The Hewitt Review, an independent review of Integrated Care Systems (ICSs) commissioned by the government in November 2022, was published on 4 April 2023.
Last summer England was formally divided into 42 ICSs, which were put on a statutory footing by the Health and Care Act 2022. ICSs are partnerships consisting of local government, the NHS, social care providers, voluntary, community, faith and social enterprise organisations. Each ICS includes a statutory integrated care partnership (ICP) and integrated care board (ICB).
Each ICS brings together local partners in a common purpose expressed in 4 main aims: improving health outcomes and services; reducing health inequalities; delivering a financially sustainable health and care system; and, supporting communities’ social and economic development. At a time of wide regional disparities in health, ICSs are widely seen as our best opportunity to transform the health and care system.
The Hewitt review puts forward a strategy that could enable ICSs to work both with the NHS and local partners outside health to develop regional plans to prevent illness, rather than the main focus being on treatment, as is currently the case. The Right Honourable Patricia Hewitt, in her review, recognises a need to create more value from investment in the NHS and recommends a streamlining of services, reduced bureaucracy and more flexibility and autonomy for ICSs to meet the needs of their local populations. The main themes of the review are summarised below.
Shift in focus – from illness to promoting health
According to The Health Foundation, the Public Health Grant has been cut by 26% on a real-terms per person basis since 2015/16, with real-term cuts tending to be greatest in more deprived areas. These are the areas with the worst health outcomes. The Hewitt review recognises the pressing need to tackle health inequalities; it proposes a shift in the allocation of resources by increasing the proportion of budget spent on prevention (a broad definition of ‘prevention’ is yet to be agreed upon) by at least 1% over the next 5 years. The review strongly advocates for a partnership approach across health, local government and voluntary, community, faith and social enterprise (VCFSE) bodies, with high quality data collection forming a foundation for proactive population health management.
The NHS is a historically centralised health system, with a large amount of funding and decision making powers being held centrally, rather than regionally. Naturally this lead to less local accountability. Currently there is inflexibility in how money can be spent regionally, with examples cited of locally tailored diagnostic centres being rejected due to them not aligning with national specifications. On their introduction, ICSs were seen as an opportunity to decentralise the system. The Hewitt review supports the push for local allocation of resources, local decision making and local accountability tempered, necessarily, by national oversight along with an enhanced role for the CQC in reviewing systems. Fewer national targets and more collaborative policy making are recommended. Again, the review highlights the need for a ‘broad church’ approach, with greater involvement needed from partners outside the NHS – social care and public health in particular.
The review focusses on the importance of the primary and social care workforce in improving population health outcomes. With the government’s long-term workforce plan for the NHS due shortly, the review recommends the development of an equivalent social care strategy “as soon as possible”, along with longer term investment in social care workforce development. The review also comments on the current framework of national negotiation for GP contracts, stating that it is out of date and “inflexible and bureaucratic”. It calls for a new framework for GP contracts, with a shift in focus towards prevention by measuring outcomes, rather than activity. The review cites “inspiring examples” of organisations delivering primary care at scale, and recommends incentives for those taking this approach – this might be by way of groups of practices, provider federations, or primary care networks.
Value for money
Investment in the NHS is shown to lead to economic growth. The Hewitt review notes, however, that we should be getting much better value from that investment. It suggests this may be helped by allowing ICSs greater freedom to set up appropriate payment mechanisms locally. This is in conflict with the current model, where payments are made per unit of activity. As a need for greater locally accountability for health outcomes was discussed above, the review highlights that this needs to include better financial reporting, giving the public the information needed to hold systems to account. Additionally, it is recommended that small in-year funding should be limited, with multi-year, recurrent, payments being the norm.
So what next?
The government will now consider the recommendations set out in the review. There is currently no indication of when DHSC will respond and it remains to be seen which, if any, of the recommendations they will accept. Importantly, the review has received the support of the NHS Confederation’s ICS Network Board.
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