Title: Exploring the local operation and impact of Healthwatch in England five years on: using actor-network theory to optimise patient and public voice in NHS commissioning and service provision
Funder: Department of Health and Social Care

Abstract: Aim: the aim of the study is to explore and enhance the operation and impact of local Healthwatch in ensuring meaningful patient and public voice in the commissioning and provision of NHS services. Methods: the study uses a mixed method design and is organised in four phases. In phase 1 we will design and carry out an online nationwide survey of the 152 local Healthwatch in England. Drawing on the phase 1 findings, we will then (phase 2) conduct an ethnographic study (informed by Actor Network Theory) in 4 purposively sampled local Healthwatch. Based on our findings from phases 1 and 2, we will conduct a Delphi study with a representative sample of key stakeholders to build consensus as to ‘good practice’ in the operation of local Heathwatch (phase 3). In phase 4 we will hold Joint Interpretative Forums (JIF) at each case study site with multiple stakeholders (local authorities, CCG, provider Trusts, CLAHRC etc) engaging them in shared reflection on our findings and analysis. We will complete our interpretation of all 4 phases and disseminate actionable recommendations for policy and practice. Analysis: The national survey data and analysis will comprise descriptive statistics consisting of single variables and include frequency and percentage response distributions, measures of central tendency, and dispersion measures such as the range and standard deviation. All open comment responses will be analysed using open coding and constant comparison. Similar codes will then be grouped to identify key concepts emerging from the data to inform conclusions as to the national findings relating to the operation and impact of Healthwatch in England. From Phase 2 onwards, data analysis will be an iterative process alongside data collection and will include 5 half-day meetings with a ‘Healthwatch Involvement Panel’ (HIP) comprising 15 local Healthwatch volunteers and staff, thus embedding PPI at key points of the research. Ethnographic data from interviews, observations and documents will be analysed in a triangulating fashion to develop descriptions of how Healthwatch are operating in the 4 case study sites. Using Actor Network Theory to interrogate our ethnographic data, we will foreground and prioritise the detailed account of interactions and relations between artefacts, human actors, and organisational policies in each Healthwatch examined. Within-case and across-case comparisons will seek to draw out any relevant and generalisable facilitating factors in the operation and impact of Healthwatch. Analysis of the Delphi survey will be iterative and thematic across the three rounds and consensus will be statistically operationalised by testing for heterogeneity and inter-quartile range dispersion. Main benefits and potential impact: a robust, theoretically-informed evidence base on how local Healthwatch acts through mutually-influencing relations with a broad range of actors. The ethnographic approach in phase 2 will allow us to map holistically everyday practices and the wider context in which they take place. This evidence will be disseminated for use by NHS managers, local and national Healthwatch and local authorities to improve the impact of local Healthwatch work in health and social care planning and provision. The involvement of the HIP, the use of a Delphi study and the discussions at the JIFs to help analyse our ethnographic findings will ensure the relevance and generalisability of our recommendations.

Lay abstract: Enabling citizens’ voices to be heard is a vital part not only of a patient-centred, publicly-funded NHS but also of ensuring that the NHS is accountable to the public, communities and patients that it serves. Healthwatch was set up in 2013 to understand the needs and experiences of patients and the local community, and to ensure citizens’ views are heard and acted on. As such, it is a key partner for the NHS. There are 152 local Healthwatch which have legal powers to advise local authorities and NHS commissioners about their communities’ needs and concerns relating to the provision of health and social care. The small number of studies to date have indicated wide variation in the impact and way of working across Healthwatch bodies. This shows itself in the range of activities undertaken, different amounts and sources of funding, and the quality of relationships with key local NHS and social care institutions. However, it is still unclear how these relationships are established and maintained and how they help or hinder the ability of local Healthwatch to represent the views and interests of their local communities. The aim of the study is to explore and enhance the way in which local Healthwatch works in order to ensure meaningful patient and public voice in the commissioning and provision of NHS services. Our study will use a range of social science research methods and will be organised in 4 phases. In phase 1, we will carry out a national survey of all local Healthwatch in England. The survey will produce a summary of local Healthwatch priorities, activities, organisational structures, size of local population, geographical location, and number of GPs, hospitals and care homes with whom they work. This information will be used to select 4 contrasting local Healthwatch that will become our case-study sites in the following phase. In phase 2, we will conduct interviews with employees, volunteers and others at each case study site, observe their work, and analyse documents to provide a rich picture of the everyday work of local Healthwatch. We will also hold regular meetings with a panel of 15 people comprising staff and volunteers from local Healthwatch not recruited as case-study sites. Throughout phase 2, we will work with this ‘Healthwatch Involvement Panel’ (HIP) to analyse data and refine our research focus. In phase 3, we will use a method called a Delphi study to involve people interested in the work of Healthwatch. Drawing on findings from phases 1 and 2, the Delphi will build agreement around what ‘good practice’ is for local Healthwatch. This activity will ensure our findings are relevant across the Healthwatch network. In phase 4 of the project, we will hold a meeting at each site with key people. During these meetings, we will discuss findings from phases 1, 2 & 3 and develop practical recommendations for Healthwatch, the NHS and others. We will share these in different ways in order to ensure greatest impact. These include national conferences, podcasts, local Healthwatch forums & the network team from Healthwatch England (the national umbrella body covering all local Healthwatch). The study will generate important new understandings about patient & public voice in the NHS. At a time when the NHS faces pressure on resources, our research will point to how the NHS can best cooperate with citizens & patients through Healthwatch to ensure the success of the changes to come.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE