Recommendation 135

Commissioner accountability to public

Accepted in part
Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement:

  • There should be a membership system whereby eligible members of the public can be involved in and contribute to the work of the commissioners.
  • There should be lay members of the commissioners’ board.        Commissioners should create and consult with patient forums and local representative groups.
  • Individual members of the public (whether or not members) must have access to a consultative process so their views can be taken into account.
  • There should be regular surveys of patients and the public more generally.
  • Decision-making processes should  be transparent: decision-making bodies should hold public meetings.

Commissioners need to create and maintain a recognisable identity which becomes a familiar point of reference for the community

Provisions for a new commissioning system in the Health and Social Care Act 2012 address most of the elements of this recommendation.  For example, provisions cover the new role of lay members on clinical commissioning group governing bodies, the duty on public involvement and consultation on both NHS England and clinical commissioning groups, and the key role of local Healthwatch in giving people a powerful voice locally in improving and shaping health services.

A range of mechanisms is now available for involving the public in commissioning decisions without requiring the development of new ‘membership’ models. In September 2013 NHS England issued Transforming Participation In Health And Care, statutory guidance for clinical commissioning groups on involving patients in planning services and in their own care. By December 2013, 80% of clinical commissioning groups will be commissioning support for patients’ participation and decisions in relation to their own care or will have a plan to do so.  This will include information and support for self-management, personalised care planning and shared decision-making.

There are a number of regular national and local patient and public surveys. These include the annual national GP patient survey, run for NHS England by Ipsos MORI, and a national programme of patient surveys run for the Care Quality Commission by Picker Institute Europe. In addition, since April 2013 all providers of NHS funded care have been required to offer inpatients and users of accident and emergency services the opportunity to provide feedback through the NHS friends and family test.  The first set of data for the A&E friends and family test, covering April, May and June was published on 30 July 2013. A second set of  this data was published on 30 August and a third on 3 October. 793,448 responses have been received to date. The current response rate is 17.1%.

The friends and family test allows hospital trusts to gain real time feedback on their services down to individual ward level, and increases the transparency of NHS data to drive up choice and quality. The real strength of friends and family test lies in the follow-up questions that can be attached to the initial question, and a rich source of patient views can be used locally to highlight and address concerns much more rapidly than with more traditional survey methods.

It is our intention that by March 2015, all NHS service users will be given the opportunity to provide feedback through the friends and family test. Maternity services started using the test from 1 October 2013, with the first set of results to be published after the first quarter, at the end of January 2014.  Work is currently underway to develop guidance for the introduction of the Test to all other NHS settings. Guidance for staff to support the introduction of the friends and family test from April 2014 is on course to be published by the end of December 2013.

NHS England is developing plans to establish in 2014 a citizen’s assembly – pioneering a new approach to ensuring citizen voice is able to hold it to account. NHS England has also established a ‘voices in governance’ model in specialised commissioning, to ensure that the patient and public voice is at the heart of commissioning processes.

NHS England and clinical commissioning groups are developing, through the NHS Commissioning Assembly, a framework for quality which will be published in autumn 2013. It will set out the steps that commissioners should take to assure themselves and their patients that the services that they are commissioning are safe, clinically effective and result in a positive experience for patients.

Clinical commissioning groups are required to take a number of steps to ensure transparency in their decision making processes. The constitution of the clinical commissioning group must specify the arrangements made for securing that there is transparency about the decisions of the group and the manner in which they are made. The governing body must also publish papers considered at its meetings (except where it would not be in the public interest to do so).


By December 2013, 80% of clinical commissioning groups were commissioning support for patients’ participation and decisions in relation to their own care or had a plan to do so.

A Citizens Assembly was launched in March 2014, with the first Excellence in Participation Awards held alongside this to celebrate excellence and innovation in patient and public participation.

A task and finish group has been established to help develop guidance for commissioners and providers on the definition, principles and processes of personalised care planning; this guidance was published in January 2015.

A number of commissioning support units have been appointed to provide support to clinical commissioning groups in engaging with patients and the public. Ongoing support is also being provided to NHS England commissioners in specialised commissioning to ensure the participation of patients and the public.

The Friends and Family test became available in GP practices on 01 December 2014 and then expanded to mental health services and community services on 01 January 2015. Other services will offer the friends and family test from April 2015 such as NHS dental practices, ambulance services, patient transport services, acute hospitals outpatients and day cases.

The aim is for the Friends and Family test to cover all NHS services by the end of 2015. Guidance for staff on the Friends and Family test was published in February 2014.