The Hewitt Review – The HOW enables the effective execution of the WHAT

In reading the NHS Confederations summary of the Hewitt review, I was struck by one sentence in particular: "While the Health and Care Act 2022 created the necessary statutory structures for integration and collaborations, legislation alone cannot create the changes in culture, behaviours and attitudes needed for effective and lasting change." This resonated with me because I used a similar description in early 2020 to partly describe the reasons for the ongoing challenges faced by the UK's second healthcare provider. As one of the eight Integrated Care Boards in Wales formed in 2013, as an organisation, it has a lot to be proud of. Unfortunately, the policy and legislative focus at inception, with limited attention given to how the organisation should work (the structure, behaviours, and enacting processes), continues to impact its ability to deliver its quality, performance & productivity goals consistently. My time with these fantastic people ended recently, and whilst they still have significant challenges, they now have an evidence-based organisation and system development route map. A coherent plan of the HOW.

It's that emerging emphasis on the HOW within the Hewitt report, which I hope won't get neglected if the politicians and regulators default only to the WHAT. As I have repeated many times in the last few years; it is the HOW of the organisation or system of care which enables the effective execution of the WHAT; health prevention & care, and the delivery of the triple aim goals of improved Quality, Performance and Productivity. 

Six Principles

The recommendations in the review are grouped into six fundamental principles, all of which relate to the HOW:

·          Collaboration.

·          a limited number of shared priorities,

·          giving local leaders space and time to lead;

·          providing systems with the right support;

·          balancing freedom with Accountability

·          enabling timely, relevant, high-quality and transparent data.

A paragraph in the NHS Confed summation of the report which best encapsulates these principles and attempts to summarise the current challenges faced by the ICB/ICS/ICP is as follows:

"The review argues that ICBs and ICPs should create the environment to support 'mutual' or 'collective' Accountability, where system partners can, with mutual respect and transparency, support and challenge each other to deliver priorities they have agreed together, irrespective of where their statutory Accountability sits. Increased availability of timely, transparent and high-quality data is vital to enabling local autonomy and supporting the move away from top-down performance management and towards self-improving systems."

However, such a long report lacked detail in terms of scope and understanding of the interdependent determinants which would facilitate the delivery of these system needs. For example a self-improvement system requires a portfolio of structural, process and behaviour products/components/interventions. As a change practitioner, I was also struck as I think other commentators were on the limited reference to change capability. Richard Taunt from Kaleidoscope Health & Care stated in his article in the HSJ on the 5th of April; "By my count, just 6 per cent of the review's 32,000 words relate to the change capabilities ICSs need themselves, or what they need to become high-performing collaborations. It's a start, but still, a significant opportunity missed."

It is that change capability which will not only help to change the WHAT but, in more rapid timescales, identify the opportunity cost savings and develop new models of care to close the workforce gap. As well as facilitating the delivery of both.

Future Funding Model

The review does challenge the current reduction in system costs, and it's a challenge I support in part. It's probably fair to assume that the target set by NHS England relates to the end of the CCGs and the amalgamation of commissioning functionality at an ICS level. What NHS England has failed to realise is the capability beyond a commissioning function needed at that level to deliver the WHAT. A proportion of that capability may already exist amongst the organisations which constitute the system. It should also be noted that transitioning from being a Commissioner to being a Change Practitioner or Informatics Analyst for example requires significant investment in time and capability building. 

A few commentators have suggested that the ICB/ICS/ICP's need to get on deliver, having spent the last few years focusing on governance and strategy. It is evident from this review and my own experience that those strategy documents have on the whole been about the WHAT (clinical and care models) not necessarily about how they will be delivered or the HOW of a self-improving system.

A strategy for the HOW

In 2019 I published a document on LinkedIn entitled Achieving Your System Goals - An assurance guide for Integrated Care Systems and Integrated Care Boards Chairs, Chief Executives & Leaders. The focus of the thought paper was very much on the HOW and the products required by an evolving ICB/ICS, with a particular emphasis on the ability to deliver change and performance management. Considering the Hewitt review, I reviewed the publication (including the embedded assurance guide); the themes are very similar, albeit I do describe in more detail the architecture and interdependent products/components/interventions which the system needs. 

I have since made a few minor additions, including some of the learning from my work over the last couple of years. The updated publication is on my LinkedIn page.

Routemap to maturity

The Hewitt report suggests that NHS England and ICB/ICS/ICP Leaders co-design a clear pathway towards ICB maturity and that the CQC should develop an assessment of the level of maturity and effectiveness of each ICB/ICS. If such an assessment is in development, I hope the sufficient focus is given to the HOW and not just the WHAT. As a starter from ten, I am more than happy if they wish to use the assessment I wrote.  

Direction of travel

Whilst there has been a muted response to the Hewitt review, it's probably fair to assume that the recommendations will influence the approach of the next evolution of the ICB/ICS/ICP model of system performance management and assurance framework(s). Therefore, if you are a Chair, Chief Executive, or System Leaders of an ICB/ICS/ICP, is now the time to start developing your evidence-based organisation and system development route map? A coherent plan of the HOW.

Michael Shaw

Independent Thinker - interested & experienced in supporting systems leaders to transform large-scale systems of care.

Want to know more: let's say hello or grab a coffee (real or virtual) for an initial discussion or email me at [email protected] to start a conversation. +44 (0)7739 687907