“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)




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

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


What are we talking about?

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

Please be patient – it is very complicated

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We share two extracts from this email.  

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

First Extract:

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

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


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

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

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

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


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

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


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


Second Extract:

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

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

We note that:

Healthwatch England produced a summary of the five key things that communities should expect in getting involved in decisions that affect them, particularly about service changes –     http://www.healthwatch.co.uk/reports/5-things-communities-should-expect-getting-involved.  These are not happening in Barnsley.

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

I understand Healthwatch has had some technical issues with their website, which have now been resolved and the information is available.  See http://healthwatchbarnsley.co.uk/get-involved/south-yorkshire-and-bassettlaw-stp/ The team has also been using social media to raise awareness of the opportunities for Barnsley people to have their say, as well as adverts in the Barnsley Chronicle.

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


BSONHS are arranging to meet with them in April –

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

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

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

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

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

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


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

Please share with us either:

  • VIA our contact page
  • OR as a comment on this post (we don’t put these online straight away)
  • OR by email to n.nhs.pv@gmail.com

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


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

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


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

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

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

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

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

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

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

The crisis in the NHS has been a political choice.

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


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


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

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


Why are STPs happening?

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

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

BUT managers responsible for NHS services have to cope with:

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

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


What have NHS leaders done to fix this?

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

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

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

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

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

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

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

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


What is an STP?  (Sustainability & Transformation Plan)

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

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


What services will be in this STP?

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

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


What will they mean for hospital services?

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


What will they mean for community services?

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


What will they mean for patients & the public?

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



NOTES – to explain some of the information 

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

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

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

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

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



2016 – A summer of secrets successfully challenged by the voice of the public.

How NHS England covered their backs by publishing, on 15/09/16, ‘Engaging Local People – a guide for local areas developing STPs’ after public outcry, including a direct challenge by National NHS Public Voice.


The wider public started to hear about STPs (Sustainability & Transformation Plans) in the late spring of 2016.  These are now required by the newly formed ‘footprints‘ which are made up of large groups of health and social care organisations in order to plan services on a larger scale, for a much larger area and population than the statutory CCGs (Clinical Commissiong Groups) that plan and contract NHS services at borough level.

This new public awareness of previously secret changes in the NHS was combined with the growing publicity about the Junior Doctors’ dispute over unsafe contract changes, the lack of funding for the NHS and the growing hospital debts.


Hospital Trust Finances        (Green = surplus  &   Red = deficit)

It was also becoming increasingly clear that the department of health was not willing to fund the increased demand for NHS services.  This predictable demand is due to an ageing population, where people live long enough to suffer from more long term conditions, and to more people surviving life-threatening conditions as there are more successful diagnostics and treatments resulting from medical research.

The work on the ‘Vanguard sites‘ was also becoming more visible to the public.  These ‘Vanguards’ were set up across England in 2015 as a number of NHS providers worked together to test out the ‘new models of care’ proposed in the 2014 NHS England Five Year Forward View. People were becoming aware of this work mainly due to the fact that many Vanguard proposals were to centralise their area’s Urgent and Emergency  Care services resulting in plans to close many local A&Es around the country.

All the documents, and guidance letters from NHSE England said that ‘engagement’ with the public was crucial to the success of the STPs and the New Models of Care, particularly in the early stages.  Such as the guidance letter dated 16th February 2016 which says:

“If we get this right, then together we will:
  engage patients, staff and communities from the start, developing priorities through the eyes of        those who use and pay for the NHS;”

However there was no public, or patient information about any of these changes, nor any involvement in the decisions to restructure local services either at an early, or at any, stage.

Informed campaigners worked hard to enlighten the public and the 38 Degrees pressure group worked with the Guardian newspaper leading to the headline on 26th August 2016:

“The NHS secret is out. And local communities won’t like it.”

This started a public outcry which grew as the message was repeated across the media. Campaigners, including those from N-NHS-PV (the National NHS Public Voice campaign), continued to challenge NHS England, about their local ‘footprints’ and their CCGs about the lack of public information on the proposed changes, together with a lack of patient and public involvement in the planning of them.

In Manchester, on the 7th and 8th of September, the NHS EXPO was held.  This was a showcase for providers in the so called ‘health economy’.  Campaigners, including from N-NHS-PV, challenged NHS England at various EXPO sessions, in public, about the secrecy of the Five Year Forward View plans through the Vanguards, New Models of Care and STPs.  NHS England senior executives were very defensive, tight lipped and gave no answers or reasons.

However one week later, on 15th September 2016, a document was published by NHS England that required the STP collaboratives to ‘engage’ with patients and the public.  This document, Engaging Local People – a guide for local areas developing Sustainability & Transformation Plans was given a very high profile on the NHS England website, and inserted at the bottom of the webpage about support for STP footprints.  This document, however had not been mentioned the week before at the NHS EXPO  –  or even appeared to exist.

This document claims that it outlines how the:

“public bodies with responsibility for the STPs have a variety of legal duties including to involve the public in the exercise of their statutory functions”.  

It goes on to say that:

“Not doing so effectively is likely to cause legal challenge and lengthy delay.”

It then repeats this message throughout the document, and on P13 it says that:

“failure to appropriately involve patients and the public in plans may lead to judicial review and criticism, regardless of any resource constraints.”

This focus on legal challenge may be linked to a Freedom of Information request sent by N-NHS-PV campaigners to NHS England in July 2016 regarding involvement of the public in the Five Year Forward View implementation, and the STPs.  This Freedom of Information request has still not been answered.


It is clear that, during the summer of 2016, the voice of the public, supported by N-NHS-PV, held NHS England to account for not making sure that the public are involved in the implementation of the Five Year Forward View proposals. 

NHS England had funded an NHS Citizen website since 2013 which included a public discussion forum called ‘Gather’. However this forum was closed overnight at the end of May 2016 – and with it went the only national public space within the NHS in England where open discussion about current NHS issues was possible for patients and the wider public.

Might it be suggested that the action, by the Director of Patient and Public Voice and Insight at NHS England, to suddenly silence the ‘NHS Citizen’ website overnight was a serious error of judgement.

Why do we need a National NHS Public Voice?

The public are not being listened to by NHS England who are responsible for the NHS in England. They don’t ask us about services only talking to the few people they select themselves. The wider public now has no voice in service changes. We should be heard.

NHS England has a legal duty to involve the public in:

  • decisions about services they commission on our behalf
  • possible changes how services are delivered to us
  • proposed changes to the range of health services available to us

But this is not happening.

NHS England pretends that it’s involving us, the patients and the public (p&p), but what is actually going on is:

  • NHS England is selecting, and paying, their own choice of individuals to ‘represent’ OUR interests and they are also inviting voluntary organisation employees to speak for US.

How can these people speak for us?  They:

  • Were not chosen by us
  • Don’t talk to us
  • Have no accountability to us

That must change.

Together we will make that change.

JOIN Our campaign for a democratic NATIONAL NHS PUBLIC VOICE (N-NHS-PV) to bring about that change.  (Please click onto our Contact Us page and give your contact details).

Regardless of this hoax, about NHS England saying they are involving us all but only actually involving a select few, NHS England has many documents and a few policies that talk about their commitment to:

“…putting patients at the heart of everything we do, promoting transparency and accountability of our work to citizens, and ensuring the most efficient, fair and inclusive use of finite taxpayer resources.”  (Malcolm Grant, Chair NHS England – the  NHS England Annual Review 2013-2014)

In October 2014 NHS England published the Five Year Forward View, which outlined proposals to change how services were delivered.  This would involve the integration of services as ‘New Models of Care‘ which would be tested out in ‘Vanguard sites‘, which are collaborations of service providers across an area covering a number of local boroughs.

In December 2015, fifteen months later, NHS England published a new Planning Guidance 2016/17-2020/21 that required all parts of England to form a ‘transformation footprint’. These were to be created by Clinical Commissioning Groups (CCGs) coming together across an area covering a number of local boroughs and based on what NHS England describes as ‘natural communities’.

There would be a maximum of 44 of these ‘footprints’ across England and each would be decided locally by the end of January 2016, that’s within a month of their announcement.  Each ‘footprint’ was required to create a ‘Transformation and Sustainability Plan’ (STP) for the population in their area, by June 2016, within six months of their announcement, and have an STP budget ready for October 2016.  Each STP would show how services for their population would be developed over the next five years, 2016 until 2021, but it was made clear in the Planning Guidance that the plans should be in line with the new models of care outlined in the Five Year Forward View proposals.

So let’s go through that schedule again:

The Five Year Forward View (FYFV) was published in October 2014, with its delivery plan published fifteen months later, but gave less than a year for the ‘footprints’ to create and submit the STPs, as a fully costed plan.

This meant NHS bodies working together, a new thing, to plan priorities and service delivery for the next few years and for a larger population, a new thing, but in a matter of months, a new thing.

The  STPs and ‘footprints’ were not mentioned in the FYFV, which, together with the increased pace of change may be connected to the change of government in mid 2015.

Where is this legally binding duty on NHS England to involve the public in how it runs Our=NHS on our behalf?

  • Were the public asked about New Models of Care?        NO.
  • Were the public asked about the new Footprints?         NO.
  • Were the public asked about Vanguards & STPs?           NO.
  • Were we asked to select our own representatives?        NO.

It is interesting to note that the only existing NHS England public voice system, the NHS Citizen website’s ‘Gather’ discussion forum, was closed at the end of May 2016 and the website made ‘read only’.  This happened overnight and without any warning and effectively took the public voice in the NHS away from the public.


Some of those who contributed regularly to the Gather discussion forum tried to meet with NHS England’s Patient and Public Participation Involvement Team to talk about the future of the public voice.  This was immediately following the unilateral closing of Gather -during the spring and summer months of 2016.  Our aim was to check that the team’s work included making sure that NHS England actually carried out its legal duty to involve the public, and did so in an open, transparent and inclusive way.

We were eventually invited to a workshop in September 2016, to discuss the future of NHS Citizen with the team and with other NHS Citizen contributors. However this plan was changed by the team later on and the invitation was then opened up to anyone who wanted to attend, without the usual restriction of ‘invitees only’, which had been implied to us earlier.


This meant the workshop included staff from any NHS or health organisation and wasn’t just involving patients and the public.  Bookings closed within hours of the event being posted on the NHS England website event pages, and many former contributors to NHS Citizen Gather and members of the public were unable to book a place.

We have to ask – Was there any connection between the following timings and actions?

  • the closure of the NHS Citizen website at the end of May 2016
  • the tight timetable for the STP submissions by June and October 2016
  • the public voice workshop being delayed until September 2016
  • the open invitation that restricted bookings from the public for this workshop

Watch out for later posts to see what happened at the September workshop.