The Dash review and its impact on the future of patient advocacy

In her analysis of six national bodies responsible for patient safety — the Care Quality Commission (CQC), Healthwatch England, Patient Safety Commissioner, Health Services Safety Investigations Body (HSSIB) and NHS Resolution — Penny Dash, chair of NHS England, found a fragmented and inefficient system.

According to the Dash review, published in July 2025, a decade-long drive to improve safety in the NHS backed by “considerable resources” has created a “cluttered landscape” of organisations covering the area, which has led to limited improvement.

The review found a “confusing” array of more than 20 organisations offering patients the opportunity for feedback, leading it to conclude that there is a need to streamline oversight and reduce duplication around the patient voice.

In addition, it said the distance of organisations from NHS services, such as Healthwatch England, “risks a lack of action and change”.

Established under the Health and Social Care Act of 2012, Healthwatch England is officially a statutory committee of the independent Care Quality Commission. Local branches are funded by, and accountable to, local authorities.

Intentionally created to act at arm’s length from central government and the NHS, its core function is to establish patients’ views on, and needs from, the health service, which it then disseminates to those running the various parts of the service.

However, later in July 2025, the government’s NHS ten-year plan outlined plans to abolish Healthwatch England entirely and bring its function in-house, with its role given a “greater profile” within a reformed Department of Health and Social Care (DHSC). It said a new national director of patient experience would be responsible for overseeing the collection of “more informed feedback”.

Future of Healthwatch 

The work of local Healthwatch bodies — of which there are 150 around the country — would be brought into integrated care boards (ICBs), with their social care oversight function moving to local authorities.

There will also be an updated complaints procedure for NHS users backed by AI for a faster response. 

Healthwatch has published several reviews of healthcare services, including into pharmacy services, since it was established in 2012, and the change to the future of Healthwatch was met with palpable concern from several organisations. This was not helped by the announcement first being mooted in the press, followed by confirmation in the NHS ten-year plan days before the Dash review published the detail.

Louise Ansari, chief executive of Healthwatch England, said in a statement following the publication of the Dash review that in its 12-year lifespan, the organisation had helped millions of people raise concerns, access vital advice and “influence real change” in services.

“Our focus now is on ensuring a smooth transition of our functions to the NHS and government, so that the voices of patients and the public continue to be heard,” she added.

Neil Tester, chair of Healthwatch Hertfordshire, says: “Nobody actually knows yet the extent of change that local Healthwatch will be facing.”

He adds that senior figures from across the NHS, local government and voluntary sector have raised concerns about the potential loss of trusted relationships with communities, particularly those who are the most underserved. 

“I’ve been struck by how consistently Healthwatch across the country have articulated that message about what would be lost around independent perspective and the trust and willingness to share insight.”

In the real world, Tester argues patients do not live in the “organisational silos” the NHS functions within, they interact with different parts of the system they see as one NHS — and Healthwatch has been able to provide scrutiny across all of it.

“To be able to have that narrative about the way people actually experience care right across the system is important,” he says.

Tester points out that Healthwatch has also reported many times on community pharmacy, both locally and nationally, where patients have often identified issues that have later been taken up more widely, such as speaking up about medicines shortages, Pharmacy First and inefficient communication in primary care.

Tase Oputu, chair of the RPS English Pharmacy Board, agrees that Healthwatch has a track record of shining a light on crucial patient issues, including medicines shortages and community pharmacy closures, and she shares concerns about the risk of losing independent insight and analysis.

“This also comes at a time when integrated care boards are facing significant cuts. It is vital that the patient voice and clinical leadership are not lost amid this disruptive organisational change,” she says.

Patients must be supported to manage their health and medicines and be listened to when they raise concerns, Oputu adds, including those from marginalised groups.

Speaking to The Pharmaceutical Journal, Louise Bate, manager at Healthwatch Dorset, has raised concerns about what the changes to her organisation will mean for health inequalities. 

Healthwatch Dorset recently reported on challenges for patients accessing pharmacy in more rural areas. Medical shortages were also flagged as particularly “troubling” by the organisation, which surveyed 900 people.

“Our independence is really important, it helps people to feel safe enough to tell us about their experiences and enables us to work with communities who don’t feel like they have a voice,” she says.

The Patients Association has accepted that the goal of the reorganisation is to focus on patient experience and reduce confusion in the system, but has serious concerns about how the Dash reforms will impact patients.  

“The culture of healthcare can be intimidating — many patients contacting our helpline are vulnerable, confused by complex systems, or afraid to speak up directly,” says Rachel Power, its chief executive. 

Bringing the functions of Healthwatch into the DHSC and ICBs will leave many patients without this “arm’s length advocacy”, she believes.

“We’ve heard through our patient engagement work about some complaints services where many patients lose confidence when that service sits within the very organisation it’s meant to scrutinise.” 

A question of priority

The King’s Fund has long warned that patient experience was “slipping down the agenda” and believes that the Dash review will bring a greater focus to patient advocacy.

Sarah Woolnough, chief executive of The King’s Fund, says that the constant cycle of increased regulation in response to crises, followed by cuts to reduce bureaucracy, has led to a collection of bodies with seemingly overlapping functions.

Although she accepts that Healthwatch England has played an important role in raising issues of concern with patient experience, “including many of the issues the government say they are trying to tackle”. 

“The government will need to provide more details on what will be put in place to replace Healthwatch England’s critical functions, including who will hold the system to account for feedback collected via the NHS app,” she adds.

Commenting on the changes to the patient advocacy landscape in the House of Commons on 7 July 2025, health secretary Wes Streeting argued that despite the number of organisations dedicated to patient advocacy, “in fact patient experience is not given the attention it deserves in the NHS”, citing the fact that few trust boards have an executive director dedicated to this purpose. 

“Patient and staff voice should not be kept at arm’s length but be at the heart of everything the NHS does,” he said.

“These changes will improve quality, including safety, by making it clear where responsibility and accountability sits at all levels of the system, and making it easier for staff, patients and users to directly feed into the system to improve quality of care.”

Meanwhile, Jackie Giltrow, chair of the Community Pharmacy Patient Safety Group, says her organisation does not believe the safety of patients in community pharmacy will be negatively impacted by the NHS ten-year plan and Dash review, despite the function’s move to different organisations, including the DHSC and CQC. 

“The purpose of the Community Pharmacy Patient Safety Group is improving patient safety within community pharmacy and, as such, we will stay close to the changes as they happen,” she says.

“We will use our collective expertise to inform government work, to ensure that this is an opportunity to promote the work community pharmacy is doing and share best practice.”