A focus on behaviour change underpins the Hewitt Review
Look beyond the Hewitt Review’s governance and policy jargon and you find an appeal to health and social care leaders to build better relationships with each other says John Copps.
‘We all need to change’.
That was Patricia Hewitt’s pithy summary of what’s needed for Integrated Care Systems to work in an interview with NHS Collab in January.
At the end of 2022, the former cabinet minister and current Chair of NHS Norfolk and Waveney Integrated Care Board, was asked by the health secretary to lead a review of the governance and accountability of integrated care systems (ICSs). Today that review was published.
During the review process, Hewitt never shied away from speaking publicly so there are no major surprises.
Most of the initial attention has focused on her recommendations to reduce the number of national targets the NHS has, and giving ICSs the 'time and space to lead'. A key thrust of the report is to move towards ICSs having more autonomy. Hewitt suggested a 'focused number of locally co-developed priorities or targets' and wants ICSs to be more involved in the development of national policy.
There's also recommendations how how ICSs should change from 'focusing on illness to promoting health', echoing the goals of the NHS Long Term Plan. Hewitt tells a revealing story from her time as Health Secretary saying that the biggest contribution she made to the health of the nation was the smoke-free legislation - a reminder to all readers that health isn't just about the NHS. The calls for the establishment of a cross-sector working group of local government, NHS and central government to agree a straighforward framework for what is meant by ‘prevention’.
Added to this, there's a lot more to digest in the report on financial mechanisms, governance and the role of regulators.
But step back from the detail and you find what I think is a very simple message that underpins all the review’s recommendations: leaders in the NHS need to change their mindset and behaviour to become more open to collaboration.
Hewitt recognises that the 42 ICSs established by The Health and Care Act represent a historic change in the NHS – from a system dominated by competition over the last three decades to one where collaboration is expected as the norm.
Making such a shift was never going to happen overnight. NHS England has long talked about ‘system by default’ to describe integrated care, but you can’t just wish that so – it has to be a process of cultural and behaviour change.
Hewitt’s review reveals that the mindset and behaviour change needs to be at several levels – between NHS leaders within systems, in how NHS leader interact with other players in their systems (notably local government), and in the way NHS England treats ICSs.
The review recognises that getting there will be a journey. It restates the position of NHS England that systems need to be treated differently given how ICSs are at very different stages of maturity in terms of their relationships, activity and finances. As Chris Ham has said about the current inconsistent state of integrated care ‘once you’ve seen one ICS, then you’ve seen one ICS’.
Boiled down, the review cannot avoid the fact that relationships lie at the heart of the success of Integrated Care.
Underpinning every conversation around money, beds, data sharing and workforce, it is down to whether colleagues in different parts of the system can work together. More than anything else, trust that is the asset that is most in demand within ICSs, between health and social care partners, and between local and national leaders.
For me, the real test of the Hewitt Review will be whether its recommendations and the response from government provides a better environment for this trust to grow.