Snap Analysis 5 April, 2023

Reform analysis: The Hewitt Review

To the casual observer, an 89 page review on Integrated Care Systems may not be the most exciting prospect for an Easter read. But at Reform, we can think of nothing better — a detailed and serious attempt to get to grips with how to make organisations which control around £110 billion of public funding work. So in lieu of our normal installment of The Week, below are our thoughts on the Hewitt Review.

Regular Reform subscribers will (of course!) know exactly what we’re talking about already, but a brief recap for those who haven’t been following: since July 2022, 42 different Integrated Care Systems (ICSs) have been the main organisations responsible for planning and commissioning health services in England. They are meant to be partnerships of equals between the NHS and local authorities (more on this below) and have four responsibilities: improving population health and healthcare outcomes, tackling inequalities, enhancing value for money and supporting social and economic development in the communities they serve.

Despite thousands of pages of documents outlining the structure and operating frameworks of ICSs and a dedicated White Paper on integration, thorny — yet essential — questions about how ICSs should operate remained unanswered. For this reason, the Chancellor (an ex-health secretary), commissioned Patricia Hewitt, a fellow ex-health secretary, to review them.

Since December last year, Hewitt has been gathering evidence and the final report goes into an impressive level of detail. Some may argue that Hewitt has strayed beyond her original remit — the report reads more like a roadmap for a future health system than a specific account of ICS accountability. But someone needed to produce a plan, and Hewitt asks exactly the right questions.

The Review focuses on four key topics (helpfully set out in the same number of chapters):

  • How ICSs can shift away from treating illness and towards health creation
  • How to get the governance structure right so that ICSs can effectively work as ‘systems’ not just collections of organisations
  • How health and care delivery must be transformed to enable integration
  • How our approach to health payment can underpin a new model of care

Read on for our take on how these are tackled...

From sickness service to health creator

The Review’s first substantive chapter, on the importance of promoting health rather than focusing on illness, is one which, for anyone who’s read Patricia Hewitt's 2006 White Paper on the future of the health system, will come as no surprise.

A major focus of this chapter is data, and rightly so. We know that shifting resources towards prevention must be supported be an accurate understanding of where each marginal pound is best spent, as well as identifying groups that may need additional, targeted support. As the Hewitt Review says, the new Federated Data Platform (to better connect and share anonymous data for health planning across an ICS) could make a “significant difference”.

In addition to this, there is a (arguably underutilised) role for data to play in encouraging citizens to take greater ownership over their health — helping them to advocate for services to remain healthy, keep close tabs on their health status, and improve their experience navigating the health and care system. The proposal to set a long-term ambition of creating “Citizen Health Accounts”, that would require health and care providers ("whether NHS funded or local authority funded or otherwise”) to upload relevant data they hold on an individual to an account “operated by citizens themselves” and linked to the NHS app, is therefore an interesting one. As ever, realising this will mean grappling with long-standing and understandable concerns about the safety and security of this personal data being aggregated, as well as the complex, technical barriers to doing so.

The chapter also contains what we’re told is the Review’s “most challenging recommendation”, to increase the share of total NHS budgets at ICS level going to prevention by one percentage point over the next five years. We’re not so convinced on the radicalism of this. The review argues ICSs should first establish a baseline of their “current investment in prevention, broadly defined”, against which to measure progress and enable comparison between ICSs. The definition here will be key.

According to the OECD, the UK is already one of the highest spenders on preventive care (but includes in this category items like disease management, to prevent deterioration of existing conditions). Hewitt’s example of refocusing clinical pathways towards prevention in this section, while important, perhaps sets the goalposts too wide. Particularly as we know (at risk of sounding like a broken record) that the most impactful and often underprioritised forms of prevention spending are much further upstream, on the social determinants of health.

Realising the benefits of a systems approach

The game-changing shift that ICSs are supposed to bring about is to ‘systematise’ our approach to health — the NHS and its partners should think about health collectively rather than as individual organisations. There are two key enablers of this change: ensuring that ICSs really are ‘partnerships of equals’ and allowing local systems to innovate rather than be told what to do from on high.

On the first of these questions, the Review points out that many ICSs currently do not give equal weight to NHS organisations and local government. However, Hewitt is reluctant to advocate solutions to this problem, noting that representation for the latter is already “hard-wired” into ICSs through Integrated Care Partnerships (the body responsible for informing the planning and commissioning strategy of the main Integrated Care Board) and a range of other bodies: Health and Wellbeing Boards, Healthwatch, and Health Overview and Scrutiny Committees (no, us neither…).

To us, this stretches the definition of “hard-wired”. Citing bodies with a ‘scrutiny’ function does not mean that organisations are really being held to account. And the NHS still holds the lions-share of responsibility and resource in the system. Integrated Care Boards who hold the purse strings in ICSs only legally have to have one local representative on them. This compares to at least four members drawn from the NHS — a chief medical officer, a chief nursing officer, and a representative each from a local Foundation Trust and General Practice. If our ambition for ICSs is to join-up the NHS this makes sense, but if we want them to boost health, local government needs real teeth.

The Review does better on the question of local system autonomy — Hewitt calls for national bodies (largely NHS England and the Department of Health and Social Care) to set and hold local systems to account on fewer, more targeted priorities (no more than 10 nationally). This is an excellent suggestion — organisations with too many priorities effectively have none and central government is often an unhelpful micro-manager of performance. However, saying less priorities are needed is far easier than choosing the targets for a new system. Most existing targets (elective wait times, emergency care targets, prevention targets) have a legitimate explanation, making deprioritisation challenging. Getting this right won’t be easy.

How to measure performance is just as important as what to measure. The Health and Care Bill already revealed that the CQC would play a key role in ICS oversight. The Hewitt review suggests how this might work.

First, we’re told that CQC reviews of ICSs should be used to incentivise improvement and not as a “box-ticking exercise”. This is of course the right ambition. Hewitt also recommends that, because ICSs have existed for different lengths of time, the CQC should in its first year focus on sharing best practice between ICSs and calibrating its assessments, rather than producing crude ratings. This seems sensible.

Beyond this point, she recommends that the CQC produce more comprehensive assessments of “ICS maturity”, including in this assessment, for example, the “coherence, consistency and impact of arrangements and place and neighbourhood level” and “how far the system is making progress in shifting resources towards prevention, population health and tackling health inequalities”.

Aside from the review stating that the CQC should “share best practice and insight” between systems, however — and the ‘stick’ of ICSs potentially receiving a negative assessment — it’s unclear what specific mechanisms are available to the CQC “support and incentivise improvement” as the Review says.

For a body that (as the name gives away) has its historic expertise in “care quality”, a key question going forward is how well placed the CQC will be to make a ‘systems’ assessment of ICSs. On this front, the review says that investing in training for the CQC workforce, and “bringing in colleagues with experience from systems”, should be a focus. Also sensible. But given the range and breath of some of the “maturity” criteria the Review cites (see page 58 for examples), it will be important oversight doesn’t crowd out the genuine, earned autonomy, needed for ICSs to succeed.

Integrating the back office and the frontline

The third chapter of the report focuses on the delivery model — how do we actually join-up care around patients and how do we ensure that ICSs have the right capabilities to understand and plan care for their populations. These themes get surprisingly short-shrift in most visions of integration, so it’s good to see them emphasised here.

We are pleased to see recommendations on reforming the Agenda for Change framework, the NHS pay system that covers all staff except doctors, dentists, and ‘very senior managers’ (for instance, Trust Chief Executives, Medical Officers and Finance Officers). Hewitt rightly recognises that transforming our approach to health requires attracting and retaining highly skilled specialists in areas such as data science, actuarial modelling and system engineering. These roles provide the building blocks for integration — data scientists allow us to more deeply understand the drivers of poor health and patterns of healthcare utilisation, and actuaries design the finance and governance structures that make join-up work in practice.

However, these are also the exact kind of jobs that pay the biggest bucks in the private sector. This leaves ICSs (and healthcare providers) without relevant expertise, or forces them to pay for expensive external support on an ad-hoc basis. Paying above the current top Agenda for Pay band (£95,135 for new joiners) is essential for building the workforce of the future (as it is across the public sector).

We would like to have seen greater ambition on primary care reform. Hewitt is absolutely right to say that primary care must be in the driving seat if we want to really integrate services around patients. Encouraging more multi-disciplinary team working in primary care and reforming the GP contract are necessary changes.

If local autonomy is to mean anything, giving ICSs more flexibility to negotiate contractual terms with GPs in their patch makes sense (though cue a major row with the BMA). And the Quality and Outcomes Framework (QOF) desperately needs reconfiguration, or wholesale replacement. But the Review’s recommendations feel like tinkering, rather than a fundamental transformation of care delivery. There is little to say about care beyond the four walls of the GP surgery, patient empowerment or breaking down barriers between primary and social care, all key planks of a future care model.

Paying for a new model

The third chapter of the report focuses on the delivery model — how do we actually join-up care around patients and how do we ensure that ICSs have the right capabilities to understand and plan care for their populations. These themes get surprisingly short-shrift in most visions of integration, so it’s good to see them emphasised here.

There are some sensible recommendations here — ending the use of small, in-year funding pots which limit the ability of systems to plan long-term; expanding organisations that are eligible for Section 75 funding (the legal mechanism by which the NHS and local authorities can pool budgets), and developing a consistent approach to financial reporting in the NHS (more of a headache than it sounds).

The most thought-provoking, though potentially challenging, section of this chapter concerns giving the most “innovative and mature” ICSs freedoms to change the way they pay for care. Under the current model, different providers of health and care tend to be paid in different ways — for instance, hospitals through activity based payments, GPs based on the number of patients on their lists. However, this system often creates the wrong incentives — driving more activity in hospitals and disincentivising preventive care. Successful international integrated care systems have adopted more innovative funding models which iron out these issues, but fundamental shifts to the payment model in the NHS have been stubbornly resisted. If integrated care is to work it needs a solid grounding in strategic finance. This is probably the most game-changing recommendation in the report, but we’ll need to wait and see if the Government is willing to be so bold.