Viewpoint: Public participation will be critical to the success of health and social care integration

Blood pressure monitor, health care, hospital, hospice

Whoever wins the election there is no doubt that the health and social care system faces an incredibly tough ride over the course of the next Parliament. The former Chief Executive of the NHS, David Nicolson recently raised his “very great concern” about the financial problems facing the health service immediately after the election.

In addition, all the main parties, and NHS England itself have identified the need to, in the words of NHS England’s Five Year Forward View, “take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care.”

Westminster politicians and NHS England are talking a lot about the twin problems of the financial hole and the need to integrate health and social care alone. However, it is local authorities which are doing most of the heavy lifting that will be required to solve the challenges of the next five years.

It is also important to note that many of the reforms and changes to health and social care services that will be required are likely to be deeply unpopular, or have unforeseen consequences, often for the weakest and most marginalised in our communities. There are significant risks for councils, NHS England and other partners if the public are not actively involved in the service redesign that will be required.

The challenge will be how to engage the public effectively in what will need to be local, regional and national conversations involving multiple partner organisations.

One part of the answer might be NHS Citizen, the design of which has recently been published after eighteen months of collaborative design with patients, public, NHS staff, civil society organisations and other partners in the health and social care system.

At its heart NHS Citizen aims to answer two questions:

  • How can the board of NHS England better take into account the views of patients, service users and the general public when making decisions about the NHS?
  • How can the board of NHS England be held to account by the public which it serves?

Through the open design process the NHS Citizen project team has developed a model for NHS Citizen which consists of:

  • Deliberative and decision-making processes and events, such as the Gather process which allows the public to raise ideas and concerns and the Assembly Meeting which creates a space for senior managers and the public to develop collaborative solutions;
  • A set of values and behaviours which are intended to create a culture of participation within NHS Citizen; and
  • A set of tools and approaches designed to find and connect pre-existing patient participation as well as to identify gaps and hidden voices.

In developing this model we have also considered how NHS Citizen might help direct questions and ideas to other parts of the NHS system in recognition of the fact that NHS England has a role as system leader. There may be role to do this more widely if appropriate.

The next stage of work will develop the different parts of the NHS Citizen design and test how they work together in a live environment. A key part of this will be working with partners at a local level to test how best to develop the system so that it supports collaboration with the public in some of the difficult decisions that will need to be taken over the next few years.

Are you interested in NHS Citizen? To learn about the project visit To find out more about the design of NHS Citizen visit

Simon Burall is Director of Involve and a member of the NHS Citizen Design Team.

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    1. Pearl Baker says:

      We have the Care Act 2014 this is a comprehensive Act informing all of their entitlement in LAW, what are you proposing to do? I just want it to be implemented. ‘Integration’ is not difficult. It should be personalised, meaning different agencies depending on your health and care needs. There must be a Care Plan for all (starting point) based on continuing Care Assessment. The CCG are (shadowed by NHS England) , they are responsible for ensuring they are knowledgeable in the Care Act 2014 Mental Capacity Act 2005 code of practice, Safeguarding in the Act, Personal Budgets. Guardianship, Section 117 of the 1983 MHA (not really understood by GPs) and the LA would rather you didn’t know about this free aftercare.

      The Care Act 2014 is now LAW, what is the debate about?

      The Public need to know their rights. A small booklet containing ‘key’ concerns, and answers.

      NHS England appear only to be accountable to the PHS Ombudsman. This is a lengthy process and quite ridiculous, or the Courts.
      GPs are often at the ‘root’ of complaints, due to their insufficient knowledge. ‘fit to practice’ complaints would be sent to the GMC.

    2. Looks like a step forward. However, how NHS Citizens engage with historically under-represented groups particularly BME groups from rural areas in the process will remain to be seen.

    3. NHS Citizens are doing really well in involving the public in decisions. I went to one of their gatherings and I got the chance to voice my thoughts to some very important and powerful people in the NHS.

    4. Mark Gamsu says:

      Hi Martin

      Thanks for this – I agree the NHS Citizen work is producing some interesting stuff – although I think the jury is still out on its relevance and impact. Nonetheless, the more activity in this area the better – in my view. I do think we need to avoid coming up with one model – the world is too diverse for that. More importantly I think the real locus for engagement is local one. While it is important that the NHSE board consider how they keep connected the direction of travel is local. I suspect that whatever happens after the election we will see a continued withering away of NHSE and a greater focus on place along the lines of DevoManc. I think that it would be very useful if NHSE were to devolve resources to at least city region level to support the development of citizen engagement that is tailored to place.

      1. Simon Burall says:

        Thanks for all your comments. Much appreciated. I thought I’d just pick-up on Mark’s and Pearl’s comments in substance.

        Pearl, it is one thing to lay something down in law, and quite another for it to have an effect. If integration were easy then it would have happened already. There are many systems of accountability that operate in the system, you note just one. But there are none that work directly with the Board of NHS England influencing the overall strategic direction of NHS England. So while I agree with you that if patients knew their rights, and were able to work with local accountability structures such as Healthwatch it would make a big difference, there is still a significant gap between the local and the national.

        Mark, I agree the jury is still out on NHS Citizen’s impact, or perhaps it is better to say possible impact. The first year was a year of design. There was no NHS Citizen system to have an impact. NHS England are now in the process of procuring the next phase which is the building of the infrastructure it will need. However, even during the design phase while we were still undertaking action research I think we can identify impact. The evaluation will be out relative soon so that others can judge.

        I cannot agree more with you about the danger of creating one model of engagement. There are lots of structures locally, much more closely connected to communities and individuals than any one national model possibly could. NHS Citizen is being designed, as I say above, to close the gap between what patients and the public are saying locally, and the Board of NHS England which is very distant from what is happening on the ground. And as you say, the devolution agenda is going to have a huge impact on NHS England and patient engagement that is better connected to place must be the way to go.

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