Local Healthwatch: progress, promise and power

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Giving people a greater say in how the health and care system works was a central pillar of the coalition government’s ambitions, and a key component of the reforms introduced as part of the Health and Social Care Act 2012. To achieve this, the coalition government outlined a framework for a network of local Healthwatch organisations, with the aim of creating a credible, representative and influential public voice in the system. So how have these organisations been developing?

Local Healthwatch organisations represent the latest in a long line of attempts to give patients and wider communities an effective collective voice. Community Health Councils and Local Involvement Networks (LINks) laid the groundwork for giving people a greater say in the local commissioning and running of services. But they were constrained by a lack of real power, often criticised for not being truly representative of their local populations, and hampered by cases of internal disputes and a lack of awareness of their work. The aspiration for local Healthwatch was to build on these foundations but overcome some of the problems.

All local Healthwatch organisations must carry out a set of statutory functions and, importantly, each has a seat on its local health and wellbeing board. As well as monitoring the quality of local services, their core role is to gather and collate people’s views and feedback about the health and care system and to use this evidence to influence the commissioning, scrutiny and provision of services in their patch.

In practice, this represents a dual role: as strategic partner (they have a seat 'at the table' with NHS bodies, local authorities and other local system leaders and take part in strategic decision-making), but also as critic (they seek to be independent and, in some cases, hold these other organisations to account as the independent voice of the public). Local Healthwatch organisations are part of the formal structures of the system and yet reliant on community engagement, meaning they walk a tightrope between two very different parts of the system – a common challenge faced by those involved in community engagement that Eileen Conn eloquently describes as ‘the social eco-system dance’.

The findings from our national evaluation of local Healthwatch shed light on how this is playing out in practice.

It appears that striking the balance between being strategic partner and critic is one that Healthwatch organisations are finding tricky and still working to refine. Some are so rooted in community activism that their opportunities to influence are limited, while others that focus whole-heartedly on influencing can end up detached from the communities whose voices they were set up to listen to and facilitate. Their relative newness may have a part to play, but it’s clear that the approach each Healthwatch organisation takes to meet its statutory functions has a profound influence.

Because local Healthwatch organisations have flexibility over how they conduct their day-to-day business, and the organisational model that underpins this, organisations have developed in very different ways. In our work we saw individual charities and community interest companies, and models where the functions of the local Healthwatch organisation were hosted by or contracted out to an existing voluntary organisation. We found that these arrangements often play a key role in defining the balance that they each take between influencing and independence. Irrespective of the organisational model used, it is important for each local Healthwatch to set a clear direction and purpose for the organisation.

So while good practice exists, there is a real need to focus on establishing the right balance. How do they do this? Top of my list of priorities would be for each to consider where they sit in the system, and how they engage with that system. There is no single right answer, so these local decisions need to be backed up by strong governance – a clearly defined role, set of responsibilities and lines of accountability for the board, transparent decision-making processes and a mix of the necessary skills and expertise at board level. In the absence of these measures, they could end up, to borrow from Conn’s analogy, dancing solo, moving to the tune of others, or excluded from the dance.

One final observation relates to a wider challenge faced by local Healthwatch organisations – and other public and patient involvement organisations: that patient and public-generated evidence, however robust and credible, is still fed into structures that can choose to act, or not act, on the intelligence laid before them. So – as we have previously argued – it seems there is still some way to go in transforming the rhetoric around involving the public in decision-making into reality.


Mark Gamsu

Visiting Professor,
Leeds Beckett University
Comment date
05 November 2015
Hi there Phoebe - really helpful piece - my particular thanks for drawing attention to Eileen Conn's elegant report for the Third Sector Research Centre which I had not come across before and is so relevant to this agenda. Best wishes - Mark

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