Statutory Guidance that the NHS England Participation Team were developing earlier this year – with the chosen few – and in secret!

The new Statutory Guidance that’s now been published (on 6th April 2017) includes some of the text from their draft – but it is not nearly so vague. It explains very clearly just exactly what the legal duty for public involvement means, and what it includes.  This gives us a much stronger tool to challenge when commissioners break the law by denying the public any involvement in commissioning decisions – as the law requires.

The NHS also published a Business Plan – called Next Steps on the Five Year Forward View on 31st March 2017.  And this says on P 35:

“As STPs move from proposals to more concrete plans, we expect them to involve local people in what these plans are and how they will be implemented.” 

The NHS also published (31st March 2017) an annex to their Business Plan – called NHS England Funding and Resource 2017-19: supporting ‘Next Steps for the NHS Five Year Forward View’ and this says on P 4:

“All the work of NHS England is focused on delivering better health services for our patients and the public. It’s essential that this work is based on a good understanding of what is important to them, and we work hard to involve patients and the public directly in the development of services and changes through encouraging and supporting active participation in improving care and services and promoting openness and transparency.”

Please note the words ‘involve patients and the public directly in the development of services and changes‘ and ‘openness and transparency‘!

We will share three things with you in this post – about public involvement in commissioning:

  1. What the law says
  2. What the new statutory guidance says
  3. How commissioners have ignored the law – for some time


WARNING – This is a LONG post!

Because we’ve included extracts from the Statutory Guidance for your information.  So we’ve made the full post, and some of the sections, available as PDFs.  (listed at the end of the post)

But first – just to be clear – there’s a need to briefly explain some of the things we will be talking about – as it will all be new to some of you.

Here we go:

THE STPs – are the ‘Local Plans to Improve Health and Care’:

  • STP stands for ‘Sustainability & Transformation Plans’
  • 44 STP areas now exist across England
  • STPs intend to deliver services more cheaply (the sustainability bit) as there’s not enough money to pay for our services
  • STPs intend to deliver our services differently (the transformation bit) so they can deliver the cheaper services safely

COMMISSIONING – is deciding how to use NHS funding to plan and buy our health and care services.  ‘Commissioners’ are the parts of the NHS that make the arrangements for commissioning, (planning and buying) our services.  There are two NHS commissioners:

  • NHS England – is responsible for ALL NHS services in England, and for commissioning (planning and buying) ‘specialist’ services (e.g. for rare conditions), and primary care services (opticians, pharmacies, dentists and some GPs)
  • CCGs, or Clinical Commissioning Groups – 207 CCGs are responsible for commissioning (planning and buying) local health and care services for people in local authority areas.  The 44 STPs are planned by a number of CCGs working together to decide about the delivery of health and care services for a larger population across a number of local authority areas.

A STATUTORY GUIDANCE explains the legal requirements in an Act of Parliament:

The new Statutory Guidance, published on 6th April 2017, is about ‘patient and public participation in commissioning’.  (‘patient & public participation’ = public involvement – in ‘NHS England speak’).

This new statutory guidance is for NHS England and all CCGs and explains the importance of their legal duty to involve the public in commissioning that was included in the Health & Social Care Act 2012.

It replaces the rather vague statutory guidance that was published in 2013 and actually strengthens our legal right to a public voice in NHS decision-making.  It is now very clear to commissioners just what their ‘legal duty for public involvement’ actually means and exactly what the law requires them to do.  Words like ‘directly‘ and ‘in a meaningful way’ are used to describe how people should be involved in commissioning decisions about services.

There is an on-line version, for quick reference, and also a word version, that can be printed out, with numbered items so they are easier to refer to (for possible challenges).


What the LAW says –

(about direct public involvement in commissioning) 

The Legal Duty for public involvement is in the Health and Social Care Act 2012.  It requires NHS England and CCGs to “involve individuals, to whom services are being or may be provided”, in their commissioning arrangements.  The public involvement duties of each of these commissioning organisations are described in separate sections of the Act, but the wording is very similar.

There are additional duties for the CCGs saying they ‘must have regard‘ to ‘any guidance‘ that the Board (now called NHS England) ‘may publish‘, and CCGs must include their public involvement plans, and the principles these are based on, in their constitution.

NHS England’s Legal Duty for Public Involvement is in Section 23. 13Q of the ‘Health and Social Care Act 2012, and is one of a number of other sections about the general (legal) duties of NHS England.  (The Act refers to the ‘NHS Commissioning Board’ but as this is the former name of NHS England, the legal duties all now apply to NHS England.)

Section 23. 13Q says:EPSON MFP image

CCGs’ Legal Duty for Public Involvement is in Section 26. 14Z2 of the ‘Health and Social Care Act 2012, and is also one of a number of other sections about the general (legal) duties of CCGs.  Section 26 14Z2 subsection (3) requires each CCG’s constitution to include a description of their arrangements to involve the public in their commissioning, and a statement of the principles they will follow in doing so.  Section 26. 14Z2 subsection (5) requires that CCGs ‘must have regard to any guidance published’ by what is now NHS England (such as this newly published Statutory Guidance.)

Section 26. 14Z2 says:EPSON MFP image

Other additional and relevant Legal Duties the NHS Commissioners have are in different sections of the Act and give commissioners legal duties that are directly relevant to public involvement.  These are reporting requirements about planning and meeting their public duty, with the CCGs having an additional legal duty to consult the public on their commissioning plans.

The commissioners also have more legal duties in the Act – about service quality,  reducing inequalities in access to services, service outcomes (or results) and the patients’ experience of services.  These are all important to people needing services and have a connection to public involvement in that, it could be argued, they demonstrate the importance of public involvement in providing effective services.

The relevant sections in the Act and the wording of these other legal duties are all listed in a document available at – Other Legal Duties of Commissioners.



What the NEW Statutory Guidance says –

(about direct public involvement in commissioning)

The new statutory guidance describes exactly which commissioning activity should involve the public, lists TEN ACTIONS that clearly say what commissioners should be doing to involve us, and gives links to other relevant guides and policies on the NHS England website.

It also lists Ten Principles of participation gathered from ‘ a review of research, best practice reports and the views of stakeholders’.  But doesn’t say which research and reports they were based on or which stakeholders were asked.  We don’t disagree with them, just think there are much stronger involvement principles that could have been listed.  See P 11 of the word version.

So – back to the 10 ACTIONS that clearly say what commissioners should do:

This guidance sets out 10 key actions for CCGs and NHS England on how to embed involvement in their work. They should:

  1. Involve the public in governance     
  2. Explain public involvement in commissioning plans/business plan  
  3. Demonstrate public involvement in annual reports  
  4. Promote and publicise public involvement  
  5. Assess, plan and take action to involve  
  6. Feed back and evaluate  
  7. Implement assurance and improvement systems  
  8. Advance equalities and reduce health inequalities  
  9. Provide support for effective involvement
  10. Hold providers to account.”  
  • Key Actions 1. to 8. are requirements specified in LAW and
  • Key Actions 9. & 10. are implied within other legal requirements

Briefly Commissioners MUST carry out the following actions:

  • Action 1. – to promote the NHS Constitution (which pledges our right to be involved) & CCGs must have a Lay Board member specifically responsibile for Public Involvement
  • Action 2. – to explain in their annual Plans how they will involve the public in commissioning decisions
  • Action 3. – to explain in their Annual Report how they met their duty to involve the public in commissioning, & CCGs must present their Annual Report directly to the public
  • Action 4. – to make sure people know that they can be involved, and how they can be involved, in decisions about services
  • Action 6. – to record – how they give feedback, and any resulting changes – and to evaluate their public involvement activity
  • Action 7. – to monitor and evaluate their public involvement systems and make sure their performance in public involvement continuously improves
  • Action 8. – to have inclusive public involvement programmes that enable people to be equally and fairly involved without discrimination
  • Action 9. – to provide support to both enable involvement and remove barriers to being involved
  • Action 10. – to be sure providers meet NHS Standard Contract service condition 12 and in particular 12.3, 12.4 and 12.5 which are about inclusive public involvement

ACTION 5. – explaining this action takes up nearly a third of the whole Statutory Guidance 

This shows how the content of Action 5 is considered very important and needed to be explained in detail – which it was in:

  • 14 pages (Ps 15-28) out of the 50 pages  word version of the Statutory Guidance and
  • 19 pages (Ps 17-35) out of the 61 pages  on-line version

It clearly explains the assessment, planning and action that needs to be taken to involve the public in commissioning in a way that meets the legal duty to do so.


8.1 and on Ps 15-18 (word version), explains how to recognise which activities are commissioning functions where the legal duty to involve the public applies, giving examples for them.  (These include things we are often told are not our business.)

It says clearly, on P16 that:

CCGs and NHS England are required to always have arrangements in place to involve the public in the planning of commissioning arrangements, regardless of the impact these plans would have on services if they were implemented.”  

The introductory list includes the following as commissioning activities:

Changes to commissioning arrangements” such as:

  • “plans to reconfigure or transform services or improve health.
  • “changes to services, new models of care, new service specifications, local improvement schemes, etc.”
  • “Reconfigurations involving movement of services from one provider or location to another.”

Procurement” such as “Considering or developing proposed models, configurations or specifications for a service and “Commencing a procurement process”

Contractssuch as “Entering into a contract with a provider” orVarying a contract, other than a variation required by law. “Serving a notice to terminate a contract with a provider” or “Receiving a notice to terminate from a provider”

“Overview and scrutiny referral” “Any instance in which a referral has been made to the local overview and scrutiny committee.”

“Equality” such as “An equality impact analysis may indicate the need for engagement, for example a lack of evidence relating to certain groups.”

Planning and taking action:

8.2 Ps 18-19 (word version) starts to explain how to plan and take action to involve the public in commissioning.  It includes the importance of looking at ‘insight’, such as information they already have from surveys, complaints etc. and any previous public involvement exercises around the same or similar service change.

8.3 Ps 19-20 (word version) looks at who should be involved in the commissioning arrangements and starts by saying, “Staff should involve patients and those who may use services in future. This includes carers and families, where relevant.”

And on P 20 (word version) it says a lot about involving the public ‘via representatives’ saying:

” Ideally, CCGs and NHS Egland should engage directly with the population affected by the commissioning activity, but in some circumstances, some aspects of public involvement  can take place via representatives.”   (our emphasis)


“Where involvement takes place via representatives, staff should seek assurance that the representatives offer a fair reflection of the views of others. Engagement through representatives should only be used where directly engaging with service users is not practicable or proportionate. It should complement – not substitute – opportunities for direct engagement.”   (again our emphasis – see the quote we show below from P20)

8.4 Ps 20-22 (word version) talks about how people should be involved saying that when “public involvement is required, staff will need to make their best possible judgement on what is a ‘fair and proportionate’ approach to the circumstances”.

8.4.1 Ps 20-21 (word version) describes the Gunning Principles as a recognised way of demonstrating ‘fairness‘ giving useful information – that could be used to challenge ‘unfair’ consultations.  They apply to a formal consultation process, though, which is only one type of public involvement.

8.4.2 Ps 21-22 (word version) describes how the commissioners should demonstrate ‘proportionate‘ activity and implies that the involvement activity should be in proportion to “the extent of changes and number of people affected“.

It says staff “need to consider their duty to involve the public alongside their duty to act effectively, efficiently and  economically”.  Also that staff “will need to consider the impact of proposals on people who may be affected” and “should also consider the potential impact on other services which they may not commission, and issues for patients beyond the clinical services themselves, such as accessibility, transport links and ambulance availability”

It then adds – “Location, access and demographic issues need to be taken into account, for example, considering how a population in a rural area or how children and young people may be particularly affected by a change to services.”    

8.5 P 23 (word version) talks about working with the VCSE or voluntary, community and social enterprise  sector as a source of expertise in reaching disadvantaged communities. But it says NOTHING about VCSE staff speaking FOR patients and the public which is what’s been happening lately.

8.6 P 24 (word version) talks about working with Healthwatch in their statutory role to gather the views of patients and the public about health and care services. However as the experience people have of the effectiveness of their local Healthwatch varies enormously we will comment no further.

8.7 Ps 25-27 (word version) looks at when involvement should take place and says that “involvement should never be left to a time when the views obtained could not make a meaningful difference to the approach being taken. Involvement should not typically be a standalone exercise such as a formal consultation. It will generally be part of an ongoing dialogue or take place in stages.” 

It suggests when the public should be involved such as:

“…… for example in: 

  • designing the approach to engagement
  • developing options
  • refining options
  • formal consultation on a limited range of options
  • and being informed about the outcome of the consultation and the decision taken.”

It also says that “Staff should continually assess the effectiveness of public involvement throughout the commissioning process” and gives examples where further work is needed – such as feedback that’s not been fully considered, repeated concerns and very few people involved.

8.8 Ps 27/28 (word version) looks at decisions needing to be taken urgently and says this is sometimes the case and it “may be necessary to consider the duty to involve the public alongside the public interest in maintaining continuity of care and protecting the health, safety or welfare of patients or staff.”  

However it goes on to say:

“It will only be reasonable to justify carrying out a limited (or no) public involvement exercise on grounds of urgency when the lack of time was genuinely caused by an urgent development or where there is a genuine risk to the health, safety or welfare of patients or staff. It does not permit CCGs and NHS England to leave public involvement until the last moment without enough time to carry out a fair and proportionate exercise, when the public could and should have been involved earlier or to a greater extent.”

8.9 P 28 (word version) looks at managing the outputs of public involvement, such as recording who was involved, how, when and where – and what was said.  It describes the conflicting opinions that are likely to be given – such as parents and young people, and patients and their carers.

The guidance says that staff “need to be able to analyse these differences of opinion and to identify the most appropriate course of action, considering factors such as the representativeness of views expressed.

However we (National NHS Public Voice) are concerned that this implies that staff should take one opinion as more valid than the other, rather than ‘taking account of’ both in the service planning and delivery, (which would be recognised as basic involvement best practice.)

Local variation in commissioning arrangements

In the summary on P5 of the Statutory Guidance it says:

“The guidance also explores some of the complexities of commissioning in a changing healthcare landscape, in relation to co-commissioning, devolution and joint arrangements, including accountable care systems (ACSs).”

On Ps 37 – 41 (word version) it does explore these issues, but using jargon.

We (National NHS Public Voice) are concerned that, despite these being new situations most people don’t understand, many people don’t even know about them, as there is no public information about them being published, or any attempt to explain the ‘complexities’.

There are NO leaflets or posters – explaining these – at all!

We also fail to see why the pages ‘exploring’ these new ‘complexities of commissioning’ describe it all in a more ‘management style’ of language and layout that appears to repeat the technical documents used in the NHS higher management circles.

How can the public be involved in local variations in NHS commissioning if the information explaining the ‘complexity‘ uses inaccessible language?

In other words – these pages (37-41, word version) are not helpful.

People, and front line staff, are trying to understand what all the NHS changes being talked about actually are, how they will be affected by them, and how will they be involved in deciding which local changes are to be made.


Plain English information is produced for the public and for front line staff.  

This needs to clearly explain the new terms, the new NHS partnerships, and any implications for accountability, for services and for public involvement in commissioning decisions.

  • What are local variations and existing flexibilities?
  • What is meant by co-commissioning, delegated commissioning, devolved commissioning and joint commissioning – and how are they different?
  • What are all the new local organisations or partnerships called?
  • Which organisations now make decisions?
  • Which one(s) are responsible for those decisions?
  • Which one(s) are responsible for the money?
  • Which one(s) are responsible when things go wrong?
  • How do these new local variations/flexibilities ensure public involvement in commissioning arrangements and commissioning activity?
  • AS LAID OUT IN THIS STATUTORY GUIDANCE (for public involvement in commissioning)


     download (2)

How commissioners ignored the law –

(about direct public involvement in commissioning)

CCGs are supposed to involve the public in their local work, and the CCGs that work together to develop STPs are supposed to involve the public in them too.

The public have had a legal right to be involved in decisions about health and care services for over ten years now, and this right was strengthened by the 2012 Act.  Our right to be involve has been respected in the past.  BUT now it is being ignored.

  • There has been little direct public involvement in local service commissioning.
  • There has been no direct public involvement in developing the STPs – at all!

Some people may disagree and say – ‘OH YES THERE HAS!‘  But they’ll be describing some local commissioning, or STP, events and meetings where a member of the public was asked to go – to ‘represent the public interest’.

  • They’ll have been either invited, or selected, by the NHS to ‘represent’ us – the public
  • There’ll have been no expectation that they’d talk to us to find out what we want them to say ‘on our behalf’
  • The meetings or events they attend are not reported publically
  • So we don’t get to know what they actually said ‘on our behalf’
  • And don’t find out what was talked about at the meeting, or event, they attended

DIRECT means ‘without any person, thing or event intervening’

REPRESENT means  ‘be a substitute or deputy for’ or ‘be entitled to act or speak for’

(Oxford English Dictionary)

The public, as individuals, should be able to be involved ‘DIRECTLY’ in NHS decisions. But we have only been involved indirectly through unaccountable representatives who don’t report anything back to us.

The public should be directly involved in ALL the NHS commisioning arrangements.   But commissioners are not involving us in any decisions about proposals for changing their commissioning arrangements, nor in procurement, or contracts, or plans for restructuring of services including their relocation.  (see Action 5 – introduction & 8.1).

The public should know when commissioning changes are being planned, and any planned public involvement in this should be widely publicised. Any involvement in commissioning is usually by invitation only, only a few people are told about it.  The public are neither told about, nor involved in, the discussions before a service change is considered by commissioners to be necessary.

The public should be consulted at the planning stage, not after a change is agreed as necessary. Commissioners mostly think they only have to consult us after they have decided to make changes to the availability of services, by closing or relocing a service.  They don’t ask us what we think could make the service(s) work better, just what we think about the decision they are taking as they believe it is necessary, on our behalf.

Public involvement should make it possible for the public to influence any decisions. Commissioners imply we can influence or alter their decision, which is clearly not their intention as they present ‘a case for change’ and a recommended option that they say is necessary.  This shows the consultation is a ‘tick box’ and endorsement exercise regardless of the responses or response rate.

The public have no forum to elect their representatives, to discuss service issues together and to have a collective voice.  The adult public are not treated as fairly as the youth forum, medical committees, or other ‘stakeholders’ who have such collective involvement and representative arrangements made available to them.

The public should be able to choose their own representatives.  But our representatives are neither chosen by us nor are they accountable to us.  There are no arrangements or support systems provided to enable people who represent us to find out what our views are, or to report back to us.

We (National NHS Public Voice) RECOMMEND that – anyone who ‘REPRESENTS the public’ should:

  • know the views of the public
  • report back to the public on what was talked about
  • report back to the public what they said ‘on our behalf’
  • and be clear and honest, in their role

In this last point, by ‘being clear and honest in their role’ we mean that when they speak at a meeting or event, as a public representative, they should be clear and honest about:

  • when they are giving their own personal opinion
  • when they are reporting the collective views of the public
  • and when they will need extra time to ask the public what their views are about a particular subject, and to bring these views back to a future meeting/event


We’ve said, many times, that our unaccountable and selected representatives, without a regular dialogue with the wider public, can only represent their own views based on their own experience and knowledge.

Our members have also said this many times in public in front of NHS England staff and Directors at event ‘Question and Answer’ sessions, and directly to them in conversation.

Have a look at this quote shown on P24 of the Online version of the Statutory Guidance:

“Are your
actually representing the
community – or just their
own personal views?

NHS England patient and
public voice partner

  • Do some NHS Patient & Public Voice Partners agree with us?
  • OR – Has NHS England actually been listening to us!


Our ‘model of involvement’ (National NHS Public Voice’s) is more inclusive and representative than the ‘model of involvement’ used by NHS England and by most CCGs as this chart shows:


We, at National NHS Public Voice, have also said many times that:

NHS England’s new public involvement arrangements are excluding individual members of the public.  

We have shown why we think this in some of our former posts, such as:

These older posts were written in December 2016 and January 2017. BUT – there is still NO information for the general public on:

  • What the new NHS Citizen Programme offers for direct public involvement, or
  • Who the new NHS Citizen Board members are, and
  • What the new Board are deciding ‘ on behalf’ of the public about
  • How  we will be involved in NHS England’s commissioning decisions.

National NHS Public Voice (N-NHS-PV) says that:

NHS ENGLAND, and all the CCGs that are arranging STPs, should OBEY THE LAW


Documents for downloading:

processed-collective-birds (1)




Shh! It’s a secret! The NHS involved us, the public, in its decisions – but they didn’t tell us how or when!

Well – NHS England has just re-written their guidance document saying how the public should be involved in decisions about the NHS. But – they kept this a SECRET! They only involved a few ‘select’ members of the public – in deciding how the NHS will involve ALL of us, the public, in NHS decisions in the future!


But – N NHS PV found out.  So we’re telling you.cropped-megaphone.jpg

(We were not included in the list of the ‘select’ few – who were invited to a workshop and sent some draft documents to comment on – but we have some new members who DID know – and they thought the Public SHOULD know!)

So – What is this all about?

In April 2013 the Health & Social Care Act became law.

This Act created both NHS England, the national organisation responsible for all NHS services in England, and Clinical Commissioning Groups, or CCGs, which are local organisations responsible for our local NHS services.

(There are 209 CCGs across England – Northern Ireland, Scotland & Wales are each responsible for their own NHS services).

The Act includes a legal duty for Public Involvement in the ‘commissioning arrangements’ of NHS services, (how they are planned and delivered) for both NHS England, in Section 23 13Q, and the CCGs, in Section 26 14Z2.

In September 2013 NHS England published a guidance document called ‘Transforming Participation in Health and Care for Clinical Commissioning Groups, CCGs.’

 This document has now been removed from the NHS website as it was replaced, on 6/4/17 by a new version , which is still the Statutory Guidance explaining the legal duty in the Act that CCGs MUST ‘have regard to’! 

This guidance shows CCGs how, and when, to involve both patients and the public in the decisions they make about how local NHS services are commissioned (planned and delivered).

The guidance is a legal document, intended to explain the wording of the Act.

It is the CCGs’ responsibility to make sure the NHS services local people need are made available to them, and they ‘must have regard to any guidance published‘ by NHS England about public involvement in decisions about these services. This requirement is also stated in Section 14Z2 of the Act.

In 2013, the original guidance explaining this legal duty was designed and written jointly, by NHS England working together with members of the public.  These were people who had used the NHS in England, and many gave their stories and described how they were often involved in improving the NHS services they relied on.

However in November 2016 Olivia Butterworth, who is the Head of Public Voice at NHS England, said she wanted people to help her make changes to the original guidance document.  She did this in a news blog, OB news blog 25.11.16, on the NHS England website News page, saying that this original guidance “has become outdated”  as “we’ve moved on” now.

Sincere apologies – the original link to her blog now takes the reader to another page on NHS England’s website as they have removed her blog from the website – completely!  

So we have inserted, instead, a copy we made and saved of her news blog – in case such a thing ever happened.

How were the public involved in ‘updating’ the guidance about involving them?

Olivia invited anyone to send in, by email to her, their ideas about how this guidance should be ‘updated’ before Friday 13th January 2017.  But this was a general invitation, for anyone, not just for the public.

And it only gave people seven weeks to respond, which included the Christmas and New Year holidays, so it was not likely to attract lots of responses.

She gave many reasons in her blog post for the urgent need to change this document.  But there were a number of people who wrote comments on her post and were not impressed.


You can see these comments by clicking on this link – comments-on-olivias-blog-post.  

They were at the bottom of her blog page, but have now been removed (in early March 2017).  

The blog post itself has also now been removed (mid-March 2017).

(They moved her blog post weeks ago from its original November position on the general News pages and put it on the Involvement Hub News pages. But there was NO information showing where it had been moved to –  in case anyone who had seen it originally wanted to revisit it.)

It makes you wonder – Did they want us to see it – or did they mean to hide it? 

We don’t know whether all these comments made on her blog post page were included, or taken account of, in the ‘updating’ of the original guidance.

This ‘send all your ideas to me’ method of ‘involving people’ meant that the ideas people sent in were only seen by her  – and those she chose to share them with.

That was not very ‘transparent‘!

There was no open discussion possible for people to share their ideas, and develop them together, other than all the blog post comments – which are no longer online for all to see!

We don’t know:

  • how many people sent ideas to her,
  • what they said, and
  • what was recorded,
  • which contributions were accepted, and
  • which were rejected
  • or why.

This is not an inclusive, meaningful or respectful way to involve the public.

It is certainly NOT ‘transparent’.

It shows a controlled, disempowering, tokenistic, and ‘managed’ approach to involving people in decisions.

What happened next?

We, the general public, haven’t heard anything since the general invitation to suggest ideas for ‘updating’ the guidance.  We haven’t been informed about what has happened.

But we now know that Olivia, on behalf of NHS England, had been busy in the meantime – behind closed doors!

Now – we can ‘show’ you the work that has been done – behind those closed doors.

Our new members include some on the list of the ‘select few’ who have been given ‘inside information’ and we thank them for sharing this with us.

We are able to reproduce it here for you, the general public, to make sure you are no longer completely ‘left out’ – not knowing what these draft plans are to involve us in decisions about our NHS.

Here is the ‘inside information’:

What happens now?

We haven’t been informed.

But the workshop slides suggest that a final version of both the Draft Guidance documents, above, will be published at the end of March 2017.  It is not clear if this will be after being approved by the the NHS England Board, or not!

We think that you, the public, should know about a decision soon to be made by NHS England about how you, the public, are to be involved in NHS decisions!

Unfortunately the deadline for comments was 23rd February 2017.  So we have all missed the deadline.  We sincerely apologise for not being able to share this with you earlier.

We can only hope that when the final version of the Statutory Guidance for Public Involvement is published, maybe at the end of March, NHS England will decide to formally consult us all before the new guidance is set in stone.

What N-NHS-PV thinks!

That NHS England is proposing to move far away from its original declared promise, and legal duty, of ‘transparency‘ and ‘participation‘:

This promise was clearly stated on P2 of the minutes of the inaugural meeting of the NHS Commissioning Board, later called NHS England, in October 2012 in the description of the role of the NHS Commissioning Board, which is now called NHS England.

But NHS England demonstrates this move away from the original promise:

  • in the content of their new draft Guidance document for involving the public
  • and in the way they seemed to rule out actually involving the public in ‘updating’ the one that was published in 2013 – about how to involve the public

NHS England has ignored ‘transparency’ in developing the draft guidance for Public Involvement which has been:

  • changed in a way that was developed and written in secret
  • changed by involving very few ‘selected’ people in its development
  • controlled by NOT ensuring these people actually ‘represented’ the wider public view
  • developed with the timescales for feedback too short to involve the wider public

We respect our new members who actually shared the drafts with lots of people.

NHS England’s new guidance gives no recognition of the tradition of user-led, inclusive Patient & Public Participation in the NHS:

  • This was still practiced when the minutes of the first meeting of the organisation later called NHS England, were written in October 2012
  • Public involvement was then still ‘facilitated’ (supported and enabled)
  • Rather than being ‘managed’ and ‘controlled’ as it is now, and as the draft guidance document suggests it should be in the future

NHS England’s new guidance does a U turn on the time when people:

  • were ‘supported’ and ‘enabled’ to be involved in decisions about the NHS
  • had individual differences recognised and any barriers to being involved removed or addressed to allow everyone an equal voice
  • had experience and understanding respected and valued
  • were treated with respect and offered an inclusive and equal model of involvement
  • were NOT segregated into ‘silos’ based on ‘need’ in a way that masquerades as equality

But that’s not the end of this down-sizing of the Public’s role in the future of Our=NHS – GONE is the accountability of:

  • NHS service planners to the Public for their decisions about the NHS
  • NHS commissioners to the Public for their Public Involvement arrangements
  • NHS-chosen ‘patient representatives’ to the Public for all they say & do ‘on our behalf’

In fact we, the public, won’t be told who these Patient representatives are, how they act and what they say as they ‘represent’ us, or even how they ‘consult’ us.

NHS England are making decisions  FOR us – the people who use, and pay for, Our=NHS

The guidance does NOT describe how to meet the actual wording of the relevant parts of the Health & Social Care Act 2012, which is its purpose: 

  • The actual wording of the Act, in both Section 23 13Q, (for NHS England) and Section 26,14Z2, (for CCGs) states clearly the legal duty to involve the public requires them to involve ‘individuals to whom the services are being or may be provided
  • The draft guidance promotes a ‘top down’, management-led approach to Public Involvement through NHS managers selecting a few people to involve in the decisions about service planning and delivery
  • It introduces a targeted approach to equality, making assumptions about people, even suggesting that voluntary organsations can speak for the people they provide services for

Individuals should decide who they want to speak, or advocate, for them:

  • The draft guidance is NOT describing the involvement of the ‘individuals to whom services are being or may be provided
  • To do this the NHS should be aiming to involve all the individuals within the general public, to hear all their views, and allow them to choose their own representatives

The new document gives Statutory Guidance and should match the requirements in the Act, which refers to ‘individuals‘:  

It should NOT substitute the people that the NHS chooses to act as ‘patient representatives’ for The Real Thing, members of the Public:

  • Members of the public mean just that – individuals
  • Individual members of the public should all select the individuals to represent US
  • We should all be informed and involved in decisions about Our=NHS


We will look at how the NHS England officers are advising CCGs to involve us, the public , in future decisions in a new post:

  • WHEN the new Statutory Guidance is published – end of March 2017 (maybe)
  • As a NEW document ABOUT INVOLVING US – that DIDN’T INVOLVE US in writing it!

Please tell us what YOU think – about this undermining of the role that the Public used to have in decisions about the future of Our=NHS.

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.






Will the New NHS Citizen Programme involve citizens (people)?

In September 2016 the Board of NHS England approved a new way of involving people in their work (to make sure that the NHS in England provides the services people need and that these services are accessible, safe and effective.)


Will the NHS Citizen Programme really involve the public in a way that allows them to influence the work of NHS England?

What’s in this New NHS Citizen Programme?   

Well to be honest we’re not really sure.  The only information that is available to the public is the paper that was presented to the NHS England Board.

And as it says:  “This paper provides a summary of the changes to NHS Citizen since the November 2015 Citizens Assembly, and the proposed new approach for delivery.”

However the paper is not written in Plain English – as the title clearly shows – it is called “Improving the quality of customer insight through NHS Citizen” – so it’s basically in ‘management speak’ and will need some translating maybe!

On P3 (item no 10.) the Board paper says: nhscitizen-guide

“The new approach for NHS Citizen aims to:

i.   Strengthen public participation in NHS England in line with our new participation policy, and to meet the requirements of the duty to involve;

see P34 – Appendix 1 – of the document this link takes you to where  Section 13Q – or the ‘duty to involve’ – is explained

ii.   Support NHS England commissioners, policy and programme leads nationally and within the regions to have the tools to engage patients and the public and learn from existing insight;  

We think this seems to be about all the different parts of NHS England  knowing how to gather the views and suggestions from patients and the public and to make use of what people say in surveys and on line feedback sites.  (basically ‘insight’ = feedback from people that offer solutions to the problems)

iii.   Enable citizen input through a single, simplified approach which is easy to access, and meets the needs of different patient groups without generating significant labour intensive approaches for citizens or for teams;  

We cannot guess what is meant by this.  Involvement takes time to plan, facilitate and support if it is to be done in a way that doesn’t exclude people, is meaningful and is led by those involved – who decide the conclusions from any collective discussions for themselves.

iv.   Manage the public’s expectation around where their feedback will lead; and    

We have no idea why there is a need to ‘manage’ the public’s expectation about where their feedback will ‘lead’.  Staff supporting involvement should be honest and open in the first place about how much influence they are offering. Involvement facilitation is about clear communication and not about ‘managing situations’.

v.   Explore further an initial partnership between NHS England and Healthwatch England to provide more of a one-stop shop for the public (with the potential to increase the reach of the partnership further as the approach develops and following discussion with other ALBs). ”    

We ask – does the public want a one-stop-shop for involvement?  Are the organisations talking about working together for their own convenience or ours?  (By the way ALBs = Arms Length Bodies or organisations that are part of the NHS but not part of NHS England).

Surely this one-stop-shop has nothing to do with involving people in NHS England’s work – it’s about involving people in the work of lots of NHS organisations. Shouldn’t each be separately held to account for what they do by the people who pay them and they effectively work for?


On Ps 3 & 4 it says:

“It is proposed that the new programme will contain:

i. NHS Citizen online: A repository (= a place to store stuff or information safely) for feedback from a variety of data and engagement, including surveys and insight from the local Healthwatch network. This will be structured around national NHS England priority areas; (Why – it should be about NHS England’s accountability to the public!)

ii. NHS Citizen outreach: Dedicated engagement and co-production (= working in an equal partnership with patients & the public) with specific communities of interest, (= people with something in common e.g. race, disability, where they live, age etc.) linking into national priority areas (Whose priority areas – ours or NHS England’s?) to ensure that we are reaching out to and hearing from all populations e.g. through the youth forum, voluntary sector strategic partners and health inequalities networks.

iii. Citizen representatives (bringing together the c800 Patient and Public Voice partners) on relevant governance groups across NHS England, building on the existing participation infrastructure of having lay representation in governance (eg on Clinical Reference Groups etc) to bring all representatives within a single repository (= safe place to keep the knowledge – or the representatives?) supported by a Customer Relationship Management (CRM) system called People Bank. (800 people representing all 55,000,000 in England?)

iv. Involvement hub: A web-based involvement hub providing on-line resources and signposting training opportunities. (Have a look and see what you think – nothing about what the 800 representatives say on our behalf or how to contact them – or what the NHS Citizen Programme is about!) This will be launched in in the autumn to support patients and the public to develop the skills and confidence to influence NHS England’s work, (What if you haven’t got access to the internet and are left out of all this?) and to support NHS England’s staff to develop the skills and confidence to work effectively with patients and the public.

v. An NHS Citizen campaign: An underpinning communications plan. This allows a means of maximising the successful brand  (Pardon – what brand? We thought this was all about the legal accountability of NHS England to the public.) to simplify the many engagement routes and approaches across the ALBs.  (ALBs = Arms Length Bodies that are part of the NHS but not part of NHS England) It is expected that this will be developed as part of the plans to support implementation of Sustainability and Transformation Plans (STPs).”  

We are aware that the STPs are local area partnerships that have each planned how services will change over the next four and a half years across their area. There are 44 STP areas in England.

Services need to change because the government is not giving the NHS – or social care – the money required to meet the increasing need for the services they provide between now and 2021.

There is an extra £22 billion needed to cover the costs of meeting this increasing need for NHS and social care in England over this time.  But with no more money, and many providers in debt already, the managers are having to make savings to cover this missing funding.

Some services will close and people will have to travel further to get treated.


N-NHS-PV (National NHS Public Voice) think that the NHS Citizen Programme:

  • Will exclude people, especially those who don’t use the internet
  • Will not follow accepted best practice in involving the public
  • Will be NHS England managers ‘ticking boxes’ – not ‘co-production’
  • Will be ‘top down’ and controlled – not collective, together or equal
  • Will not allow the public to offer ideas and solutions to improve services
  • Will not allow the public to influence any NHS England decisions
  • Will not involve the public in decisions at all – only representatives
  • Will only ‘consult’ the public – ask what we think of decisions already made

Please let us know what you think about the NHS Citizen Programme.