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Is Hewitt turning the tide of performance management or swimming against it?

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Patricia Hewitt’s independent review of integrated care systems (ICSs) is aimed squarely at one of the biggest challenges facing ICSs – the strong culture of top-down performance management in the NHS. The reforms introduced by the 2022 Health and Care Act, with their focus on collaboration across boundaries in local systems, represent a direct challenge to this hierarchical culture, and without a new approach to accountability in the NHS there is little hope of ICSs living up to their original promise.

Recent comments from ICS leaders illustrate how culturally centralised the NHS can be. The chief executive of Dorset integrated care board (ICB) remarked that she ‘felt as if I’ve been managed in a straitjacket’ and ‘might as well be a band seven’. In a recent report from The King’s Fund, the chair of another ICB had this to say:

'I personally have found really quite egregious the extent to which relatively junior people at a regional level have acted and used the authority of their regional position to completely undermine more senior people working within their systems.'

While accepting that there will always need to be accountability to national bodies and government, Hewitt wants to replace the current performance management culture with a stronger focus on learning and improvement. The review proposes some specific measures that could help to turn the tide, including:

  • fewer national targets, with local priorities given equal weight to national targets

  • stronger mutual accountability within systems, including a national peer review offer to help systems compare themselves against each other, and an explicit role for joint overview and scrutiny committees in scrutinising the work of ICSs

  • CQC assessments of systems to be framed as developmental feedback rather than a compliance checklist, and to include an assessment of whether system partners are developing ‘a framework of mutual accountability’

  • smarter use of data for accountability to reduce the reporting burdens on ICBs

  • strengthening learning and improvement capabilities in systems by shifting resources from regions to ICBs

These are technical solutions to what is, at least in part, a cultural and behavioural problem. Hewitt acknowledges this herself, commenting that ‘while structures matter, culture, leadership and behaviours matter far more’. However, beyond a call for sustained investment in leadership development and organisational development, it is striking how little the review says about how, in practical terms, leadership behaviours and cultures within the NHS can be shifted to reflect the new focus on collaboration and partnership-working and the principle of subsidiarity to local tiers of organisation.

Perhaps it’s best to see Hewitt as a companion piece to the Messenger review of leadership in health and social care. This identified a similar challenge: ‘The sense of constant demands from above, including from politicians, creates an institutional instinct… to look upwards to furnish the needs of the hierarchy rather than downwards to the needs of the service-user’. Its proposals, focusing on investment in people and ‘targeted interventions’ to build collaborative leadership, could be complementary to the changes to accountability arrangements suggested by Hewitt.

As well as being cultural, the challenges Hewitt seeks to address are also deeply political. Hierarchical behaviours exist for a reason, and part of that reason is the politics surrounding the NHS. Several of the review’s recommendations would require bold leadership from national and local politicians if they are to have a chance of seeing the light of day.

'Hierarchical behaviours exist for a reason, and part of that reason is the politics surrounding the NHS.'

For example, giving local priorities genuinely equal status to national targets would involve parliament and the public understanding that there are some things that the NHS is accountable for nationally, and others for which responsibility and accountability sits locally. There would also need to be sufficient confidence that national and local accountability mechanisms can both be effective in driving improvement.

The highly welcome proposal to increase the share of the NHS budget spent on prevention over the next five years is also a tough political sell, in that it would involve directing resources to prevention rather than treatment at a time when services are already struggling. This would require MPs and others being willing to invest considerable political capital in making the case for it, and Hewitt herself acknowledges that it is her ‘most challenging recommendation’.

Finally, the proposal to reduce the volume of conditions attached to ICB funding by moving away from non-recurrent funding and ring-fenced budgets (albeit gradually) will also come up against stiff opposition in parts of Whitehall, where keeping control of spending is the name of the game. Again, changing this would be a political undertaking as much as a technical one – as Hewitt will of course be well aware.

Overall, there is much to welcome in this review. But Hewitt’s vision of self-improving systems will require paying more attention to the cultural aspects of change and will also need concerted political leadership. The review has at least one high-profile political backer – having been commissioned by the Chancellor – but so far, the response from the Department of Health and Social Care has been muted. Unless this changes it is hard to see the review’s proposals becoming government policy.