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Integrated Care Systems 'Need Culture Change to Work': Hewitt Review

Integrated care systems (ICSs) represented "the best opportunity in a generation" to improve health and social care in England but will need new structures, a shift in resources, and a culture change if they're to work effectively, a major review said.

Bringing partner organisations together to plan and deliver joined up health and care systems within local areas could "sustainably tackle the causes and not just the symptoms of an over-burdened NHS" and required "moving resources upstream to enable people to live independently for as long as possible, build more resilient communities and reduce health inequalities".

Relieving Pressure on the NHS

The Hewitt Review, chaired by former Labour Health Secretary Patricia Hewitt, said that the NHS was in practice "more of a National Illness Service" than a National Health Service, and "the reality is that we are a very long way from devoting anything like the same amount of time, energy and money to the causes of poor health as to its treatment".

Her review proposed greater autonomy to enable ICSs to bolster health prevention, improve NHS productivity and care, and create accountability. It called for significantly reducing the number of national targets, as too many top-down targets and performance standards led to 'gaming' the system by managers, or even "disastrous neglect" of patients. These should be replaced instead by a maximum of 10 national priorities to concentrate minds on the most important issues for improving patient care. 

Both the Care Quality Commission and NHS England would continue to have a vital role to play in oversight and accountability, but national and regional organisations must support ICSs to evolve into "self improving systems", giving them "the time and space to lead", the report said.

A Larger Slice of the Health Budget

On preventing ill health, the review called for the share of total NHS budgets at ICS level going towards prevention to be increased by at least 1% over the next 5 years. The shift of funds would "require cross-governmental collaboration to embed a national mission for health improvement and the establishment of a new Health, Wellbeing and Care Assembly".

At the same time, the public health grant to local authorities needed to be increased following "8 years of real-term squeeze on local authority funding for public health and other essential services".

The Rt Hon Patricia Hewitt said: "Integrated care systems represent the best opportunity in a generation for the urgently needed transformation that we need in our health and care system. Everyone wants them to succeed. To fulfil their potential, however, we need not only to back our new structures, but also to change our culture. Everyone needs to change, and everyone needs to play their part."

Reaction to the Review

Amanda Pritchard, NHS England chief executive, said: "Integrated care systems have the power to change the way the NHS provides care for people while working alongside local government to ensure people live healthier lives."

Responding to the review, Sir Julian Hartley, chief executive of NHS Providers said: "At a time of great pressure across the health and care system, ensuring the right oversight, accountability, and support for trusts and integrated care systems is critical. We welcome this report as it highlights how ICSs can help integrate care, forge partnerships within and beyond the NHS, and shift towards a preventative model of care. The emphasis on improvement over top-down performance management is essential and we hope the NHS at all levels will commit to the cultural shift necessary to bring this about."

Patricia Marquis, director for England at the Royal College of Nursing, said: "Almost every day a new report highlights the crisis in our NHS with patients suffering and staff struggling. We welcome many of the measures set out in this report as starting points to reverse the dramatic deterioration that health services – and those working on the frontline – are facing. 

"Ultimately this report highlights the importance of investing in the workforce – including training for staff and a strategy for the social care workforce. But nothing will be achieved without funding and investment from government."

The Department of Health and Social Care said ministers would review the recommendations "in due course". A spokesperson said: "Integrated care systems are an important part of the Government's plan to deliver more joined up and effective health and care services and to cut waiting times for patients, one of the Prime Minister's key priorities for 2023."