The Hewitt Review

05 April 2023

GGI has been supporting the Hewitt Review and as part of our work facilitating the development of the new integrated care boards. GGI’s developmental work with ICBs covers everything from supporting better risk management, through board development to co-creating better, lean governance structures. Our Principal Consultant Simon Hall has put together our thoughts.

Patricia Hewitt’s review of integrated care systems is a well-crafted response to the brief given to the former secretary of state by the current Chancellor of the Exchequer.

From the outset she appears very conscious of the widespread cynicism of ‘yet another review’ that will be talked about and then sit on digital shelves, so she has made great efforts to ensure that it contains practical recommendations that might actually have a chance of being implemented.

In the introduction to the review Hewitt is also at pains to state that there is actually cross-party political support for integrated care systems and that the vast majority of her recommendations will command widespread support.

GGI suggests that all her recommendations will command support, but the main criticism that could be levelled at them is that they contain much that has been proposed before, they go into the minutiae of NHS workings a bit too much, and they don’t really get to grips with issues around workforce, capital funding or social care. In fairness, recommending further work on strategy in these areas is very sensible and, if carried out in the spirit of consensus that Hewitt herself embodies, could merit real positive change in the future.

The whole of the health and care system will welcome the call for fewer central targets. Already this year’s planning regime began a move in that direction, and hopefully this call from Hewitt will be listened to as having any more than ten ‘key’ targets to meet for boards can cause a lack of focus and grip on what really matters.

The proof of the pudding on this one will be in the small print, the move to any ‘sub-targets’, and the extent to which central targets going forward are focused on outcomes rather than traditional output measures.

No more National Illness Service

The second area where Hewitt puts much emphasis is on how to accelerate the shift that is needed towards prevention rather than a continuation of the ‘National Illness Service’ of the past. There are warm words about the need for a cross-government mission for health improvement, a desire to increase the public health grant to local authorities, and an aspiration to shift 1% of local NHS budgets towards prevention within the next five years.

While setting such a target seems a bit of a blunt instrument, this type of tool is something the health service is familiar with and has worked in the past. Linking up across government departments to think more broadly about health improvement is an obvious win, and something that local government in many areas has been doing for some time.

The review’s recommendations on data are ones that have been many times before, but it does feel that more of a head of steam has built up behind this since the Covid pandemic and they may actually have a chance of implementation, in part even if not wholly.

It was good to see reference to the Australian Health Performance Framework (AHPF), which has shown the potential to increase consumer engagement and improve performance, quality and safety. Having aggregated health information available should not be difficult to implement, but care will need to be taken to ensure that providers are collecting data in the same or similar ways for it to be meaningful. We would also ask the so-what? question, but if it included social care and local public health data it could really empower health and wellbeing boards in their new proposed system scrutiny role.

App support

We strongly support the expansion of the use of the NHS App, and the remarks about the shared care record being nationally available are welcome. There is a wealth of data that the NHS has to support people in managing their own health, and so this initiative is welcome. It will also be crucial to think about those populations where there is less digital connectivity (e.g. for age, cultural or financial reasons).

There is an acknowledgement throughout the review of the challenges that ICSs and ICBs are currently facing, and a high proportion of the review is centred on trying to define the accountabilities in the system more clearly. Hewitt makes helpful recommendations on national peer review, and stresses ‘with and through’ in descriptions of the inter-relationship of NHS England and the ICBs.

There are mixed views about the new proposal for HARPs (High Accountability and Responsibility Partnerships). This is likely to be very empowering for systems where new freedoms and flexibilities will be given, but these are already systems that are meeting the challenges for their local populations better. The worry is this could create a two-tier system, rather like occurred with the advent of foundation trusts, where the goal becomes getting to HARP status rather than population health improvement, and that those already challenged ICS areas will get further left behind.

The recommendations on the enhanced role for the CQC with a Chief System Inspector being created should feel very welcome. Hewitt herself says, though, that real system change can only come through good partnerships and building up trust and expertise over time. It will be interesting to see how the CQC rises to the challenges outlined.

Primary issues

Primary care comes in for mention in the report, and Hewitt rightly commends the transfer of responsibilities for dental and those other areas of primary care outside of general practice to ICBs from this month.

Multi-year funding is of course a no-brainer, although I would not want to have this linked only to HARP areas in the future. Overall, there is understandably a lack of specifics on how finance models will change towards longer term budgeting and different funding models for transformational change, but this will need much more detailed work which is proposed over the next year. We also welcome the call for the 10% RCA reduction planned for 2025/26 (which is on top of the 20% planned for 2024/25) to be scrapped.

Elephant in the room

The biggest elephant in the room here is the expectation on ICSs and their various partners and elements to deliver on Hewitt’s justly ambitious agenda with many staff still exhausted after the pandemic, very new management teams in many ICBs after tiring recruitment rounds, and with a further 20-30% reduction in staffing numbers on the cards.

The NHS is intrinsically political, and as we head up to an election in 2024 it will be surprising if this consensus on integrated care holds. Will Hewitt’s proposals make it any easier for ICSs to weather any political storms on the horizon?

Meet the author: Simon Hall

Principal Consultant

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Prepared by GGI Development and Research LLP for the Good Governance Institute.

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