Health scrutiny and the Hewitt Review
On 4th April, the final report of the Hewitt Review was published. This review, commissioned by Government, was carried out by former health minister Patricia Hewitt, looking at the operation of integrated care systems (ICSs).
The report has some interesting – and immediately pertinent – things to say about the operation of local health scrutiny arrangements as part of the new “system architecture” in health and care. Before we get onto that though a quick reminder of how we’ve got here.
Integrated care systems are the centrepiece of reforms brought in by a change in the law last year. They bring strategic decision-making to a wider geographical level. Comprised of statutory integrated care boards (ICBs) and integrated care partnerships (ICPs) which involve local authorities and other partners, they potentially give rise to increased complexity around decision-making. With increased complexity comes risk to governance – around accountability and responsibility for decision-making, over the status and role of the various people involved in both decision-making, oversight, and relating to the transparency of the system as a whole.
Hewitt sees local accountability as important in securing both the credibility of these arrangements, and in assuring its effectiveness. Local autonomy, to her, is an important component of making systems work – with more local decision-making the need for local oversight is also heightened.
It had been speculated that the review would recommend to Government the establishment of compulsory joint scrutiny arrangements for ICSs – but in the end, it doesn’t go that far. Instead, she argues that HOSCs should be recognised as being overview and scrutiny committees for the “system” – that is, for health and care overall, with a responsibility for working with (and scrutinising) all those partners with a stake in the system. She leaves the door open as to whether more of this should happen at system (ICS) or place (council) level.
She also, importantly, recommends that CQC consider in their work reviewing the maturity of ICSs the effectiveness of system oversight provided by HOSCs. If this comes to pass it will provide a strong impetus for colleagues in the NHS (and on ICPs) to take scrutiny seriously – while many areas have done so in the past, there is also a trend, in some areas, for scrutiny to be forborne under sufferance, which hardly provides the strong foundation of culture and behaviours that we would like.
In our view the core focus of health and care scrutiny should remain at place level. Individual councils are best placed to engage with health and care partners over the specific needs of their residents – it is at place level that those needs can best be understood and explored, using councillors’ knowledge and insight into their own communities. But we do accept that new arrangements will mean a bolstering and development of joint arrangements.
In some areas that will be quite easy, for example, county areas, ) ICSs are coterminous with county councils (i.e., they follow the same boundaries or very nearly the same boundaries). In other areas, joint working on scrutiny is mature, and already well-advanced – councils are used to working with their neighbours.
But there are two challenges.
The first is the building of relationships, overall, where ICSs follow largely novel boundaries, without a history of joint working. Here, significant investment will need to be made, in time and resources, to make scrutiny work.
The second is the building of relationships between councils and ICSs themselves. We know that changes in personnel in the NHS mean that organisational memory about the work of scrutiny may have faded. This is why material like the Government’s recently published “principles” to underpin health scrutiny are so important – they underpin new relationships where they may need to be created from scratch.
Finally, what Hewitt has to say about the “system oversight” role of HOSCs raises questions about councils’ scrutiny committee structure. There is nothing here, we think, which should be seen as compelling individual councils to appoint separate “health and care” scrutiny committees. Some authorities do have such bodies – some don’t. Committee structures are for each individual council to determine and we would hate for Hewitt’s recommendations to be translated inelegantly into a blanket injunction on every council to appoint a scrutiny committee on health and care with the same terms of reference; and/or for CQC to “mark down” any council that does not have such systems in place.
These are all reasons why more needs to be done in the coming months to formally clarify the role of health scrutiny in the system – and to systematise its approach through Regulations and guidance. Currently HOSCs are working in an environment of uncertainty – knowing that some of the existing statutory powers around health scrutiny will come to an end soon, but with no clear timescale to work to and no real sense of what follows on. We’re continuing to work with Government to understand when and how change will happen – and to make sure that Hewitt’s recommendations are picked up, and acted on, in a meaningful way.