Introduction

This chapter focuses on the changing local structures of patient and public involvement (PPI) in the English NHS, and on their basis in health policy. Reforms to processes of PPI intersect with, and have co-existed alongside reforms to, all the key analytic axes highlighted in this volume: hierarchies, markets and networks; the public and the private; professionals and the state. However in this chapter, our focus is how PPI intersects with one of the axes identified by the editors: dynamics of centralisation and decentralisation in the NHS. At the core of this interest is something of a paradox. Greer et al have argued, with a focus on health governance during the pandemic, that political decisions about centralisation and decentralisation are a question of credit and blame: ‘politicians who wish to be effective and elected seek credit and avoid blame’ (Greer et al, 2021). In this view, decentralisations – especially those driven by New Public Management logics – are a route by which government ministers avoid public blame and muddy accountability. Thus we might assume that questions of public voice are better served by a centralised healthcare system with clean, direct lines of accountability. To draw on one of Bevan’s ever-quotable speeches (discussed further in the next section), the ‘slops bucket’ is knocked over, and a patient’s complaint will be heard in Whitehall. However, the English NHS, is, by the standards of similar health system types, far too large for this centralised vision of responsiveness to be viable via command and control. Substantive calls for greater democratic control of the NHS are invariably couched at the local, and not the national, level (Klein, 2010).

The NHS in England has seen repeated attempts to devise adequate local structures of patient and public voice over the decades, alongside repeated dynamics of decentralisation, and recentralisation, in broader structural change (Peckham et al, 2005). Within the reforms (listed in Table 12.1) we argue that there are at least two competing visions of effective PPI, reflecting a distinction Day and Klein (1987) posit between political and managerial accountability.