Enabling ‘citizen voice’ in the English health and social care system: A national survey of the organizational structures, relationships and impacts of local Healthwatch in England

Abstract Background Local Healthwatch have been operating since 2013 as ‘consumer champions’ in health and social care in England. There is little evidence about how they operate and the daily practices through which they seek to represent citizen views and influence others. Objective To explore (a) the current organizational arrangements, relationships and impact of local Healthwatch in England, and (b) to what extent do these vary across local Healthwatch organizations. Design An online survey of all 150 local Healthwatch in England between December 2018 and January 2019. The survey comprised 47 questions and used a combination of closed‐ and open‐response questions. Results We received responses from 96 local Healthwatch (68% response rate). Most local Healthwatch reported that they are ‘independent’ organizations that only do Healthwatch‐related work (58.3%) and are funded through a contract (79.2%). Budget cuts have affected four‐fifths of local Healthwatch (79.3%) since 2013. Three‐quarters (74%) of local Healthwatch currently receive funding external to that provided by their local authority for their Healthwatch functions. Most Healthwatch engage with only one CCG (56.3%), one mental health trust (82.3%) and one community health trust (62.5%), though 59.4% engage with more than one hospital trust. Healthwatch respondents overwhelmingly reported impacts that were local in nature. Conclusions Geographical and historical factors, the quality and quantity of their relationships with stakeholders, and different funding arrangements all contribute to high variability in the structure and activities of local Healthwatch and to shaping the nature of their work and impact across England.


| INTRODUC TI ON
Enabling citizens' voices to be heard is vital for planning the provision of publicly funded health and social care services and to ensure that the wider systems-of which such services are a part-are accountable to the public, communities and patients that they serve. In  Table 1, adapted from Hogg 1 ).
Originally conceived as a 'consumer champion in health and care', local Healthwatch are now ostensibly a major partner through which local government monitor the quality-and support the design-of health and social care. 3  • Make reports and make recommendations about how those services could or should be improved.

2013-now Healthwatch
• Promote and support the involvement of people in the monitoring, commissioning and provision of local health and social care services.
• Provide information and advice to the public about accessing health and social care services and the options available to them.
• Make the views and experiences of people known to Healthwatch England, supporting its role as national champion.
• Make recommendations to Healthwatch England to advise the Care Quality Commission (CQC) to carry out special reviews or investigations into areas of concern.
• our independent project Advisory Group, which comprises academic and professional members, including a representative of A copy of the survey questionnaire is included as supplementary Material to the paper.

| RE SULTS
We received responses from 96 local Healthwatch. This was a response rate of 68% (as eight Healthwatch responded on behalf of two or more Healthwatch which they operated as a combined organization

| Contracts or grants?
We also explored the different mechanisms by which Healthwatch are funded by their local authority. The main difference between contracts and grants is that the former must be tendered according London Boroughs (n = 2, 12.5%) and metropolitan local authorities (n = 3, 13.0%) reported lower proportions of grants than the national picture. We found a much smaller proportion of hosted Healthwatch hold grants (n = 2, 5.0%) compared to those describing themselves as 'independent' (n = 17, 30.4%).

| External funding
Since   Overall, volunteers were reported to contribute significantly to 'Enter and View' visits. These visits are statutory powers used by

| Staffing
Healthwatch to observe and gather information from staff and users of health and social care services at sites of care (eg a GP surgery or a care home) in order to assess the quality and standard of care.
Forty-two (43.8%) Healthwatch said that these were carried out 'mostly by volunteers with some employed staff contribution'; 29 (30.2%) said that they were 'equally carried out by employed staff and volunteers'. Conversely, administrative and clerical work (n = 95, 99.0%), research and report writing (n = 87, 90.7%), and communications and social media (n = 92, 95.8%) were either 'wholly carried out by employed staff' or 'mostly by employed staff with some volunteer contribution'.

| Relationships
In order to build a picture of the network of Healthwatch relationships, we asked how many CCGs, hospital trusts, mental health trusts, community health trusts, GP surgeries and care homes Healthwatch respondents engaged. We found that • 54 (56.3%) Healthwatch respondents engage with only one CCG.
A small number of Healthwatch engage with five or more CCGs (n = 9, 9.4%).
• 60 (62.5%) Healthwatch respondents engage with only one community health trust. 23 (24.0%) do not engage with any community health trusts.
• A third of all respondents (n = 32, 33.3%) engage with more than 50 care homes. Five (5.2%) respondents engage with none.
To provide further insight into the institutional and relational complexity of Healthwatch networks, we also asked whether local

| Quality of relationships
We  (Table 3). However, the survey highlighted significant regional variation across the network. For instance, we found that five out of six Healthwatch respondents in the North East of England reported having no or limited involvement in STP and ICS development.
More than half of Healthwatch (n = 31, 57.4%) that reported a 'good' overall quality of cooperation among stakeholders in their area reported either a 'high' or 'good' involvement in STPs/ICSs. In contrast, three-fifths of Healthwatch (n = 9, 60.0%) in areas of 'limited' cooperation reported only 'some' or 'not much' involvement in STPs and ICSs.

| Impact
Healthwatch overwhelmingly reported impacts that were local in nature. The most common response among the 13 options provided was 'Improved access to care and treatment for members of our community', selected by 73 (76.0%) Healthwatch, followed by 'Increased levels of participation in co-production of people who use a service' (n = 65, 67.7%). National-level impacts were selected by far fewer respondents: 10 (10.4%) local Healthwatch reported that they had influenced changes in national policy or specialist commissioning and eight (8.3%) had escalated an issue to Healthwatch England which was later actioned.

TA B L E 3
How would you describe the overall quality of cooperation among key health and social care stakeholders in your local area, and to what extent has your Healthwatch been involved in the development of STPs/ICSs? We explored the relationship between the number of 'full-time equivalent' (FTE) staff and (a) the number of types of local impact reported by respondents, and (b) whether they reported national impact. We found that the greater the staff FTE, the greater the number of types of local impact as well as the greater the likelihood of reporting a national impact.

| Examples of successful impact
We asked respondents to identify a successful piece of work they had (n = 11, 12.9%), social care (n = 10, 11.8%) and disability (n = 10, 11.8%) being the most common (see Table 4).
Regarding the type of impact achieved, almost a third of

| Examples of failed impact
We asked respondents to briefly outline a piece of work they had completed in the past three years which they regarded to have been unsuccessful. We also asked to select the type of impact they wanted to achieve and to describe the main barriers to impact they faced on its delivery (Box 3).

Local Healthwatch respondents chose examples of unsuccessful
projects that covered a broad range of topics. The most common were primary care (n = 17, 17.7%), hospital care (n = 14, 14.6%), disability (n = 10, 10.4%) and mental health (n = 9, 9.4%). Regarding the type of impact intended to be achieved, the majority of our Healthwatch respondents (n = 45, 46.9%) selected projects that intended to 'improve access to care and treatment' for members of their local community.
The two most common barriers to impact identified by local Healthwatch were the 'lack of cooperation among or by key institutional stakeholders' (n = 36, 37.5%), and the 'systemic complexity or lack of clarity among stakeholders about respective organizational roles, responsibilities' (n = 27, 28.1%), which when combined were

EXAMPLE #1
What was the piece of work about?. Activities in Care Homes. Study looking at the level of activities in care homes and the impact upon the well-being of residents.
What was the key impact you achieved?. Other-influenced Care Home providers to develop their activity programmes to offer a more varied and stimulating programme of activities for residents.
How long did it take to achieve this impact?. 12 months.
How was the impact delivered (eg research presenting evidence, publicity activity etc)?. Research, followed by a conference, social media attention.
Which of the following local stakeholders did you involve to achieve this impact? Please select the three most important.
• Social care providers • Media

EXAMPLE #2
What was the piece of work about?. Access to eyecareto give people a strong voice and ensure their experiences and views are considered and influence how eye care services are provided.
What was the key impact you achieved?. Improved access to care and treatment for members of our local community.
How long did it take to achieve this impact?. While the project took two years from proposal through to our final evidence-based research report, action was quickly taken based on our recommendations.
How was the impact delivered (eg research presenting evidence and publicity activity)?. Evidence/ findings presented in a research report following focus groups, site visits and interviews with members of the public.
Which of the following local stakeholders did you involve to achieve this impact? Please select the three most important.
• Other-Local Eye Health Network • Local patient or condition-specific groups • Community voluntary sector organizations selected by almost two thirds of our survey respondents. Despite widespread concern about decreasing Healthwatch budgets, only ten (10.4%) local Healthwatch identified a 'lack of resources' as the main barrier to impact.

EXAMPLE #1
What was the piece of work about?. Need for residents with autism.
What was the impact you wanted to achieve?. Promote issues which were adopted into a strategy (locally, regionally or nationally).
Please briefly describe the barriers to impact you experienced. The commissioner writing the strategy was really engaged and also put us in contact with a variety of relevant departments and NHS commissioners (who actually ended up acting on our feedback and making a change on their side). However, the commissioner left, and the posts responsibilities were left vacant for some time. We are still waiting for an opportunity to discuss the findings again. A board set up to look at the strategy did discuss the report and told us it was insightful but we have not been able to look at a longer term influence.

EXAMPLE #2
What was the piece of work about?. Community Dental Services-access to procedures carried out under general anaesthesia.
What was the impact you wanted to achieve?. Improve access to care and treatment for members of our local community.
Please briefly describe the barriers to impact you experienced. We ended up in a morass of different organizations with different responsibilities. Not everything they were each telling us could be true, as they were contradictory. The commissioner (NHS England) has been helpful in some ways but defensive in others. But we have not given up. We continue to press for answers. It is over 2 years since we began work on this.
twelve months long ethnographic study of five purposely sampled local Healthwatch, six sense-making workshops with research participants and relevant local and national stakeholders and a 'Delphi' analysis of our findings. As such, this paper is limited in its ability to draw wide-ranging conclusions about more nuanced aspects of local Healthwatch work, like for example, specific challenges and strategies to maximize their impact. Our approach to the investigation of local Healthwatch impact also limits the breadth of the conclusions we are able to draw in this paper. In the survey, we opted for qualitative questions about types of impact and about specific examples of impact achieved or failed by each local Healthwatch respondent.
Instead, we avoided more general questions about the overall impact of each organization. This was because we regard 'impact' as the relative outcome of a complex array of interrelated factors, which are better suited to the in-depth qualitative investigation we carry out in the latter phases of this study. One limitation to the usefulness of this kind of self-reported information on impact is that we unable at this stage of research to draw conclusions as to whether particular organizational arrangements and relationship types lead to better impact among our local Healthwatch respondents.

ACK N OWLED G EM ENTS
We would like to thank all the local Healthwatch staff who gave up their time to take part in the survey. We also thank all the participants to the workshop we held at the Healthwatch Annual Conference in October 2018; the five former local Healthwatch CEOs and Directors we piloted the survey with; and the members of our Advisory Group who all contributed to shape the survey. Finally, thanks to Healthwatch England for their continuous support during this study.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.