This guidance for Memorandums of Understanding (MoU) provides a structure which local Healthwatch and the Integrated Care System (ICS) can use and adapt to reach an agreement on how they will work together.

This Guidance is designed to use existing and emerging guidance and legislation, whilst also taking into consideration the differences that exist across systems.

Before you start drafting an Memorandum of Understanding with your ICS, you should work with other local Healthwatch to develop a collaboration agreement. This will help you determine a shared understanding of how you want to work together with other local Healthwatch first. To do this, check out our Collaboration Toolkit, which gives you a step by step guide on how you can build a solid working relationship with other Healthwatch.

The Health and Care Bill is expected to pass in time for changes to come into effect in July 2022. This transformation will change health and social care decision making across 42 ICS footprints. In turn, the way that people's experiences inform these decisions will also need to change. 

Local Healthwatch, have a vital role in ensuring that the public continues to be heard. Whilst they already do this within Local Authority boundaries (at 'place' level), they will now need to work together with other Healthwatch to ensure the system acts on what they hear from communities across wider areas. 

Common themes for success

Although every case study is different based on population needs in each area, there are some common themes for success which you could consider when working with your ICS or local Healthwatch.

• A formalised working agreement between local Healthwatch, which defines how you will work together.
• Clear roles and responsibilities for local Healthwatch when representing on Integrated Care Boards, partnerships and committees.
• Clarity on the local Healthwatch resources currently available and a realistic expectation about what ICS involvement is possible within these limitations.
• The ICS resources local Healthwatch representation, engagement and insight gathering.
• Local Healthwatch are proactive in demonstrating the support they can offer the ICS.
• Local Healthwatch coordinate the sharing of insight and learning from engagement of people and communities and use this expertise to inform system decision making.
• An agreement between local Healthwatch and ICS guides the relationship, recognising the autonomy of local Healthwatch.
• The role of local Healthwatch in development, delivery and governance of ICS people and communities engagement is clearly defined and championed by the ICS.
• The independent role of Local Healthwatch is understood and valued by the system.
• The ICS utilises the strength of local Healthwatch to ensure that the voice of the public is heard.

From April 2022, new health and care legislation will come into force, changing the way the NHS and other organisations plan and fund the delivery of care. The development of Integrated Care Systems (ICSs) through the Health and Care Bill will make significant changes, shaking up the system as we know it. 

It's essential that you understand how ICSs will affect the way you work locally, as well as the steps you’ll need to take to be ready for this change. If we aren't prepared as a network, it will be harder for us to get NHS decision-makers to hear people’s views and hold services to account moving forward.

How will the new structure work?

Systems, places and neighbourhoods

As the legislation is debated over the next few months, we will get a clearer view of how the new structure will work. We currently know that NHS England and NHS Improvement have proposed a three-tiered model of systems, places, and neighbourhoods to better integrate care.

At ‘System’ level, the Integrated Care Board (ICB) and Integrated Care Partnership (ICP) will set out the plans and strategy for the area. At ‘Place’ level, local organisations will collaborate on local planning and delivery. ICSs will be based on the principle of ‘subsidiarity’, with planning and delivery being based as close to local communities as possible.

For more information, read the King’s Fund’s explainer guide.

What does ICS guidance say about Healthwatch?

Although the legislation is based on implementation starting from April 2022, guidance has already been published, setting out various aspects of how ICSs will work. Although these may be revised in the light of Parliamentary decisions, they are useful indications of what will be expected of ICSs.

We’ve outlined a quick summary of each guidance document and how they might affect Healthwatch:

1. The Design Framework (June 2021): Sets out the high-level ambitions for ICSs. It also includes the principles that ICSs should use to develop their engagement strategy, building on the existing relationships, good practice and networks across system partners.
2. Thriving Places (September 2021): Looks at what is needed to support work more locally than at System level. It considers how ‘Place’ may be defined, who should be involved and different types of governance. Healthwatch is listed as being expected to be involved at this level. As decision-making will be delegated to the most appropriate level, Healthwatch needs to be clear about when and where decisions will be made. It’s important to note that this is the Place-based partnership which is different from the ICP that works at System level.
3. ICS implementation guidance on working with people and communities (September 2021) Includes System-level guidance setting out how ICSs should work with people and communities. It includes a section on working with Healthwatch, building on current good work, and draws a distinction between Healthwatch and the wider Voluntary, Community and Social Enterprise (VCSE) sector. This guidance can provide a helpful basis for you to discuss engagement plans with ICS engagement leads as well as other Healthwatch in your ICS area.
4. The Integrated Care Partnership (ICP) engagement document (September 2021): Is designed to engage partners in the development of ICPs. It sets out how ICPs should build on existing good practice and structures, such as Health and Wellbeing Boards, and includes "mandatory requirements" and "guiding expectations". It also emphasises the role of Healthwatch “to bring senior-level expertise in how to do engagement and to provide scrutiny”, with the expectation that Healthwatch will be members of the ICP. This guidance has been developed with local government, VCSE organisations and other stakeholders, including Healthwatch England. It will be updated following this piece of engagement.
5. ICS implementation guidance on partnerships with the voluntary community and social enterprise sector (September 2021):  Recognises both the challenges and the benefits of partnership working. It includes different models of engagement, including working at System and Place level, supported by short case studies. Healthwatch across the country have strong relationships with VCSE partners, so it is worth thinking about what you can offer to help build relationships between the VCSE sector and the ICS, particularly to tackle health inequalities.

To support the development of governance arrangements, NHS England has set out the functions of clinical commissioning groups that will be transferred to ICSs and has produced a model constitution. Other guidance covers issues such as the HR Framework, clinical leadership and ICB readiness to operate.

Additional guidance being developed

A working group, which includes Healthwatch England, is currently developing statutory guidance about working with people and communities. This guidance is expected to be completed early in 2022.

What will this mean for you?

Local systems will be working their way through the guidance and deciding what this means, so this is the best time to influence their thinking and remind them of the contribution that Healthwatch can make. When your ICS includes several Healthwatch, you will need to ensure a coordinated and consistent approach so that the ICS has a clear picture. Some of the key questions you might want to consider asking include:

• How will local voices be heard by the ICS?
• What is the ICS strategy for involving local people?
• How will the engagement strategy ensure that marginalised communities are properly represented?
• How can the ICS best use Healthwatch insight?
• How will issues raised at Place level get heard at System level?
• How will the ICS ensure it is transparent and accountable to local people?
• How can Healthwatch best support the development of the ICS?

What is Healthwatch England doing?

We are working at both the national and ICS level to get our message across. Our contribution includes participating in groups that have developed or are currently developing guidance. As the Health and Care Bill works its way through parliament, we are meeting with politicians from all parties to make sure that they understand our case. For example, Sir Robert’s recent appearance at the legislative scrutiny committee was an excellent opportunity to raise the issue of public voice in ICSs, and Healthwatch’s role in supporting that.

Sir Robert has had a programme of meetings with ICS lead and chairs. These help us get a sense of where ICSs are and how they are developing - yet another opportunity for us to talk about what Healthwatch has to offer. Your local insight has been instrumental in the briefings we produce for these meetings.

We are also working with the System Transformation Team at NHS England to identify and promote good practice across the country. The Transformation Team surveyed ICSs and the network to test out relationships. We have also commissioned case studies to show good practice where ICSs and Healthwatch collaborate well, which can also help other areas with ideas to consider and adapt. This work is supported by an ICS Readiness reference group drawn from volunteers across the network.

To help local areas, we are working with Traverse to provide bespoke support for a small number of ICS areas that face particular challenges in developing their partnerships.

As legislation progresses and ICS arrangements become clearer, we will keep you updated on changes that you may need to respond to.

Background

The Health and Care Bill is expected to pass in time for changes to come into effect in July 2022. This transformation will change health and social care decision making across 42 ICS footprints. In turn, the way that people's experiences inform these decisions will also need to change. 

As a local Healthwatch, you have a vital role in ensuring that the public continues to be heard. Whilst you already do this within your Local Authority boundary (at 'place' level), you will now need to work together with other Healthwatch to ensure the system acts on what they hear from communities across wider areas. 

To better understand what support you need to do this, we have been working with NHS Transformation Unit to learn more about the relationship between local Healthwatch and your ICS.

What did we do?

We surveyed local Healthwatch and ICS stakeholders. The response was excellent, with answers from 103 local Healthwatch and 37 ICS patches. The breadth of information has given us a clear understanding of strong relationships and areas for improvement. Thank you to everyone who took the time to respond to this important piece of work.

What does this mean for you? 

Based on the findings, your local Healthwatch should consider:

• Developing and presenting a strong, clear, evidenced-based case to ICS leaders
  This would demonstrate the value of Healthwatch, supporting the ICS to place Healthwatch appropriately in its governance framework during their consultation on their constitution.
• Formalise agreements
  Multiple local Healthwatch organisations within a single ICS boundary should develop formalised agreements on the terms of their collaboration at ICS level. These agreements should set out joint working arrangements and data sharing agreements as well as clarity on key contacts for ICS engagement, ideally via a single point of contact.
• Working with the voluntary sector
  Healthwatch and the voluntary sector have a strong track record of working in partnership.  This can be built on by local Healthwatch and the voluntary sector collaborating closely to ensure the public’s views inform the decisions made by the ICS. Local Healthwatch should explore this further to establish a form of collaboration and intelligence sharing with the voluntary sector and agreeing channels for representation of people’s views to ensure that they have maximum impact.
• Proactively offer support
  Local Healthwatch should proactively approach their ICS to support the development or revision of the people and communities engagement strategy, its delivery and in supporting the reporting back on its performance through ICS assurance processes.
• Establish governance responsibility
  Local Healthwatch should also engage with their ICS to establish who will have governance responsibility for engagement with people and communities.

What should I do next? 

We encourage you to read these documents, share them with your ICS colleagues and discuss together across your patch where you may need to take action to improve your collaboration between local Healthwatch and with your ICS? 

What support can you expect? 

We will be joining your regional meetings soon to present these findings and provide an opportunity to discuss how they might be relevant for your area. This will also give us a better understanding of what support you need moving forward.

Over the next few months, we will be sharing tools that you can use locally to help formalise relationships with other local Healthwatch, your ICS, and working with the voluntary sector. We'll also be publishing a series of case studies, so you can see examples of best practice taking place, which you can apply in your area.

About

Healthwatch Week ran from 9-12 November 2021 and saw staff and volunteers join us online from across England. Find out the key takeaways from each day and access further resources to help you apply what we learned. 

• Day one
• Day two
• Day three
• Day four

Day one

A message from NHS England

The conference got going with a welcome message from NHS England Chief Executive Amanda Pritchard. Amanda spoke about how much the NHS appreciates the work you do to make care better and the vital role Healthwatch can play in helping to overcome the challenges that health and social care services face. 

Our Chair, Sir Robert Francis QC, then talked about how far we had come, with more than two million people supported to share their experience or get advice last year. However, he warned delegates that we still faced challenges that we must overcome to remain relevant. 

Takeaways from other sessions

Putting our values into practice

Most staff believe our brand is critical to our work but do deliver a strong brand we need to embed our values in our work. Tips include:

• Have clear objectives and follow up on work to understand your impact so we can demonstrate our value of 'acting'.
• Train staff to ensure our communications are accessible to help deliver our value of 'including'. 
• Adopt our new brand behaviours when they are launched. 

Healthwatch brand messaging guidance

Collecting demographic data

Lots of factors, like ethnicity and peoples income levels, can affect peoples care. Collecting demographic data is key to understanding the experiences of different sections of the community. When you live in areas that are not as diverse, this information is even more critical. Asking for demographic data is not always straightforward, but there is training to support you. Every little bit of information helps when collecting demographic data and even answering one question is better than answering none. 

How to collect and use demographic data

Using the quality framework

The Quality Framework self-assessment tool has helped many local Healthwatch understand work areas that might need improvement. Lessons from local Healthwatch who have been through the exercise includes the importance of harnessing the different perspectives of board members, staff and volunteers and prioritising actions over time to make them manageable. 

The Quality Framework: How can it help you?

Communicating the difference we make

People must understand the difference their views have made to local services. Tactics to achieve this goal include:

• Make time to track if changes have occurred and plan this into your work.
• Promoting the improvements that have been achieved rather than the tasks that got you there. 
• Describe what you have achieved engagingly and what would have happened if services had not acted on your evidence. 

Demonstrating impact – new resources

Key reflections

Ending the day, our former national director Imelda Redmond reflected on the unique role of Healthwatch.

Day two

Holding services to account

Day two kicked off with a debate about one of our important roles - holding care services to account. Delegates agreed that this works best when we build constructive relationships with health and social care decision-makers, and we can influence decisions before they are made. Many of you think that carrying out this role will be challenging in the new health and care landscape, but we can if we continue building our skills, relationships and working together to be heard. 

Takeaways from other sessions

Making your communications accessible

Accessibility isn't a box-ticking exercise and should be an essential part of our everyday work. To make sure your communications are accessible, there are straightforward steps you can take, like using ALT tags. You can also avoid doing things, like using complex language, to ensure what you say is easy for people to understand. The brand language guide includes an accessibility checklist you can use.

How can we make our information as accessible as possible?

Using data to make a difference

Once you're collecting demographic data, analysing it to understand what it can tell you involves trial, error and exploration. Top tips include using statistical approaches like ratios and pivot tables to see what you uncover and using external data to make comparisons. 

How to collect and use demographic data

How volunteers can help tackle inequalities

In helping to tackle health inequalities, its important to have volunteers drawn from across the diverse communities we serve. Our volunteers can play an essential role by championing equality in our work, raising awareness of the different perspectives some groups have and helping to build relationships with their communities.

Guide to Volunteering

Day three

A message from Government

Minister of State for Health Mr Edward Argar MP welcomed delegates by speaking about our role in the future NHS landscape.

Takeaways from other sessions

Policy breakfast briefing: Social care

The public are unclear on the recent changes to social care and are increasingly concerned about issues like access, eligibility and how to pay for care. There are a lot of issues across the country at the moment with inconsistent care and financial assessments. This can lead to people giving up and not getting the care they need. We can help by focussing on clear advice and highlighting where local needs are not being met.

Advice and information: What is adult social care? 

Supporting volunteers in the new health and social care landscape

The role of volunteers within the new ICS landscape is unclear and only just over a third of delegates were confident that their ICS had volunteering on their agenda. Without a statutory requirement volunteer and patient involvement is likely to be inconsistent across the country. You can help by raising volunteering with your ICS and encouraging a discussion to find out what roles our volunteers can help with.  

Resources to support volunteering

Representation of people and communities through local Healthwatch 

Having a seat at the ICS table is important that Healthwatch demonstrate the value they bring. Bring able provide to provide evidence we collect at an ICS level and build trust through this valuable insight is key. Having Healthwatch representation will also give us the opportunity to hold systems to account for their decisions. Doing this is often a difficult task that uses a lot of resource, so it is important we come together, support and learn from each other. 

Watch the recording of this session on YouTube.

How are Healthwatch and ICS's working together?

Celebrating the difference we make

Day three also saw our annual network awards ceremony, celebrating the difference you've made over the last twelve months. 

Day four

The final day of the conference included a debate about our role in public health and an overview of net steps following Healthwatch Week.  

Takeaways from other sessions

Using our new Healthwatch brand

Consistently using the new Healthwatch tone of voice and personality takes practice but will help you grab people's attention, keep them interested and build trust. Tips to help you write like Healthwatch include:

• Speak to the reader
• Keep copy short, sharp and write in an active tone
• Use plain English and cut unnecessary information
• Write with specific personality points in mind

Brand messaging guidance

Turning evidence into change: Stakeholder influencing

Local Healthwatch are currently spending a lot of time influencing ICSs and it is not yet clear what the impact of this influencing is. However, we also sit on boards and committees such as Health and Wellbeing boards and this can lead to a lot of impact, helping to build relationships with local stakeholders and ensuring the Healthwatch voice is heard.

A guide to running Healthwatch

Working together: CQC, NICE and Healthwatch England

We are all aligned on our strategy to prioritise tackling health inequalities in our work. This gives us the opportunity to collaborate more, particularly in targeting seldom heard communities and making it as easy as possible for these communities to talk to us. Demonstrating the outcomes of our work will be key to demonstrating success in this new strategy – and all three organisations are looking at new ways of ‘closing the loop’ and showing people the impact their feedback has had.  

Watch the recording of this session on YouTube.

CQC and local Healthwatch working together

Working with partners to undertake research projects can be very beneficial. However, it is also important for you to maintain independence when delivering your statutory duties as an independent champion for the health and social care services users. 

This guidance will help you to understand why you should work with other organisations on research projects. It includes examples of previous Healthwatch research with successful partnerships, tips on how to maintain independence and how to manage intellectual property rights when working with partners. 

About this resource

Our Policy Forum focusing on Special Educational Needs and Disability for children and young people aged 0-25 participants had an opportunity to:

• Share their work on Special Educational Needs and Disability, and hear from others in the network.
• Tell us more about what we can do to help you engage with Special Educational Needs and Disability work in your area.
• Hear from Parent Carer Forums and experiences of local parents and carers.

About this resource

Healthwatch aim to reach every section of their community to gather evidence and insight about people’s experiences of health and social care in their communities.

Using Special Educational Needs and Disability (SEND) as an example, this resource explains how Healthwatch can use this insight to have a greater impact and influence areas outside of health and social care by working with partners.

Produced with Contact and National Network of Parent Carer Forums, this resource provides information about SEND and how Healthwatch can work with SEND and Parent Carer Forums locally to improve services for their community.

Step one - Find who you need to talk to

The first step is to research which elected representatives would benefit from hearing about your work.

To find the MPs who represent the community you work with, visit https://www.parliament.uk to search for MPs by postcode.

To get the contact details for local councillors, check out the website of your local authorities in your area. District councillors in two-tier areas may be less directly involved in health and social care, but will still be interested in local issues.

Remember to be clear about why you want to talk to them. Are they a community representative or do they hold a specific position or sit on a relevant committee as well?

Understanding how decisions are made locally will help with this research. For example, what type of council is the elected representative involved in? What are they responsible for? This guide to local government can help you.

Step two - Be proactive and relevant

An election gives you a great opportunity to get in touch with an elected representative to make sure they understand the role of local Healthwatch and how you can help.

Whether there has been an election or not, MPs and councillors will be interested in local people’s views, and the concerns they have. However, you can help by ensuring what you share is tailored and relevant.

• Does it relate to their constituency or ward?
• Does the elected representative have a history of being interested in certain issues?
• Will the information help them with an upcoming decision or debate?

You can find out about the upcoming work of elected representative by looking at the forward plan of a local council or what is coming up in Parliament using the Parliament calendar. You can also contact local or national committees to ask them about their future work.

Your role on local Health and Wellbeing Boards also provide another opportunity to alert elected representatives about the experiences people have shared with you. 

Step three - Keep the lines of communication open

Stay in touch after the first contact. Steps you can take include:

• Sending them new reports, news and your annual report
• Offering them briefings a few times a year on the key issues facing the community

Some local Healthwatch support elected representatives by helping to answer the health and social care questions from local people. Holding joint health and social care information surgeries is one way to do this and can help you a gathering more feedback from your community.

Step four - Remember our role. Remember purdah.

A productive relationship with elected representatives will benefit your community but it’s important to always maintain your independence and political impartiality.

Our ‘Guide to maintaining independence’ can help you do this. 

With elections regularly being held across England, it’s also essential that, when they happen, you act in a politically neutral manner.

Our ‘Purdah guidance’ explains more about how you should behave during national and local elections.