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Autonomy and accountability in Integrated Care Systems: unpacking the Hewitt Review and Health & Social Care Select Committee report


In November 2022 the Chancellor, Jeremy Hunt, announced a review into the oversight of governance of Integrated Care Systems (ICSs) chaired by former Secretary of State for Health and current Chair of Norfolk and Waveney ICS, Patricia Hewitt. The findings of the review were published yesterday (04/04/2023) and are available in full here.

The Health and Social Care Select Committee launched an inquiry with a similar focus in mid-2022. The inquiry looked into how Integrated care systems will deliver joined up health and care services, including how systems should balance increased flexibility over budgets and how services are commissioned with the need for clear accountability. The committee published their final report on 30/03/2023. It is available to read here.

We shared insights with both inquiries, with input from our member organisations. Our response to the Health and Social Care Select Committee call for evidence is available here.

Our key recommendations included the need for meaningful engagement from integrated care systems with people affected by neurological conditions and patient organisations, the importance of good quality data alongside agreed outcome measures and a focus on addressing unwarranted variation in treatment and care, including health inequalities.

Below we unpack some of the findings that are relevant to these recommendations and share our reflections.

Involving people who use services and organisations who work with them

The Health and Care Act places a duty on systems to involve people who use services and those who support them in decision making. We welcome the emphasis in both the Hewitt Review and health and care committee report on the vital importance of working alongside local communities, people who use services and the voluntary sector to deliver on the aims of integrated care systems.

The Hewitt Review is explicit in expressing the need for local communities to be involved in decision making and service design through an ongoing process of engagement, consultation and co-production.

The Health and Social Care Committee report builds on this, noting that the core purpose of integrated care systems will not be met without good patient and carer involvement and recommending a review of resources available to Healthwatch to facilitate this. We believe there is a similar need to support the voluntary and community sector (VCSE) to fully engage with integrated care systems.

Improving data and evidence

Good quality data is a key element of the population health approach adopted by many integrated care systems and plays a vital role in making sure services can be planned and commissioned appropriately. There is also a need for systems to make better use of patient experience data and insights to support effective commissioning and service improvement, ensuring that they are responsive to the priorities of people who use services including those with neurological conditions.

The Health and Social Care Committee report notes evidence provided by Louise Ansari, the national director of Healthwatch, on the need for systems to value personal experiences of health and care services and regard them as equal to the statistical data that often drives system priorities.

The Hewitt Review notes the importance of high-quality, accessible data in improving services and building public trust in local health systems. The report goes on to recommend that data collection should increasingly include patient reported experience and outcome measures, replacing the current focus on inputs and processes.

The Hewitt Review also calls for systems to work in partnership, including with VCSE organisations, to collect and utilise high-quality data to better understand population and personal health within integrated care systems.

We welcome the Hewitt Review’s focus on outcomes and will consider the recommendations the report makes in this area in detail. In our responses to both inquiries we highlighted the importance of agreed outcome measures alongside robust clinical standards in improving services, reducing variation and addressing health inequalities – this remains our priority.

Tackling health inequalities

The Neurological Alliance’s My Neuro Survey highlighted that health inequalities continue to persist in people’s experiences of treatment, care and support for their neurological condition. For example, people living in areas of higher deprivation were more likely to report experiencing delays to their care.

We welcome the vital call made in both reports to recognise and address the significant challenge facing integrated care systems: balancing demands to address immediate, short-term pressures such as elective care waiting lists with longer-term objectives including tackling health inequalities and population health management.

The Hewitt Review states: “Prevention, population health management and tackling health inequalities are not a distraction from the immediate priorities: indeed, they are the key to sustainable solutions to those immediate performance challenges.”

Specialised commissioning and workforce

Changes to how specialised services are commissioned are of significant interest to the Alliance and many of our members. Many services for people with neurological conditions were previously commissioned nationally by NHS England. However, from April 2023, and to a greater extent from April 2024, most will be commissioned at an integrated care system level.

The Hewitt Review acknowledges questions about how specialised services will fit within the new system. However, it does not provide detail about how these might be resolved. We support the report’s call for the proposed joint commissioning approach between NHSE and integrated care systems, coming into place from April 2023, to be kept under review.

The Hewitt Review also recommends that the Government produce a strategy for the social care workforce alongside the long-awaited NHS workforce plan. The current omission of social care from the forthcoming NHS workforce plan leaves a significant gap to be addressed in ensuring we have the workforce to meet the needs of people with neurological conditions. We would add that both the NHS workforce plan and proposed social care workforce plan must be comprehensive and fully funded.

What next?

The Government is yet to respond in detail to either of the reports. Without support and action from Government it is unlikely that any of the recommendations will be implemented.

We share concerns raised by others that the Government’s initial response to the Hewitt Review has been muted. The announcement of the Hewitt Review did not include a quote from the Secretary of State for Health and Social Care and there was no commitment to respond in detail to its recommendations.  

We encourage the Government to engage fully with the findings and recommendations of both reports. We would like to thank our member organisations for their insights and support with our response to these inquiries. We will provide further updates in future.