The Hewitt Review - one year on

We are in an incredibly difficult situation, and when I say we, I don't just mean the National Health Service, I mean social care, I mean local government, including but not only its responsibilities for public health. And I mean also our partners in the voluntary, the community, the faith, the social enterprise sectors. All of us are facing enormous challenges, including financial challenges.

But despite all the challenges that I think everyone on this call is grappling with every day, I'm very optimistic about not simply the impact of the review, but about the prospects for a real shift in the model of care, and the way we think about health and health policy, which was at the heart really of the review.

I want to go back to that core argument that was at the heart of the review, and which I can see increasingly not just accepted, but echoed, developed, reflected in so much of the debate and policy making that's going on at the moment. Essentially, the argument is that we have a model of care absolutely focused around treating illness rather than promoting health and focus, especially on acute hospitals. Which you know was right for its time, but increasingly is wrong for the population in which we and many, many other countries have to provide healthcare.

And if we go on in essence, leaving people without the support that they need to manage multiple chronic conditions, which typically is the healthcare challenge we face, and we lead them to the point where really the only place they can find the treatment they need is in the acutes, then we will never have enough money, enough staff, enough beds, enough hospitals to meet the needs of an increasingly older but also increasingly sick and unequal population. And that, fundamentally, is why we have to change the model of care and change it in precisely the direction for which integrated care systems were set up and put on a statutory basis 18 months ago.

The argument is that the shift to prevention, to a focus on outcomes rather than simply treating illness, to understanding and acting on the wider determinants of health and, in particular, acting to tackle the gross health inequalities we have in this country, those things aren't simply a nice to have or the thing that we will get round to after we've dealt with four-hour weights in A&E, or unacceptable delays for ambulance handovers, or long waiting lists for elective care, or long queues to see your GP. In fact, tackling those bigger issues are the only sustainable way of dealing with the symptoms of the problem which are all those bottlenecks and pressures in the system on which not surprisingly public attention, as well as political attention and media headlines, are most concentrated.

We're having to tackle them when finances are incredibly tight. We don't have the luxury that arguably we did have at earlier stages in the NHS – of additional money that we could use for double-running, creating new services, and so on. So the challenge to us as leaders is to tackle performance pressures today in a way that builds for the transformation that we need to be sustainable tomorrow.

Now, this argument about the need for that shift to prevention, the shift to supported self-care and management of chronic conditions, all of that, this argument is increasingly accepted because everybody can see what's happening. So, if you look at the Times Healthcare Commission, or the excellent book that's recently come out, edited by David Hunter and colleagues, or many other reports, a lot of the work being done in the think tanks, and so on, they're all essentially making the same argument and that is one of the reasons why I am genuinely optimistic about the situation we find ourselves in, and the possibility of really moving forward, particularly after the election, when at least hopefully the element of political uncertainty will be removed.

When we published the Review, and indeed when the Government published its response last year, which was already more positive than I had expected, and has actually developed even since, I said at the time that statutory integrated care systems are here to stay and to some extent that was a statement of faith rather than fact. But increasingly, it is fact, because we now have a situation where both the government and the main opposition parties are crystal-clear that they are not going to have another top-down reorganisation, and they do see integrated care systems as critical to the way forward.

Although Amanda Pritchard always uses that very nice phrase about as leaders we have to balance the optimism with the realism, I do think that not just as a matter of personal preference, it is absolutely clear that there are elements in this current very difficult situation that we can and should use as leaders and stakeholders who share the vision and the purposes of integrated care systems to build a better future.

We need to know as a country how much of the NHS budget is currently being spent on something that we could broadly define and agree on as prevention, whether that is primary prevention or something further, if you like, along the scale and we need as integrated care systems to be able to baseline what we're currently spending and then benchmark both our own progress, but also benchmark ourselves against other systems.

But what we need at the national level is all parts of government pulling together, we suggested through a cabinet committee, a national mission to improve the health of the population, but joined-up working between ministers and between departments. And one of the recommendations we made to help that was for a national forum bringing together integrated care partnerships, their leaders with all the relevant government departments, and that recommendation now looks as if it will be accepted. And we're seeing, even at the moment more of that joined-up working. We're expecting a statement from the Secretary of State in the next few weeks on prevention. We have Labour's commitment to a national health mission and so on. So I think we're making progress, even though we haven't yet got that commitment to 1%. But we absolutely need that because that was really at the heart of the report, and it's a way of operationalising and then measuring progress on this critical shift in the fundamental model of care.

One of the really significant changes between the CCGs and now the integrated care boards is that integrated care boards have medical directors on their boards, part of the statutory framework, and what I'm seeing certainly in our own and many other integrated care boards is the really powerful impact of a medical director who isn't seen as belonging to any one of the provider trusts, but has that system-wide lens convening power, acting as catalyst, working closely with the director of nursing… and that is making a real difference.

But given the accountability of the Integrated Care Board for the finances and performance of the entire NHS in its geography, and the framework of mutual accountability that we all have to create and make real, but backed up by that statutory duty to collaborate, that for me means that medical directors and other senior leaders in provider trusts need to be thinking and acting differently, and recognizing that most of the problems that are so visible on the provider side – sure, some can be solved and need to be solved by action purely inside that organization – but most of them have to be solved in a partnership that will often go well beyond the NHS, but certainly includes all the different bits of the NHS.

With that focus from NHS England, both centrally and regionally on performance. And yeah, we're only interested in the performance of the NHS trust. And basically we're interested in the acute performance, a bit on GP access, and all that other stuff – health inequalities, we’ll deal with that next time. What I've noticed is several integrated care boards, and I'd include our own in this, have said. ‘No, we are going to talk about that as well. And so actually in the East of England, because there are so many performance meetings, depending on the situation in each trust or system, but there are so many performance meetings focused on four-hour or elective waits or UAC, or whatever it is, actually, we've we found we can make space with some work and preparation and everything else, to look at those wider issues, including the partnership with local government, and how we work with not just the council, as, for instance, social care commissioners, but with social care providers, and not in a spirit of social care's job is to get people out of hospital so that the acutes can meet their targets, but in a spirit of how do we learn from social care about supporting people to lead as good a life as they can in their own homes?

We then try and shape the agenda for the meeting with a slightly wider focus, and we bring appropriate people to that meeting. I know different regions work in different ways. But I think, especially with what you're describing. We have a community interest company that provides community services for about 10% of our population. And it's very frustrating that at the moment the NHS performance management system just doesn't recognise the importance of those partners. And that for me feels like another step we need to be taking nationally and with all regions as well as within our end systems.

We have got some superb practices which are using both the workforce mix and the data, smartly interrogated, not simply to deal with the 8AM queue on a Monday morning but actually, proactively to go out and reach out to the people who aren't getting through on the phone, aren't coming to the GP, and who, of course, end up with a stage-4 cancer diagnosis in A&E and all kinds of other horror stories that we're all familiar with. That is happening at significant scale in many parts of the country.

What I think we very badly need is a new framework for the GP contract. We need to remove the frankly absurd incentives in the current system that encourage GPS to be locums and profoundly discourage them from being GP partners. But I think we also have to recognise that partnership isn't for everybody, so we need a variety of models here. And we need a focus on outcomes that will enable us not simply to hold up the great examples of what's happening and try and exhort others to follow them but actually build that work into the system, because there's a lot of money already tied up in primary care and we could do even better if we were, for instance, to say that any growth money, or some, or, better still, in my view, all of the benefits released by the productivity gains that the NHS is now committed to over the next five years, those will flow into prevention, primary and community and support.

I think the mood amongst GPs is mixed, but I absolutely recognise that pessimism and ‘oh God, we can't bear it, and we're going to take early retirement, or we're going to become a locum, or you know, whatever or it's all the ICB's fault. Why haven't you fixed it?’ There's a lot of that going on, and I think, certainly in a system like ours, the work we've done very successfully to build relationships across providers in that organisational sense, we now need to be doing even more of that with our GPs because it’s too mixed a picture at the moment. But we do need those national and institution changes at that local level putting together constrained resources. If you've got enough willing leaders, or can mobilize some more, and then tap into both statutory and non-statutory sources of funding. It isn't easy. It isn't nearly as quick as it should be. I mean, you know, we are struggling with this because of having to balance the NHS budgets as everybody is. But we can do something, I think, there. And that's what we have to do. And of course we've also got the lever that the integrated care board itself does need to demonstrate how its own strategy and joint forward plan serves and contributes to the aspiration, the goals and priorities that have been set in the wider partnership strategy. So we've got some levers there and the productivity piece really contributes to that, because it comes back to the fact that we are basically spending too much money in the acutes.

We've got this massive challenge of how we, as a society and as families and individuals, as well as in terms of government and taxpayers, how we fund a decent quality of social care for those who need it, especially for older people. […] Some changes have been made in the regulatory regime and funding regime for social care, but the much bigger job of confronting how we are going to pay for this and ensure that people who don't have high incomes, or even middle level incomes, and who don't have property, or other assets and wealth get a good quality of care. And that in turn means what are we willing as a society and as taxpayers to pay the people who work in social care? And those fundamental questions aren't going to be addressed before the election. We've seen in past elections the disaster of trying to address them, you know, with a rabbit out of the hat during an election campaign. So that is one for a post-election government and there's no shortage of policy thinking and very serious and well-costed reports on this, but it will require, I think, a big national conversation and some very difficult decisions given the state of public finances and all the demands on them. We think about social care so often in completely the wrong way. We talk about it as if its role is to be a handmaiden to the NHS, and it isn't. The NHS can learn a great deal from social care and from the feel like the assets-based approach to supporting people who are often hugely vulnerable, despite living good lives, despite very serious and complex physical and sometimes mental, emotional, and cognitive challenges as well, but there are also things the NHS can learn from social care on productivity.

If you haven't had a chance to look at the work of CERA. I have no financial interest in them or anything else, but they are using artificial intelligence and digital platforms to transform the model of domiciliary social care, both in relation to individual, self-pay clients, but increasingly as partners with local councils, and indeed integrated care boards. They happen to be our largest provider of domiciliary social care in Norfolk and Waveney, but they will be operating in in many of the systems who are here today. They're transforming the way they recruit and train and develop and deploy social care staff and are achieving really significant improvements in both their success in recruitment but also their success in retention, reduced absenteeism, and much higher productivity. We could learn quite a lot from them in the NHS.

I think we have a real opportunity in the run up to a quite extraordinary election to help

shape the conversation and use our influence as leaders, both individually through our own networks and more collectively, and the work that the Local Government Association, the NHS Confederation and others are doing to reflect what I think is the great weight of opinion amongst those of us working in integrated care systems, and then use that appropriately with the political parties – nationally, but also locally.

All of us, I think, have pretty close relationships with our own members of parliament, and increasingly there are also relationships with candidates in the run-up to the elections. So I think we've got an opportunity there to use our voice and our relationships for good, and to try and get from whoever is the next health secretary, the next prime minister, the next cabinet, that national mission for health improvement which is what we need, coupled with a whole lot of other reforms, some of which we've been talking about – including that 1% or 5% shift that will really enable integrated care systems to further accelerate and deepen the work. It's been happening over the last 18 months since we've been put on a statutory basis. But we've got a real opportunity to turbo charge that if we can get a more supportive policy environment after the election.