Improving population health and reducing pressures on health and care systems
The recently published Hewitt Review seeks to provide clearer direction for the governance of the Integrated Care Systems that have managed local health and care provision across England since 2022. Public Voice summarises the key points in the Review, and how they reflect our own learning from working in health and social care, and with our local communities.
Earlier in April, the government published the Hewitt Review into oversight, governance and accountability of integrated care systems (ICSs). Many had hoped the review would offer greater clarity about the new way of working that ICSs represented for the health and social care sector – particularly in the context of increasing pressures on the NHS and growing, more complex demands for health and social care.
ICSs were established across England in 2022, to provide locally focused and joined up health and care services. They replaced the Clinical Commissioning Groups (CCGs) that had come before, and were similarly responsible for planning and funding local health and care services. As the provider of Healthwatch Haringey, Public Voice participates in North Central London’s Integrated Care Board (ICB), a component of an ICS that helps it to plan for meeting the health needs of the local population.
The Health and Care Act 2022 that triggered the move to ICSs covered the statutory structures for integration; but could not reasonably cover the diverse changes in cultures and behaviours required to make the shift a success. Acknowledging this point, the Hewitt Review looked at what has worked to date, and how to better define and deliver its role across the 42 ICSs in England.
A central point of the Review, frequently cited by others, is the urgent need to shift the focus of the sector upstream, to improve population health through empowerment and prevention, in turn reducing the pressures on established health and care systems.
The Review notes: “care and treatment provided by the NHS, vital and often lifesaving though it is, only accounts for a relatively small part of each individual’s health and wellbeing. Significantly more important are the wider determinants of health.”
This challenge is all the more acutely felt in straitened economic times, with much discussion about NHS and social care budgets – particularly as demand for health and care grows and becomes more complex. The Review cites Public Health England data showing health inequalities costing the NHS an estimated extra £4.8 billion a year, as well as around £31 billion in lost productivity, and as much as £32 billion a year in lost tax revenue and benefit payments.
ICSs were established to ensure decisions could be made locally and in an integrated way, to provide local communities with the health and care services they needed. The Hewitt Review seeks to highlight ways to do so that can address the wider determinants of health, and reduce damaging and costly inequalities in access and outcomes.
Bringing primary care and communities together
One area of good practice highlighted in the review is where participants in an ICS – such as primary care, local government, and voluntary and community organisations – work as one to focus on and address particular causes of health inequalities. This approach works especially well with seldom heard communities, who often face additional barriers to access or disproportionately poor health outcomes. The Review highlights an example in Greater Manchester, where the Healthy Hyde Primary Care Network of GP practices employs 34 people across different disciplines to tackle health inequalities. For instance, six health and wellbeing coaches work directly in foodbanks, schools and other locations to reach local residents. Team members also provide English for speakers of other languages (ESOL) lessons for asylum seekers and refugees.
Such activities ensure seldom heard groups can be proactively engaged, health and care advisors are embedded in familiar community settings, and residents can be referred to services where necessary, meaning better access. As a partner in the Haringey Advice Partnership (alongside Citizens Advice Haringey and Vibrance), Public Voice similarly attends foodbanks, community groups and local group activities across Haringey to engage a diversity of residents who may need advice and support due to their financial circumstances. Residents with a need are then referred to information, advice and guidance professionals at Citizens Advice Haringey regarding household and finance matters, or to Public Voice and Vibrance for related health and social care support – for instance, where housing or debt issues are impacting a resident’s mental health.
A key method of encouraging more creative, integrated approaches to supporting local communities is to get smarter about commissioning and funding interventions, according to the Hewitt Review: “Adding new targets and initiatives, providing small funding pots (often with complex rules and reporting requirements), or non-recurrent funding makes it impossible to plan or even recruit, wastes money and time, and weakens impact and accountability. Multi-year funding horizons, with proportionate reporting requirements, are essential.”
As ICBs develop their ways of working, and agree and actively pursue strategies to improve local health outcomes, funding can also become more focused and strategic.
A thread running throughout the Hewitt Review – a welcome one from Public Voice’s perspective – is participation and co-production. The Review recognises that the wide range of stakeholders influenced and/or impacted by the commissioning and delivery of health and care services in a location should be deeply involved in the planning and delivery of the ICB and its functions.
The Review notes: “Rather than thinking about national organisations, regions, systems, places and neighbourhoods as a hierarchy, we should view each other as real partners with complementary and interdependent roles and work accordingly.”
And this applies not only to the people and bodies we might conventionally think of as making decisions about health and social care services, such as local NHS trusts, GP federations or local councils. It emphasises the role of voluntary and community organisations, and residents themselves.
The Review adds: “local communities must be involved through a continual process of engagement, consultation and co-production in design and decision making about local services.” Doing so helps promote the ICB’s legitimacy, if it is “empowering” the community, “accountable” to them, and “transparent” in how decisions are made.
As an organisation dedicated to empowering residents and communities, giving us all a voice in decision making that improves public services, Public Voice looks forward to working with its local ICB partners, and others, to realise the vision of integrated care and co-production set out in the Hewitt Review.
 Public Health England (March 2021). ‘Inclusion and sustainable economies: leaving no one behind.’