Cleaning up: can Hewitt help integrated care systems work?

Everyone has one. That pot of cleaning stuff you bought hoping it would be the answer to some unshiftable grime. Often a lurid colour, a funny whiff, and a title involving questionable punctuation. You rush it home and apply in great quantity, only to find the dirt stubbornly remains – just as it had after every previous assault.

So has the cleaning stuff failed? Or was it never going to succeed anyway?

Welcome to the world of NHS reform: a land where every major change follows a similar pattern to the cleaning adventure. A problem persists, an attractive new solution (normally structural) is found, the problem remains, the solution is thrown out in favour of a different attempt.

It’s not hard to see the issues here. A starter of misunderstanding just how knotty and difficult some of the problems of modern healthcare are. A main course of failing to give any solution the time to work. And finished with a dessert of believing that ‘the answer’ is always just around the corner.

Strike you as cynical? It’s not meant to be – rather a reflection of the revolving door we’re trapped in, and the desire surely for a better way out. Part of this is a long term job to improve policymaking in healthcare. But it’s also about how we learn from history and do a better job with our latest incarnation, integrated care systems, the subject of the Hewitt Review, by former Health Secretary Patricia Hewitt.

In arguing for a reduction in national diktat and an increase in local leadership, Hewitt is on the right track.

Hewitt’s review steps into this normal cycle of reform: ICSs are only celebrating their first birthday this week, and there’s little certainty they’ll survive beyond (or even until) the next general election a mere 20 months away. In time, it’s quite possible the review will be remembered only as a step towards the inevitable rummage at the back of the cupboard to see if there’s anything better than ICSs on offer.

But maybe it’s not. What if it could genuinely help ICSs to buck the build-abolish-rebuild NHS dance craze? Here are the three key areas to watch if so.

Short term realism

Every healthcare system in the world is struggling with how to contain costs at a time of rising expectations and ageing populations. Add the post Covid-19 effect of shattered staff and increased urgent care pressures, and the task gets even harder – as David Haslam describes in forensic detail in his book, Side Effects.

ICSs will not fix these problems. They simply can’t. Working out what is success for ICSs is a far more nuanced task but essential to inform a sensible debate. In arguing for a reduction in national diktat and an increase in local leadership, Hewitt is on the right track (even if targets tend to be as easy to remove as chewing gum in carpet).

Long term foundations

The collaborative ecosystems that ICSs seek to create take around a decade to create – much longer than the half-life of most NHS structures. As such, part of the task for ICSs is to think about what it can build which will outlive it. For example, building community among individual system leaders (such as through our work at Kaleidoscope with South East London ICS) creates a long term legacy of people wanting, and knowing how, to collaborate.

Building for long-term effect is obviously part of Hewitt’s call for more money to go into prevention. Case for doing so? Strong. Sources proposed to find the money? Absent. Coming on the same day as the government halves funding for another area crying out for cash, social care reform, you’re right to raise an eyebrow.

Focus on care

This might seem obvious, or naive, but it’s worth reiterating that the point of ICSs is in the title: integrated care. Most ICSs will have spent the last year focusing on their governance structures and strategy documents. The time has come to shift that to the nitty gritty of actually changing care for patients and populations.

Our work in supporting new diabetes pathways in Cambridgeshire and Peterborough is a great example of how collaboration across boundaries can change lives. On this, the review is a bit of a damp squib. It’s far more a report for policy geeks rather than those interested in how change actually happens. By my count, just 6% of the review’s 32,000 words relate to the change capabilities ICSs need themselves, or what they need to become high-performing collaborations. It’s a start, but still a significant opportunity missed.

Yet there’s still a glimmer of hope about Hewitt’s review. It reminds us that ICSs have the right aims, and sensibly argues they need a bit of love to get there. At the end of the day, structures are simply containers for the people they contain. Those people need support, a nudge in the right direction, and the time to focus on the job in hand. Maybe, just maybe, this time the product might work.

This blog was first published in the Health Service Journal.