Government publishes findings of Hewitt review of integrated care systems

An independent review of integrated care systems (ICSs) led by former Health Secretary Patricia Hewitt has been published this month to consider how the oversight and governance of Integrated Care Systems (ICSs) can “best enable them to succeed”.

ICSs were introduced across England in 2022, bringing the NHS, local government and other partners together to improve the health and care of the people who live and work in their area.

The Hewitt Review, published by the Department of Health and Social Care (DHSC), draws on the insights of leaders from across the NHS, local government, social care providers, the charitable and the voluntary and social enterprise sector.

Its proposals include that:

• There should be a shift in resources - the share of total NHS budgets at ICS level going towards prevention should be increased by at least 1% over the next 5 years.
• There should be cross-governmental collaboration to embed a national mission for health improvement.
• A new Health, Wellbeing and Care Assembly should be established.
• There should be improved data interoperability and more effective use of high-quality data.
• The public should be empowered through greater use of the NHS App and there should be further long-term commitment for the development of citizen health accounts.
• 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, with certainly no more than 10 national priorities”.
• Subsidiarity at place, system, regional and national levels should be encouraged and delivered. “We are currently one of the most centralised health systems in the world, and ICSs give us an opportunity to rebalance this.”
• The most effective ICSs should also be encouraged to go further, working with NHS England to develop a new model with a far greater degree of autonomy, combined with robust and effective accountability.
• The availability of timely, transparent and high-quality data must be a priority, and NHS England and the Department of Health and Social Care (DHSC) should incentivise the flow and quality of data between providers and systems. The Federated Data Platform can provide the basis for a radical change in oversight.
• Both the Care Quality Commission (CQC) and NHS England will continue to have a vital role to play in oversight and accountability, “but they should ensure that their improvement approaches are as complementary as possible, and complementary to peer review arrangements between systems”.
• It will be vital to ensure the right skills and capabilities are available to ICSs as both systems and national organisations manage "through a period of challenge for the nation’s finances". There needs to be consideration given to the balance between national, regional and system resource with a larger shift of resource towards systems.
• Some of the barriers that currently exist for primary care, social care and the way the health and care workforce is trained should be pulled down. The Government should produce a complementary strategy for the social care workforce. More should also be done to enable flexibility for health and care staff, both in moving between roles and in the delegation of some healthcare tasks.
• National contracts present “a significant barrier to local leaders wanting to work in innovative and transformational ways”. The review recommends that work should be undertaken to design a new framework for General Practice (GP) primary care contracts, as well as a review into other primary care contracts.
• NHS funding remains over-focused on treatment of illness or injury rather than prevention of them and ICS partners “struggle to work around over-complex, uncoordinated funding systems and rules in order to shift resource to where it is most needed”. Instead, it is important to identify the most effective payment models, nationally and internationally, with an aim to implement a new model with population-based budgets, which will incentivise and enable better outcomes and significantly improve productivity.
• There should be a review into the NHS capital regime to address the inflexibility in use of capital and the layering of different capital allocations and approvals processes.
• NHS England should ensure that systems are able to draw upon a full range of improvement resources to support them to understand their productivity, finance and quality challenges and opportunities.

The Hewitt Review comes after an inquiry by the Health and Social Care Committee recently found “genuine enthusiasm” for the potential of Integrated Care Systems to deliver on challenges facing the health and care sectors, but warned of a “serious lack of clarity” in some areas.

The MPs on the committee called on the Government and NHS England to address key concerns if an “opportunity to deliver real change is to be realised”, highlighting the risk that acute short-term pressures could be given priority over longer term ambitions such as preventing ill-health.

The Health and Social Care Committee’s report said it was “vital that the Government and NHS England should not dictate how ICSs deliver local outcomes”.  

A Department of Health and Social Care spokesperson said: “Integrated care systems are an important part of the government’s plan to deliver more joined-up and effective health and care services, and to cut waiting times for patients, one of the Prime Minister’s key priorities for 2023.”

Patricia Hewitt, said: “Integrated care systems represent the best opportunity in a generation for the urgently needed transformation that we need in our health and care system. Everyone wants them to succeed.

“To fulfil their potential, however, we need not only to back our new structures, but also to change our culture. Everyone needs to change, and everyone needs to play their part.

“My recommendations are intended to help the health and care system make those changes - and I hope that ministers, NHS England and others will feel able to take them forward.”

Chair of the Health and Social Care Committee Steve Brine MP said: “We were pleased that the Government commissioned the Hewitt Review, considering similar themes to our own inquiry, and welcome the spotlight that is being shone on ICSs at this early stage in their development. We hope to see this focus maintained and look forward to considering the Review’s findings.”

Commenting on the review, Sarah McClinton, President of the Association of Directors of Adult Social Services said: “The Hewitt review is spot on, the current sticking-plaster response to health and care crises isn’t working. We need to shift public funds into preventing ill-health on a big scale. That will mean people can get great quality care and support in their communities when they need it before their health deteriorates and they need expensive acute care.

“But you won’t be able to do that without a long-term, fully funded plan to fix adult social care. For decades Government’s have ducked that challenge, and the road has run out now. We need to fix adult social care to ensure our families and friends get the care and support they need in the future. As the Hewitt Review points out, that must include a national workforce strategy to sort the staffing crisis in social care, complementing the one the Government is developing for the NHS.

“And Patricia Hewitt’s prescription of fewer national targets is right. The new local health and care partnerships the Government have set up could transform care for people in their areas, but only if they’re given the freedom to respond to the needs and wishes of the people they serve. Social care, public health and the voluntary sector need to be equal partners at the heart of decision-making which needs to happen closer to communities. People need to be in control of their own care. What we need from the Government is the sustainable funding and backing to improve care and solve the current crises in the NHS and adult social care.”

Lottie Winson