Hewitt review: call for evidence – Care England Response
*On 18 January, the Rt Hon Patricia Hewitt published a letter to stakeholders outlining the next steps of the review, click here to see the letter.*
Empowering local leaders
Please share examples from the health and care system, where local leaders and organisations have created transformational change to improve people’s lives. (250-word limit)
Care providers deliver transformational change to lives on a daily basis. However, the lack of a long-term sustainable funding solution continues to threaten the delivery of quality and timely care, crucial in enabling meaningful life. Those who work in adult social care are everyday heroes whose voices must be listened to and constitute the cornerstone of any future reform.
Money alone is not the answer; the independent adult social care sector is a key part of our health and care system and one that can help lead us into a stronger future underpinned by integration. Future integration must centre around individuals, freeing much of the excessive bureaucracy and neglect within the government that has characterised the attitude towards this sector for too long. What is required now is a different culture, one where social care is given an equal say in supporting transformational change for the people they support, and one where success is measured in outcomes, and in terms of the benefit delivered to people and communities more widely.
Do you have examples where policy frameworks, policies and support mechanisms have enabled local leaders and, in particular, ICSs to achieve their goals? (250-word limit)
This can include local, regional or national examples.
One of the core objectives of ICSs is to ‘enhance productivity and value for money.’ Independent care providers can offer flexible, best-value solutions that will help maximise the independence of older people and improve their quality of life. Joint strategic planning should build upon meaningful, positive relationships between independent and statutory organisations. This will benefit the NHS, as there is capacity in the care sector for individuals to receive more appropriate care at a more affordable rate. For comparison, the average cost for a non-elective short stay (one or two nights) at an NHS hospital is ‘£959’ (National Cost Collection: National Schedule of NHS costs – Year 2020-21) which is more expensive in comparison care homes, with the average cost for an entire week is just ‘£704’.
With the social care workforce currently in crisis, with 165,000 vacancies and more staff leaving than providers can recruit, ICSs must be pragmatic to resolve this pressing issue. South West London ICS has built a long-term workforce plan dedicated to social care workers, and South Yorkshire ICS look to deconstruct the barriers between health and care to develop ‘one’ workforce.
Whilst all ICSs will naturally operate and plan slightly differently, the above examples evidence that ICSs can develop solutions to benefit those within their systems. Existing work done to improve the workforce can act as a lesson for ICSs yet to determine their future plans.
Do you have examples where policy frameworks, policies, and support mechanisms made it difficult for local leaders and, in particular, ICSs to achieve their goals? (250-word limit)
This can include local, regional or national examples.
The governance structure of ICSs has led to a variation in practice amongst systems, resulting in different relationships of engagement. For example, Frimley ICS has no limit on membership, granting providers access to the ICP, whereas South Yorkshire ICS has a limited social care involvement of care providers in the ICP. South Yorkshire recognises the need that engagement with ASC will need to be accounted for, however, it is hard to see how this will be adequately accomplished without inclusion at system level outside the remit of a local authority.
Accordingly, the national guidance dictating the overall governance structure of ICSs has made it difficult for providers to achieve consistent improvements in the care sector, as care providers do not have the same representation everywhere. The independent sector has a host of resources available, often not utilised by the public sector.
An example is the lack of utilisation of the care sector in overcoming ‘winter pressures.’ Each year there is an inconsistent approach (regionally and nationally) to the delivery of discharge policies, resulting in a stagnant approach that creates extra burden for health and care services The independent sector is comprised of a multitude of services which are readily available to support the NHS. Such services include care homes, daycare, home care and assisted living and sheltered housing, etc. This permits a huge scope for the independent sector involvement in strategic planning to overcome long-term pressures.
What do you think would be needed for ICSs and the organisations and partnerships within them to increase innovation and go further and faster in pursuing their goals? (250-word limit)
ICSs need to develop their systems to create true, equal partnerships between health and social care services. Further, if they are used for short-term pressures, they should be consulted properly and be able to input policies that will impact their running.
The sector needs proper funding support from ICSs so systems can utilise them to alleviate healthcare pressures. Implementing a national tariff for all NHS commissioned services would provide sustained funding and enable better care planning for providers. While social care offers high-quality support to some of society’s most vulnerable, ICSs must look to rectify the systemic challenges facing the care sector, especially the predominant workforce, funding, and the current cost-of-living crisis that is rampantly impacting the sector.
There are three core themes ICSs should consider when working with their local care providers:
Transparency of funding: Short‐term funding does not allow the independent sector to devise good schemes to alleviate pressures on health services. Long-term contracts with timely notification of available future funding will be essential to allow the independent sector to plan services adequately, and be innovative in their approach.
Joint strategy planning: To fully pursue and achieve ICS core objectives, independent sector care providers should be seen as long-term legitimate partners instead of being used to overcome short-term pressures, such as discharge for the winter period.
Shared learning: At a local level, organisations will benefit from collaborations‐ sharing experiences, good or bad practices etc.
What policy frameworks, regulations or support mechanisms do you think could best support the active involvement of partners in integrated care systems? (250-word limit)
Examples of partners include adult social care providers, children’s social care services and voluntary, community and social enterprise (VCSE) organisations. This can include local, regional or national suggestions.
Due to the lack of standardisation of the membership remit of an ICP to include adult social care (ASC) providers, there should be a national policy framework that holds the ICP leaders to account with a duty to consult ASC providers on the strategic direction of the system. This will ensure an ICS does not become too healthcare focused. If an ICS does not allow ASC ICP membership, then a direct assembly should be organised that is used by the partnership to consult policy, as seen in Herefordshire and Worcestershire. Frameworks such as these will provide care services with the respect they deserve and increase their voice within the strategic direction of the ICS.
Support mechanisms should prioritise integration and partnership between health and care services. Services should provide value for money and be seamless for people using them. An ICS should focus on the individual, giving them greater say in how policy is developed and money is spent. These support mechanisms will provide a better quality of care and overall experience.
At a national level, NHSE and DHSC need to set clear frameworks that ensure commissioners and providers work together to increase capacity within hospitals and communities. Generating and utilising capacity will enable ICSs to develop plans that holistically tackle health inequalities within their localities rather than address short-term annual pressures, such as winter discharge. CQC has a responsibility in ensuring that LAs within an ICB/ICP are meeting their Care Act duties and must provide support where needed.
National targets and accountability
What recommendations would you give national bodies setting national targets or priorities in identifying which issues to include and which to leave to local or system-level decision-making? (250-word limit)
National organisations should set a standardised approach on several policy areas that will impact all ICSs. By setting standardisation, ICSs will not differ too greatly on the following: Commissioning process (FNC/CHC); Discharge Policies; Workforce recruitment and retention (national programmes such as retention bonuses for example); Digitalisation (connectivity, infrastructure, cyber-security)
The above areas of policy do not require local initiatives, but rather a national framework that ensures consistency that clearly outlines success and standard procedures. It would still allow ICSs to facilitate local initiatives to address local health and care needs: Digitalisation (DSCRs, falls prevention, digital tools, digital skills, AI exploration etc.); Workforce (training, recruitment programmes, local academies); Covid/Winter response policies; New models of care development
Although the above areas of policy will have ties to national agendas, they require a greater amount of local collaboration and understanding of the local geography. A way for national bodies to recognise which policy should be conducted at a national vs local level is to ascertain the impact of two ICSs facilitating a policy in extremely contrasting ways. For example, if one ICS facilitates an extensive process for CHC commissioning, e.g., requiring the provider to complete a full CHC checklist, which is not normal practice, in comparison to another ICS that does not, it will increase the administrative burden for the care provider in one area, impacting the delivery of care. A standardised approach to commissioning will help ensure minimum burden for both the provider and ICS.
What mechanisms outside of national targets could be used to support performance improvement? (250-word limit)
Examples could include peer support, peer review, shared learning and the publication of data at a local level. Please provide any examples of existing successful or unsuccessful mechanisms.
ICSs should be set up with a platform to communicate best-practice and understand the different approaches to health and care that are taking place across the country. This will enable integrated care strategies to address local priorities while keeping in line with national policy. It will allow an ICS to understand how a neighbouring system conducted and implemented a policy and learn which core themes enabled successful implementation (e.g. communication, transparency etc.).
Integration must be judged by the experiences of people who use services. We must shift our focus from organisations and processes to people and outcomes. A truly integrated health and social care system has the capacity to improve outcomes and experiences of care.
Bridging the gap between health and social care stretches beyond funding integration, but also encompasses reforming commissioning practice, data and information practice and service delivery. This would aid in relieving the pressure on finite NHS and emergency services, which we know are extremely stretched currently. All regulatory and support organisations commissioned by government that surround the sector should be reviewed. Their success measures must be aligned to ensure all parts of an ICS work toward one strategic goal and are judged by a set of agreed outcome measures that benefit all of those working in and supported by the integrated care system.
Data and transparency
Do you have any examples, at a neighbourhood, place or system level, of innovative uses of data or digital services? (250-word limit)
Please refer to examples that improve outcomes for populations and the quality, safety, transparency or experience of services for people; or that increase the productivity and efficiency of services.
Frimley ICS is utilising AI/Digitalisation to alleviate some of the burdens of a vacant workforce (not removing the need for care workers, as the system still looks to recruit, but wants to use technology to support long-term).
Digital Social Care is helping support ICSs with the Digitising Transformation Fund (DFT) implementation and enabling ICSs to meet the commitment of digitising 80% of the sector by 2024. This has enabled ICSs to further understand their digital landscape and devise plans to achieve greater connectivity, develop digital tools, and increase cyber-security awareness.
Bath and North East Somerset, Swindon and Wiltshire (BSW) ICS have included ex-care providers within the digitising team. This has led to greater engagement and understanding of the barriers to digital transformation within the ICS. It promotes shared learning and joint strategy planning at all levels.
To help promote the take-up of the Data Security and Protection Toolkit (DSPT), Gloucestershire ICS has worked with their local care association to encourage the completion of the toolkit. The ICS reaches out to care providers who have not completed the toolkit, makes the provider aware of it and talks through its benefits. Even if the provider does not choose to complete the toolkit, the ICS has made them aware of the DSPT and thus creates greater awareness.
How could the collection of data from ICSs, including ICBs and partner organisations, such as trusts, be streamlined and what collections and standards should be set nationally? (250-word limit)
Within ASC, a great wealth of data could be effectively utilised to improve the quality of care being delivered, the service and the sector. However, one issue facing care providers there is an abundance of tools/systems used to collect data. This results in the duplication of data and an increase in administrative burden.
For ICSs to achieve full digital maturity and effectively utilise all data within their system, they need to ensure that care providers are engaged throughout each stage. Providers often have different digital tools for various initiatives and ICSs need to be aware of this when wanting to gather data. Interoperability is key to achieving streamlined data collection. Providers must be engaged to ensure that software integrates with an ICSs’. Joint strategy planning will be essential for this. ICSs should also take advantage of national bodies, such as Digital Social Care, to understand best practice and what care providers are currently using digital tools.
There is also the need for ICSs to work together. Data can and should flow between each system without any challenges, but this is not always the case. If two ICSs deploy two separate systems that do not necessarily speak to one another, it will create problems for the ICS, care providers, and other H&SC services. ICSs must therefore work together to ensure that the digital tools deployed can integrate with one another.
What standards and support should be provided by national bodies to support effective data use and digital services? (250-word limit)
With the Digital Transformation Fund being utilised to advance the care sector’s digital progression, it is important to recognise that not every provider is at the same level – support needs to be given for even the most basic parts of digitalisation. For example, one barrier to digitising records for providers in rural areas is connectivity issues. Norfolk and Waveney ICS are implementing support that matches their digital programme (50% of the total cost, up to £10,000 per location, to support with license, hardware, implementation and time costs) exclusively to resolve provider issues with connectivity.
There must be a precise and consistent approach to data standards across all systems. Ensuring that the PRSB Standards are effectively enacted throughout each system will help provide a consistent approach to effectively using data.
There must also be support in developing cyber-security infrastructure across all health and care services. The advanced cyber-attack throughout the summer of 2022 demonstrated the ASC’s vulnerability to cyber-attacks. Providers saw little support from authorities in comparison to the NHS. As the sector continues to move towards a greater reliance on data, there needs to be assurances that the data being supplied will be protected. Providers cannot facilitate these costs by themselves and, therefore, will need ICSs to accommodate such funds. This will also help build up trust between health and care and further generate joint strategic planning.
What does think are the most important things for NHS England, the CQC and DHSC to monitor, to allow them to identify performance or capability issues and variations within an ICS that require support? (250-word limit)
There must be recognition by national bodies (DHSC/NHSE/CQC), that there are different approaches within the adult social care sector to the delivery of care, both regionally and nationally. National targets need to consider the regional variation of adult social care providers and the interactions they have with different ICSs. National frameworks must be clear in what constitutes successful delivery of policy, and provide some form of standardised approach on specific policy (e.g., digital infrastructure and commissioning). This will provide clear guidelines for an ICS, whilst still allowing a system to meet local needs through regional and local mechanisms.
The CQC has a role within the production of the single assessment framework to clearly set a precedent as to what policies hinder national standardisation and a clear framework as to the standards that ICS leaders will be held to.
National bodies should help guide ICSs to ensure some level of conformity in standards and representation. ICSs should be allowed to engage and develop their long-term plans to meet their core goals, however, there must be some level of consistency between each system. Each ICS should foster and uphold a clear set of guiding principles (equal representation and joint strategy planning, transparency, and shared learning). If one ICS devolves significantly from another, it will lead to significant operational problems for H&SC organisations that operate across multiple systems. One example of this happening is the approach to Winter discharge policies and different ICSs/ NHS Trusts deploying a different policy.
What type of support, regulation and intervention do you think would be most appropriate for ICSs or other organisations that are experiencing performance or capability issues? (250-word limit)
DHSC, NHSE and CQC are all accountable for ensuring ICSs do not differ too greatly from one another. The single assessment framework being developed by CQC must address the issue of consistency. DHSC and NHSE must provide support and clarity on keeping ICSs in line with the national agenda.
The National Audit Office’s report, Introducing Integrated Care Systems: joining up local services to improve health outcomes, highlights key recommendations that should be considered to ensure success:
- Transparency across government and stakeholders to ensure delivery of improved health outcomes
- National oversight in establishing strategic drivers for an integrated workforce
- Cost saving measures that streamline funding to ICBs
- NHSE should align ICB oversight to meet the four core objectives of an ICS
- NHSE should learn from the simplified system of commissioning and contracting between 2020-22 and evaluate what processes could be replicated.
Accountability of leadership will be vital to establishing the performance of an ICS. ICS leaders must be better integrated into the breadth of health and care policy across the whole system. ICS leaders are there to support and build fundamental relationships across health and care services and not just maintain NHS continuity. System leaders must empower and support local leadership, although not restricting this to local authorities. At a national level, elevating non-NHS accountability and scrutiny to the same standards as an ICB will aid performance barriers. However, parity in roles and funding will be required to ensure the successful empowerment of non-healthcare leadership.
Is there any additional evidence you would like the review to consider? (250-word limit)
See the Hewitt review terms of reference as a guide to what additional evidence may be relevant.
Commissioning processes, specifically FNC and CHC, have been inadvertently hindered from the transition process from CCG to ICS. The infancy of ICSs has meant a variance in the process and forms used by ICS to make these payments to providers. Standardisation ensures that ICSs are held to account in their payments as deviating from the standard practice will be clearer to identify when comparing against established precedence through guidance produced by NHSE.
Another point that ICSs should consider, particularly regarding FNC/CHC, is consideration of the wider health and social care market. These funding packages for ASC has now fallen behind the true cost of care. The recent fair cost of care exercise undertaken by care providers throughout 2022, demonstrated the underfunding of contracts and commissioned packages. Therefore, for successful outcomes, and improved care to be delivered, ICSs need to consider raising these packages for care providers to facilitate more effective care.