Another waiting game? National Voices’ reflections on the Hewitt Review

The Review was commissioned in response to concerns that newly emerging Integrated Care Systems (ICSs) were being drowned in red tape to such an extent that they could not get on with their core work to improve health and care in places. A key question of the Review was whether ICSs should be given more freedoms, and be measured against fewer national targets and standards.

National Voices’ initial response to the Review’s (rather rushed) call for evidence over the Christmas period highlighted our concerns about the risks of sweeping away guidance and regulation without proper engagement with the Voluntary, Community and Social Enterprise (VCSE) sector, and with people and communities, and about how our sector’s voice could be heard both in the Review and within ICSs.

We highlighted ways in which Government could make what matters to people count in any data collected or targets set to measure ICSs’ productivity, performance and effectiveness. We also flagged our concerns around ICSs’ accountability to reducing health inequalities, particularly if approaches taken were based on aggregate data sets.

In early 2023 we were invited to be part of two working groups exploring areas of interest identified by Patricia Hewitt. We sat on the Prevention and Population Health working group, were represented by the Neurological Alliance on the Data and Digital working group while other sector colleagues sat on the other three working groups. We also met with Patricia Hewitt as part of the VCSE Health and Wellbeing Alliance.

In all of our engagements we were reassured that Patricia Hewitt, and her fellow ICS leaders who contributed to the Review, understood the importance of VCSE sector involvement in the future health system and the contribution we can make to creating health in places. Our engagements were positive, with conversations around ensuring ICS were informed by the insights of people and communities, and delivering longer-term funding to our sector as part of the work to support population health.

But, throughout the conversations a tension remained between the drive to free ICSs from red tape so that those of good intent have more space to be creative and responsive to local need; and the desire of a VCSE sector that has been burned one too many times, to build in safeguards to the system against leaving some areas, where leaders are less enlightened, behind.

So where were we left at the end of the Review? And what will it mean for people using health and care services?

The Review makes a strong case for long-term investment in community-based solutions and recognises the role of the VCSE sector in delivering support that helps people stay well. It recognises that health and social care are interdependent and the ongoing underinvestment in social care and in public health is unsustainable. It also argues for involving people with lived experience, and VCSE sector representatives in the next steps – including developing a shared understanding of “prevention” and ensuring all ICSs shift investment towards it.  If this were realised it could make a real difference to people living with long term conditions, by bringing new investment into the services that we know people want – community-based, person-centred support that encompasses not just medical care, but also practical, social and emotional support.

However, to all intents and purposes the risks that we identified at the outset of the process remain. As expected, the Review argues that its ambitions can only be achieved if we also strip back the central targets against which ICSs are measured, and give them more freedom to set their own agenda. If this went ahead it would mean that it would be harder to people living in areas where care is poor to pull on national levers for change – a situation which feels risky given the lack of clear mechanisms for local accountability (especially while Local Government remains a relatively junior partner in many ICSs – a wrong which the Review helpfully recognises, but which will take time to right).

While the Review recognises the need for ICSs to drive work to address health inequalities, it is light on specifics around how this will happen. Given how glaringly the pandemic exposed health inequalities across our system it is disappointing not to see greater emphasis on this agenda. Once again we are asked to trust ICS leaders to take up the mantel and to work out the best approach for their areas – informed by the wider group of voices the Review argues should be engaged. But given how long this agenda has been neglected in the face of clear evidence of wide inequalities, this feels risky.

Whether any of this will happen, though, remains to be seen. While the Hewitt Review has been warmly welcomed by leaders across the system, one critical leader, the Secretary of State for Health and Social Care, has been decidedly quiet about it. Without Ministerial backing the Review’s recommendations are unlikely to be enacted.  And with so many other priorities on the desk – including a long-awaited workforce plan for the NHS, and a Major Conditions Strategy to be delivered – once again we find ourselves forced to wait and see.

Biography

Kate Jopling is a policy and strategy consultant, and a National Voices Associate.  She has extensive experience of working with voluntary sector organisations across the fields of health, care and ageing. Kate has worked extensively on loneliness, and has authored several influential reports including the final report of the Jo Cox Commission on Loneliness. A former Director of the International Longevity Centre and the Campaign to End Loneliness, and Head of Public Affairs for Help the Aged, Kate has a wealth of experience of influencing policy and practice.