Opinions are split on the Hewitt review of integrated care systems. Some people feel it strays outside its remit and others say it doesn’t go far enough.
I have a foot in both camps. It veers off-road at times, and ventures into areas where others fear to tread. Yet some of the recommendations appear to be constrained within firm boundaries. I suspect that some of these are long-term residents of the ‘too difficult’ box. But also, as I lower my head close to the pages, I’m sure I detect a whiff of pragmatism…so perhaps there has been at least one eye on what might realistically be achieved.
Regardless of the route it takes, there is a lot to welcome. Some of it may be viewed as stating the obvious – but that can often be helpful. And as it wanders down some of those less travelled routes, it does attempt to clear some undergrowth along the way.
Much of the content is familiar, reflecting many of the themes identified in CIPFA’s own Integrating Care report. There are a few areas that I was particularly glad to see – one stating the obvious, one in the ‘too difficult’ box and one road less travelled.
On the blatantly obvious, the recommendation for a ‘bonfire’ of targets, to be replaced with a few national priorities, stands out. Too many targets often mean that none of them will be achieved. A focus on a few carefully selected national outcomes is likely to be much more effective in the long-term. However, these have to be realistic and backed with the appropriate commitment, evidence and resources. Embracing the principle of subsidiarity (also espoused by Hewitt) these outcomes must be able to be translated down to local level. The emphasis should be on local priorities reflecting national outcomes, not national prescription driving local activity.
Turning to the difficult, there is welcome recognition of the need to view health as an asset, with an emphasis on upstream prevention. Few would argue against this, but in the face of acute pressures, it is often seen as the easy tap to turn off. Securing a twin-track approach to deal with immediate pressures and make such essential long-term investments has been a resident of the ‘too difficult’ box for many years. So, the recommendation to increase spending on prevention from NHS budgets is welcome, but too narrow.
The review recognises that the social determinants of health have greater impact on population health than healthcare itself, yet the recommendations stop at the boundaries of the NHS. Perhaps this is evidence of that pragmatism? The review also highlights one of the major stumbling blocks to prevention, namely the ability to identify how much we currently spend. As we know from prior experience this is a tough nut to crack, but an essential one in making the case for greater investment.
The review bravely heads down a road less travelled too, and faces the issues of funding and finance. Again, much of this is familiar. Calls for fewer funding pots and expansion of arrangements for pooled budgets echo our findings. The largest hedge blocking this path is the vastly different systems at play in the NHS and local government and the complexities this brings. The review tries to address parts of this by calling for greater alignment between budget and grant allocations for councils and the NHS. When looked at from a particular angle, could this be a first nudge towards the idea of place-based funding? It also addresses financial accountability, calling for the government and NHS to work with CIPFA and others on a consistent method of financial reporting. That sounds simple enough, but given the different statutory responsibilities involved, it’s likely to be challenging. However, that’s a challenge we welcome and are keen to explore.
While there may be differing opinions on the review, it does provide the beginnings of a plan for what integrated care systems could achieve, given the right tools. What remains unknown is how much notice the Government will take. The fact the report was published in the shadow of the plan to roll back on funding for social care reforms perhaps does not bode well. However, I remain optimistic that the benefits of finally grasping some of the nettles along the paths to integrated care will be seen and embraced.
Eleanor Roy is health and social care policy manager at the Chartered Institute of Public Finance and Accountancy (CIPFA)
@CIPFA
