The Hewitt Review

The Hewitt Review of Integrated Care Systems (ICS ) was published on 4 April 2023.

The objectives of the Review, commissioned by the Secretary of State for Health and Social Care in December 2022, included a requirement to make recommendations on ways ‘to empower local leaders to focus on improving population outcomes, giving them greater control while making them more accountable for performance and spending’. The output comprises some 36 recommendations on a range of key areas. 

So, what does the Review say in relation to provider collaboratives, which are core components of successful ICSs? We have identified the following themes focusing on responsibility and accountability, which also reflect insights from our ongoing work with collaboratives and integrated care boards (ICBs) across the country:

1. The ICB as convenor and supporter of provider collaboratives

• Mature ICBs are supporting their provider collaboratives to drive initiatives and giving them autonomy to define their own priorities within the ‘guardrails’ of the local integrated care strategy. In less mature systems, however, collaboratives have little support from their ICB, including in terms of management resource and capacity, to develop their operating model and deliver. 
• The Review suggests that provider collaboratives have the potential to become the ‘core NHS delivery arm for achieving key system objectives’. The need for clarity in the relationship between the ICB and each provider collaborative is emphasised. This aligns with observations from our work, with some provider collaboratives seeking ICB engagement and support as well as resource to drive forward key system initiatives but receiving little in return. With ICBs facing inevitable distractions through establishing their own operating models and, as recently announced, a requirement to make significant cost savings, this is likely to remain a challenge for collaboratives looking to establish their roles.  As NHS Providers  have also highlighted, the potential conflict of roles for ICBs as, on the one hand, overseeing provider performance, whilst on the other, convening and supporting providers to collaborate, may be difficult to resolve.
• The Review recommends that new ‘High Accountability and Responsibility Partnerships’ should be formed, i.e. allowing the most mature systems more autonomy and responsibility to go ‘further and faster’. This could alleviate the current frustrations of some collaboratives, and systems, although it remains to be seen if this recommendation is taken forward by the Government. 

2. Subsidiarity of decision-making

• Subsidiarity within each ICS is emphasised in the Review, with the role of Place-based Partnerships and provider collaboratives being central to delivery of the integrated care strategy and improving population health outcomes. In our experience, however, very few ICBs have delegated significant, if any, resource and responsibility to provider collaboratives or indeed their own staff or committees at Place. Whilst this may be due to a lack of maturity with ICBs not yet a year into their establishment, there are also cultural barriers within some ICS where trust and relationships between system partners are not well developed. In those systems the Review suggests that provider collaboratives and particularly place-based partnerships are looking ‘upwards’ to the ICB for permission and/or a role in the system, rather than ‘outwards’ to their populations. 
• The recent update to the Statutory Guidance on Delegation and Joint Working (published in March 2023) has delayed plans ICBs may have had to start delegating functions and resources to provider collaboratives, with a ‘hold’ on delegation before April 2024. This will cause frustration to the more mature collaboratives who are keen to move to the next level of operation and start to take on more responsibility and resource from ICBs. If collaboratives are to become the “core NHS delivery arm” the Review suggests then this needs to be addressed as soon as possible, with the delay in the timeframe being used to prepare systems for meaningful delegation to their collaboratives (and the provider collaborative innovators scheme  seems set to test some of these models).  In the meantime, collaboratives are starting to look at using their new powers under the Health and Care Act 2022 to jointly exercise their functions between provider organisations (and potentially pool funds) where doing so at scale makes sense. They may look to do this through a joint committee, an option which was not available under previous legislation and which may be advantageous because it allows providers to make binding joint decisions.
• Linked to the above, in our experience provider collaborative leaders recognise that Place is where the most impact can be made in terms of improving population health outcomes. The issue for many is how best to link into Place given management capacity constraints, differing Place models and levels of maturity, and how to avoid unnecessary duplication of effort. The Review does not suggest a solution here other than emphasising the need for close collaboration between providers, place and system leaders to ensure the best outcomes for residents. This cuts both ways, and the Review stresses the need for place-based leaders to feed into system conversations, plans and funding arrangements, which should include provider collaboratives.

3. Incentivising the “left-shift”

• Significant reform to the NHS financial system is another key tenet of the Review. A review of the NHS payment scheme to look at ways to incentivise prioritisation of resource on ‘upstream’ population health improvement activities is recommended, with acknowledgement that payment by results and small in-year funding pots will not achieve this. If provider collaboratives are to play a ‘core delivery’ role in systems then, notwithstanding the current pressures on waiting lists, enabling collaboratives to take on responsibility for delegated budgets to achieve outcomes through working together will be key. The existing NHS-led mental health, learning disability and autism provider collaboratives should provide valuable learning in this regard, with many having reinvested savings against their overall budgets into community-focused activities.  
• Equally it is acknowledged in the Review that the current NHS capital regime does not enable transformation and a thorough review is required to enable systems, including collaboratives, to have greater access to and responsibility for capital funding for their populations, and to create a longer term and more flexible regime. 

The Review echoes many concerns we have heard and continue to hear from collaboratives who wish to have a clear role in their respective systems with increased responsibility over resource and functions to enable them to achieve better population outcomes. Although it remains to be seen whether or not any of the Review’s recommendations will be taken forward by the Government, the most successful collaboratives will be looking to develop further by using new legislative tools where this achieves their objectives and preparing as best they can to receive delegated functions and resources from their respective ICBs.  

We are hosting a breakfast roundtable event at this year’s NHS ConfedExpo on Thursday 15 June in Manchester, where we will be reviewing how Provider Collaboratives have fared in the past year and what is in store for them in future. Joining us are executives from Provider Collaboratives across the UK, who will share their experiences. This will soon be live to sign up to, in the meantime please contact Esther Venning or Robert McGough for more details, or click here to subscribe to our mailing list and keep in touch with the latest insights and events from Hill Dickinson.