Still in their infancy and formed in stormy times, there is broad consensus that the NHS’s new integrated care systems (ICSs) – regional bodies responsible for planning health and care services – are the best way forward for improving services and making best use of public money. But system leaders are grappling with opaque lines of accountability, a long list of (potentially competing) priorities, a lack of clarity around system oversight and broader political decisions that risk holding back progress. Enter the Hewitt review – an independent review led by former health secretary, Patricia Hewitt, that aimed to provide clarity.
Although the initial scope of the review focused on ensuring ICSs could operate ‘efficiently with appropriate autonomy and accountability’, the final report, published the week before last, is vast. Running to 89 pages, the 36 (multi-part) recommendations span everything from prevention to social care, payment models to the role of local government scrutiny committees.
Looking across Hewitt’s overarching ambitions, there’s not much to disagree with. Few, for example, would argue with the need for a stronger focus on prevention, longer term and better aligned budgets, fewer national priorities and less top-down performance management, or the importance of good management and strengthened improvement capabilities. Several useful pointers, then, for further work, reviews and working groups (of which several are recommended). But detail on how some of these proposals should be taken forward is not always forthcoming.
Aside from a smattering of additional recommendations on social care and primary care, Hewitt’s proposals fall into three main areas.
Oversight and accountability – a missed opportunity?
Autonomy, accountability and oversight of ICSs was at the heart of the review’s initial terms of reference. Hewitt makes several welcome suggestions here – such as improving data flows, giving greater emphasis to local priorities and reducing the overall number of priorities set by government (though stating there should be no more than 10 feels a little arbitrary without fleshing out how policymakers might approach this task).
The emphasis on ensuring ICSs have the capability, capacity and agency to evolve into ‘self-improving systems’ is welcome, and Hewitt rightly highlights the need to give ICSs the scope to develop their own strategies for building local capability and addressing improvement priorities. The report makes the point that some quality improvement work has had to be ‘deprioritised’ due to other pressing challenges, and calls for it to be backed by system leaders. Evidence shows that the most mature and effective healthcare systems are those than can balance short-term delivery targets and long-term improvement goals so it’s vital that leaders find space for improvement in their strategic and operational agendas. Past experience suggests that previous versions of ICSs have not always had the capacity or the support to do this.
But the report skates over fundamental questions about the purpose of measurement and alignment between the different parts of ICS assessment, and does little to clarify some of the murkier lines of accountability in the current system. It states, for example, that ‘ICB CEOs are accountable […] for delivery of agreed priorities and plans – including elective recovery, urgent and emergency care’ and more, and that this ‘is different from being accountable for the performance of individual trusts’, but stops short of explaining how this will work in practice. Not pushing back on the idea of problematic single summary ratings for ICSs also feels like a missed opportunity. And there is a question about whether CQC has the resources to undertake the significant task set out for it in the review.
Welcome rhetoric on prevention but broader government policy is lacking
Hewitt’s ambitions to enable ‘a shift to upstream investment in preventative services and interventions’ form a major thread throughout the review and – again – contain some laudable ambitions. Chief among these is the (slightly ambiguous) proposal to increase the share of local NHS spend on prevention by at least 1% over the next 5 years. While the intention behind this is positive, assessing how ambitious or workable it is as a proposal is challenging without an agreed definition of what NHS spend on ‘prevention’ entails or an idea of current spend and how this varies between ICS areas – building blocks the review acknowledges are needed. Other recommendations focus on the need for greater cross-government collaboration to improve health (in the form of a new ‘national mission for health improvement’ led by the prime minister, for example), but wider government policy to back this up currently falls short.
Proposals on ‘resetting’ NHS finances hinge on political commitment
The section on funding contains many proposals that will garner widespread support: a cross-government review of ‘the entire’ NHS capital regime, putting an end to the use of small in-year funding pots, giving systems more financial flexibility and increasing alignment between NHS and local government budgets.
The limiting factor here and with several of Hewitt’s more radical proposals may well be that making any progress will require central government action. If the timing of the report’s publication or the unenthusiastic response from the Department are anything to go by, the review – and its longer term impact – looks to be on shakier ground.