The Hewitt Review: key takeaways so far
The eagerly anticipated Review into integrated care systems (ICSs), led by former Health Secretary Patricia Hewitt was published today, setting prevention decentralisation and cross government co-production as key priorities. What have we learned so far?
Former Health Secretary and current Chair of Norfolk and Waveny ICS Patricia Hewitt, was commissioned by Chancellor Jeremy Hunt last year to undertake a substantial review into the accountability, governance and oversight of ICSs. The 89-page Review, published on Tuesday, covers England’s 42 ICSs and makes a series of recommendations to enhance the autonomy of ICSs.
In the forward to her report, Ms Hewitt says: “Unless we transform our model of health and care, as a nation we will not achieve the health and wellbeing we want for all our communities – or have the right care and treatment available when it is needed.”
The Hewitt Review calls for ICSs to be given the time and support to succeed. The establishment of ICSs must not simply be another superficial reorganisation – and the Review acknowledges a growing policy alignment ICSs that will “last well beyond one parliament, government or minister,” giving ICSs the time and space to embed the new model.
Shifting power from the centre
The Review also outlines how growing acceptance of the ICS model from DHSC and NHS England should come with a drive towards decentralisation wherever possible. To realise the promise of these systems, the Review states that “national and regional organisations should support ICSs in becoming ‘self improving systems’ given the time and space to lead – with national government and NHS England significantly reducing the number of national targets to no more than 10 key national priorities.”
Central to providing ICSs with greater autonomy is to reset approaches to health and care finance. Accordingly, the Review calls for greater funding flexibility for 10 of the most mature and best performing ICSs, as well as for broader funding reforms to be “multi-year and recurrent”.
Commenting on this, Sir Julian Hartley, Chief Executive of NHS Providers, said: “The emphasis on improvement over top-down performance management is essential and we hope the NHS at all levels will commit to the cultural shift necessary to bring this about.”
However, Hartley went on to call for greater clarity on the responsibilities and accountabilities of the different system players.
“We worry that trusts and integrated care boards (ICBs) will struggle to work as equal partners while ICBs have day-to-day oversight of providers.
“We’re also concerned that some recommendations could add complexity and bureaucracy – for example, with auditing prevention spending and reframing the role of local government oversight.”
Hewitt insists that, for ICSs to be successful, substantial reform is also required at the heart of government. Article 1.25 of the Review states that:
“Critically, all of us need to change. Local partners within every ICS need to put collaboration and cooperation at the heart of their organisations. NHS England, DHSC and CQC need to support and reflect this new model in the crucial work they do; and central government needs to change, mirroring integration within local systems with much closer collaboration between central government departments and other national bodies.”
Hewitt also calls upon the government to lead a “national mission for health improvement” to shift the national conversation around health promotion – this forms a central part of Hewitt’s drive to promote better health and wellbeing, rather than simply treating sickness. “To underline its importance, this could be led personally by the prime minister,” the Review states.
The Review also calls for the establishment of a central Health and Wellbeing Assembly with a membership that “mirrors the full range of partners within ICSs, including local government, social care providers and the VCFSE sector as well as the NHS itself.”
Shifting the dial on prevention
Hewitt makes a number of recommendations to embed prevention as an overarching principle for ICSs. This includes increasing the share of NHS budgets at the ICS level going towards prevention by 1 per cent over the next five years. While acknowledging that many systems will struggle with this adjustment, the Review insists that:
“An ambition of this kind is essential if we are to avoid simply another round of rhetorical commitment to prevention.”
The Hewitt Review also calls for a consistent national framework to monitor prevention investment by Autumn 2023, and suggests that ICSs should establish and publish their baseline investment in prevention by April 2024. Further, the Hewitt Review includes a recommendation to increase the public health grant allocation, which is central to enabling systems to drive forward their ambitions for the health of their local populations
Commenting on the Review’s focus on prevention, Mathew Taylor, Chief Executive of the NHS Confederation, said: “The focus on prevention is crucial for long term sustainability of both the NHS and more broadly to increase health and wellbeing of the population, and something for which we have long been advocating.“
Health inequalities as the primary objective
Recent research from Public Policy Projects revealed widespread acceptance among ICS leaders that reducing health inequality is the biggest priority for integrated care. However, with ongoing immediate pressures and a seemingly endless cycle of year-on-year winter crises, many systems have been unable to develop the long term population health strategies needed to bring down health inequality.
In arguing that action on health inequalities is far more than a ‘nice to have’, the Hewitt Review echoes PPP’s position that action on health inequality is itself the primary objective of ICSs and essential for the long-term viability of the health and care system.
Hewitt said in her review that: “I heard real concern that the transformational work of ICSs and specifically the opportunity to focus on prevention, population health and health inequalities might be treated as a ‘nice to have’ that must wait until the immediate pressures upon the NHS had been addressed and NHS performance recovers. That is what has always happened before, and must not happen this time.
“Prevention, population health management and tackling health inequalities are not a distraction from the immediate priorities: indeed, they are the key to sustainable solutions to those immediate performance challenges.”
The Hewitt Review also suggests a number of measures to give greater significance to the role of integrated care partnerships (ICPs), including the establishment of a national ICP Forum to create direct communication between ICPs and DHSC and to make the ICP the primary mechanism through which preventative health policy can be delivered.
The Review also gives due consideration to the need for cultural change within NHS, local government and provider bodies. As stated in PPP’s report, Ensuring ICSs represent a partnership of equals, it will take time for the constituent parts of ICSs to become familiar both with each other and with collaborating across organisational boundaries.
There is also welcome recognition in the Hewitt Review that the lack of digital skills at all levels of the health and care workforce is a significant barrier to the success of digital and data-driven transformation. This formed a core recommendation of PPP’s ICS Futures, which calls for mandatory digital expertise at board level and efforts to increase the digital competency of the workforce more broadly.
Expanding the role of CQC
With greater autonomy for ICSs will come a greater need for flexible accountability and as such, the role of CQC, and how it can be enhanced to provide greater system oversight, is one of the key focuses of the Hewitt Review. In accord with PPP’s Ensuring ICSs represent a partnership of equals, the Hewitt Review calls for increasing expectations of CQC to assess the level of mutual accountability between partners within a system. This will include assessments on cultural change and system integration.
Section 3.87 of the Review states that: “CQC should take into account the extent of collaboration around organisational development and quality improvement.” This, the Review states, should be led by a “Chief Inspector of Systems” who should draw upon the multiple sources of quantitative and qualitative data available to CQC.