The NHS Assembly was established by NHS England in 2019 to collaborate with the Board of NHS England on the implementation of the NHS Long Term Plan. It comprised around 50 people drawn from diverse backgrounds. These people were appointed by the leaders of NHS England in consultation with the co-chairs of the Assembly, who were also chosen by the leaders of NHS England.
The terms of reference for the Assembly identified its role as to bring ‘broad stakeholder insight and frontline experience to discussions, serving as a ‘guiding coalition’ on implementation of the improvements outlined in the plan’. Approximately twenty per cent of members came from each of the following four categories:
- patients, public and carers
- frontline staff and clinicians
- the voluntary, community and social enterprise sector, and
- health and care system leaders.
The remaining members are either national clinical leaders or from think tanks, professional networks and other backgrounds. All members served in a personal capacity and not as representatives of the organisations or interests from which they were drawn. Members and co-chairs had expenses reimbursed, but received no remuneration.
There were marginally more women than men on the Assembly (54% vs. 46%), and the appointment process sought to ensure representation of people from diverse ethnic backgrounds, as well as those with protected characteristics. In some respects, the Assembly became a microcosm of the NHS, as noted by Fatima Khan-Shah, an Assembly member from West Yorkshire, which facilitated knowledge sharing and joint problem-solving on complex issues.
Assembly meetings
The work of the Assembly is discharged primarily through meetings that occur five or six times each year. Initially, these meetings were in person, but during the COVID-19 pandemic, they became virtual before reverting back to in-person during 2023. In some cases, subgroups of members were established to consider and report to the Assembly on specific issues of concern (see below). Agendas for meetings were developed by the Assembly’s co-chairs in discussion with the leaders of NHS England, supported by a small secretariat.
Members bringing the voices of patients, the public, and carers were closely involved in shaping the work of the Assembly. This helped in delivering the aspiration that the Assembly should focus on people, not organisations, and always keep the needs of patients and service users at the heart of its deliberations. A number of members brought invaluable lived experience of NHS care to discussions, and their contributions ensured the Assembly’s work was grounded in the realities, positive and negative, of patients.
Other aspirations included serving as a sounding board for policy at an early stage of development, identifying barriers to implementing change, engaging in difficult conversations to bring the ambitions of the Long Term Plan to reality, and modelling compassionate and positive leadership. Assembly members were discouraged from using jargon and acronyms in support of the inclusive approach taken in meetings.
At an early stage, the co-chairs developed a method of working in which each meeting heard an update from the Chief Executive of NHS England on current issues, followed by an in-depth discussion of three or four policy priorities. Formal presentations and PowerPoint slides were kept to a minimum, allowing most of the time for Assembly members to express their views on the issues under discussion. These issues included planning and supporting the health and care workforce, tackling health inequalities and preventing ill health, and fostering a culture in which leaders and staff could thrive.
The chief executives and chairs of NHS England attended almost all meetings, listening to discussions, offering reflections on views expressed within the Assembly, and participating where appropriate in the discussions. They were frank in sharing what was happening in the environment in which they were operating and the pressures this created.
While NHS England’s chair and chief executive also met regularly with representatives of other stakeholders, the Assembly was unique in bringing together so many voices to provide a sense-checking forum for these leaders. In the view of Richard Meddings, chair of NHS England between 2022 and 2025 “The NHS Assembly was a key and trusted sounding board, providing input across a range of issues and drawn from committed members representing a broad mix of experience and insight.”
Other senior NHS England leaders attended meetings by invitation, and occasionally, contributions were made by experts from other organisations. Assembly members were not only active participants but also frequently took the lead in introducing topics. To foster open discussion, meetings were conducted under the Chatham House rule. This was important in assuring that information shared at meetings would not be misused while also helping Assembly members understand the diverse and complex demands placed on NHS England.
The geographical spread of the membership necessitated that in-person meetings be held in London for the convenience of travel. One of these meetings was based in North West London to enable members to see for themselves some of the work being done to integrate care. The meeting was hosted by an Assembly member based at Imperial College Healthcare NHS Trust. It included a guided walk in the area to understand the diverse communities served and how their needs were being met by the trust and its partners in the integrated care system.
The COVID-19 pandemic
During the COVID-19 pandemic, meetings received updates on how the NHS and its partners were managing the demands placed on them, and heard from Assembly members about their experiences. A central theme at this time was the role of communities in moderating the impact of the pandemic, for example, through increasing vaccine uptake and providing mutual support to friends and neighbours in their areas. Members were active in highlighting the adverse effects of lockdowns on different groups and the challenges faced by many families and frontline staff.
The Assembly’s discussions on the pandemic drew on the wide variety of perspectives and experiences of its members. Perhaps uniquely, these perspectives included those of national and local NHS leaders, frontline staff, patients, the public, carers, and partners in sectors working with the NHS. At one meeting, filmed interviews with directors of public health provided information on how local authorities were working with their communities to provide test and trace services and reach hesitant groups in the population.
Working during the pandemic highlighted the importance of partnerships between the NHS and other organisations, as well as the value of local NHS leaders having the authority to make decisions tailored to their communities and services within the framework established by NHS England.
Assembly influence
An example of the Assembly’s influence was the decision of NHS England to appoint a leader for work in tackling health inequalities in health care. This arose from discussions by a group of Assembly members highlighting the need to redouble work on prevention and ensure this was targeted at groups in the population in the poorest health. A GP from Derbyshire, Bola Owolabi, was appointed to take forward these efforts, leading to the Core20PLUS5 initiative across the NHS.
Another example concerned changes to legislation to support increased collaboration between NHS bodies and their partners. Senior NHS England staff brought this issue to the Assembly to seek advice on the proposed changes before they were taken forward. This example was linked to the emergence of integrated care systems in England, which aim to develop closer partnerships within the NHS, with local government, and the voluntary and community sectors, an issue regularly discussed at meetings.
A recurring theme in Assembly meetings was the health and well-being of NHS staff and their training, recruitment and retention. The NHS Long Term Workforce Plan, published in 2023, was discussed with the NHS England team responsible for its development on more than one occasion. This included consideration of the People Promise and support for staff in need of medical advice, as well as how this should be provided.
The Assembly’s influence was often felt when NHS England’s leaders were ‘in the room’ during meetings and heard voices and perspectives that were not usually prominent in their work. This was an example of the soft power exercised by the Assembly, resulting from the composition and diversity of its membership, as well as the respect shown to members from all backgrounds. These members included those from the voluntary sector, frontline clinicians, and local government, as well as those speaking on behalf of patients, the public, and carers.
One way in which voices and perspectives from less visible groups were amplified was through small group discussions at Assembly meetings. These discussions were an invaluable complement to plenary sessions and enabled members less experienced in working in these kinds of forums to contribute. The size of the Assembly was another factor in the decision to vary the style of meetings. Surveys of members were conducted to gather feedback on the Assembly’s performance and solicit suggestions for improvement.
Connections made through the Assembly led to members working together in informal groups beyond regular meetings, thereby enabling shared learning in areas of common concern. Contact was facilitated by the use of Teams meetings and occasionally were held in person, as when a number of members attended the NHS ConfedExpo conference.
The NHS in England at 75: priorities for the future report
The 75th anniversary of the NHS in 2023 provided an opportunity for the Assembly to consolidate much of its work in a report designed to inform NHS England and the wider NHS on future priorities. The report benefited from a rapid process of engagement with patients, staff and partners supported by the extensive networks of Assembly members.
It identified three shifts to enable the NHS to rise to future challenges, predating those advocated by Wes Streeting, reflecting arguments put forward by a range of stakeholders. These initiatives aimed to promote prevention both within the NHS and in partnership with others, support personalisation and participation to give people more control over their care, and develop coordinated care closer to home to reduce pressure on hospitals.
The report argued that delivering these three shifts should be supported by the following seven enablers:
- a thriving workforce and better-supported carers
- stronger partnerships, including with social care and the voluntary and community sector
- better use of digital technology and data
- a modernised infrastructure, particularly in primary care
- maximising the value of care and treatment
- creating a well-led, learning and self-improving system
- a new compact with the public
The full report, including a view on a new relationship between the NHS and the public, can be accessed here: NHS England » The NHS in England at 75: priorities for the future
In taking these ideas forward, the Assembly set out several ‘asks’ of NHS England, including to put in place a clear policy framework and a small number of goals. In the Assembly’s view, local leaders, staff and partners were best placed to lead change, recognising that transformation usually results from many small improvements rather than major breakthroughs. This required the centre to become smaller and more unified, building on the absorption of arm’s length bodies like Health Education England into NHS England and cuts in central staffing The Assembly advocated shorter lines of communication within the NHS and more effective and direct dialogue with those delivering care.
Viewed in the broader context, the NHS Assembly is an example of how citizens’ assemblies are being used in the development of public policy in some countries. Experience shows that assemblies take different forms and undertake a range of tasks in the development of policy on important and contested issues. Some focus on a specific question, such as in Ireland where abortion and climate change were both considered, and then move on to other questions. The NHS Assembly worked differently, adopting a broad scope and having an ongoing remit until the government’s decision to abolish NHS England removed its rationale and signalled the end of its work, at least in its current form.
What lessons can be drawn from its work?
Opinions within the Assembly’s membership were overwhelmingly positive. The opportunity to be part of a diverse group and to work closely with the leaders of NHS England was highly valued. Likewise, NHS England’s staff who worked with the Assembly testified to the benefits they experienced in hearing different voices and having their views challenged constructively. They highlighted the value of the interaction between Assembly members, noting how views emerged and sometimes changed as a result of discussions that drew on a range of perspectives.
The importance of the commitment to the Assembly, as demonstrated by the regular attendance of the chief executives and chairs of NHS England, is hard to exaggerate. It resulted in a clear sense of purpose and high levels of attendance and energy at meetings as well as a unique opportunity for many of those involved to contribute to the development of national thinking. Chris Hopson, former Chief Strategy Officer at NHS England, commented, “It gave us the chance to hear direct, in one room, the views of all those with a stake in the NHS – patients, staff, the voluntary sector and frontline leaders – and to understand the interplay between these differing perspectives.
Respect for the (often different) views of other Assembly members was another notable feature. This was especially important during the COVID-19 pandemic when there was much uncertainty and debate about how best to respond. Diversity of thought generated a wide range of ideas and greater understanding of the impact of different options.
Scottish philosopher, David Hume, famously wrote that ‘truth springs from argument amongst friends’. Hume’s observation recognised that exposure to dissenting opinions is a way of challenging preconceived notions, and this may be uncomfortable. Clenton Farquharson, an Assembly member with lived experience and expertise in personalised care, reflected that ‘The NHS Assembly proved that good policy doesn’t only come from the top, it comes from listening deeply across difference’.
As co-chairs, we worked hard to create a working environment that valued all contributions and protected as much time as possible for members to contribute. This involved liaising closely with the secretariat to formulate agendas and agree on the running of meetings. Pre-meetings with NHS England’s chief executives supported these endeavours. As a bridge between members and NHS England’s leadership, we were able to manage and anticipate possible challenges before they emerged.
Adherence to the Chatham House rule ensured that discussions were open and honest with all involved assured of confidentiality.
Assembly members challenged us regularly to demonstrate that our work was making a difference. This took time, especially when the Assembly’s influence was often intangible. Recognition of the Assembly’s advisory rather than executive role and that influence derived from ‘soft power’ rather than conflict and confrontation undoubtedly helped. At no time did meetings feel unduly cosy or comfortable and we felt tested continually to seek and act on feedback.
To borrow a phrase from a different context, the Assembly developed over time into a ‘team of teams’ (McChrystal et al, 2015) in which barriers between different stakeholders were broken down thereby enabling much richer and informed discussion. Leadership research has shown that teams with diverse members often perform better than those without. The experience reported here echoes this research while also pointing to factors that contribute to the development of teams and enable them to perform effectively
It is for others to decide whether a body like the Assembly should have a role in future. A case can be made for a national forum of this kind, as well as local forums, perhaps aligned with the work of integrated care boards. Whatever emerges, the point we would emphasise above all others is the value of diversity in all its senses, and of nurturing ways of working that respect diversity and enable NHS leaders to engage with different interests and voices in one forum.
While the Assembly may not have had executive powers, its experience highlights the benefits of forums where leaders can test their thinking and hear alternative views. In the view of Rob Webster, chief executive of West Yorkshire Integrated Care Board, “the Assembly illustrated the importance of the physiology of the NHS – how work is done – alongside its anatomy or structure”. This was most apparent in the connections that were created and the conversations that resulted, akin to Hume’s arguments amongst friends.
Chris Ham and Clare Gerada