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Standing back from The Hewitt Review: six key take-aways


The much-anticipated Hewitt Review into the oversight, governance and accountability of integrated care systems (ICSs) landed last week, to surprisingly little fanfare and a somewhat muted reception. To anyone that has followed the path of the review since its launch in November 2022, it will come as no surprise that it is both comprehensive in its breadth and that it draws on extensive engagement with the sector and key partners, for which the review team and its leadership should be given due credit. Reflecting this, the final document weighs in at a hefty 89 pages. So, standing back from the detail, what are the key take-aways?

The central premise is to shift away from a culture of top-down performance management to one of learning and improvement. The ambition is for national and regional bodies to support ICSs to become ‘self-improving’ systems. One of the most eye-catching proposals is to vastly reduce the number of national targets and priorities, with Hewitt suggesting these should be limited to no more than ten. That isn’t to say that systems would be left unchecked. The review advocates stronger local and mutual accountability within systems, underpinned by timely, transparent data (streamlined to address excessive and duplicative reporting), a national peer review offer (building on established approaches in local government), Care Quality Commission (CQC) assessments looking at how systems are creating cultures of learning and improvement, and an explicit role for overview and scrutiny committees (made up of local councillors) in scrutinising the work of ICSs.

The review calls for a reset in national/local relationships. In line with ambitions previously outlined in the NHS Operating Framework and elsewhere, the review envisages a shift from the current hierarchical approach towards a partnership of equals. As well as reducing the number of targets and streamlining reporting requirements, it suggests ICSs should co-develop local priorities, with these being given equal weight to national targets. Other steps to support the reset include largely ending the use of small, in-year funding pots and giving systems more flexibility to determine budget allocations within their boundaries, as well as rebalancing resources across central and regional bodies and ICSs, shifting a greater share into systems themselves. These ambitions may come as music to the ears of many local health and care leaders, but some will be disappointed by the absence of concrete changes to the powers of the Department of Health and Social Care and NHS England that could help bake this in. Furthermore, there is minimal focus on how to support the cultural and behavioural changes on which these ambitions will ultimately stand or fall.

Local variation will remain the name of the game when it comes to ICS development and ways of working. The development of ICSs so far has been marked by local flexibility, reflected in significant variation in their size, complexity and maturity. The review does not seek to change this. Indeed, it restates ambitions around subsidiarity (the idea that decisions should be taken as close to local communities as possible) and suggests systems could strengthen this by ensuring there is visible and accountable leadership at place, and supporting places to define their own priorities and initiatives within their overarching ICS strategies. The most advanced ICSs would be supported to go further, with around ten systems selected as ‘high accountability and responsibility partnerships’ to take on greater local autonomy and trial new ways of working with regional and national bodies. This echoes the early development of ICSs (and other similar initiatives), where new arrangements were tested in a small number of frontrunner areas.

A commitment to prevention is at the heart of the review. Although not central to its original terms of reference, the review makes a strong case for a greater focus on prevention, calling for a shift in resources to support this (specifically, recommending the share of ICS budgets going towards prevention should increase by at least 1 per cent over the next 5 years, as well as an increase in the public health grant allocation). It also calls for cross-government collaboration on prevention (which The King’s Fund and has long-argued for) with formal arrangements to underpin this, and the establishment of a national integrated care partnership forum and new health, wellbeing and care assembly to support engagement.

The review stops short of giving firm answers on the respective roles and responsibilities of providers and ICBs. There have for some time been differing views about how providers and ICBs should relate to one another, particularly the question of whether providers ‘report into’ ICBs. At points it seemed the review would offer direction on this, and the mood music of those privy to earlier drafts was that it looked likely to come down in favour of ICSs being responsible for the management of providers. however, perhaps unsurprisingly given the interests at play, the final draft reaches no such position. Local ICBs and providers will have to continue to live with and work through the complexities of how they relate to one another.

The impact of the proposals is by no means certain. The Hewitt Review is not short on ambition; in addition to the takeaways above, it makes proposals ranging from a strategy for the social care workforce, to new GP contracts, and a review of the NHS capital funding regime. It is both comprehensive and thorough and contains many well-thought-through policy ideas that could help progress the four purposes of ICSs. But it is not yet government policy; indeed, the only response so far is a commitment that ministers will review the recommendations ‘in due course’. It’s far from clear that those ministers would be willing to relinquish central control to give ICSs the freedoms Hewitt suggests. It therefore remains to be seen whether her work will translate into any real changes in the environment ICSs find themselves in.