Dear Wes Streeting, I’m worried about patient and public involvement

This is Blog no 96

Everyone realises what a tough job the Health Secretary faces.

That’s why criticism of his decision to scrap NHS England has been muted. In any event, there was a strong case for dismantling a structure whose raison d’etre was to oversee the cumbersome structure of 300+ Clinical Commissioning Groups (CCGs) invented by Andrew, now Lord Lansley. 

I had expected many of its functions to be absorbed into the Department of Health & Social Care, but I’d also assumed that some other activities would have been ‘devolved’ downwards to the Integrated Care Boards (ICBs).Instead, Ministers are obliging the 43 ICBs to halve their administrative costs – apparently in the belief that this will help rather than hinder the transformation that’s needed in the NHS. It is a very risky strategy.

I will leave others to debate whether or not this all makes sense in terms of clinical and health improvement objectives. But this blog will consider the potential implications for patient and public involvement, which, until now I had believed to be a  fundamental cornerstone of our NHS.

The involvement of local communities has been ‘baked into’ the NHS culture for years. It goes back to its earliest days when Aneurin Bevan’s organisational design amounted to a giant top-down autocracy, moderated by a commitment to engage with and consult local people and preserve a local identity for the new service. In time, these became enshrined in law – with special provisions for consultation and engagement whenever changes to the services were contemplated. In all the reorganisations and reconfigurations, the duty to involve patients and public remained sacrosanct, and legislative opportunities to water them down firmly resisted. No Minister wanted to be accused of downgrading the voice of patients.

However, it has not been plain sailing. Politicians in a hurry and clinicians under pressure have frequently sought to by-pass or circumvent the legal requirements to consult. Many have ended up in the High Court and been reminded that it is unlawful to deny local people their rights to be consulted on significant changes to their health service. Neither have Ministers been too eager to be identified with unpopular changes. They invented the (excellent) Independent Reconfiguration Panel (IRP) to help adjudicate on the most contentious ones, and when withdrawing the right of local Health Scrutiny bodies to refer them to the Secretary of State, opted for the power to ‘call in’ some proposals. Why? Because the voice of patient and public matters. And that won’t change.

What MAY change – is the ability to carry it out.

On 1 April, this was spelt out. NHS England announced its forward approach to ICBs and explained where it expects to shed staff. This is the crucial paragraph:

    “To meet this expectation, you should look carefully at functions where there is duplication. This includes:

• a number of assurance and regulatory functions (for example, safeguarding and infection control) where this is already done in providers and, in some cases, regions, without compromising statutory responsibilities.
• wider performance management (as opposed to contract management) of providers which again already takes place in providers and at regional level.
• comms and engagement which similarly exists in local authorities, providers and regions."

The intention could not be clearer, and whilst it is true that there are communications teams in Councils and in Hospital trusts, any thought that they could cover the community engagement work currently undertaken by ICBs is fanciful.

The 2022 Act introduced Integrated Care Partnerships (ICPs) – recognising the need to engage Councils, health providers and the voluntary and community sector together in addressing health inequalities, preventative health and social care. Legislative intentions don’t always translate into effective activity, and it is usually because Parliament can “will the ends”, but it is Governments that control the means. Creating, sustaining and empowering these partnerships does not happen at the keystroke of a laptop. They need experienced community engagement staff able to work with representatives of very diverse organisations. Reducing their number will inevitably affect progress towards these laudable aims.

In a previous Blog, I quoted from last Summer’s Darzi Report: He was critical of the impact of Lansley’s re-organisation. He said: “Experienced managers left meaning the NHS lost their skills, relationships and institutional memory.” If we experience a further haemorrhage of community engagement staff from ICBs, precisely the same will happen. Last time, it took years to rebuild the capacity and capability to engage professionally with anxious patients and public. If we allow the same to happen, it will slow down the recovery of the NHS.

A further cause for concern is the suggestion that Ministers want to discourage any opposition to their plans – similar to their rush to approve major infrastructure projects by limiting the scope for dissent and legal challenge. I was struck by this passage from HANSARD on 13 March when the demise of NHS England was announced by the Secretary of State

        “My cautionary note to Members across the House is that when we ask frontline leaders to reform and to    

         change ways of working, sometimes that requires not just changes to the bureaucracy as it were—the

         easier and lower hanging fruit—but service reconfiguration in the interests of patient outcomes and better

         use of taxpayers’ money. Sometimes, they get those changes wrong. I have successfully campaigned

         against closures of services such as the King George accident and emergency department, which should

         not have closed and where we won the case on clinical grounds.

         Sometimes, let us be honest, the public can get anxious, and Members of Parliament feel duty bound to

         act as megaphones and amplifiers for public concerns. It is important that we support and engage with

         local NHS leaders. By all means, we should scrutinise, challenge and ask questions, but we must give

         local leaders the support to do the task that we are asking of them on behalf of patients and taxpayers.

         The powers that I have to intervene in those frontline service reconfigurations are ones that I will use only

         in the most exceptional and necessary cases, and that is why I have not used them once in the past

         eight months."

On matters like this, one must be careful not to over-interpret the odd sentence in the House of Commons, but do I detect in this passage a characterisation of some local people as being the ‘blockers’ that the PM has castigated for opposing housing or infrastructure projects?

For certain, if we economise on the NHS’s ability to communicate its local messages well, to meet with and address their concerns and to mobilise community talent and know-how through co-production and other methods, we will just antagonise patients and public, and the task of re-configuration will simply get harder.

Now for some positives:

• This gives us a perfect opportunity to think through the role and necessity for patient and public involvement in the NHS – and the struggle to integrate those ideas with the fragmented social care sector.
• The need for community engagement remains – both in statute – and in practice. If the dedicated headcount is reduced, history shows that Senior Managers will have no choice but transfer others – often untrained – because there are tasks that someone will have to perform. It could be a great time to be a freelance consultant in public engagement – or to be one of the handful of specialist firms who know how to design and deliver public consultations …!
• Members of Parliament will face conflicting pressures. Wes Streeting discouraging them from acting as ‘megaphones’ will not dispel their constituents’ anxieties. Now is the time for existing public and patient staff to approach them costructively - and help them understand the lubricants necessary to oil the wheels of local involvement.

In addition, however, the public engagement community – myself included – need to be creative. The one-size-fits-all approach to consultation needs a serious re-think as we embrace different, quicker, and more effective ways to listen to the public.

In Blog 79, I argued that the Darzi Report’s catalogue of NHS failures should also have included the failure of patient and public involvement to challenge the NHS decline in recent years.

Maybe we now have a chance to do better!

Rhion H Jones LL.B

2 April 2025

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