At a time of unprecedented operational challenges for the NHS, Patricia Hewitt's review of integrated care systems (ICSs) provides an opportunity to ensure the right balance between central direction and flex for local health and care systems to meet the needs of their populations. In the midst of escalating industrial action and with waiting times under scrutiny, how can it add value, and what will trust leaders hope to see when the report is published on 15 March?
Trust leaders welcome the Hewitt Review but recognise that ICSs and integrated care boards (ICBs) are still evolving, having very recently been placed on a statutory footing. Trusts are aspirational and prepared for change but given the potent mix of pandemic legacies, unprecedented operational pressure, and recent legislative reform, the Hewitt Review will need to chart a careful and iterative course to effect change without overwhelming NHS leaders with limited bandwidth. Trusts also point to the new NHS England operating framework as an important reference point for the review because it promotes a constructive, open culture alongside evolving roles for a more focused and streamlined national body, regional teams and local systems.
The Hewitt Review will need to chart a careful and iterative course to effect change without overwhelming NHS leaders with limited bandwidth.
Co-Director of Development and Engagement
Recognising local variation and being ambitious about population health improvement will be key. Each ICS varies considerably in population size, geography, levels of deprivation and provider make-up. This means exploring more flexible and localised models of delivery makes a lot of sense. Providers remain supportive of the strategic aims which ICSs were established to deliver: to improve outcomes in population health; tackle inequalities in outcomes, experience and access; enhance productivity; and help the NHS support broader social and economic development.
Trusts are therefore keen that ICBs and integrated care partnerships are allowed the headroom to broker productive relationships between health, care and other public services, to tackle the broader determinants of health and drive down health inequalities, rather than being forced to operate as a duplicative layer of performance management.
The review commits to exploring a new balance of targets with the potential for fewer – and more outcome-focused – national requirements, with more flex for local system partners to agree priorities in response to the health needs of their populations. Trust leaders support this, but have asked for a clearly articulated steer on the 'what?' from government and national bodies, and much less prescription on the 'how?'. It is also important to remember that despite a more collaborative landscape, trust boards retain legal accountability for the care provided by their organisations and therefore need the autonomy to make improvements and forge new partnerships without undue bureaucracy or burdensome oversight from national bodies or emergent ICBs.
Trust leaders are clear that although fewer national targets would be welcome, this must not dilute the focus on improving mental health care, or on the critical roles played by community services. This means protecting the mental health investment standard and protecting the consistency of useful national data sets (including for community services) which are needed to make the case for investment in key services, and for many of the transformative approaches the NHS is striving to deliver to improve care for patients.
Providers are co-leaders within systems and fully support the new collaborative endeavour underpinning the introduction of ICSs. They also see real value in the role of provider collaboratives leading and driving transformation, supporting local systems to reduce care backlogs, improve efficiency and reduce unwarranted variation in quality. The provider landscape varies considerably between systems so recognising the value of provider collaboration, and formal collaboratives – as well as place-based arrangements – will be key in ensuring the review's recommendations gain traction.
Trusts remain hopeful that the Hewitt Review will drive action to streamline national priorities and reduce bureaucratic burden.
Co-Director of Development and Engagement
Trusts have consistently called for better alignment across Care Quality Commission and NHS England oversight and performance management frameworks. It is also essential that ICBs are not tasked to fulfil a reductive and duplicative performance management role. Finally, regulators' behaviours need to match their stated intention of promoting autonomy and providing access to improvement support where helpful.
In short, trusts remain hopeful that the Hewitt Review will drive action to streamline national priorities and reduce bureaucratic burden. But the review will land at a time of unprecedented pressure when many ICSs are in the process of maturing. To effect change, the review's recommendations must respect local variability and leadership capacity as well as the benefits of local autonomy.
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