The government published its response on 14th June 2023 to the Rt Hon Patricia Hewitt’s review examining Integrated Care Systems (ICSs) on autonomy and accountability. It has responded to both the Hewitt Review and the Health and Social Care Select Committee’s report from its inquiry on ICSs at the same time.
The government’s response sets out its commitment to supporting ICS development, reducing the number of national targets and to reviewing the NHS capital regime. It also recognises that decisions should be made at the most appropriate level, whether system or place.
Speaking at the NHS ConfedExpo conference on 15th June 2023, Patricia Hewitt said the government response was more positive than she had feared at some points, and it “would have been a complete miracle” if ministers had backed all her recommendations. She added: “What’s really clear is we’ve got the cross-party support for ICSs that I referenced in the review. We’ve [also] got the legislation, we are here to stay.” Hewitt continued: “[This] policy stability should make everybody who might be hesitating a bit about whether or not really to commit to their local system, their local partnership [and] their local ICB, now put aside all of those doubts, get stuck in.”
Read on for our summary of the key themes from the government response.
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Government response: key themes
Theme 1: targets and priorities for ICSs
Hewitt recommended a substantial reduction in the number of national targets set by DHSC and NHSE, with no more than 10 national priorities. In its response, DHSC and NHSE “recognise the benefit of the centre focusing on a small core set of priorities… and [that] will be reflected in the forthcoming mandate to NHS England.”
Commenting on the government’s agreement to reduce the number of overarching national targets imposed on ICSs, Matthew Taylor, chief executive of NHS confederation said it will be “music to the ears of ICS leaders, empowering them to focus on the priorities of their localities.”
Theme 2: autonomy, leadership, and support for ICSs
Both Hewitt and the HSCSC report highlighted the importance of a leadership development programme. Hewitt also suggested ICBs should take the lead in working with providers facing difficulties and emphasised the role of ICS leaders in co designing the next evolution of NHSE regions.
The government’s response is supportive of a leadership programme. Notwithstanding NHSE’s statutory role, the government agrees that, in general, NHSE will discharge their duties in collaboration with ICBs “asking ICBs to oversee and seek to resolve local issues before escalation”. NHSE’s new operating framework sets out how it will operate in the new structure. NHSE has subsequently written to all ICBs/ICPs, reinforcing the operating framework and confirming systems and national partners now need to focus on the following four keys areas:
• supporting collaborative leadership
• encouraging local leadership
• developing the ‘one team’ approach
• being informed by local leaders in how ways of working are reorganised
Theme 3: ICS governance, accountability and oversight
Hewitt’s proposal was that the 10 best performing ICSs should be designated “high accountability and responsibility partnerships” and given “far greater financial flexibilities and freedoms than other systems”.
In its response, the government state that ICSs “are still in their infancy, having been placed on a statutory footing less than a year ago, and are still finalising their first joint forward plans and integrated care strategies…But we need to consider further the most appropriate way of achieving this aim”.
Theme 4: assessments and review of ICSs
On regulatory oversight, the review made recommendations about what CQC’s reviews of ICSs should measure and the importance of NHSE and CQC having complimentary and non duplicative assessments and approaches to improvement. Specifically, Hewitt recommended that the CQC should have powers to “make an assessment of the level of maturity and effectiveness of each ICS as a whole, including a rating of the ICS leadership itself, based on an assessment of how far ICS structures are adding value and enabling the system as a whole to meet its objectives and improve outcomes”.
The government’s response provides:
“We support the vision set out in the Hewitt Review and will consider the best approach regarding ICS ratings. This would build on existing plans and development work led by CQC and include ratings on the quality of services within the ICS across the key domains of care and ICS leadership; and we agree that the highest ratings would not be given to a system where the financial position is not being well-managed. DHSC and CQC will work with NHSE and other partners to develop these measures and CQC will start to test the ratings as suggested by the Hewitt Review in 2024 to 2025.”
Theme 5: prevention and the promotion of health
While government has recognised the importance of prevention and keeping people well for longer, it has rejected the review’s proposals to increase the share of total NHS budgets at ICS level which goes towards prevention by at least 1% over the next five years and deemed it unnecessary explaining that they have “already committed to a UK-wide Levelling Up health mission to narrow the gap in life expectancy.. as announced in the Levelling Up white paper.”
Theme 6: Finance and funding
The government has accepted the need for a capital review which will be welcomed by ICS leaders, but they will have to wait for further detail on how it will reduce red tape NHS leaders face when trying to access NHS capital funding, particularly for primary care, private finance and NHS estate.
The review also called for the government to reconsider ICB running cost cuts, but the government has rejected this explaining that “The 10 per cent cut… has been agreed with government and… forms part of NHS financial plans.”
On the pooling of budgets between health and social care through section 75 agreements, the response reinstates previous commitments (Integration white paper) to review the legislation to simplify and update the regulations.
Additional Hewitt Review recommendations: data and digital
The review called for the development of a minimum data sharing standard framework to be adopted by all ICSs to improve interoperability and data sharing across organisations. The government’s response does not include new announcements, but it supports the intent of Hewitt’s recommendations.
Additional Hewitt Review recommendations: primary and social care
Hewitt recommended the development of a new framework for GP primary care contracts. In its response, the government refer to its Delivery plan to recover access to primary care and confirm that over 2023/24 they will engage with stakeholders to build on the recommendations in the Fuller Stocktake and the development of the GP contract.
Hewitt recommended a social care workforce plan complementary to the NHS workforce plan to support recruitment issues. In its response, the government refers to its 2022 integrated care strategy guidance calling on ICSs to take forward joint workforce planning with local authorities and independent care providers to ensure system wide coordination of recruitment and development.