Hewitt review: the case for ‘glaziers’

Yesterday the Rt Hon Patricia Hewitt published her independent review of integrated care systems – the Hewitt Review. Its recommendations – while acknowledging that there won’t be unanimity around them – offers a space for integrated care systems to self-improve in a balanced way, while building on accountabilities and collaboration with all partners. As is remarked in the foreword, it is more ‘glazier’ in tone than ‘window-breaker’ – much needed given the challenges across all systems. In particular, the focus on primary and social care, and workforce, is much needed as this is at the root of many of the most pressing issues we see across the systems we are working with now.

In our November 2022 report co-produced with the County Councils Network (CCN), ‘The evolving role of county authorities in integrated care systems’, we identified three key themes which we are pleased to see come through loud and clear in the Hewitt Review:

1. Central government policy should be less restrictive, and more supportive of local flexibility recognising the variation across integrated care systems
2. Genuine partnership working is yet to be embraced across the full ICS spectrum, and
3. ‘Place’ needs to have primacy.

We also made a range of recommendations, many echoing those in the 36 recommendations in the Hewitt Review. We believe however that there will be several questions that the centre and systems will need to answer to bring these to life.

The focus on increasing prevention spending by 1% over the next five years and publicly reporting on investment is good (Recommendation 1) – however, defining ‘prevention’ is hard. In our report with CCN we suggested ‘out of hospital spend’ as a starting point, but this will require building out a trusted data set linking spend and activity across the NHS and local government. This requires significant focus now, starting with an honest conversation on definitions across partners. Our first-hand experience of doing this has shown it is no quick fix.

The shared outcomes framework approach (Recommendation 2) is not dissimilar to that proposed in the Government’s previous plan for health and social care. While it is a good idea, the tension with the number of central targets across all systems is marked. In our report, we advocated that systems should develop a small number of achievable local priorities that build an inclusive ambition, and that government should track a small subset of national aims, therefore building more of a balanced score card that respects subsidiarity which drives better outcomes.

While the need for collaboration is a central tenet, we suggest that a more active role working with local government should lie at the heart of self-improving systems. For example, the Local Government Association’s best practice of peer-review applications to ICSs is highlighted. We’d go one step beyond and suggest systems look to genuinely partner with local government to not only use their tools for self-improvement, but work with them to do this together, to deliver better outcomes across care and health.

Finally, in our report with CCN we specifically called out the need for prioritisation – to provide focus and build confidence that real change can happen – and so does the Hewitt Review. We identified two common priorities from primary research that sit at the top of ICB and local government leaders agendas; hospital discharge and admission prevention.

While the Hewitt Review has rightfully taken the headlines, yesterday the Government also set out the next steps to support social care. In particular, the Better Care Fund has been increased by 13% over the next two years, with a focus on funding hospital discharge projects, to a total of £1.6 billion. As our Valuing Home work has shown, the way to deliver meaningful impact and better system working is working in true partnerships to improve discharge and admission avoidance. This new funding gives an opportunity for systems to show how to bring balance, accountability, and place to life this year and next. To act as ‘glaziers’ collectively, rather than work individually as ‘window-breakers’. If you would like to discuss our work and research further, please get in touch.