Written evidence submitted Healthwatch England


About Healthwatch

  1. Healthwatch England is the independent statutory champion for people who use health and care services. Our job is to make sure that those who run local health and care services understand and act on what really matters to people.


  1. A local Healthwatch exists in every area of England. We support them to find out what people want from health and care services and to advocate for services that work for local communities. Local Healthwatch also act as our eyes and ears on the ground, telling us what people think about local health and social care services.


  1. We use the information the network shares with us and our statutory powers to ensure the voice of the public is strengthened and heard by those who design, commission, deliver and regulate health and care services.


The Healthwatch role in working with commissioning bodies

  1. Ever since Healthwatch was launched more than nine years ago, via the Health and Social Care Act (2012), the network of 152 local Healthwatch has strived to give local people a voice over NHS and social care commissioning decisions.


  1. Local Healthwatch took this journey at the same time as 211 new NHS clinical commissioning groups, which were also enacted by the same legislation. Relationships were imperfect but aided by the fact that GP-led CCGs often served and worked within the same local communities as those covered by local Healthwatch (who have always worked on a local authority, not NHS, footprint). Local Healthwatch worked to develop strong relationships with local GPs, CCG officers and lay members to create opportunities for local people to share their feedback and suggestions and influence decision-making.


  1. The importance of the local Healthwatch role in commissioning was emphasised in NHS England (NHSE) guidance in 2017 on the 10 key actions that CCGs should take to embed public involvement in their work[1]. This included the call to ‘proactively seek participation from people who experience health inequalities and poor health outcomes’, citing the ‘well placed’ role of local Healthwatch in engaging with ‘harder to reach groups’.
  2. As the NHS landscape began to change from 2016 with new bodies like sustainability and transformation partnerships (the precursors to today’s ICSs), local Healthwatch faced new challenges of trying to keep a spotlight on the needs of local communities as healthcare planning bodies became larger. Healthwatch England responded by tasking its network development team with supporting and empowering local Healthwatch to develop new ways of working with commissioners as well as each other.


  1. By 2021, when it was clear that integrated care systems would become statutory bodies and take over functions of CCGs via an ICS commissioning arm known as integrated care boards (ICBs), Healthwatch England was asked by NHSE to map collaboration between local Healthwatch within each ICS and between local Healthwatch and their ICS. Healthwatch England commissioned the NHS Transformation Unit to gather views from local Healthwatch and ICSs and the insight we gained from intelligence shared by 100 local Healthwatch and 37 ICSs, helped us to identify which areas needed more guidance and support. Our findings[2] found, for example, that around 80% of local Healthwatch had good working relationships with each other but 60% said a lack of funding and/or staff, were key barriers to effective engagement with their ICS.


  1. Our work also helped to shape new statutory guidance published in July 22[3] setting out the expectation of NHS bodies to work more collaboratively with Healthwatch, local authorities, the charity sector and local populations.
  2. After ICSs formally launched, Healthwatch England carried out another survey of local Healthwatch to establish how relationships had developed and to what level they said ICSs were funding them to support public involvement in commissioning. Findings of this (as yet unpublished) survey, answered by 133 local Healthwatch, are discussed in more detail below.


  1. We welcome the opportunity this inquiry affords to learn lessons and identify areas for improvement, by sharing our latest evidence, as summarised in Box 1.




  1. Response to inquiry questions

Our response to the committee’s central question, of whether ICSs are being set up in a way that will allow them to achieve their objectives, focuses on two of the four main objectives for systems:

  1. We welcomed the NHSE July 2022 guidance that emphasised to ICSs that they could not meet their objectives without involving people and to ensure they made resources available to organisations such as local Healthwatch who facilitated this work. Involvement ‘helps [the NHS] prioritise resources to have the greatest impact; and helps us make better decisions about changing services,’ the guidance says, including the locations, opening times, models of care, and patient information’ suitable for the communities that ICSs serve.


  1. However, the challenge for local Healthwatch in assisting ICSs includes the absence of a statutory seat for local Healthwatch on the governance structures of ICSs and ICBs and the lack of mandatory guidance on how constituent local Healthwatch within each ICS can be granted equal opportunity to be involved. Local Healthwatch have been obliged to dedicate extra time and effort in negotiating their place within ICS structures and working out a code for joint working with neighbouring local Healthwatch.


  1. After laying the groundwork for collaboration over the past year, we found in our latest survey that local Healthwatch confidence in their ability to influence plans for integrated care over the coming year, varied from as low as 10% in some ICS areas through to 100% in others.
  2. Most ICSs (83%) we surveyed in 2021 said that they highly valued the role of Healthwatch, particularly the constructive challenge they provided, or engagement work they carried out with local communities. At that time, 23% of ICS respondents said local Healthwatch had representation – or would do in the future – on their ICB.  This figure has now increased to 45%, according to our most recent survey of local Healthwatch.


  1. We believe this change is due to resource-intensive partnership work, that could have been circumvented if local Healthwatch had been given a mandatory, non-voting seat on ICBs. If the government had mandated such a seat, 80% of ICSs had told us in 2021 they would have supported such a measure.


  1. We would now like to see a greater number of local Healthwatch on ICBs to help ensure the ‘transparent decision-making’ required of ICBs by the NHSE July 2022 guidance. People and communities’ involvement in governance, ‘helps make the NHS accountable to communities’, the guidance states. Where ICBs choose not to involve local Healthwatch, we would call for greater transparency from ICBs of their assurance process for meeting these aims without the inclusion of local Healthwatch.
  2. The same NHSE guidance urges ICSs to ‘recognise that resources can be limited and that organisations [such as Healthwatch and the voluntary sector] may need financial support and capacity building to take on partnership roles’. This work will help address health inequalities, the guidance adds, by understanding communities’ needs and developing solutions with them.


  1. But local Healthwatch reported in our 2022 survey that 20 ICSs did not fund them for the extra responsibility of collaborating with systems, which could risk evidence on health inequalities going unheard and failing to shape service provision in some areas of England. Funding from 17 ICSs was reported by 28 local Healthwatch for individual collaboration work and six ICSs were reported to be funding nine local Healthwatch to host funding that was later distributed to other local Healthwatch in the ICS area.


  1. Thirty local Healthwatch were able to name specific amounts they had received, ranging from small sums of around £1,000 for specific engagement projects to investment of more than £200,000 for systemic involvement. This funding came from 15 ICSs and together totalled £993,449 – or an average of £66,230 per system. A typical ICS covers a population of 1.5m people.
  2. We acknowledge that any ICS investment in local Healthwatch is welcome, especially at a time when local Healthwatch budgets have fallen. Healthwatch England wrote to the then health secretary in February 2022 to warn that 81 local authorities had not passed on in full, their government allocation for local Healthwatch[4]. Variation in council funding has left a significant number of local Healthwatch running on £100,000 a year or less – some as low as £60,000 - meaning their average number of full-time equivalent staff has reduced to only 1.7 and their chief officers in some cases are only funded to work two days a week[5]. This has already created a postcode lottery in terms of the strength of user voice, which is likely to be exacerbated under the new ICS arrangements,” Healthwatch England chair, Sir Robert Francis QC, warned in his letter.


  1. Despite the funding challenges, local Healthwatch remain committed to giving people a voice and we believe their work represents excellent value for money. In 2021-22, around 600 local Healthwatch staff across the network, supported by more than 3,700 volunteers, engaged with 750,000 local people to gather experiences of health and care, supported a further 2 million people to find the right information and advice through our signposting services and increased, by 36%, the use of our evidence by stakeholders[6].


  1. Similarly, ICS investment in local Healthwatch can also pay great dividends, as work in North East London shows (see Box 2).


  1. We would urge greater consistency in ICS funding of local Healthwatch, particularly for areas with the greatest health inequalities. People who experience poorer health outcomes also face barriers to becoming involved in activities to give feedback and suggest changes, such as literacy, language, time and trust in official bodies. Local Healthwatch are skilled at breaking down these barriers but require extra resources to use tailored engagement methods such as hiring professional interpreters, holding face-to-face sessions in community locations or creating Easy Read materials.


  1. ICSs are receiving extra money from NHSE to tackle health inequalities, through the national ‘Core20Plus5’ programme that aims to find grassroots solutions to health and care needs of people living in areas of deprivation[7]. WE have been told that four local Healthwatch have so far been funded to run pilot programmes and we hope ICSs resource more local Healthwatch for this important work.


  1. Other national programmes on health inequalities include a £50m research fund recently announced by DHSC[8] to set up Health Determinants Research Collaborations’ involving experts and universities ‘to address knowledge gaps’ in 13 areas, mostly cities.


  1. Quantitative data can help pinpoint where you have inequality and the impact on health outcomes for these groups. However, it takes a deeper understanding of people’s stories to get to grips with why inequalities persist, and it takes trust to get communities to work with you on designing solutions together.


  1. Conclusion


Healthwatch England believes the advent of ICSs creates opportunities to feed people’s views into the planning and running of services but they are yet to be fully realised.


  1. Local Healthwatch are committed to playing their part in creating true partnerships between services and the public. We want those partnerships to result in communities being represented at every level of decision-making; people facing the greatest inequalities, being heard; and ongoing conversations about how we can make care better together.


  1. But with local Healthwatch reporting that they only have representation on 45% of ICBs, more work is needed to increase this figure or to increase transparency about the alternative models ICBs use to ensure communities can hold decision-makers to account for plans to deliver joined-up health and care.


  1. Our evidence also highlights the general funding pressures on local Healthwatch to carry out their core role and the need to resource the extra work involved in collaborating with ICSs. We call on NHSE to support ICSs that not yet doing this, to close the gap and maximise opportunities to tackle health inequalities and improve population health.


October 2022

[1] Involving people in their own health and care: Statutory guidance for clinical commissioning groups and NHS England, NHS England, 2017


[2] Mapping the relationship between local Healthwatch and Integrated Care Systems, Healthwatch England, 2021

[3] Working in Partnership with People and Communities Statutory Guidance, NHS England and Department of Health and Social Care, 2022


[4]  Letter from Healthwatch England to the then health secretary, Healthwatch England, 2022

[5] Healthwatch resourcing in the new health and care landscape, Healthwatch England, 2022

[6] Championing what matters to you: Healthwatch England annual report 2021-22, Healthwatch England, 2022

[7] Core20Plus5 webpage on NHSE website, accessed October 2022

[8] DHSC press release, 11 October 2022