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The Hewitt Review is a unique chance to commit to the ICS agenda

Barely six months in and ICSs are already subject to their first independent review – but Patricia Hewitt’s re-evaluation of integration represents a genuine attempt to finally empower ICSs, not another deck chair reorganisation.

– By David Duffy –

Unless you were plugged into the health and care sector, you could be forgiven for not even realising that the NHS had only just undergone its biggest reorganisation in a decade. As we emerge from the toughest winter health and care services have ever faced, images of patients waiting on trolleys for emergency care and of people waiting years for life-altering elective treatment are now etched into the public psyche. The situation has, unsurprisingly, led to calls for fundamental reform in our system of health and care.

But while honest conversations about the state of UK health and care are essential, so too are accurate depictions of the current state of reform – as well as clear and realistic expectations of what these reforms can be expected to achieve.

“It is welcome, therefore, that rather than announce more ‘deckchair reorganisation’, the government has this time opted for a more considered re-evaluation as to the role of ICSs.”

Integrated care systems (ICSs) took up statutory footing in July 2022 with a mandate to deliver joined-up services along a place-based approach, using population health management techniques to bring down health inequalities across the country. Achieving improved health outcomes through these means cannot be accurately assessed in six months’ time, but that hasn’t stopped many commentators from calling for further wholesale reform of the NHS. No major corporation would expect instantaneous results following a merger or acquisition, so why are such patently unrealistic achievements persistently expected from the largest employer in Europe?

The answer, of course, is that our health matters to all of us, and that the government has consistently mismanaged the health service over the course of 13 years. However, the ‘holy grail’ of any health system in the world is a locally responsive integrated care system (or whatever name is used for it) and ICSs do represent a step in the right direction. What they require is time and support to harness their still new statutory position and achieve their goals.

It is welcome, therefore, that rather than announce more ‘deckchair reorganisation’, the government has this time opted for a more considered re-evaluation as to the role of ICSs. The ongoing review of ICS autonomy and accountability, led by former Health Secretary Patricia Hewitt and commissioned by former Health and Care Secretary Jeremy Hunt, amounts to a recognition of two key points: 1) that ICSs are here to stay 2) that if they are to work at a truly local level, central NHS and Whitehall must finally learn to let go.

Hewitt’s combined experience as a former Health Secretary and current ICB chair of Norfolk and Waveney ICS makes her more than well suited to conducting such a timely review. That a Tory Chancellor has asked a former Labour cabinet minister to review the government’s flagship health reform could be seen as something of an olive branch to a Labour Party that will likely inherit England’s nascent 42 ICSs. Any government would be loath to commit to another reform agenda and more legislative upheaval would neglect the significant impact ICSs have already had.

“ICSs have finallly started to build bridges between NHS providers, who are finally taking system-wide views to finance and care strategy based on joint working.”

What ICSs have been able to do so far is address tensions between commissioners (CCGs) and NHS trusts – a dynamic deliberately designed to spark competition and innovation across health and care. Many NHS regions were plagued by tense relationships as NHS trusts competed with each other for funding and CCGs sought to avoid giving said funding. This collaborative, joined-up approach has already promted system-wide approaches to financial decision-making and better adoption of digital innovation.

Hewitt will look to build on this momentum – and first among her six priorities for the review is collaboration.

The issue of collaboration versus competition in the NHS has long been debated, with proponents of the latter arguing that it promotes innovation, while those favouring the former stress that collaboration can reduce risk, expedite information sharing and facilitate scaled innovation. Evidence suggests that, given the choice, most NHS leaders prefer collaborating over competing.

Despite moving towards a collaborative model, it is the age-old shortcomings of centralisation, and an ‘NHS first’ approach to health and care, that continue to hamper the progress of integrated care in England.

Fundamentally, Hewitt is examining the overly centralised, target-driven environment in which health and care operate. Central support and direction for ICSs cannot be overly proscriptive, as the delivery of a truly integrated system is reliant on developing collaborative frameworks that respond to the differences in size, stakeholders and priorities that characterise each ICS region.

“The Hewitt Review must help empower ICSs to cut through these tensions and develop locally responsive and locally reflective service delivery.”

Despite ICSs’ remit for locally managed healthcare with a new brief to connect with local authorities and wider community services, the 2022 Health and Care Act saw Whitehall assume more central power to outline targets, creating fundamental contradictions within the current reforms. At times, ICSs across the country feel squeezed by NHS England and DHSC at a national level, and by individual providers locally.

This tension has come into sharp focus as ICSs have sought to merge the NHS with local government. If ICSs have shown us anything so far, it is that the NHS is not yet ready to marry its own accountability frameworks to those from local government. The NHS is not democratically accountable to its citizens like local authorities are, but is subject to scrutiny from central NHS, DHSC and the Care Quality Commission (CQC) – the latter of which does of course regulate social care, but this is only one part of the community service offering from local government. The Hewitt Review must help empower ICSs to cut through these tensions and develop locally responsive and locally reflective service delivery.

“The absence of an all encompassing metric is not an admission of failure, but rather an acceptance that collaborative models for health delivery are inherently complex and unique to individual localities.”

It will be fascinating to see how Hewitt will seek to reimagine the role of the CQC, which has made repeated efforts to shift its inspection regime to evaluate the progress of integration and wider system working. However, without a comprehensive remit and authority to evaluate whole systems, their impact has been limited.

Assessing the impact of such a model is extremely complicated. Globally, few have been able to produce measurement frameworks or metrics to accurately assess the impact of integrated care. Even the government’s own impact assessment of the 2022 Health and Care Act stated that “there is mixed evidence on whether collaboration can provide cost savings in the delivery of services”.

The absence of an all encompassing metric is not an admission of failure, but rather an acceptance that collaborative models for health delivery are inherently complex and unique to individual localities. Ultimately, the introduction of the Hewitt review is a recognition that successful collaboration is as dependent on culture, management, and resources as it is on rules and structures.

So, before ICSs are consigned to the scrap heap of failed health reforms, Whitehall must finally let go and provide these still young organisations with the autonomy, accountability and cultural freedom to demonstrate what they can do.

David Duffy is Head of Content for Public Policy Projects.

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