The Hewitt Review, led by former Health Secretary Patricia Hewitt, which examined the autonomy and accountability of ICSs produced was released last week.
The review was tasked with producing recommendations in three areas:
- How to empower local leaders to focus on improving outcomes for their populations, giving them greater control while making them more accountable for performance and spending
- The scope and options for a significantly smaller number of national targets for which NHS ICBs should be both held accountable for and supported to improve by NHS England and other national bodies, alongside local priorities, reflecting the particular needs of communities
- How the role of the Care Quality Commission (CQC) can be enhanced in system oversight
The review itself draws on six key principles: collaboration; a limited number of shared priorities, giving local leaders space and time to lead; providing systems with the right support; balancing freedom with accountability; and enabling timely, relevant, high-quality and transparent data. Overall, 36 recommendations were made by the report.
Prevention
The report states that now is the perfect time to focus on preventative services, however a framework outlining what ‘prevention’ means must be established by autumn 2023. There also needs to be a fundamental shift from a singular focus on illness to promoting healthy living. Hewitt recommends that the Prime Minister lead a government national health improvement mission alongside other departments involved in setting the national health improvement strategy.
There is also a recommendation to for the share of total NHS budgets going towards prevention to be increased by at least 1% over the next 5 years, which would improve population health and reduce pressure on an already strained health system. However, ultimately, this is dependent on collaboration across Government and better use of data, including sharing data held by NHSE on each ICS’s performance, which should be shared with individual ICSs themselves. Better connectivity of data across ICSs would rapidly enhance ICSs’ abilities to improve their work tackling health inequalities and system inefficiencies.
The review also calls for a baseline of current investment within each ICS. Thereafter, progress can then be measured to understand how prevention strategies are working in each area. Investment reporting in each ICS must then be reported consistently from 1 April 2024.
Hewitt goes further than the Care Data Matters Strategy, suggesting that NHSE, DHSC and ICSs cooperate to establish a minimum data sharing standards framework for ICSs to allow for better interoperability cross-organisationally.
Moreover, she suggests that ICSs have an internal digital and data leader join the Data Alliance and Partnership Board, within the Transformation Directorate of NHS England, to ensure that the potential of digitisation in ICSs is maximised, with the Board being such a key instrument in overall NHS digitisation.
Patient information needs to be better utilised to allow patients to better manage their health, building upon patients’ existing usage of digital tools and technology in this area. This sentiment should be noted in future health strategies, particularly the prevention agenda. Reform of the Control of Patient Information regulations, ready to be implemented in practice via the Data Saves Lives Strategy, is essential in allowing local health authorities and partners to work more effectively and should be implemented this year.
Other recommendations include: the establishment of a Government-backed health, wellbeing and care assembly; making the NHS App code open-source to approved developers; and, in time, the development of Citizen Health Accounts.
System Delivery
Hewitt reasserts the importance of the in-built localism of ICSs; emphasising that local communities and authorities must be central to any decisions made about local services. Accountability in ICSs, as defined by the review, is said to lie with the organisation which has responsibility for all or the majority of an issue and possesses the resources to solve it. The NHS and DHSC remain poised to review the accountability of all partners, including ICBs, to ensure that maximum performance is achieved.
Hewitt has been critical of the distinctions of the roles of DHSC and NHSE in current practice, accusing the existing system of not being sufficiently clear in its definitions. Currently, all NHS providers are accountable to NHSE who are themselves accountable to the Secretary of State and, ultimately, Parliament.
The role of ICBs has also been divulged in full, as stated in the new NHSE operating model:
- First line of oversight of health providers
- To coordinate and help tailor support for providers
- Assurance and input to regulators’ assessment of providers
- Liaison or escalation to NHS England
Two recommendations have been given targets for next year. The report states that NHSE and ICB leaders should cooperate to construct a path to achieving ICS maturity, taking effect from next April. While a grouping comprising of ICS leaders, DHSC, DHLUC and NHS England, called the High Accountability and Responsibility Partnerships (HARPs), should also be created by next April.
One of Hewitt’s key recommendations is the imposition of fewer central targets by Government to allow greater flexibility for ICSs to choose how best to allocate resources depending on local needs.
On CQCs, the review states that there should be better collaboration between ICSs and the CQC to develop a long-term approach to systems inspections, while ensuring the CQC increases its skillset to support successful development of ICSs. It suggests that 2023 to 2024 should be a transitional year to allow ICSs and the CQC to produce the best system for CQC reviews. This cooperation should create ratings which are trusted by both the public and other NHS partners.
Public trust is indeed key, and therefore easily accessible information will be produced to enable patients to see whether the services they are provided are effective and of high-quality, or not. By harnessing data in this way and demonstrating its utility, public confidence in data sharing should increase, which is a merited achievement in and of itself.
Other recommendations include: ICSs should be able to produce locally agreed targets with their own measurement system which have equal weight to national targets; ICBs should spearhead efforts to help struggling providers; and in this financial year, a larger share of resources should be allocated to systems to ensure better balance.
Primary and Social Care
Hewitt provides a number of recommendations which aim to ease pressures on the health service by improving workings at an integrated level, notably through the ICSs vision of tackling local problems to alleviate national problems as a whole. Greater powers for local leaders to intervene in primary and social care would likely elicit an immediate improvement in performance.
The review notes that workforce issues remain one of the biggest problems within the NHS and confirms that the Government is working to produce a long-term workforce plan imminently. Hewitt suggests that the Government also release a social care workforce strategy to accompany the aforementioned workforce plan. Indeed, to make best use of the integrated nature of ICSs, social care investment and development must be prioritised, with a longer-term vision based on minimum 3-year planning cycles to benefit multi-year investment programmes.
In order to unlock flexibility across different health and care positions, governance and frameworks should be standardised. It is also recommended that DHSC convenes a group of relevant regulators to amend the processes and guidance around delegated healthcare tasks.
Improvements to the digital workforce also forms a central part of the review’s workforce suggestions. More must be done to adequately recruit and train staff in specialist fields, particularly data science, risk management, actuarial modelling, system engineering, general and specialised analytical and intelligence. Hewitt recommends that in order to increase the digital workforce to a satisfactory level, NHSE and Minsters should seek to work alongside trade unions to alter existing frameworks which fail to reward staff in specialist areas with competitive salaries.
Due to rules implemented in April 2023, ICBs are now responsible for commissioning, which brings many welcome opportunities in primary care. Now is the perfect time for reform, as it coincides with the conclusion of the current GP five-year deal. Thus, Hewitt states that NHSE and DHSC should establish a national partnership group to develop a framework for new GP contracts, building on the existing model.
Financing
As mentioned previously, Hewitt has been critical of current financing, claiming that resources are skewed far too heavily towards treating ill health rather than preventing it. This represents poor value for money for the health service.
The review recommends that DHSC, the DLUHC and NHS England should align budget and grant allocations for local government (including social care and public health, which are allocated at different points) and the NHS, to ensure systems can better plan their local priorities over a longer period; an improvement on current small in-year funding pot usage. Any additional funding pots should be considered in exceptional circumstances with stringent rules for approval in place.
Fresh methods for financial reporting should be delivered by NHSE, DHSC, the Treasury, ICSs and others without creating new requirements which add bureaucratic pressures. The intended benefit of this measure would be to provide greater transparency for public scrutiny, particularly at a local level.
The review claims that the NHS can improve ways of working through technical efficiency by drawing upon various improvement resources. Hewitt calls for the full range of these improvement resources to be accessible to NHS leaders so they can fully appraise the various opportunities and challenges across their system.
It also asserts that NHSE should work with Government departments – namely DHSC and the Treasury – and the most dynamic and well-run ICSs and ICBs to establish the most effective payment models to increase productivity and identify best system value for patients.
Other recommendations include: the establishment of a cross-Government review of the NHS capital regime with recommendations to be implemented from next year.
Final thoughts
The review is overall greatly optimistic of the benefits of ICSs, if governed correctly, arguing that they represent the best opportunity for a generation to radically improve our health and care system. They are also ideally placed to aid the growing, necessary trend towards prevention in healthcare. Institutional change is also said to be more important than just greater investment, as without fundamental behavioural change community health and wellbeing will not reach the desired level.
Hewitt also believes that ICSs represent an incredible opportunity to transform health across the country in a more holistic way through their in-built collaborative approach to systems and an emphasis on local needs. Central NHS policy, while important, will itself not solve all complex health challenges across the country. If the Government is fully supportive in creating an environment where local leaders and partners are empowered to make decisions which best benefit their community, then aspirational progress can be achieved.
