An independent review into integrated care systems (ICSs) today published its final report.
ICSs were launched last year and bring together the NHS, local government, social care providers, charities, and other partners to deliver on four goals:
- Improving outcomes in population health and healthcare
- Tackling inequalities in outcomes, experience, and access
- Enhancing productivity and value for money
- Helping the NHS support broader social and economic development
Health and Social Care Secretary, Steve Barclay, commissioned the Rt Hon Patricia Hewitt to lead the independent review in November 2022, asking her to consider how the oversight and governance of these systems can best enable them to succeed.
And, drawing on the insights of leaders from across the NHS, local government, social care providers, the charitable and the voluntary and social enterprise sector, it looked at how best to empower local leaders to focus on improving outcomes for their populations.
Integrated care systems represent the best opportunity in a generation for the urgently-needed transformation that we need in our health and care system and everyone wants them to succeed
Organisations representing patients, as well as experts in academia and think tanks, also fed into a call for evidence that received more than 400 responses.
And the work has led to recommendations across four key focus areas, including embracing technology, outlining the potential of virtual wards, fall prevention technology, support for out-of-hours clinical teams to respond to care homes and prevent admission, and wearables that empower people to monitor their own health.
Recommendations include a shift from reactive to preventative care and a new funding model to promote partnership working
The recommendations are:
- A shift from focusing on illness to promoting health
- The share of total NHS budgets at ICS level should increase by at least 1% every five years.
- The public health grant to local authorities needs to be increased
- To enable successful local integration, parallel integration across Whitehall is needed and the Government should oversee a national mission for health improvement, led personally by the Prime Minister, and establish a new Health, Wellbeing and Care Assembly
- Improving data interoperability should be a priority and the public need to be encouraged to make greater use of the NHS App to manage their own health
- Delivering on the promise of systems
- The number of overall targets should be reduced, with a maximum of 10 national priorities
- NHS England should work with ICSs to deliver more autonomy
- The most-effective ICSs should be encouraged to go further, working with NHS England to develop a new model with more autonomy
- NHS England and the Department for Health and Social Care should incentivise the flow and quality of data between providers and systems
- Unlocking the potential of primary and social care and building a sustainable, skilled workforce
- There is a need for a national plan for the social care workforce and flexibility between health and care staff should be created
- A new framework is needed for General Practice primary care contracts, as national contracts present a barrier to local leaders working in innovative ways
- There is a need to recruit and train specialists in data science, risk management, etc
- Resetting our approach to finance to embed change
- NHS funding is too weighted towards treatment rather than prevention of illness
- Complex, unco-ordinated funding systems mean that potential partners struggle to work with ICSs
- There is a need for a review into the NHS capital regime to address the lack of flexibility
- We should identify the most-effective payment models, nationally and internationally, implementing a new model with population-based budgets
Hewitt said: “It was an enormous privilege to undertake this review, published today.
“Integrated care systems represent the best opportunity in a generation for the urgently-needed transformation that we need in our health and care system and everyone wants them to succeed.
“To fulfil their potential, however, we need not only to back our new structures, but also to change our culture.
“Everyone needs to change, and everyone needs to play their part.
“My recommendations are intended to help the health and care system make those changes and I hope that ministers, NHS England, and others will feel able to take them forward.”
A Department of Health and Social Care spokesperson added: “Integrated care systems are an important part of the Government’s plan to deliver more-joined-up and effective health and care services and to cut waiting times for patients, one of the Prime Minister’s key priorities for 2023.
“Ministers will review recommendations of this report in due course.”
And, welcoming the report, Amanda Pritchard, NHS chief executive, said: “Integrated care systems have the power to change the way the NHS provides care for people while working alongside local government to ensure people live healthier lives.
“We know health systems across the country are already taking significant action to do this and we are grateful to Patricia Hewitt for this important report and will look in detail at the recommendations as we continue to support local areas to improve outcomes for patients.”
In particular, the report highlights the role technology will play in helping to share information and monitor inequalities.
Technology will have a key role to play in driving efficiencies, according to the report
The role of technology
The review pays significant attention to digital, data, and technology, stating that ‘Digital tools and Apps can play a vital role in enabling ICSs to improve population health outcomes’.
And it recommends a longer-term ambition of establishing Citizen Health Accounts, requiring all health and care providers to publish relevant data they hold on an individual into an account outside the health and care IT systems, owned and operated by citizens themselves.
This would enable people to proactively manage their own health and care, link to the NHS App, and provide a gateway into clinical trials.
It states that data and digital tools should be used to prevent ill health, and ICSs should be enabled to:
- Connect data from multiple sources to improve care outcomes and population health, tackle health inequalities, and improve the wellbeing of staff
- Work with NHSE and DHSC to develop a minimum data-sharing standards framework to be adopted by all ICSs to improve interoperability
- Put forward digital and data leaders to join the Data Alliance and Partnership Board
The review also states that the public must be empowered to manage their health via digital tools, meaning such tools must be inclusive and not exacerbate inequalities.
For example, a high street pharmacy could work with ICSs to help someone into a digital consultation booth.
Reacting to the focus on technology, heathtech leaders have welcomed the report, but claim more action is needed to realise the ambitions.
Here, we quiz some of the leading healthtech bosses to get their views on the next steps…
Tom Whicher, chief executive of DrDoctor
“The much-awaited ICS review recommends a significant reduction in national targets. This seems to be a recurring trend in recent times, with the digital PIFU adoption target being dropped earlier this year.
“But, while this can come with risks, such a pragmatic approach can unlock progress.
“Pandemic-borne technology adoption testifies this.
“However, there are still major challenges facing frontline workers. The backlog of more than seven million appointments is one of the most daunting.
While the review suggests that digital technology can aid this effort, the report doesn’t highlight enough innovative and practical ways that ICSs can advance this agenda
“The proposed longer-term funding streams and greater autonomy for ICBs should empower commissioners and providers to make collaborative decisions based on regional needs, using local budgets, but it is imperative that patients also benefit from this.
“And this will require national bodies to also continue pressing forward to make nationwide progress, alongside ICBs with their local focus.
“We must ensure a seamless experience for patients across the entire system.
“While the review suggests that digital technology can aid this effort, the report doesn’t highlight enough innovative and practical ways that ICSs can advance this agenda.
“We need to focus on the systems that will make the most-significant impact on patients and make sure ICSs are a place that nurture innovation, not stifle it.”
Alan Payne, development director at The Access Group
“As raised in the Hewitt Review, the mounting pressure placed upon NHS and social care services, compounded by the growing number of people living with complex, long-term conditions, and the deteriorating health of our population, has demonstrated the need for a new approach in how we deliver health and care.
“But, while the concept of integrated care has always promised to help providers meet modern health challenges, previous attempts at integration serve only to highlight the difficulty of achieving real and lasting change.
“As such, it is important that we take Patricia Hewitt’s recommendations seriously.
“A key point raised in the review is the need to utilise technology better to reduce administrative burdens on health and care professionals, including the digitisation of health and care records.
“While the focus on shared digital records isn’t new, it is crucial, as it will increase the efficiency and productivity for the workforce.
“It will also serve as a key enabler for virtual wards, which will fail to meet the national ambition to have 40-50 virtual wards per 100,000 population without a scalable ‘single version of the truth’ to facilitate integration with other services.
While the concept of integrated care has always promised to help providers meet modern health challenges, previous attempts at integration serve only to highlight the difficulty of achieving real and lasting change
“Further to this, the review rightly references the need to ‘unlock’ the potential of social care and its workforce, recommending that the Government produces a complementary strategy for the social care workforce as soon as possible.
“We hope this strategy aligns with NHS England’s long-awaited workforce plan, with a strong focus on preventative care.
“Persistent workforce shortages in social care jeopardise patient safety and with the low pay rates and the cost-of-living crisis causing an increasing number of people to leave the sector, care workers are simply unable to keep up with work demands and the ever-growing backlog of people in need of support.
“As such, we wholeheartedly support the urgent need for a clear, strategic direction and the introduction of a more-integrated health and social care workforce.”
Rachael Fox, executive vice president for UK and EMEA, at Altera Digital Health
“Above all else, this review emphasises the importance of collaboration.
Collaboration between people, to enable high-quality leadership and autonomy of integrated care systems; between suppliers to develop solutions that benefit citizens and between care systems, to enable much-needed interoperability.
“As the review states, ICSs hold great promise. Though, to make what they promise – joined-up health and care – a reality, interoperability must be a top priority.
It is vitally important that patient information can be accessed and mobilised from anywhere within an ICS so people can access the same standard of care, wherever they are
“Progress is already being made, with the development of shared care records being a great example.
“Such developments will enable us to properly prioritise population health, and eventually shift the focus upstream to preventative care.
“However, this must start with accessible records in open, interoperable clinical systems.
“There is no place for inflexible legacy systems in an integrated model of care.
“We are just a few months shy of celebrating the NHS’s 75th birthday, but we need to start looking at it in a very-different way to we did back then.
“Care is increasingly being delivered in a broader range of settings, outside of hospital. And, as such, it is vitally important that patient information can be accessed and mobilised from anywhere within an ICS so people can access the same standard of care, wherever they are.”
Matt Cox, managing director for the UK and Ireland at Better
“The ambitions for ICSs are absolutely the right ones. However, as is laid out in the Hewitt Report, there needs to be clarity on their accountability if these ambitions are to be achieved, especially when it comes to digital transformation.
“Local priorities vary vastly from region to region, but we've seen what can be achieved when true collaboration across all care settings is nurtured and ICSs are given the freedom to drive their own digital transformation, as demonstrated by the OneLondon team.
“I welcome the reiteration of the recommendation that NHS England, DHSC, and ICSs work together to develop a minimum data sharing standards framework in order to improve interoperability and data sharing across organisational barriers.
“However, I would also add the supplier community to the list of stakeholders that must be involved in this conversation.
I welcome the reiteration of the recommendation that NHS England, DHSC, and ICSs work together to develop a minimum data sharing standards framework in order to improve interoperability and data sharing across organisational barriers
“I am also pleased to see further support for empowering people to have input into their own care, by contributing to their own citizen health records.
"Providing truly-personalised care is something that is often spoken about, but not always delivered. Providing the ability for people to make a contribution to their care brings together various settings, making it possible for genuine holistic, preventative care to be provided.”
Craig Oates, managing director of Doctrin UK
“We welcome the publication of the Hewitt Review, which reflects the fact that integrated care is the only way to deliver affordable and efficient care that meets modern health needs and demand for care.
“However, with such a broad scope, the review may fail to deliver the deliver the required tactical and detailed changes with the pace and focus that is needed.
“It is also important to remember that while digital tools are a key enabler for the needed transformation in the NHS, they must support access, triage, and care navigation to effectively improve patient care.
“That being said, it was pleasing to see reference to the current GP framework in the review, which builds upon the recommendations set out in the Fuller Report by highlighting the fact that the framework isn’t consistently delivering the multi- disciplinary-led improvements we need to see across the primary care sector.
With such a broad scope, the review may fail to deliver the deliver the required tactical and detailed changes with the pace and focus that is needed
A new framework is needed to reflect the diversity of the primary care workforce and incentivise transformation.
“Further to this, we wholeheartedly agree with the review’s emphasis on collaboration and joined-up working across primary care settings.
“Collaboration is key to transformation and we need to encourage primary care staff to see the benefits digital, making them more willing to adopt these systems.
“Even so, it is worth noting that constant change can inhibit innovation.
“We need to follow through with the implementation of digital and keep the momentum going – small quick steps, rather than large leaps.
“It is also critical that we address the link between urgent care and other care settings.
“Urgent care cannot be an alternative to primary care or overburdened emergency departments. It is not a replacement for failure in other care settings and should be acknowledged in its own right.”
Kenny Bloxham, healthcare director at Healthcare Communications
“It is encouraging to see patient empowerment at the heart of the recommendations made in the Hewitt Report.
“Similarly, the focus on democratising and personalising data and digital tools used to support patients and their long-term health and wellbeing is a positive step.
“However, while technology plays an important role, transformative change is only possible if every person is empowered to be an active participant in their care and given the right tools to engage with all care providers through their channel of choice.
While technology plays an important role, transformative change is only possible if every person is empowered to be an active participant in their care and given the right tools to engage with all care providers through their channel of choice
“All patients will soon have the option to manage their care digitally thanks to the recently-proposed national requirement for all patient-facing portals to integrate with the NHS App.
“Patient portals are essential for effective communication and support the shift upstream towards a preventative health and care system.
“It’s crucial that healthcare providers are empowering the public through patient-facing tools that integrate with the NHS App, which will be central to the future development of citizen health accounts.”
Dr Rachael Grimaldi, chief executive at CardMedic
"I am personally so pleased to see that reducing health inequalities remains central in the recommendations made by the Hewitt Report, and not a ‘nice to have’. This will be pivotal if the unacceptable 19-year gap in healthy life expectancy between people in the most- and least-deprived areas of the country is going to be reduced, while shifting focus to prevention and outcomes-focused targets.
“As highlighted in the report, while the longer-term ambitions of ICSs must be balanced with shorter-term operational priorities, the two are not mutually exclusive.
“It is important, therefore, that ICSs are given the freedom to make decisions that are best for their populations, and regional leaders are empowered to make it happen so we can tackle the causes, not the symptoms, of an over-burdened health system.
While the longer-term ambitions of ICSs must be balanced with shorter-term operational priorities, the two are not mutually exclusive
“Technology has an important role to play in helping all care services become more efficient, patient centred and personalised. And intrinsic to this will be reducing communication barriers for patients; something regions such as Suffolk and North East Essex have built into their ICS-wide health inequalities strategy.
“But, this will only be achieved if the teams working tirelessly to keep core services on an even keel are given the support and freedom to be able to drive forward innovation.”
Careology's award-winning cancer care platform is an example of how healthtech will underpin the success of ICSs
Paul Landau, chief executive of Careology
“Patricia Hewitt rightly outlines the need for prevention, but if we are to truly transform the way we manage major health conditions, such as cancer, we need long-term thinking and a coherent approach to this.
“The 1% funding Hewitt has suggested will not be enough for preventing conditions such as cancer. This is why we need a clear strategy, such as the 10-year cancer plan, which was frustratingly scrapped earlier this year.
“It is encouraging to see Hewitt acknowledge the opportunity digital technologies and real-time data can bring in reducing administrative burdens on healthcare professionals.
“We have already seen how access to this data in cancer care is significantly changing how clinicians monitor patient progress during treatment, providing more-effective delivery of care and improving people’s long-term survival rates.
It is encouraging to see Hewitt acknowledge the opportunity digital technologies and real-time data can bring in reducing administrative burdens on healthcare professionals
“Technology can provide more-accessible, consistent, and person-centred care which will ultimately help with population health approaches.
“We must modernise existing cancer pathways to improve the millions of lives of people living with cancer by helping them to better navigate their treatment and be more in control of it.
“This will free up thousands of hours of clinical time and reduce the number of appointments needed.”
Paul McGinness, chief executive of Lenus Health
“Digital transformation must play a critical role in the ultimate success of integrated care systems as they look to jointly deliver for local communities and boost access to care.
“With unprecedented demands on limited health and care services, there is a balance to be struck between longer-term goals and short-term operational pressures, but by investing in predictive technologies that strategically target major conditions like COPD, it is possible to prioritise resources more effectively while reorientating from reactive to proactive and preventive care.
“We are committed to working in partnership with ICSs to drive transformative change and build a healthier, more-equitable future for all.”
By investing in predictive technologies that strategically target major conditions like COPD, it is possible to prioritise resources more effectively while reorientating from reactive to proactive and preventive care
Mark England, chief executive of HN
“The Hewitt Review represents a crucial step in resetting responsibilities between the new ICSs and the centre.
“At such scale, and with such complexity, this will always be imperfect. “The review recognises the need to shift towards preventative services, which is heartening to see and sets a clear target to move to allocate 1% of NHS budgets to this over the next five years.
“This will be challenging, but we question whether this is ambitious enough.
“At HN we have long been calling for technology-enabled models for proactive and preventative care, particularly for high-need patients with long-term conditions.
“We need to move away from a purely-reactive model and instead use data to highlight people with rising health risks.
Artificial Intelligence must play a part with its ability to predict which patients could benefit from more-proactive support
“The Hewitt Review clearly sees the value and opportunity digital technology can have.
“Artificial Intelligence must play a part in this with its ability to predict which patients could benefit from more-proactive support. We must also leverage data and use this predictive model alongside a substantial prevention model to make a substantial change for healthcare.
“Although Hewitt's suggestion of Citizen Health Accounts will go some way to help people manage their own health and care, real impact could be through clinical coaching which provides truly-personalised support centred around the patient to support his change.
“However, to build the future of the NHS, we must make sure all of this is reinforced by a fully-funded and functional workforce development plan.”
Kieran Hughes, president of Europe and the Middle East at Nordic Consulting
“The workforce will make or break the impact of this review – notably ensuring staff have the right skills and capabilities to deliver, especially when it comes to digital transformation at system level.
“However, as the review rightly recognises, there is a shortage of skilled professionals, particularly those with experience of the culture change needed to deliver and optimise these transformation projects.
In order to grow regional digital capability that is sustainable and closes the skills gaps, in lieu of the workforce plan, we would urge the NHS to engage with industry partners to ensure we have a shared service which delivers effectively
“While the suggested plan to develop a skilled in-house team is applauded, it is not always possible, especially given the day-to-day demands on existing staff and ongoing challenges in recruitment.
“In order to grow regional digital capability that is sustainable and closes the skills gaps, in lieu of the workforce plan, we would urge the NHS to engage with industry partners to ensure we have a shared service which delivers effectively.
“It is vital to recognise the limitations within and to utilise partnerships with organisations that can provide this ready-made expertise, even if it is in the short term, while healthcare professionals are upskilled and/or recruited.”