The Hewitt Review unpacked

In July 2022, Integrated Care Systems (ICSs) were formally established with the intention of delivering joined-up services along a place-based approach, improve outcomes in population health and tackle health inequalities across the country. 

Yet, just six months into their formation, Chancellor Jeremy Hunt announced a review to be undertaken by Patricia Hewitt, former Secretary of State for Health and current chair of Norfolk and Waveney Integrated Care Board.  

The review sought to consider the oversight and governance of ICSs, examining the balance between greater autonomy and accountability for these emerging structures.  

Hewitt’s paper, published yesterday, reiterates the significant potential of the new NHS structures to deliver more strategic and sustainable healthcare – albeit with refinements. However, with a muted response from the DHSC and NHS England on timelines for responding to the review’s findings, there are questions over whether core recommendations will be taken onboard with any sense of urgency. 

What stood out? 

Prevention and population health 

The review reiterates the big opportunity of prevention and proactive population health as key to sustainable solutions to immediate performance pressures in the NHS. This is a well-trodden message – but one that continues to be easier to write about than deliver.  

To address this gap, Hewitt argues for a change in how the health and care system operates. This includes a shift in resources, to which she recommends a 1% increase in the NHS budgets going towards prevention. She also calls for a Government-led national mission on health improvement, with prevention, the reduction of health inequalities and the social determinants of health as musts, rather than ‘nice to haves.’ 

This sentiment is in keeping with other recent policy reports on prevention and early intervention, such as the recent Health and Social Care Committee inquiry into prevention which received over 600 stakeholder responses.  

Largely missing was any focus on industry partnership beyond high level commentary on evolving pathways and vendor management. This suggests that treatments are still not seen as a key part of the approach towards better population health.  

The potential of delivering on placed-based priority and need 

A big theme in the review is the need for a shift from a top-down, centralised system of managing the NHS to a bottom-up system, responsive and responsible to local communities.  

To facilitate this, Hewitt recommends a reduction in national targets with no more than 10 national priorities and the development of ‘High Accountability and Responsibility Partnerships’ (HARPs). These are additional mechanisms aimed at incentivising integration across all partners of a local system.  

However, integration and true place-based care cannot be fully achieved without local government and social care involvement. This has already been somewhat muted with the decision to create two local bodies – healthcare-led Integrated Care Boards and wider community involvement through the Integrated Care Partnerships. And there is an irony that on the same day as Hewitt review was published calling for better integration of health and social care, a £250m of budget committed to support social care innovation and training was withdrawn. Without a genuine joined-up approach, the opportunity for integration is unlikely to be truly realised.  

Decisions on accountability and governance  

Fundamentally, the review was commissioned to consider the oversight and governance of ICSs. However, it is not immediately clear whether this question has been answered and the critical question of whether ICBs or NHS England manages Trusts has been fudged.  

The review recommends that any intervention from NHS England direct to Trusts should come through the ICB structures. However, it then peddles back on that ambition by stating that it needs to be proportionate to the strength of the relationships, leadership and challenges facing a local system. 

Therefore, there is still considerable room for NHS England to be involved in the performance of local care providers. This takes away from the intended freedoms and flexibility at the forefront of the ICS model. 

Better funding flows 

The review does not call for any additional funding for NHS services but rather scratches beneath the surface to offer a remedy for how operationally government spending on health can achieve value for money.  

Hewitt identifies “over-complex, uncoordinated funding systems” as an impediment to achieving this principle. She calls for ICS funding to “be largely multi-year and recurrent” and for budgets across health and local government to be better aligned.  

Greater financial autonomy as well as simplified and coordinated funding behind ICSs has been welcomed as a recommendation. However, the varying degree of maturity of ICSs across the country, as recognised in the review, risks investors needing to adopt a more cumbersome and tailored approach depending on the ICS. 

What’s next? 

As yet, next steps remain unclear. The Government will respond to the central recommendations, but not immediately. Clarity around responsibility and accountability between NHS bodies may take more time. Many other key points may be chalked up as ‘requiring further consideration’. 

Jeremy Hunt – who commissioned the review – retains his interest in health improvement and is keen to drive better outcomes and efficiencies for patients and the public purse. How far he is prepared to loosen the grip on NHS budgets remains to be seen.