The Week 16 June 2023

This week, the Government issued its?combined response?to the Hewitt Review and the Health and Social Care Select Committee inquiry into Integrated Care Systems (ICSs). At?Reform?we’ve long obsessed over ICSs. More attention should have been paid to getting the nuts and bolts right before launching organisations responsible for spending ￡120 billion of taxpayer money and for commissioning almost all healthcare services in the country. But we are where we are and both the Hewitt Review and the Committee report rightly identified some key areas for reform — you can read our response to the Hewitt Review’s recommendations in full?here.

So what does the Government make of the reports’ findings?

Both the Committee and Hewitt argued that realising ICSs’ potential in planning services?genuinely?matched to local need, means?central government (through NHS England) getting out of the way. For Hewitt, the first port of call is to reduce the number of national targets set by NHS England to “no more than ten”. This makes good sense — targets have their uses, but they?run the risk?of creating perverse incentives and are often narrowly focused on outputs rather than outcomes. Set too many of them nationally and you can stifle the localised innovation that must sit at the heart of a future system.

The government’s response? They’ve already lowered the number of targets…to 31! In fairness, that’s down from 133 in 2022, and NHS England seems to have belatedly clocked the age-old adage that if “everything is a priority, then nothing is”. But there’s still a long way to go in rebalancing the system to reflect local rather than national priorities.

Ensuring that ICSs represent their whole local health and care system, not just major NHS providers is another theme which emerges strongly in both reports. Government is reluctant to commit to the recommendations made on this — the Committee’s suggestion that all Integrated Care Boards (the part of the ICS which holds the purse strings) should include a public health representative is discounted, as is its recommendation to publish easily accessible information on the composition of these boards. And though the government is right to be suspicious of nationally set ‘mandates’ for the shape of ICSs — these are meant to be?locally?driven organisations after all — there remains a major risk that acute hospitals will remain the shot-callers in our health system.

The final topic that?both reports emphasise is prevention. Improving health outcomes for whole populations (rather than just healthcare services) is a core duty of ICSs and that means getting serious about tackling the drivers of poor health. The Hewitt Review recommended a novel approach — ICSs should be mandated to shift 1% of their resources into prevention over the next five years. The Government’s response here is direct: “We do not agree with imposing a national expectation of an essentially arbitrary shift in spending.”

At?Reform, we’re big fans of making a preventative shift, but Government rejecting this proposal is not unjustified. For one, defining ‘prevention’ spend is notoriously difficult — clever accounting may allow systems to meet the target but miss the point. More importantly, driving the prevention revolution is better served by directly resourcing public health rather than tinkering with NHS budgets. As we’ve?long pointed out, while NHS funding has risen significantly in recent years, the public health grant — which funds services such as a drug and alcohol treatment, sexual health clinics and health visitors — has faced year-on-year real terms cuts. The NHS can and should improve its prevention offer, but when it comes to prioritising resources, looking elsewhere to boost health is a better bet.