As Wes Streeting enters the murky waters of a leadership challenge, he jumps ship as the NHS heads turn towards another messy reorganisation that will squeeze out scrutiny and the public voice in the NHS.
The King’s Speech included a commitment for the government to put forward an ‘NHS Modernisation Bill’ that will trigger another massive round of reorganisation in England’s NHS, along lines embraced by Mr Streeting.
This will divert management and government attention away from the urgent issues of improving front line services, and create uncertainty that is likely to last right up to the next election.
Like most of the previous reorganisations in the last 40 years, Labour’s proposals, vaguely outlined in last year’s so-called Ten Year Plan seem doomed to squander vital time, money and energy on once more dividing the NHS into a “market.”
However, this time the number of ‘commissioners’ holding the purse strings (the Integrated Care Boards) are to be heavily reduced (down from 42 last year to 36 in 2026-7 and probably down again to 27 in 2027-28) while in many areas NHS providers (trusts and foundation trusts) are also increasingly merging together or forming “provider collaboratives”.
The result will be a 50% increase in the average catchment population of each ICB (to an average of over 2.2 million), and (for those merging) a very significant increase in the geographical spread and the number of local communities, constituencies and local councils they will cover. This means the voice and needs of each locality are even less influential than they have been under ICBs,
Merging trusts also in many cases spans several hospitals … and several towns, again widening the catchment population. Previous such mergers have often been followed by plans to “avoid duplication” by closing selected services in one location – resulting in many patients (and anyone visiting them in hospital) having to make substantial journeys. The continuing tight cash constraints on the NHS, and requirement to deliver tough savings targets make it likely similar ‘centralisation’ could again become widespread … in the run-up to the next general election.
The proposed reforms also include:
- abolishing NHS England (NHSE), with its functions taken over by the Department of Health and Social Care (DHSC), and some of its powers to be taken by the Secretary of State, as the combined total of staff is halved. This means that the public meetings of the Board and the publication of Board papers will come to a halt: all business will be conducted behind closed doors.
- reducing the staffing and running costs of Integrated Care Boards (ICBs), with corresponding reduction in their powers and duties, and their ability to respond to local issues and patients’ concerns.
- abolition of local and national Healthwatch bodies: their independent role speaking up for patients is to be brought “in-house” to ICBs and the DHSC, where of course it will no longer be independent – even if the pretence of responding to patient issues lives on.
In addition, although as yet there is no published draft of the ‘Modernisation Bill’, the Ten Year Plan also proposes:
- to remove the requirement for each Foundation Trusts to have an elected board of governors (again limiting the chance of any challenge to policies and proposals);
- to scrap the Integrated Care Partnerships (the nebulous bodies set up as a means to entice local authorities to accept the 2022 Health and Care Bill) – further limiting any voice or scope for councils to develop a role in shaping the local NHS;
- and for local council representation on ICBs to be replaced by elected Mayors (who are mostly elected from much wider electorates).
All of these various changes head in one direction: squeezing out the possibility of local voice and influence, and thus restricting any serious questioning or challenge to centralised and regional-level bodies – whatever they decide to do.
Sarah Woolnough, Chief Executive of The King’s Fund, said:
“The government has said it wants to devolve power from Whitehall and give patients more control over their care. There is a danger that the Bill creates the opposite impression, of a government pulling power back to the centre and disbanding the independent organisations set up to listen to patients and ensure their voices are heard across health and care services.”
By stripping back the staffing of the central bodies, any possibility of responding to patient experience or the concerns and needs of specific local communities is minimised.
So we have the contradictory plan for the role of 153 Local Healthwatch bodies to somehow be brought “in-house” to 27 ICBs – at the same time as many ICBs are supposed to be cutting back on staff, and covering wider areas. It’s immediately obvious that the consequence will be a serious loss of local responsiveness to patients’ needs and concerns.
Last summer’s review of patient safety by NHS England chair Penny Dash gives an idea of the scale and spread of the network of local Healthwatch groups:
“Local authorities are legally required to establish a Local Healthwatch to capture feedback on health and care services. … They are accountable to that local authority. Local Healthwatch received £25.4 million in financial year 2023 to 2024 … The 153 Local Healthwatch organisations employ 570 FTEs (around 4 each).”
But Dr Dash’s review was focused single-mindedly on safety rather than any of the wider concerns on access and gaps in care that local patients and public may wish to raise. She concludes that a decade-long drive to improve safety in the NHS has created a “cluttered landscape” of organisations, and led to limited improvement.
The “confusing” array of more than 20 organisations offering patients the opportunity for feedback on their experiences of the NHS led her to conclude that there is a need to “streamline oversight and reduce duplication around the patient voice.”
And since Local Healthwatch is only partly concerned with safety, she regards it as one of the targets for demolition in order to “streamline” the system.
This low point in the fight for independent bodies able to stand up for patients and local communities comes after years of declining resources.
History repeating
It’s worth remembering that until Wes Streeting’s mentor, former Health Secretary Alan Milburn, scrapped them in 2003, the views of local communities as well as the needs and complaints of patients could be championed by a network of Community Health Councils, one in each health authority. The CHCs were established in 1973 as part of the reorganisation of local health authorities, to ensure there was an independent body with powers to speak up on service changes and on standards of care.
The CHCs had considerable statutory powers to make unannounced visits to hospitals, and to force a halt to contested cuts or changes to local services until the plan had been reviewed by the Secretary of State. The best CHCs made full use of their independence, where necessary supporting or leading campaigns against hospital or service closures, and conducting regular surveys on the performance of A&E services.
It was the most active, popular local CHCs that annoyed and frustrated Milburn, not least in the ferocious campaign in the run-up to the 1997 election to stop the closure of Edgware Hospital, in which Barnet CHC played a leading role. One of Milburn’s first decisions as junior health minister to Frank Dobson was to anger and disappoint that campaign by declaring that the battle was already lost, just a short time after Labour took office.
In place of the CHCs, Milburn’s legislation (which also established Foundation Trusts) set up toothless “Public and Patient Involvement Forums”, and then Local Involvement Networks (LINKs), again with reduced statutory rights. The power to demand a ‘status quo’ halt to contested changes was handed to previously inert council health oversight and scrutiny committees.
Ten years later Andrew Lansley’s hugely controversial Health and Social Care Act closed down the LINKs, some of which had begun to link up and campaign, and established Healthwatch as even more limited and narrow-focused bodies exclusively dealing with patient experiences rather than the wider needs and views of local communities.
Why it matters
That’s why none of the major battles against hospital closures since 2013 have involved Healthwatch. While some local groups may take up their advocacy for patients more strongly than others (with wide variation in the numbers of publications from the various local Healthwatches), none have seen their role as engaging in a political fight.
This is vividly illustrated by the tepid response from Healthwatch England (HWE) to Labour’s plan to scrap them and the whole network. In June 2025, HWE reacted lamely to the first news that they were to face the axe:
“Today, media reports, including the BBC, have reported on the Government’s plans to close Healthwatch England, the National Guardian’s office, and others. The media reports suggest that following the closure of Healthwatch, our statutory function will transfer to the Department of Health and Social Care. …
“This is clearly a sad day for our staff, volunteers, and everyone associated with Healthwatch who have proudly supported people and communities to speak up about their experiences of health and social care.”
But rather than even question the decision, HWE opted for instant surrender, concluding:
“Our focus now is on ensuring a smooth transition of our functions to the NHS and Government, so that the voices of patients and the public continue to be heard.”
By contrast, some of the local Healthwatches took a more combative view: in Devon, Plymouth and Torbay, for example, the response was:
“We recognise the Government’s ambition to simplify structures and make better use of feedback to improve care. We also strongly believe that independence matters.
“… Our independence allows people to speak openly, without fear or pressure, and helps decision-makers hear honest, unfiltered feedback about what is – and isn’t – working.
“The Government’s response confirms that patient voice functions are moving into organisations that also plan, fund or deliver services. We are therefore seeking clarity on how independence, transparency and public trust will be protected within any future system.”
North Yorkshire Healthwatch’s response was even stronger:
“We continue to raise concerns that plans to remove Healthwatch independence could weaken the public voice in health and care. Local Healthwatch organisations were created so people have a trusted way to share what they experience in health and social care. … The current proposals from Government threaten to remove that independence.
“… People tell us they are worried about what these changes will mean for their right to speak up. Our role is to make sure changes do not reduce the options for people to ask questions, find support or challenge decisions that affect their lives. …
“Healthwatch North Yorkshire was established in response to past failures when residents were not heard for long periods of time. Independent oversight was introduced to make sure the public voice did not disappear within large systems.”
Despite these, and other combative local responses to the closure threat, Healthwatch England set the tone by effectively rolling over and giving up.
The Dash review summary understated the extent to which Local Healthwatch can have wide support and links with local communities. The 153 bodies have over 4,000 volunteers who work with them (an average of 26 for each local group) which does seem to indicate that their local work has significant support in some areas.
Having said that, however, there was an extraordinarily feeble response to the petition launched last August, asking the government to
- Revisit its decision to abolish local independent services that speak up for the public
• Consult with the public to codesign a service which meets their needs and supports the NHS to realise its ambitions
• Invest in and strengthen independent services
By the time the petition closed seven months later, 4,600 staff and volunteers had secured just 11,042 signatures, suggesting few of the volunteers worked at all to gather support, but also perhaps that the vanishingly low profile of Healthwatch in many areas meant few people who were not personally involved could see any real reason to oppose its abolition.
By giving up without a fight, Healthwatch has in effect opened the door to a new dark age of limited information and voice for communities whose health services can be pared back in closed sessions of ICBs, trust boards and the DHSC.
Ministers and NHS bosses will continue of course to pay lip service to the idea of taking patient and public views seriously: but with no statutory organisations or properly resourced experts able to intervene on behalf of patients, and every section of the NHS under the cosh of limited funds even the finest words lack any real clout.
The demise of Healthwatch as the last vestige of any real patient and public representation is Streeting’s parting gift to the NHS. Will Labour activists remember this when they vote to elect a new leader (or stick with the old one)?
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