The future of integrated care: GGI reflects on the Hewitt Review

On 17 November 2022, the Chancellor, Jeremy Hunt, announced a review of integrated care systems (ICSs) to be undertaken by Patricia Hewitt, former Secretary of State for Health and current chair of Norfolk and Waveney Integrated Care Board.

The review considers how the oversight and governance of ICSs can best enable them to succeed. It covers ICSs in England and the NHS targets and priorities for which integrated care boards (ICBs) are accountable, including those set out in the government’s mandate to NHS England.

The review has been designed to 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.

GGI has provided evidence for the review, captured in a paper written by principal consultant Simon Hall. You can download our full response here.

Highlights of GGI’s response

The Hewitt Review invited input on 11 questions, covering everything from how local organisations have created transformational change, to highlighting obstacles to this sort of change, and how national bodies should divide responsibility between themselves and local organisations when it comes to setting priorities and targets. There follows a selection of highlights of GGI’s responses.

Question 2: What examples are there of local, regional or national policy frameworks, policies, and support mechanisms that enable or make it difficult for local leaders and, in particular, ICSs to achieve their goals?

One of the most difficult issues that we are finding for local leaders is navigating the line between organisational and system risk in order to achieve their goals. While working as a system is the most beneficial approach for patients, the NHS and the wider economy, it remains the case that each organisation within an ICS is an individual statutory body, including the ICB. As such, each has a regulatory framework that it must operate within, which may be explicitly at odds with the national policy direction for ICSs.

If a point of conflict arises, each organisation must ultimately meet its own statutory requirements, even if that is to the detriment of the wider system. ICSs are not statutory organisations and therefore any joint goals are effectively voluntary, and there is no requirement for the different organisations within an ICS (or on an ICB) to adopt and work to mitigate system risks or support system population health outcomes.

Question 3: What would be needed for ICSs and the organisations and partnerships within them to increase innovation and go further and faster in pursuing their goals?

Partnership working beyond the boundaries of the NHS can be challenging due to differing financial and governance regimes, for example, different approaches to VAT in local government and the NHS, and non-aligned financial reporting timetables. We have found very few places where Section 75 flexibilities are being used beyond the areas covered by the Better Care Fund.

The other area that should be mentioned as critical is workforce. There remain insufficient staff to deliver current services at the level required, with significant vacancies in all sectors. New initiatives and service models can sometimes draw staff away from under pressure services to a more attractive role, thus exacerbating the pressures on the day-to-day delivery of services. As the NHS seeks to implement integrated care plans, it is expected that more services and provision will move to community settings. This needs to be supported by making staff movement between organisations and sectors much easier.

Question 4: What local, regional or national policy frameworks, regulations and support mechanisms could best support the active involvement of partners, including adult social care, children’s social care services and voluntary, community and social enterprise (VCSE) in integrated care systems?

In order to achieve the aims that they were set up to do, ICSs need to nurture effective relationships and trust across sectors and between a wide range of partner agencies, and our experience shows that this cannot be fast-tracked. Partner member roles on ICSs/ICBs are difficult roles, and have inherent conflicts of interest, bandwidth issues, mis-alignment, differing cultures and governance systems. It is, though, very desirable to have partner members hard-wired into ICB governance. The trick that we believe has been missed is to also involve them in ICB executive teams, and there are multiple ways of doing this – and indeed a ready model with acute hospitals and how clinical directors are involved in trust management groups.

We also believe it is vital that ICSs think about care home providers as partners and as separate from local authorities. We have found, working with Care England, a poor understanding of care homes by NHS leaders and trite, out of date assumptions. The care home market is so fractured it is often very hard to get someone to represent care homes in any ICS structure.

ICBs need to bite the bullet and pay the voluntary, community and care home sectors for the time it takes to engage in ICB work, and there are some good examples of this starting to happen in some places across England. The real engagement an ICB can get from this exercise is well worth this investment, particularly as traditionally management structures have been inexorably thin in these sectors.

Question 7: What examples are there at a neighbourhood, place or system level, of innovative uses of data or digital services to improve outcomes for populations, improve quality, safety, transparency, or experience of services for people, or to increase productivity and efficiency?

We have seen examples of good practice across the country where data has been used very effectively to improve outcomes for populations. This has been particularly the case where the lead has been taken by Directors of Public Health to drive data sharing on a population health basis, with the ability to link this in with wider data available across Councils. We are encouraged by the New NHS Code of Governance that requires boards to look to their local populations as well as those that use their services. Some boards are setting up population health committees as an interesting first step, such as University Hospitals of Dorset NHS Foundation Trust.

Question 10: What are the most important things for NHS England, the CQC and DHSC to monitor, to allow them to identify performance or capability issues and variation within an ICS that require support?

The NHS has traditionally been very inward thinking when it comes to thinking about how to improve performance or capability, and we believe that ICSs would benefit from adopting a much less cosy approach. ICSs, and ICBs in particular, need new thinking and skills to do very different roles from their predecessor NHS organisations, and we would suggest that looking to wider industry standards would be a useful start for NHS England, the CQC and the DHSC as they think about how to monitor the new bodies.

To create a step change in the NHS around integration may require more radical steps, and a new regulatory and support regime should be designed to enable rather than hinder this. If performance monitoring focuses on activity in individual organisations, it will work against the wider desire to encourage and promote system working. There is a danger that a new oversight process designed in the same way as those in the past could rebuild the barriers that the Health and Care Act 2022 seeks to remove.