This brief provides a broad overview of the independent Hewitt Review, produced by the Rt. Hon. Patricia Hewitt, which the Government commissioned in December 2022. This overview highlights the key areas focusing on adult social care whilst providing a complete list of all the recommendations outlined within the Review.
Care England participated in the initial consultation for the Review and subsequent engagement sessions. Care England also provided further supporting documents for the Review.
What are the objectives and scope of the Review?
The Review considers how the governance of integrated care systems (ICSs) can be best enabled to succeed. There are three areas it will consider and make recommendations on:
- how to empower local leaders to focus on improving outcomes for their populations, giving them greater control while making them more accountable for performance and spending
- the scope and options for a significantly smaller number of national targets for which NHS ICBs should be both held accountable for and supported to improve by NHS England and other national bodies, alongside local priorities reflecting the particular needs of communities
- how the role of the Care Quality Commission (CQC) can be enhanced in system oversight
What has the Review identified?
The Review has identified six key principles:
1 – collaboration within and between systems and national bodies;
- Rather than focusing on hierarchy, nationally and within a system, organisations within an ICS should be viewed as complementary partners who are interdependent on one another
- NHSE has a responsibility on ensuring that there is a greater emphasis on collaboration between systems
2 – a limited number of shared priorities;
- Access to all forms of care
- Promoting best practice and ensuring policy is evidence based
3 – allowing local leaders the space and time to lead;
- Requires consistent policy, finances, support and regulation over several years
4 – the right support;
- Support and intervention from NHS England to ICSs, through ICBs, needs to be proportionate
5 – balancing freedom with accountability;
- Consider the vital, but different, role of supporting ICSs, ICBs and providers with great challenges to improve, particularly where there are major failings in care.
6 – enabling access to timely, transparent and high-quality data.
- Defining standards on data taxonomy and interoperability, and coordinating data requests to the system
The Review further outlines that the share of total NHS budgets at the ICS level going towards prevention should be increased by at least 1% over the next five years. There is a great emphasis on the need to focus efforts on prevention. Data will also need to be optimised and; interoperability features throughout the document. Transparency within an ICS is also considered vital to enabling local autonomy.
The CQC is identified as a key player in the success of ICSs, particularly regarding oversight and accountability. However, the Review identifies that complementary approaches should mirror improvement.
There is an emphasis on regional collaboration, with the Review noting the NHSE Regions being used as a collective agent for ICBs and could be used to facilitate the resolution of difficult issues. Care England has been pushing for at least regional standardisation regarding NHS commissioning, particularly around continuing healthcare (CHC) and funded nursing care (FNC).
As expected, the need for productive collaboration runs throughout the Hewitt Review. The Review recommends that to help support organisational development for ICSs, NHSE should work closely with the LGA, NHS Confed and NHS Providers to further develop leadership support. Whilst these organisations will help provide meaningful support to NHSE and ICBs, there is no reference to an adult social care representative body, such as the Care Provider Alliance (CPA).
What about social care?
There is a clear recognition that with an ageing population and the increase in complex, long-term physical and mental health conditions, social care needs to be better integrated into an ICS more successfully to meet these demands.
The Hewitt Review recommends that there needs to be a clear and agreed framework as to what ‘prevention’ means to help inform localised approaches.
It is positive that the Review understands the importance of social care, calling for it to be a priority for national investment, particularly regarding workforce development. The Review further entails the need for ICSs to support and maintain a sustainable social care sector by:
- taking an integrated approach to reduce the gap between demand for care and available supply
- encouraging the adoption of personalised, preventative and proactive models of care
To support the sector with these recommendations, the Review suggests that the Fair Cost of Care (FCoC) is accelerated and expanded before implementing the proposed cap on adult social care costs. The Review views the FCoC as a helpful exercise that helps authorities and the Government understand the layout of the sector, whilst further providing a fairer cost model. The Review also suggests that the FCoC should be expanded to the learning disability, working age adults, and children sectors.
The Hewitt Review outlines that for ICSs to succeed, historic barriers must be pulled down. In particular, the Review recommends that the Government should produce a social care workforce strategy that compliments the NHS’.
Specific measures such as shared training are suggested as policies that should be implemented across the sector. This would create a ‘passport’ system, allowing individuals to move and work across the entire health and social care sector. Investment into the social care workforce should be a continuous developing plan. The Review suggests that at a minimum level, there should be a 3-year rolling planning cycle to support multi-year investment programmes. To help improve the integration of roles across the health and social care sector the Review recommends that DHSC bring together the relevant regulators to reform the processes and guidance around delegated healthcare tasks.
What does the Review say about integrated care boards (ICBs)?
Despite a ‘compelling case’ for social care providers to have a stronger voice within the system level of an ICS, the Review does not recommend having a mandated place for social care providers within the ICB/ICP. The Review instead, reiterates that it is for each ICS to decide how to accommodate social care provider voices. It is outlined that ICSs are in the process of reviewing their governance structure and within this remit each system should consider whether it needs to do more to ensure that social care providers are involved in planning and decision-making, that public health expertise is being effectively deployed within the system.
What does the Review say about integrated care partnerships (ICPs)?
The Review outlines that the ICP shall be a driver for developing preventative policies and therefore the Government should facilitate an ICP forum that connects ICPs with government departments, allowing smoother communication and engagement.
What does the Review say about Place?
The Review recognises the importance of Place and how it can transform local communities to address local health inequalities. However, it recognises the confusing nature of Place and the difficulty ascertaining appropriate Place contact or who is accountable. Therefore, there is a greater emphasis on the need for transparency across each integrated care system as to how they operate and for the need to provide greater inclusion of local leaders.
Does the Hewitt Review reference NHS Payments?
The Review acknowledges that funding settlements for the NHS, social care and public health are announced at different times throughout the year along with the different approaches to funding being a preventative measure to integration. Whilst the Review isn’t specific as to which funding mechanisms it is referring to, inconsistency between CHC and FNC could be placed in this issue. Therefore, the Review recommends that DHSC, DLUHC and NHSE align budget and grant allocations for local government and NHSE to enable a more cohesive delivery.
Interestingly, when referring to Financial Flexibility for Intra-System Funding, the Hewitt Review recommends the role of consistency and the need for national guidance that provides a default position for payment mechanisms for inter-system allocations to be further developed. Care England has repeatedly called for consistent approaches to NHS Commissioning, however, this appears to have been overlooked by the Review.
Who will be accountable within an ICS?
Accountability is one of the six key principles mentioned within the Hewitt Review and is essential to ensuring sustainability across the health and social care sector. The Review highlights that a baseline should be established when engaging in a policy that is set to tackle health inequalities. Implementing a baseline would enable benchmarking across all 42 ICSs and help all stakeholders (DHSC; NHSE; ICSs; Trusts; Social care providers; VCSE; the public etc.) understand the progress being made by each ICS on their prevention agenda. The Review notes that this process would include the £200m allocated nationally towards tackling health inequalities.
Following the establishment of the benchmark, ICSs will be expected to publish their baseline investment into prevention. It is expected that the ICPs will facilitate this. By autumn 2023, we should expect the framework to be completed, with all ICSs reporting their prevention investment consistently by 1 April 2024.
Within the remit of accountability, the ICB and ICP should look to implement a collective policy of accountability. However, the Review does not note the permanent inclusion of adult social care within ICBs/ICPs.
What about the digital agenda?
There is a specific reference within the document to the proposed data framework for adult social care outlined in Care Data Matters. It is positive that the document makes specific reference to the need for adult social care providers to be fully involved in finalising the data framework, both digitally developed and undeveloped. The Review reflects on two interesting digital case studies:
Norfolk and Waveney ICS
Norfolk and Waveney ICS has built on its award-winning COVID Protect approach, establishing Protect NOW, a GP-led collaboration that uses data analytics and risk stratification to identify people at risk of undiagnosed or poorly managed Type 2 diabetes to improve patient engagement, care and outcomes.
North East and North Cumbria ICS
The North East and North Cumbria ICS is successfully joining up healthcare and social care data, using the OPTICA software, to streamline and simplify processes to effectively support discharge.
Regarding the usage of data, the Review recommends that as a whole data collection should increasingly include outcomes (including, crucially, Patient Reported Experiences and Outcomes) rather than mainly focusing on inputs and processes.
Full list of all the recommendations:
Chapter 2: recommendations:
- The share of total NHS budgets at the ICS level going towards prevention should be increased by at least 1% over the next 5 years. To deliver this the following enablers are required:
- a) DHSC establish a working group of local government, public health leaders, OHID, NHS England and DHSC, as well as leaders from arrange of ICSs, to agree on a straightforward and easily understood framework for broadly defining what we mean by prevention.
- b) Following an agreed framework ICSs establish and publish their baseline of investment in prevention.
- That the government leads and convenes a national mission for health improvement. I also support the Health and Social Care Select Committee’s recommendation that DHSC should publish, as soon as possible, the proposed shared outcomes framework.
- That a national Integrated Care Partnership Forum is established.
- The government establish a Health, Wellbeing and Care Assembly.
- That NHS England, DHSC and ICSs work together to develop a minimum data sharing standards framework to be adopted by all ICSs in order to improve interoperability and data sharing across organisational barriers.
- DHSC should, this year, implement the proposed reform of Control of Patient Information regulations, building on the successful change during the pandemic and set out in the Data Saves Lives Strategy (2022).
- NHS England should invite ICSs to identify appropriate digital and data leaders from within ICSs – including from local government, social care providers and the VCFSE provider sector – to join the Data Alliance and Partnership Board.
- Building on the existing work of NHS England, the NHS App should become an even stronger platform for innovation, with the code being made open source to approved developers as each new function is developed.
- The government should set a longer-term ambition of establishing Citizen Health Accounts.
Chapter 3: recommendations:
- HOSCs (and, where agreed, Joint HOSCs) should have an explicit role as System Overview and Scrutiny Committees. To enable this DHSC should work with local government to develop a renewed support offer to HOSCs and to provide support to ICSs where needed in this respect.
- Each ICS should be enabled to set a focused number of locally co-developed priorities or targets and decide the metrics for measuring these. These priorities should be treated with equal weight to national targets and should span across health and social care.
- In line with the new operating framework, the ICB should take the lead in working with providers facing difficulties, supporting the Trust to agree an internal plan of action, calling on support from the region as required. To enable this support and intervention should be exercised about providers ‘with and through’ ICBs as the default arrangement.
- NHS England and CQC should work together to ensure that as far as possible their approach to improvement is complementary and mutually reinforcing.
- A national peer review offer for systems should be developed, building on learning from the LGA approach.
- NHS England should work with ICB leaders to co-design and agree on a clear pathway towards ICB maturity, to take effect from April 2024.
- An appropriate group of ICS leaders should work together with DHSC, DHLUC and NHS England to create new ‘High Accountability and Responsibility Partnerships’.
- During the 2023 to 2024 financial year further consideration should be given to the balance between national, regional and system resources with a larger shift of resources towards systems; and the required 10% cut in the RCA for 2025 to 2026 financial year should be reconsidered before Budget 2024.
- NHS England and central government should work together to review and reduce the burden of the approvals process of individual ICB, foundation trust and trust salaries.
- ICS leaders should be closely involved in the work to build on the new NHS England operating framework to codesign the next evolution of NHSE regions. 20. NHS England should work closely with the LGA, Confed and NHS Providers to further develop the leadership support offer.
- The implementation groups for the Messenger review should include individuals with significant experience in leading sustained cultural and organisational change in local government and the voluntary sector as well as the NHS. 63
- Ministers should consider a substantial reduction in the priorities set out in the new Mandate to the NHS – significantly reduce the number of national targets, with certainly no more than 10 national priorities.
- NHS England and ICBs need to agree on a common approach to co-production working with organisations like the NHS Confederation, NHS Providers and the LGA.
- As part of CQC’s new role in assessing systems, CQC should consider within their assessment of ICS maturity a range of factors (set out on page 58).
- ICSs, DHSC, NHS England and CQC should all have access to the same, automated, accurate and high quality data required for improvement and accountability. In particular:
- a) NHS England and DHSC should incentivise the flow and quality of data between providers and systems by taking SITREP and other reported data directly from the FDP and other automated sources, replacing both SITREPS and additional data requests
- b) Data required in real-time by NHS England and DHSC should be taken from automated receipt of summaries to drive consistency; where possible without creating excessive reporting requirements, data should enable site-level analysis
- c) Data collection should increasingly include outcomes (including, crucially, Patient Reported Experiences and Outcomes) rather than mainly focusing on inputs and processes
- d) Data held by NHS England (including NHSE regions) about performance within an ICS, including benchmarking with other providers and systems, should be available to the ICS itself and national government
- e) DHSC and NHS England work with nominated ICS colleagues to conduct a rapid review of existing data collections to reset the baseline, removing requests that are duplicative, unnecessary or not used for any significant purpose. This work should be completed within 3 months
Chapter 4: recommendations
- NHS England and DHSC should, as soon as possible, convene a national partnership group to develop together a new framework for GP primary care contracts.
- The government should produce a strategy for the social care workforce, complementary to the NHS workforce plan, as soon as possible.
- DHSC should bring together the relevant regulators to reform the processes and guidance around delegated healthcare tasks.
- Currently the agenda for change framework for NHS staff makes it impossible for systems to pay competitive salaries for specialists in fields such as data science, risk management, actuarial modelling, system engineering, general and specialised analytical and intelligence. Ministers and NHS England should work with trade unions to resolve this issue as quickly as possible.
Chapter 5: recommendations
- NHS England, DHSC and HM Treasury should work with ICSs collectively, and with other key partners including the Office for Local Government and CIPFA to develop a consistent method of financial reporting.
- Building on the work already done to ensure greater financial freedoms and more recurrent funding mechanisms, I recommend:
- a) Ending, as far as possible, the use of small in-year funding pots with extensive reporting requirements;
- b) Giving systems more flexibility to determine allocations for services and appropriate payment mechanisms within their own boundaries, and updating the NHS payment scheme to reflect this; and
- c) National guidance should be further developed providing a default position for payment mechanisms for inter system allocations.
- DHSC, DLUHC and NHS England should align budget and grant allocations for local government (including social care and public health and the NHS).
- Government should accelerate the work to widen the scope of s.75 to include previously excluded functions (such as the full range of primary care services) and review the regulations to simplify them. This should also include reviewing the legislation to expand the scope of the organisations that can be part of s.75 arrangements.
- NHS England should ensure that systems can draw upon a full range of improvement resources to support them to understand their productivity, finance and quality challenges and opportunities.
- NHS England should work with DHSC, HM Treasury and the most innovative and mature ICBs and ICSs, drawing upon international examples as well as local best practice, to identify the most effective payment models to incentivise and enable better outcomes and significantly improve productivity.
- There should be a cross-government review of the entire NHS capital regime, working with systems, to implement its recommendations from 2024.