Patricia Hewitt: There’s a real chance to tackle health differently this time

Matthew

Hello and welcome to a special edition of Health on the Line. I'm pleased to be able to welcome back Patricia Hewitt. Patricia joined us back in January [2003] at a relatively early stage of our independent review of the oversight and governance of integrated care systems.

But now we're speaking a few hours ahead of the publication of her final report. So, Patricia, welcome. How are you? I know from my own review a few years ago that these last few hours before publication can be a frenetic and somewhat anxious time.

Patricia

Absolutely, Matthew. And it's no different with this review. But I do want to thank you personally, all the Confed team, because you've given such great support to this review from the very beginning, and it's been invaluable having the various networks that the Confed mobilises.

So that I've been able to engage through those networks with so many of the hundreds of individuals and organisations who've been engaged in this review.

Matthew

Now when we spoke in January, Patricia, you talked about what you'd learned through the process by then. That was, I think, a couple of months into this review. You talked about how your ideas shifted from initially thinking that the issue was around the kind of micro-management by the centre to moving to an idea that we all need to change, to live up to the challenges of the new ways of working implicit in the creation of ICSs. Has that that journey continued for you as the review has unfolded?

Patricia

Yes. Yes, it has. But the starting point and in a sense the platform for this review does remain the same because all of us, I think, can see that integrated care systems are the best opportunity we will ever have in this generation to transform our health and care system.

And frankly, the pressures upon the 3 million, nearly 3 million people working in the NHS and in social care and the frustration of patients and carers who not, all the time but far too often, can't get the care they need. That is exactly why we have to have this fundamental transformation of our health and care system. So, what has struck me as this review has gone on is how absolutely committed everybody is to the success of this reform.

It really is the right reform at the right time. And the commitment is there. It's there from ministers. It's there across political parties. It's there, of course, in NHS England, and it's there in all the partners local government, the voluntary, community, faith, social enterprise sector. It's there.

But we do all have to change. And just as we all find in our own local systems that we have to build relationships, we have to understand each other's points of view and we have to compromise in order to get the best possible results for the people we're looking after and supporting, that has to happen right through the system.

Matthew

And I found that reading through the final report and I would really encourage people not just to look at the headlines or even just the recommendations, but to read the report, because I think it's a really important overall statement about the challenges and the opportunities for this new way of working.

I'm going to take one quote from the review, because I felt that kind of summed up in a sense, the feeling that I know you've picked up from ICSs and from your own experience as the chair of an ICS.

So, here’s the quote you write for the new system we have created to succeed:

“We need some honest conversations about what is working and what needs to change. There are many unsung examples of effective teamwork between the department and NHSE and systems in all and every permutation, but there are also examples of tensions wasted time and needless frictional costs generated by uncoordinated pursuit of organisational goals that do not take account of the wider effects.

“This also makes it harder for vital partners outside the NHS, including local government, the VCSE and social care providers to collaborate effectively with the NHS. It can often feel to them like looking in on a purely NHS conversation that absorbs enormous amounts of time and energy that could be devoted to joint working. Everyone needs to change, and everyone needs to give a little so that the system as a whole works better.”

Do you feel, Patricia, that you've had those honest conversations and more importantly, how confident are you about them continuing?

Patricia

I've been in this, I think, extraordinarily privileged position, Matthew. I've been able to have honest conversations with many people privately as well as very open and engaging and often creative conversations in more public forums. And like you, I really would urge people to read the report, and I apologise for the fact that it is so long.

But including that crucial section you've just quoted from on the relationship between the Department for Health and Social Care, NHS England itself, and integrated care systems, because I think I've been able I certainly tried to stand in the shoes of different people because I have been health secretary myself. I chair an integrated care board and of course I've worked exceptionally closely with NHS England, so I understand those different perspectives.

And what I've tried to do in the report is not just reflect those differences where they do exist, but also to make very practical recommendations about how we can move things forward. So, for instance, where there are disagreements about the extent to which data is shared, I've suggested a review inside government, maybe led by the Number Ten delivery unit, to take a clear view on that that everybody can rely on.

But more importantly, what I've suggested is that, for instance, in relation to the whole problem of discharge and the lessons that we're all learning in each of our systems from this last winter, that process should actually involve the department, NHS England and integrated care systems ourselves, and that it should report, if you like, or be overseen by the minister for health and social care, the appropriate minister from the levelling up department, and of course the chief executive of the National Health Service, because one of the issues for integrated care systems, we are broad and increasingly effective partnerships locally with local government and other partners equally involved alongside the NHS itself and we need those similar cross government cross-departmental arrangements nationally in order to really give integrated care systems the support we need, the understanding from different policy perspectives, give us the best chance of success.

Matthew

Yes, and I think this is such an important point Patricia, in my own conversations with officials in the department and senior leaders in NHSE, I think the thing that I've found that I have to keep kind of reminding folk is that ICSs, unlike any other health institutions we've had before, have this strong sense of lateral accountability to their partners locally and that therefore the question that we've discussed in the past with any organisation, which is the kind of distribution of power within the NHS funnel, is now a different conversation because of the fact that ICSs both have and want to have this lateral accountability to partners. It feels to me still as though there's some distance to go in the centre to fully appreciate that.

Patricia  

I completely agree with that. Matthew, there was a point actually not so many weeks ago when some of my team and I, we were having a very intense, really important private conversation with very senior leaders from NHS England.

And what became clear was NHS England rightly see integrated care boards, the NHS part, if you like, of an integrated care system, as part of the one NHS team that is so vividly, I think, expressed in the new operating framework. But at the same time as every one of us in integrated care boards knew, we are part of the one system that we belong to in our own integrated care system.

And there's always been a tension between that, if you like, vertical accountability and the looking upwards, if you like, to NHS England and the horizontal looking outwards to our partners, our patients, our communities, the people we are fundamentally accountable to, and getting that balance right. We're certainly not there yet. But many of the recommendations I make in the report, for instance, for a much shorter mandate, building on the improvements in last year's planning guidance, much greater financial and other freedoms and flexibilities, particular clearly for the more mature systems.

All those things are designed to give us in the integrated care boards, the space and time and the tools we need to be really great partners within the wider integrated care systems, which is where the real transformation will happen, whether it's at the system level or crucially in our place partnerships, our integrated neighbourhood teams, our provider collaboratives and so on.

Matthew

I think that there's one particular kind of element of this which really brings it into stark relief, which is that integrated care partnerships, partnership bodies, where the health services exist on an equal level with local government and other partners. I think something we discussed, you and I early on is that they were existing in a sense, in a kind of accountability vacuum, and they couldn't be accountable purely to the NHS because of their partnership status.

But other parts of the government didn't have a kind of relationship with them. And I think there's a specific recommendation, isn't there, in your report about how we deal with this kind of accountability vacuum for ICP?

Patricia

Well, at a local level, of course, local government is intensely accountable through to their own voters. But I do make a number of recommendations for how we ensure that there is a proper understanding and accountability for integrated care systems nationally, but without creating the, if you like, micro-management of local government. I think you were the one who pointed out, was so prevalent 20 years ago and has taken quite some time to unpick.

But I think for instance, my recommendation for a national forum of integrated care partnerships so that we bring those wider partnerships together and give them a voice directly into government and ensure that again, you've got the department for levelling up, you've got the new office for local government, of course, and the Department of Health and Social Care, of course, NHS England, but also other government departments whose work impacts on that broader purpose of integrated care systems, including the work on prevention, population, health management and tackling those appalling health inequalities because they can't wait until after we've fixed the NHS performance problems.

They are actually the best and indeed the only sustainable route to dealing with the performance problems and actually creating much better health outcomes and much better care.

Matthew

Throughout the report, Patricia, you encourage parliament, NHS England to acknowledge the role of ICSs to, for example, the default should be that when it comes to interventions in relation to providers that those interventions should come through, rather than going round, ICBs.

But you also have a really interesting idea, and I think it's not revealing too much to say. This is an idea that came quite late in the process of the development of your thinking, which is this idea of high accountability and responsibility partnerships, HARPs, to some people. This idea might seem as though in the debate you had early on in the review between those who argue the kind of earned autonomy versus those who argued for assumed autonomy, they might feel that the notion of the HARP high accountability, responsibility, partnership, high-achieving ICSs that sounds a bit more like the earned rather than the assumed model.

Patricia

This has been a really interesting debate. And you're right, my new four-letter acronym - got to have one of those - as the HSJ pointed out, that crystallised quite late in the day; what I found was you have some people at one end who basically would say maximum autonomy for all integrated care systems immediately and then rely on transparent data and the CQC to ensure that they're accountable.

At the other end of the spectrum, I've found people who I think really saw and see greater autonomy as almost the reward for sorting out performance and delivery issues. And I have to say, I don't sit at either extreme and I really understand the distaste for that phrase ‘earned autonomy’. It brings an awful lot of baggage with it.

But what I'm proposing here with these high accountability and responsibility partnerships, I think gives us a really radical opportunity to, if you like, create the new and really show what success looks like and what I'm envisaging is, I would say, at least ten integrated care systems operating as hubs with maximum freedoms, flexibility and responsibility. But of course, within a robust system for accountability, operating in that way from the 1st of April next year.

Matthew

One of the other themes in the report, which goes with this, Patricia, and that we discussed a little when we spoke in January, was around an idea I sometimes articulate it as for ICSs to succeed, they have to demonstrate a different kind of public sector leadership. You put quite a lot of emphasis in the review on the need for support.

Investment in organisational development in ICSs for leadership. You remind us of the recommendations of the Messenger review and you kind of prompt NHSE to take forward Messenger a little bit, but perhaps more quickly than we have done thus far. So, I think would I be right in saying that this idea that we do need to cultivate a new type of leadership is something that's been confirmed during the review process?

Patricia

Absolutely. It was really interesting during the review, I think we started off with quite a focus on structures and as you were saying, top-down performance management and all of that. But actually, as the discussion went on, this whole issue of culture, collaborative leadership behaviours emerged as one of the most important issues. Now, the new operating framework, and particularly what I think is a very powerful definition of the kind of leadership and values and behaviours that we need within the National Health Service.

I'm seeing that reflected in the wider discussion going on inside most, I suspect all, systems about the values and behaviours that we want right across the system, right across the whole partnership. So that's really important. And I think the Messenger review has given us a very clear description of the collaborative leadership that's needed, not just within the NHS but across systems and across government.

That requires time and investment in organisational development. I'm urging, recommending to ministers as well as to NHS England and to ICSs themselves, that we should all commit to that goal of self-improving systems. It means a much stronger focus on improvement rather than performance management in the old sense and regulatory intervention. And in particular I’m recommending that the implementation group for the Messenger review, which is just being set up, and needs to be set up, should include outstanding leaders from outside the NHS as well as inside it, including particularly those who've led transformation in local government and in the voluntary sector.

Matthew

Let's turn to another area, Patricia, where I think your thinking evolved during the review.

Indeed, I can quote you from the review. You say: “Having started the review with a degree of scepticism about the CQC, I now strongly support their enhanced role in relation to ICSs”. Tell us why you kind of changed your view about the CQC and what you're recommending to ensure that the CQC role really is as benign as possible.

Patricia

I've been very impressed by the conversations that I've been having with the CQC itself, but also with others about their potential role. A lot of people have had bad experience of box-ticking, compliance-focused CQC inspections in the past, sometimes with inspection teams who simply didn't have the right understanding of what a particular, perhaps specialist, trust was doing.

And it was that kind of experience, I suppose, that had made me and many others sceptical. But what I'm also seeing is real improvements actually in the way that CQC is carrying out many of its inspections and the determination on the part of its leadership and senior people within that organisation to avoid those, frankly either unhelpful or even destructive box-ticking exercises.

And I think the way that CQC has already been going about its work, but in tends to in what in effect is going to be a transitional year, really gives us in integrated care systems a chance to work with and alongside CQC, effectively designing in partnership an effective system of assessment, including critically of how systems themselves are adding value and really making a difference as we bring different parts of health and social care together to focus on outcomes and transform services, tackle inequalities and so on.

All based on our four core purposes as well as of course, helping to solve those immediate delivery challenges. So, I think with this year's work ahead of us and with CQC recognising the need that they have to build the right capability and expertise within their teams, get the right part-time inspectors onto the teams, including from within integrated care systems, from local government and the VCFSE sector and social care providers as well as ICBs themselves.

I think all of that gives me real confidence that they can be a powerful but independent ally in this quest for self-improving and high-performing systems.

Matthew

What's really important though, isn't it, Patricia, is what it is that we measure, what it is that we focus upon. And as our conversation draws to an end, just to go back to the driving inspiration behind the review.

And I think what's motivated you - here's another quote from the review. You say: “I heard real concerns that the transformational work of ICSs and specifically the opportunity to focus on prevention, population health and health inequalities might be treated as a ‘nice-to-have’ that must wait until the immediate pressures upon the NHS have been addressed and NHS performance recovers. But that is what has always happened before, and it must not happen this time.”

That is a critical theme running through the review isn’t it, Patricia?

Patricia

Absolutely. So many of us have been involved in the past in, you know, the CCGs, the PCT, many, many attempts to make this decisive shift of upstream prevention, population health management, above all, tackling health inequalities.

There's a real chance to do it differently this time. It's one reason why I make this highly controversial but essential recommendation that we see at least a 1 per cent shift in the share of the NHS budgets locally going to prevention over the next five years. And there are many, many others all making that same case for a national mission for improving the health of the nation alongside the local mission.

And that means also focusing on outcomes. Are we supporting people to live longer, healthier, happier lives? Are we starting to narrow the quite shocking position we have now, where life expectancy has stalled. For some people, it's gone, some groups it's gone backwards. And as a nation, we are becoming less healthy rather than more healthy. We have to reverse that because apart from anything else, if we don't, we will never be able to build enough hospitals or employ enough staff or create enough beds to look after our ageing population.

Matthew

Now, one of the things that one always does in these reviews, and it's inevitable, is identify areas that no one can fully resolve but clearly need further work. And it feels to me one of those, Patricia, that you point to strongly, but that you yourself have not been able to fully grapple with, is around funding, basically.

And towards the end of the review, you call for an assessment of the capital regime in order to have a more flexible, more devolved approach to capital spending. And also, you intriguingly talk about the overall funding model. Here's another quote. You say: “I therefore recommend that NHS England work with the DHSC, HM Treasury and the most innovative, mature ICB and ICSs, drawing upon international examples as well as local best practice to identify the most effective payment models, to incentivise and enable better outcomes and significantly improved productivity.”

And I think that although you've not been able to kind of resolve that issue yourself, there's a sense that the past has seen models in which we fund activities in the health service or we fund institutions in the health service, but somehow, we have to fund outcomes. We have to fund pathways, we have to fund services; that this is a really important piece of work that has to be undertaken.

Patricia

That's absolutely right, Matthew. And, you know, talking about payment mechanisms and capital expenditure and so on can sound very dry, but they're absolutely critical. Just to take a slightly different but related example, if we look at primary care and particularly GP practices, we can see from the Fuller stocktake, other examples in this review, we can see outstanding examples of primary care at scale, integrated neighbourhood teams where people can get the appointments they need.

But better still, instead of waiting for people to come to the NHS, phone up or whatever it is, we can take the NHS and other support to them. Now that really starts to transform services. But if we go on funding GP practices through one silo, community pharmacies for another community health, mental health, acute hospitals, all different silos and different payment mechanisms will never make the changes we need.

And that's why I recommend a completely different approach to GP contracts. The current system is simply not fit for purpose and it's also why I'm recommending this cross-government review of what is now frankly a Byzantine process for trying to get approval for very badly needed capital expenditure, recognising amongst other things, that half the GP practices that we're expecting GPs and their staff to work from were built before 1948.

We need to change that.

Matthew

The writing of a review, of course, is only part of a process in terms of trying to make sure it's impactful. And I think one of the great opportunities we've got now is that an aspect of loads of all the government reviews I've seen is that when the review is published, if you're the author of the review, in a sense you're left then without a role and simply watching from the sidelines, hoping the review gets taken forward.

But of course, in this case, not only are you chair of an ICS yourself, but you're also a very active part of the Confed’s own ICS Network. So, there's a real opportunity here, isn't there? Now through that network to begin work on how we encourage implementation of your recommendations, how we do further work in those areas you identify which that need further work.

So, I guess in a sense there's no rest for you. I would say you'll be we're speaking as the review is published, that the work of then working with the department, with NHSE on implementation and development, well, that starts immediately.

Patricia

Absolutely starts immediately. Although I have to say I will be very grateful and I hope my own Norfolk and Waveney partners will be grateful, very grateful to have rather more of my time devoted to our just over a million people here and the things we are doing and need to do more of to support them in a longer, healthier, happier lives where we're doing that. But of course, there's follow up work to do, and that does start immediately. I'm looking forward very much to meeting with, I hope, many colleagues in the integrated care systems session that the Confed, thank you, is arranging in a few weeks’ time. But I also think more broadly there is such an opportunity for the 42 integrated care systems to learn and grow together. A lot of it is happening informally, often through Confed networks. I think we can do more of that, many of the recommendations as I've indicated are designed to be very action focused so that we learn by doing and we collaborate more effectively by doing it together.

But I think we could also, as a network and with support from the Confed, really think about how we learn together so that systems who've really made an advance in a particular aspect of our work can even more effectively buddy with and support systems who are struggling in that respect. There are so many ways in which I found over the years of chairing the Norfolk and Waveney STP and now the integrated care board.

I learned so much from other colleagues. I have learned so much in the course of this review. So, let's take that forward and make integrated care systems, as a whole, a learning system that will benefit all of us and benefit the residents we're all here to serve.

Matthew

Patricia, one final question, and we've only touched on the many recommendations and insights in the review.

And I would encourage people, it's not that long; it's a couple of hours’ time really well spent, I think, reading the whole review. And there's a lot that's very rich that isn't in the specific recommendations, but in the broader text. But and I'm going to say something, Patricia, that I don't think you can say because you’re far too stoical and professional to do this.

I know that in the last few weeks, the challenge of finding a kind of landing ground in which you are firstly meeting some of the aspirations of your ICS colleagues. Secondly, addressing the concerns of NHS England, particularly their sense that a lot of what you're encouraging they are already doing through their own change processes and then the concerns of the department, and particularly inevitably the kind of desire of the Secretary of State to be able to show that he has got a direct grip over some of the things that matter most to the public - that finding a landing ground between these different perspectives, there were times when it felt incredibly difficult, but you have managed it.

But nevertheless, it does lead me to want to close with this question. If you could go back now to, I think it was November and you got the call and you were given, I think, less than 24 hours to decide whether you wanted to do this for you. If you could go back, Patricia, would you still say yes?

Patricia

Oh well, there have been times, and look, thank you for recognising some of those challenges. And of course, there have been times when I thought, goodness me, I must have been completely mad to take this on. But I've learned so much and worked with, you know, just even more of the inspiring colleagues that we have throughout our health and care system.

Of course, I'm glad I've done it. Inevitably, the report is not going to be the perfect report that everybody, I'm sure wanted and had in their mind. I'm very conscious of the weight of expectations upon it and inevitably any report, particularly dealing with the complex ecosystem of health and care, any report is going to disappoint many of those expectations.

But if we can all pull together and really concentrate on the great bulk, I would say, of this report, where we are all at least broadly in agreement, let's concentrate on the work we need to do together as integrated care systems and with national bodies. Let's get on with that. And then for what it's worth, I will certainly feel this has been worthwhile and glad that I accepted what was undoubtedly a very big challenge.

Matthew

Well, Patricia, thank you very much. Thank you for joining us on Health on the Line. And thank you for the work you've done on this really important review.

Patricia

Thank you, Matthew.