Engagement Methods for NHS Service Redesign

With Health Overview and Scrutiny Committees referring an increasing number of NHS service change processes for inadequate involvement, commissioners are under pressure to show not just that engagement happened, but that the right method was used. This article sets out the main engagement methods, what each delivers, and how to match the approach to the decision.

What engagement methods are available for NHS service redesign?

Five engagement methods are used in NHS service redesign: co-production, in which patients and staff work as equal partners; experience-based co-design (EBCD), which uses patient narratives to identify improvement points; Patient and Public Involvement (PPI) panels; deliberative events and citizens’ juries; and surveys and structured feedback tools. Each carries a different evidential weight and suits a different type of decision.

The distinction that matters most in practice is not between methods but between their purpose. Some methods are designed to inform a decision: they gather views and feed them into a process that remains in the hands of commissioners. Others are designed to co-create a decision: patients and staff share authorship of the outcome. Treating an informing method as though it were co-creation, or vice versa, produces a process that is neither legally adequate nor operationally useful.

Co-production is equal partnership between patients with lived experience and clinical and managerial staff, working together from the outset to design or redesign a service. It requires a genuine redistribution of decision-making power, not just patient representation at a committee. NHS England’s literature review on co-production finds consistent qualitative evidence of improved patient experience and clinical outcomes. It is the most resource-intensive method and is most appropriate for complex redesigns where community ownership of the outcome is essential to implementation.

Experience-based co-design (EBCD) uses filmed patient narratives to identify the moments in a care pathway, known as touchpoints, where patient experience diverges from clinical intentions. Patients and staff then redesign those touchpoints together. A maternity services co-design study found that involving users across four design stages produced patient-centred clinical resources and strong feedback on patients feeling genuinely valued. EBCD is well-suited to acute and community settings where specific gaps between clinical process and patient experience can be identified and targeted.

Patient and Public Involvement (PPI) panels are formal advisory groups providing ongoing input into service planning. They work well for board-level oversight and sustained formal consultation. The risk of tokenism is real: panels that are heard and then set aside do not constitute meaningful involvement, and a PPI process that cannot demonstrate its input influenced the outcome is a process that has not met the standard.

Deliberative events and citizens’ juries bring members of the public together to examine evidence and reach considered conclusions. They are particularly suited to contested proposals involving significant trade-offs, such as service closures or large-scale reconfigurations, where a transparent record of how competing public views were heard and weighed is important.

Surveys and structured feedback tools provide breadth of reach at relatively low cost and are appropriate for monitoring patient experience trends or gathering initial intelligence. They are not adequate as the primary evidence base for a significant service change. A self-selecting online survey used as the sole basis for a major reconfiguration will not withstand scrutiny.

How do you choose the right engagement method for an NHS service change?

Method selection should be driven by the stage of the decision, the scope of the proposed change, and the population affected. The legal duty under Section 14Z2 of the NHS Act 2006 requires involvement throughout the commissioning process, not at its end, which means that co-production and EBCD, both of which require early access to the design process, are not options that can be retrofitted once a direction of travel is set.

On scope, the evidence is consistent. Surveys and focus groups are appropriate for lower-stakes decisions or initial intelligence-gathering. Co-production is intensive but generates the clinical alignment and community ownership that complex redesigns depend on. Applying a light-touch method to a high-stakes decision because resource is short produces engagement that satisfies no one.

On population, the Public Sector Equality Duty (PSED), the requirement under the Equality Act 2010 for public bodies to have due regard to equality, means that any engagement process must actively reach groups that standard methods do not reach. Healthwatch guidance on co-producing with seldom-heard groups is a practical starting point. The absence of seldom-heard groups from an engagement process is both an evidence gap and, under the PSED, a legal exposure.

The organisations that get this wrong are not usually those that chose a bad method deliberately. They are those that picked a familiar method because time was short, or because it was what had always been done. A survey sent to an existing mailing list is not an engagement strategy for a significant service change. Neither is a PPI panel consulted after the preferred option has been agreed. The method has to be proportionate to the decision, and it has to be chosen before the process begins, not retrofitted to a decision already made.

Commissioners who are unsure whether their proposed approach is adequate for the decision they are making should seek an independent view before the process starts, not after a challenge has been made.

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How tCI Can Help

Advice and Guidance
A tCI faculty member will work alongside you to support the development of your decisions and engagement approach. We provide independent, constructive advice at critical stages, helping you strengthen stakeholder mapping, test communication strategies, and plan robust post-decision engagement. Our role is to act as a critical friend, offering practical recommendations grounded in consultation law and good practice that build confidence in your process.

Risk Assessment
Early identification of legal, political or reputational risks in your engagement approach. Using tCI’s five-risk methodology, we spot gaps before challenge arises, helping you strengthen stakeholder communication and demonstrate procedural fairness from the outset.

Executive Briefings
Concise updates for senior leaders on consultation law, engagement duties and post-decision risks. Helps boards and leadership teams make confident, defensible decisions when under pressure, with clear guidance on what good engagement looks like after difficult choices are made.

Whether you’re preparing for a high stakes service change or building defensible evidence for complex decisions, we can help.

Contact tCI: hello@consultationinstitute.org