The Hewitt review: where are we one year on?

Key points

• It is now just over a year since the previous government’s formal response to Patricia Hewitt’s review of integrated care systems’ (ICS) autonomy and accountability. The proposals set out in the review are still overwhelmingly supported by ICS leaders and national partners as the right direction of travel to improve the population’s health, reduce health inequalities, improve patient care and get best value for money. Using integration, devolution, digitisation and shifting resources to prevent worsening ill health are essential to using resources more effectively and ensuring the long-term sustainability of the NHS.
• Only two years into statutory governance arrangements, it is still early days for ICSs. Changing the law does not immediately lead to the changes in services, behaviour and the ways of working that systems want to achieve. ICSs need time and structural stability to continue delivering reform.
• Some progress has been made towards aligning with the review’s principles and approach and in some cases implementing the review’s recommendations. For example, there has been some progress towards embedding accountability arrangements in system oversight, towards establishing a national ICP forum to support cross-government working and providing a baseline to shift resources towards preventative services.
• However, implementation needs to go further and faster. Short-term pressures and a short-termist political climate have impeded ICSs’ agency to drive change. Therefore, progress has been slow in implementing many important recommendations, such as streamlining and automating data collation; reducing the burden of top-down micro-management and reporting to enable a focus on longer-term improvement in health outcomes; and improving value for money by reducing use of small in-year funding pots.
• While the commitments made on the recommendations were under the previous government, following the UK general election ICS leaders believe the Hewitt review is still the right blueprint for the new Labour government to create the conditions ICSs need to reform public services and provide the best care for patients. 

Background

The Health and Care Act 2022 introduced statutory structures for integrated care systems (ICSs) – including integrated care boards (ICBs) and integrated care partnerships (ICPs) – to improve health outcomes and productivity, reduce inequalities and drive local social and economic development through increased collaboration between the health and care sector. 

While the 2022 Act created the necessary statutory structures for integration and collaboration, legislation alone cannot create the shift in culture, behaviours and attitudes needed for effective and lasting change. The Department of Health and Social Care (DHSC) and NHS England (NHSE) – working closely with partners including the NHS Confederation, the Local Government Association (LGA) and others – have developed guidance and policy to help deliver these changes. Notable examples include: 

• the previous Conservative government’s integration white paper 
• NHS England’s ICS Design Framework
• NHS England’s operating framework 
• DHSC’s guidance on the preparation of integrated care strategies
• NHS England’s guidance on working with people and communities and place-based partnerships. 

In March 2023, the Health and Social Care Select Committee published findings from its inquiry into ICSs. This was shortly followed by Rt Hon Patricia Hewitt’s review of the oversight, governance and accountability of integrated care systems in April 2023, commissioned by DHSC. To inform the review, the NHS Confederation worked closely with Patricia Hewitt and the DHSC secretariat to facilitate wide-ranging engagement with leaders from the NHS; local government; voluntary, community, faith and social enterprise (VCFSE) sector; patient groups, social care providers and others. The review made 36 recommendations to government, national bodies and system leaders proposing greater autonomy to enable ICSs to better prevent ill health and improve NHS productivity and care, matched by renewed accountability. These recommendations are broadly supported by ICS leaders.

Following publication of the review, the ICS Network convened a steering group to support delivery of its recommendations. This includes senior leaders from the NHS, local government, DHSC, NHSE, the Ministry of Housing, Communities and Local Government (MHCLG), the Care Quality Commission and the LGA. The NHS Confederation has worked with this steering group and colleagues from DHSC, NHS England and CQC to take stock of progress one year after publication of the government’s response to the review. This analysis was done prior to the commencement of the 2024 UK general election, with this long read written during the campaign period and finalised shortly after the new Labour government came into office. 

Below, we set out progress against key themes in the review. The commitment and progress made on the recommendations were under the previous Conservative government and may not necessarily reflect the position of the new Labour government. The views expressed here are those of the NHS Confederation, not of government nor necessarily any of the stakeholders with whom we have collaborated.

From treatment to prevention

Shifting resources towards earlier interventions to prevent worsening ill health and improve allocative efficiency is at the heart of ICSs’ mission. Recommendation 1 of the Hewitt review proposed shifting a greater share of ICSs’ collective spending towards prevention and the creation of a definition of preventative services to help provide a baseline and help ICSs to assess progress. 

This recommendation is a top priority for ICS leaders and has received much attention over the past year from think tanks, the Health and Social Care Select Committee and DHSC, as well as appearing in the three main political parties’ manifestos. Yet it is among the most difficult to implement. In fact, analysis by the Nuffield Trust shows the proportion of NHS spending going into acute care has actually increased between 2016 and 2023 – the opposite direction of travel. 

A practical definition can and should be delivered much faster, informed by local definitions which have already been developed

DHSC and NHS England have been collaborating to develop a practical definition to define, measure and code spending on prevention across ICSs (both by the NHS and local government) and generate comparative data to inform service design. They are doing so in parallel with recommendation 30 (developing a consistent method of financial reporting). Development of an initial definition and applying this for benchmarking is currently expected to take several years. Simultaneously, the Chartered Institute of Public Finance and Accountancy (CIPFA) and the Health Foundation are attempting to define and categorise prevention spend within local government over two years. 

These steps are welcome, but the timescales risk slowing the pace of reform. A practical definition can and should be delivered much faster, informed by local definitions which have already been developed. This will be critical to supporting a shift in investment towards preventative services.

From centralisation to devolution and local accountability

Greater local autonomy is seen as key to enabling a faster pace of innovation, change and improvement of services, with accountability focusing on outcomes systems aim to achieve rather than their outputs and activity. Recommendations 11 and 22 therefore proposed that each ICS be enabled to set local priorities and targets with equal weight to national targets and that ministers reduce the number of targets and priorities in the NHS Mandate to no more than ten. 

NHS England published Planning Guidance for 2024/25 in March 2024, with the number of national objectives remaining the same as the previous year. The new NHS Mandate published in 2023 is also shorter than previous versions, with fewer targets than previous versions and four national priorities. DHSC has also published the Shared Outcomes Toolkit, as recommendation 2 called for, in October 2023 to support the development of shared outcomes at place level. These steps are welcome, but many ICS leaders feel much further progress is needed.

Top-down performance management has increased and is stifling the innovation and change needed to improve care and access to service

While there have been attempts to reduce the number of central programmes, guidance and reporting requirements, top-down performance management has increased and is stifling the innovation and change needed to improve care and access to services. Publishing the 2024/25 national planning guidance just one working day before the start of the new fiscal year does not help systems to plan for the year ahead. This delay has led to a cycle of resubmitting, reviewing and editing plans during the year, which has drawn away time and capacity from delivering essential change. 

There is variation in the way NHS England’s regional team works with local leaders. ICB leaders have shared examples of being by-passed by NHS England regional and national teams in the management of acute services. This underestimates the role of the rest of the system in reducing demand on services and improving discharge of patients. NHS England performance meetings focus almost solely on short-term issues at the exclusion of longer-term reform – both are crucial to NHS recovery and sustainability. This is also reflected in the draft oversight framework delivery metrics, which lean more heavily towards acute services than, for example, community and mental health services. 

NHS England intends to work with national representative bodies and other stakeholders to refine, test and embed its approach to fully implement its new operating model (as per recommendation 19). It has already sought to co-design policy and strategy with system leaders and national partners throughout 2023/24, including to develop the NHS Vaccination Strategy. Further organisational development should seek to evolve and develop a common approach to co-production. 

Several recommendations were also made on ICB maturity (notably recommendations 15 and 16). To accelerate their development, ICBs are strengthening partnership working, refreshing their plans and strategies, conducting self-assessment and engaging in peer review. NHS England included consideration of ICB capability within its draft oversight framework. However, a concerted effort is needed to support ICSs to mature and to overcome some of the issues that stand in their way. ICS leaders also suggest that further support to evolve ICBs’ commissioning capabilities to best use available data and deliver best value integrated care.

Recommendation 20 suggested the development of an overall ICS leadership offer. While NHS England offers a range of leadership development offers, these appear to be predominantly provider focused. NHSE is coordinating leadership development offers with the NHS Confederation and NHS Providers to provide a comprehensive offer available for all levels and has published a directory of board-level development offers which will be continually updated. NHSE is also relaunching the Aspiring Chief Executives programme (with the NHS Confederation and NHS Providers) alongside the Aspirant Chair programme, Nye Bevan programme and national leadership programmes at more junior levels. Evaluation is underway for the first cohort of ICB chief executives and ICB and ICP chairs undertaking the Connected Leadership Programme, run by the NHS Confederation, although future funding for the programme is uncertain.

From performance management to improvement

The review made various recommendations on regulation and oversight (most notably 12, 13, 16 and 24). CQC and NHS England continue to work closely with system leaders to evolve their approaches to overseeing and assessing ICSs. The CQC has adapted its single assessment framework in response to feedback from ICS leaders and carried out pilots across two ICSs – Dorset and Birmingham and Solihull – to test its ICS assessment methodology and process. This has also allowed it to improve understanding of ICSs and how it can work alongside NHS England to support  improvement. Rollout of ICS assessments has been delayed to refine the methodology and how assessments are reported. Meanwhile, Dr Penny Dash has been commissioned to lead a review into the operational effectiveness of the CQC, providing an opportunity to make further improvements in CQC’s approach.

Alongside this, NHS England is refreshing its oversight and assessment framework to take on board recommendations, in particular by clarifying accountabilities for provider oversight and the interplay between provider and ICS assessments. CQC and NHS England colleagues are working collaboratively and constructively to streamline their respective assessment processes. DHSC is collaborating with NHS England, CQC and MHCLG to align oversight mechanisms to reduce the burden on systems. 

ICSs want to see further expansion of a national peer offer

The Hewitt review argued that improving the quality of care and the experience of patients will require a culture of continuous improvement, greater use of peer review (recommendation 14), co-production of policy and strategy (recommendation 23) and a national improvement support offer (recommendation 34). Local government already makes wide use of insights from peers in other areas to identify practical changes to improve delivery of services, facilitated by the LGA. The LGA has recently reviewed its offer to ensure it is delivering value for participants and complements other mechanisms for providing assurance to local and national government. The same can be done in healthcare. NHS England and CQC are currently considering ways to include peer review in their assessment approaches. CQC has committed to increasing the use of appropriate peer and national professional specialists in their ICS assessments. NHS England has launched a new, single, shared NHS improvement programme that aims to support organisations, systems and providers to share best practice and drive continuous improvement. 

Additionally, the Leading Integration Peer Support Programme – run jointly by the NHS Confederation, NHS Providers and the Local Government Association – has provided partnership development and peer support for integrated care systems since March 2021, but its future funding is uncertain and the programme is currently paused. ICSs want to see further expansion of a national peer offer. The NHS Confederation has also launched a joint system improvement programme with the Health Foundation and its Q Community to strengthen ICSs’ approaches to collectively leading improvement through cross-ICS sharing and learning via peer-to-peer networks and collaboratives. This has received high levels of interest and uptake. NHS England and the NHS Confederation are working together to align our offers. 

Paying for outcomes, not outputs

Financial incentives can improve allocative efficiency (through shifting resources towards preventative services) and technical efficiency (delivering more activity with available resources). Recommendation 35 of the Hewitt review proposed examining international and domestic best practice to identify most effective payment models to incentivise and enable better outcomes and significantly improve productivity. Additionally, recommendation 31 proposed updating the NHS Payment Scheme to give ICSs greater flexibility to determine allocations for services and appropriate payment mechanisms within their own boundaries, which maintained standardised national rules for inter-system payments. 

The NHS Confederation has explored both international and domestic payment mechanisms with ICS leaders, NHS England and KPMG to consider how innovative financial incentives could be best used to integrate care and support ICSs’ core purposes. The findings have been published in the report ‘Unlocking reform and financial sustainability: NHS payment mechanisms for the integrated care age, including proposals for trial and adoption in the NHS, such as pathway-based payments by outcomes and risk-weighted, capitated payments. The NHS Confederation is now supporting several ICSs to develop proposal pilots to be trialled in 2025/26 to inform the NHS Payment Scheme in 2026 and beyond.

The NHS Payment Scheme for 2026 onwards should go further in encouraging local innovation and experimenting with new approaches

Although not a silver bullet, payment mechanisms can enable changes in services and behaviour which can boost allocative and technical productivity, including a leftward shift to earlier, more preventative, upstream interventions. This is crucial to improving health outcomes and the financial sustainability of the health and care system amid rising demand for services driven by demographic trends. 

The 2023-25 NHS Payment Scheme does allow ICSs some flexibility to use alternative payment mechanisms with national approval. For example, West Yorkshire ICS trialled a new payment mechanism for elective care in 2023/24 that incentivised reducing long waiters, rather than increasing overall activity levels, although this new model was ultimately not taken forward. Such innovation has been few and far between and the criteria for experimentation is limited. The NHS Payment Scheme for 2026 onwards should go further in encouraging local innovation and experimenting with new approaches. 

Planning for the longer term, not just the short term

Recommendation 31 suggested, where possible, ending the use of small in-year funding pots with extensive reporting requirements. However, ICBs report an overall increase in the use of small, in-year funding pots with tight deadlines to be spent and excessive reporting requirements proportional to the size of the funding. While some commissioning teams are moving from NHSE regional teams to ICBs as commissioning of primary pharmacy, optometry and dentistry (POD) services and some specialised services are delegated, further progress towards a larger shift of resource towards systems (recommendation 17) is still needed so they have the right skills and capabilities to effect reform. 

Recommendation 32 proposed DHSC, DLUHC and NHS England align budget and grant allocations for local government (including social care and public health and the NHS). The next opportunity to demonstrate progress on it will be for 2025/26 allocations, which are all subject to the next Spending Review. We hope to see progress in this area to support partnership working, in particular on areas such as prevention. 

Section 75 arrangements allow local government and NHS organisations to pool budgets to help integrate services. Recommendation 33 proposed widening the scope of Section 75 to go further, adding new functions (such as the full range of primary care services), simplifying regulations and expand the scope of the organisations that can legally pool budgets. DHSC collected feedback on potential changes to S75 arrangements in autumn 2023 – conclusions from that analysis and proposal for future amendments to S75 are yet to be published.

From outdated to modern estate and equipment

ICS leaders tell us that capital funding is their top financial priority. Yet the manifesto pledges of the three main political parties all fell well short of the £6.4 billion increase NHS leaders say they need to repair crumbling estates and modernise equipment and healthcare settings to increase annual productivity growth to 2 per cent per year. NHS leaders report various national or regional criteria for approving capital projects leading to money being spent on poorer investments. While allocation of funding is delayed, construction costs have escalated and made crucial projects no longer affordable. 

To address this, the Hewitt review recommended a cross-government review of the entire NHS capital regime to improve the value delivered from existing capital budgets, to be implemented from 2024 (recommendation 36). Since then, NHS England has introduced a new capital incentive scheme, tying capital funding to performance against the 76 per cent A&E four-hour performance target, as well as making capital funding conditional on submitting breakeven or surplus financial plans.

DHSC has stated its intention to publish a capital strategy by the end of 2024. This aims to provide a clear long-term direction on infrastructure for the health and care system and set out where capital investment is best placed to deliver key outcomes such as the productivity targets set out in the Long Term Workforce Plan. The strategy should consider the flow of funding to systems. The approval of projects can also be improved to reduce project delays, overspend and get best value, as proposed by the Hewitt review. The NHS Confederation will be convening NHS leaders to make proposals to this end. Alongside this, NHS England is currently updating its assessment of NHS estate needs and simultaneously ICBs are producing local capital strategies.

From siloed to joined-up government

ICS were designed to enable collaborative working between public sector and wider organisations at a local level to improve the health of the nation. To enable local collaboration, recommendation 3 proposed a national Integrated Care Partnership Forum, bringing together government departments, arm’s-length bodies and ICS leaders to align national policy and support cross-government working to enhance the health of the national. 

The NHS Confederation encourages the new Labour government to quickly establish a national ICP forum to support joined-up government and its health mission

Prior to the 2024 general election, DHSC developed plans to run a national ICP forum, partnering with NHS England, the LGA and the NHS Confederation, chaired by the Minister for Integration. The NHS Confederation encourages the new Labour government to quickly establish a national ICP forum to support joined-up government and its health mission. 

From analogue to digital

Improving access to and interoperability of NHS data is critical to building an NHS fit for the future, targeting precious resources to where they can have most effect and ensuring patients do not have to re-tell their story each time they interact with a new healthcare provider. 

Recommendations 5, 6, 7, 8, 9, 25 and 29 all set out proposals for improving data sharing, digital leadership, making best use of the NHS App and data integration. Implementing these recommendations can help realise the new government’s aspiration to shift the NHS from analogue to digital to improve patient care and productivity. 

NHS England, DHSC, data privacy groups, patient organisations and ICSs are working together to embed the Federated Data Platform (FDP). Two key components are the Federated Data Platform and Associated Services (FDP-AS) contract for trusts and systems, and the Privacy Enhancing Technology (PET) contract, which will embed the cybersecurity measures that accompany the FDP. These initiatives should provide trusts and commissioners with tools to unlock the potential of their data, to improve how they coordinate care for patients. This action to provide minimum data-sharing standards framework to improve interoperability and data sharing across organisational barriers, as recommended by the Hewitt review, is welcome. 

The evolution of the NHS App should enable greater personalisation of digital access to personal health and other services. NHS leaders also recommend that a new government should make a longer-term commitment to establishing citizen health accounts, which would unlock the full benefits of digital for personalisation and citizen empowerment.

It is crucial that digital leaders are equipped with the right support, tools and capabilities to deliver the ambitious transformation agenda

Streamlining and automating data collation remains a key priority for ICSs. But a rapid review of existing data collections which was proposed by the review (recommendation 25), to take place within three months of its publication, is yet to happen. The experience, cited in the Hewitt review, of one ICS receiving 97 ad-hoc requests from DHSC and NHS England, in addition to the six key monthly, 11 weekly and three daily data returns in November 2022, remains common. Such requests continue to focus on outputs and activity, rather than health outcomes. The volume of these data collations place a bureaucratic burden on provider and ICB teams – the latter having seen their resourcing reduced by 30 per cent – and risk distracting from delivering improvements to care which patients need. Streamlining and automating data collation would empower the new government with timely data to understand NHS performance while reducing bureaucracy and waste at a system level, which is currently slowing improvement efforts. 

Digital transformation is a fundamental enabler in achieving the four core purposes of ICSs and therefore it is critical that all system leaders understand their role in driving the digital agenda. It is crucial that digital leaders are equipped with the right support, tools and capabilities to deliver the ambitious transformation agenda. As such, the recommendation for the government and NHS England to fund an ICS leadership development programme is a significant opportunity to enable digital leaders to fulfil the digital transformation agenda. 

Thus far – aside from pockets of organisationally delivered local programmes – little tangible progress has been made on realising this recommendation. The need for the leadership development programme remains urgent, especially when contrasted against a large gap in the overall digital, data and technology workforce. This specialist workforce remains underinvested in within the NHS. The significant gaps in the capacity, capability and diversity within the professional digital leadership workforce presents the NHS with risks in fully meeting the evolving needs and demands of a modernised and fit for purpose NHS healthcare system. Accordingly, it is essential that the national Digital, Data and Technology workforce plan is published. The plan should address the DDaT workforce shortages; promotion of career opportunities; continued professional development; upskilling of the DDaT workforce and therefore encourage a clear leadership development offer for ICSs to be established. 

Wider considerations: scrutiny, pay, social care and general practice

The review made several further recommendations, including giving health overview and scrutiny committees (HOSCs) a renewed national support offer to help them do so (recommendation 10). This work has not progressed but DHSC remains committed to working with local government and ICSs to identify ways to support HOSCs further.

DHSC and NHSE are working towards implementation of recommendation 18 by developing a new publicly available very senior manager (VSM) pay framework to improve consistency and transparency of VSM pay-setting processes. It is hoped that this will prevent unnecessary bureaucracy and delay which hinders recruitment of the best talent to NHS leadership roles.

Social care services are a critical part of integrated care systems, yet the sector is struggling to retain its workforce and therefore to keep up with increasing demand. The Hewitt review recommended that the government should produce a strategy for the social care workforce, complementary to the NHS workforce plan, as soon as possible (recommendation 27). Subsequently, Skills for Care has worked with the sector to develop a 15-year strategy for the adult social care workforce. We believe the new government should support this strategy – not least because without an equivalent plan for social care, the full benefits of the NHS workforce plan will not be realised.

An increase in the proportion of the NHS budget that is spent in primary and community care is needed to prevent worsening ill health and deliver best value

Alongside this, DHSC launched the Care Workforce Pathway to provide a national career structure for the adult social care workforce. Phase 1 of the pathway was published in January 2024, setting out the knowledge, skills, values and behaviours needed for people in direct care and support roles. 

General practice is the front door to the health service for most people and an increase in the proportion of the NHS budget that is spent in primary and community care is needed to prevent worsening ill health and deliver best value. This also needs to be underpinned by reform of the GP contract to support and better integrate primary care, as proposed in recommendation 26 – a measure widely supported by ICS leaders. 

While the contract for 2024/25 has now been published, DHSC intends to develop plans to engage the profession and stakeholders on priorities for change to fix this front door, which will require both investment and reform. In addition, there are significant opportunities to be achieved from collaborating within and across primary care through primary care networks and GP federations. A future role for primary care provider collaboratives is emerging, bringing all primary care professions together to provide a collective voice, an infrastructure to not only support individual providers but to enable a left shift of services into the community. The NHS Confederation’s Primary Care Network members are united in calling for greater local flexibilities to enable innovation and reform. 

Appendix: Summary of Hewitt review recommendations

1. Defining prevention: The share of total NHS budgets at ICS level going towards prevention should be increased by at least 1 per cent over the next five years. 

a) DHSC establishes a working group of local government, public health leaders, OHID, NHS England and DHSC, as well as leaders from a range of ICSs, to agree a straightforward and easily understood framework for broadly defining what we mean by prevention. 

b) Following an agreed framework, ICSs establish and publish their baseline of investment in prevention.

2. National health improvement mission: The government leads and convenes a national mission for health improvement.  DHSC should also publish, as soon as possible, the proposed shared outcomes framework.

3. National ICP Forum: A national Integrated Care Partnership Forum is established. 

4. Health, Wellbeing and Care Assembly: The government establish a Health, Wellbeing and Care Assembly.

5. Data-sharing standards: NHS England, DHSC and ICSs work together to develop a minimum data sharing standards framework to be adopted by all ICSs in order to improve interoperability and data sharing across organisational barriers. 

6. Patient information: DHSC should, this year, implement the proposed reform of Control of Patient Information regulations, building on the successful change during the pandemic and set out in the Data Saves Lives Strategy (2022).

7. Digital leadership: NHS England should invite ICSs to identify appropriate digital and data leaders from within ICSs - including from local government, social care providers and the VCFSE provider sector - to join the Data Alliance and Partnership Board. 

8. NHS App: Building on the existing work of NHS England, the NHS App should become an even stronger platform for innovation, with the code being made open source to approved developers as each new function is developed.

9. Citizen health accounts: The government should set a longer-term ambition of establishing citizen health accounts.

10. HOSCs: Health Overview and Scrutiny Committees (HOSCs)(and, where agreed, joint HOSCs) should have an explicit role as system overview and scrutiny committees. To enable this, DHSC should work with local government to develop a renewed support offer to HOSCs and to provide support to ICSs where needed in this respect. 

11. Fewer national targets: Each ICS should be enabled to set a focused number of locally co-developed priorities or targets and decide the metrics for measuring these. These priorities should be treated with equal weight to national targets and should span across health and social care. 

12. ICB role in oversight: In line with the new operating framework, the ICB should take the lead in working with providers facing difficulties, supporting the Trust to agree an internal plan of action, calling on support from region as required. To enable this support and intervention should be exercised in relation to providers ‘with and through’ ICBs as the default arrangement.

13. Regulation: NHS England and CQC should work together to ensure that as far as possible their approach to improvement is complementary and mutually reinforcing.

14. Peer review offer: A national peer review offer for systems should be developed, building on learning from the LGA approach.

15. ICB maturity: NHS England should work with ICB leaders to co-design and agree a clear pathway towards ICB maturity, to take effect from April 2024. 

16. ICB maturity: An appropriate group of ICS leaders should work together with DHSC, Department for Levelling Up, Housing and Communities (DLUHC), and NHS England to create new high accountability and responsibility partnerships.

17. ICB resources: During 2023 to 2024 financial year further consideration should be given to the balance between national, regional and system resource with a larger shift of resource towards systems; and that the required 10 per cent cut in the RCA for 2025 to 2026 financial year should be reconsidered before Budget 2024.

18. Salary sign off: NHS England and central government should work together to review and reduce the burden of the approvals process of individual ICB, foundation trust and trust salaries.

19. Operating framework: ICS leaders should be closely involved in the work to build on the new NHS England operating framework to co-design the next evolution of NHSE regions.

20. Leadership support offer: NHS England should work closely with the LGA, NHS Confederation and NHS Providers to further develop the leadership support offer. 

21. Leadership development: The implementation groups for the Messenger review should include individuals with significant experience of leading sustained cultural and organisational change in local government and the voluntary sector as well as the NHS.

22. Fewer national targets: Ministers should consider a substantial reduction in the priorities set out in the new Mandate to the NHS - significantly reduce the number of national targets, with certainly no more than 10 national priorities. 

23. Co-production: NHS England and ICBs need to agree a common approach to co-production, working with organisations like the NHS Confederation, NHS Providers and the LGA.

24. Regulation: As part of CQC’s new role in assessing systems, CQC should consider within its assessment of ICS maturity a range of factors (set out on page 58).

25. Data integration: ICSs, DHSC, NHS England and CQC should all have access to the same, automated, accurate and high quality data required for the purposes of improvement and accountability. In particular:

a) NHS England and DHSC should incentivise the flow and quality of data between
providers and systems by taking SITREP and other reported data directly from the FDP
and other automated sources, replacing both SITREPS and additional data requests

b) Data required in real-time by NHS England and DHSC should be taken from automated
receipt of summaries to drive consistency; where possible without creating excessive
reporting requirements, data should enable site-level analysis

c) Data collection should increasingly include outcomes (including, crucially, Patient
Reported Experiences and Outcomes) rather than mainly focusing on inputs and
processes

d) Data held by NHS England (including NHSE regions) about performance within an ICS,
including benchmarking with other providers and systems, should be available to the ICS
itself and national government

e) DHSC and NHS England work with nominated ICS colleagues to conduct a rapid review of existing data collections to reset the baseline, removing requests that are duplicative,
unnecessary or not used for any significant purpose. This work should be completed within
three months

26. GP Contract reform: NHS England and DHSC should, as soon as possible, convene a national partnership group to develop together a new framework for GP primary care contracts. 

27. Social care workforce plan: The government should produce a strategy for the social care workforce, complementary to the NHS workforce plan, as soon as possible.

28. Delegated healthcare tasks:  DHSC should bring together the relevant regulators to reform the processes and guidance around delegated healthcare tasks. 

29. Digital workforce: Currently the agenda for change framework for NHS staff makes it impossible for systems to pay competitive salaries for specialists in fields such as data science, risk management, actuarial modelling, system engineering, general and specialized analytical and intelligence. Ministers and NHS England should work with trade unions to resolve this issue as quickly as possible.

30. Financial reporting: NHS England, DHSC and HM Treasury should work with ICSs collectively, and with other key partners including the Office for Local Government and the Chartered Institute of Public Finance and Accountancy (CIPFA), to develop a consistent method of financial reporting. 

31. Allocations and payment mechanism flexibility: Building on the work already done to ensure greater financial freedoms and more recurrent funding mechanisms: 
a) Ending, as far as possible, the use of small in-year funding pots with extensive reporting requirements. 

b) Giving systems more flexibility to determine allocations for services and appropriate payment mechanisms within their own boundaries and updating the NHS payment scheme to reflect this. 

c) National guidance should be further developed providing a default position for payment mechanisms for inter system allocations.

32. Budget alignment: DHSC, DLUHC and NHS England should align budget and grant allocations for local government (including social care and public health and the NHS).

33. Section 75: Government should accelerate the work to widen the scope of s.75 to include previously excluded functions (such as the full range of primary care services) and review the regulations with a view to simplifying them. This should also include reviewing the legislation with a view to expanding the scope of the organisations that can be part of s.75 arrangements. 

34. Improvement support: NHS England should ensure that systems are able to draw upon a full range of improvement resources to support them to understand their productivity, finance and quality challenges and opportunities. 

35. New NHS payment mechanisms: NHS England should work with DHSC, HM Treasury and the most innovative and mature ICBs and ICSs, drawing upon international examples as well as local best practice, to identify most effective payment models to incentivise and enable better outcomes and significantly improve productivity.

36. Capital: There should be a cross-government review of the entire NHS capital regime, working with systems, with a view to implementing its recommendations from 2024.