Co-Design: Robust Patient Engagement or Just a Tick Box Exercise?

When the NHS procures a new digital health system, the business case is likely to mention the need for patient engagement. Procurement documents typically reference co-design principles. Project boards often include patient representatives. So that's all the right boxes ticked...

Right?

Not necessarily.

NHS England requires patient involvement in commissioning under the Health and Care Act 2022. However, in January 2025, The King's Fund published concerning findings about digital transformation: designing services with user involvement "isn't routinely done." This followed Lord Darzi's independent investigation, which also found the patient voice is "not sufficiently heard in NHS decision-making."

These aren't isolated observations.

The Health Equity Evidence Centre warns of a specific risk: co-production becoming "tokenistic" when organisations prioritise "easy-to-count measures over genuine influence."

This matters. Asking for feedback on a pre-selected platform just before it is launched is not the same as involving users during the design process or before selecting suppliers. Measuring how many patients attended workshops is not the same as measuring whether their input shaped technical specifications and improved use across diverse users.

When NHS organisations face national targets for digital transformation — widespread EPR implementation by March 2026, FDP adoption across 85% of trusts, NHS App rollouts with defined schedules — priorities shift to speed of deployment over safe, equitable, and effective deployment.

The NHS Alliance has correctly identified this tension:

"There's a juxtaposition between racing towards nationally set targets against the reality of necessary in-depth methodology, processes and planning."

When urgency drives implementation, robust iterative co-design takes a back seat to delivery deadlines.

Even when co-design happens, there's often a gap in who participates. The people most likely to struggle with digital services are least likely to be involved in designing them.

NHS England recommends identifying those "most likely to be digitally excluded" and co-designing specifically with patients who "struggle with digital access or skills." Yet The King's Fund notes that "digital service design often fails to gather a wide range of perspectives, particularly from those who are digitally excluded."

NHS procurement often operates through framework agreements which build lists of pre-qualified suppliers with already-developed products. The scope for patient feedback to change fundamental product architecture at this stage is constrained by what suppliers can offer within framework terms and reasonable costs. Feedback can only reasonably influence implementation approach, training design, and communication strategies — with limited influence on core specifications.

A 2025 review on co-production in digital health found "specific evidence relating to successful co-creation strategies is scarce with a lack of consensus over the metrics needed to support its long-term sustainability."

Without evidence demonstrating that co-design improves outcomes, organisations struggle to justify extended timelines or additional costs. The Health Equity Evidence Centre acknowledges:

Co-production can be a challenging and potentially uncomfortable space for everyone involved. Professionals can be resistant to co-production. It can create challenges around identity, power and reveal issues around staff morale and empowerment… Additional resources, time and money are needed, which are hard to find in stretched health systems.

NHS procurement emphasises standardisation, compliance, and value for money. Co-production guidance emphasises flexibility, iteration, and power-sharing. These are structurally different approaches to decision-making.

If co-design genuinely shapes technical requirements, procurement cannot begin until co-design provides those requirements. If co-design is iterative and ongoing, procurement specifications must accommodate flexibility for refinement based on user testing.

Until we address the structural barriers, co-design risks remaining performative — good governance tick boxes that reassure boards without actually changing what gets purchased and implemented.

NHS England's guidance on co-production identifies what's actually needed: "rapidly translating co-production outputs into strategic decision making" with "sufficient dedicated time and resourcing for service redesign."

Good Things Foundation's methodology further emphasises the need for understanding user needs through sustained engagement, creating recommendations, testing iteratively, taking stock of what works, then delivering and evaluating. This process requires flexibility to refine specifications based on what's been learned.

1. Start co-design before procurement begins. Patient engagement that starts after supplier frameworks are selected cannot influence core technical decisions. Co-design must inform requirements before procurement documents are written.

2. Build co-design costs into business cases from the start. The House of Commons Health and Social Care Committee was clear: "time and resources must be built into programmes" for effective co-design.

3. Actively recruit digitally excluded populations. The King's Fund recommends "reaching out to representative organisations and trusted intermediaries and joining existing gatherings." This requires going to where people are, not waiting for them to come to consultation events.

4. Make technical specifications modifiable based on feedback. If procurement frameworks only allow selection between pre-built products with fixed specifications, patient feedback has little power to shape what is actually delivered.

5. Measure influence, not just engagement. Document which aspects of technical specifications changed because of patient input and why — not just workshop attendance figures.

6. Allow realistic timelines for genuine co-design. Good Things Foundation's methodology requires sustained engagement, iterative testing, and refinement. ICBs need authority to extend procurement schedules when meaningful co-design justifies it.

7. Train procurement teams in co-production principles. Procurement professionals need to understand co-production methodology and how to translate user feedback into technical requirements — skills that differ from compliance and contract management.

8. Create accountability for co-design quality. If systems show poor adoption among populations supposedly 'involved', that should trigger a review of the co-design process itself.

9. Document what changed and what couldn't be. When patient feedback does not result in changes due to framework constraints or funding limitations, document this explicitly. Being transparent about limitations is better than implied influence.

10. Pilot procurement approaches that genuinely integrate iteration. ICBs should pilot models where co-design genuinely shapes specifications, with evaluation of whether this produces better adoption and outcomes.

These recommendations require structural changes to procurement, additional resources in constrained systems, and longer timelines — all challenging in an environment of constrained budgets and pressure for speed.

But the alternative is continuing to describe patient engagement as co-design when it's actually consultation on decisions already made.

The challenge isn't to better understand what good co-design looks like. NHS England's own guidance describes it clearly. The real challenge is closing the gap — which requires changing the structures that currently limit genuine patient influence.

Until then, our digital health systems will continue to be designed without meaningful input from the people we need to use them. And we'll continue to wonder why adoption falls short of projections.