Hewitt review: what you need to know

Summary and analysis of Rt Hon Patricia Hewitt's review into the oversight, governance and accountability of integrated care systems (ICSs).
Annie Bliss

4 April 2023

The Hewitt review proposes greater autonomy to enable ICSs to better prevent ill health and improve NHS productivity and care, matched by renewed accountability. If fully implemented, the review’s recommendations offer a step change in enabling ICSs to deliver their four main statutory purposes.

Key points

  • Rt Hon Patricia Hewitt has conducted a review of the oversight, governance and accountability of integrated care systems (ICSs), constituted of NHS integrated care boards (ICB), joint NHS and local authority integrated care partnerships (ICP) and all health and care providers who work together in a single system. It proposes greater autonomy to enable ICSs to better prevent ill health and improve NHS productivity and care, matched by renewed accountability.  
  • While the Health and Care Act 2022 created the necessary statutory structures for integration and collaborations, legislation alone cannot create the changes in culture, behaviours and attitudes needed for effective and lasting change. Greater autonomy for ICSs combined with the right support from the centre, greater transparency about performance and robust accountability including an enhanced role for the CQC, will together enable ICSs to succeed.
  • This review sought to hear directly from the system about what changes are needed. The NHS Confederation worked closely with Patricia Hewitt and the Department of Health and Social Care (DHSC) secretariat, ensuring that the findings have been informed by the views of a wide selection of key stakeholders, including leaders from the NHS; local government; voluntary, community, faith and social enterprise (VCFSE) sector; those representing patients, social care providers and other key stakeholders. The overall direction of the recommendations are broadly supported by ICS leaders as well as wider provider leaders. Healthcare leaders across the country are ready to make the changes necessary to embed system working, but implementation will rely on the government accepting the recommendations.
  • The review makes several recommendations of particular significance:
    • Fewer central targets – The review recommends that government and NHS England set fewer central targets, to enable systems to prioritise how they use their resources based on the needs of their local populations. It also recommends they involve systems in the development of national policies - with no more than ten national priorities. This greater focus should be reflected in a shorter, streamlined mandate for the NHS in England.
    • Enabling a shift towards upstream investment in prevention – A combination of increased prevention funding and attention are needed to embed health promotion at all levels to improve population health and ensure the longer-term sustainability of the health and care system. As well as increasing the share of total NHS budgets at ICS level going towards prevention by at least 1 per cent over the next five years, the government should lead and convene a national mission for health improvement, headed by the Prime Minister and involving relevant government departments and offices, tasked with creating a national health improvement strategy.
    • Multi-year funding – The government and NHS England should end the use of small in-year funding pots with extensive reporting requirements for the NHS and social care. Instead, DHSC, the Department for Levelling Up, Housing and Communities and NHS England should align budget and grant allocations for local government (including social care and public health, which are allocated at different points) and the NHS, so that systems can more cohesively plan their local priorities over a longer time period. Additionally, government should commission a review of the entire NHS capital regime, working with systems, to move towards a ten-year NHS capital plan from 2024.
    • Payment mechanism flexibility – NHS England should give ICSs more flexibility to determine allocations for services and appropriate payment mechanisms within system boundaries, and the NHS payment scheme should be updated to reflect this. Longer term, government should review international payment mechanisms.
    • Defining accountabilities – Guidance on system accountabilities, including NHS England’s operating framework, should be updated so that national support and intervention in providers should be exercised ‘with and through’ ICBs as the default arrangement. NHS England should work with ICB leaders to co-design and agree a clear pathway towards ICB maturity, supporting a move over time to a model of High Accountability and Responsibility Partnerships (HARPs).
    • Data available to ICSs – Data held by NHS England (including regions) about performance within an ICS, including benchmarking with other providers and systems, should be shared with ICSs themselves.
    • An enhanced role for the CQC in systems – CQC and ICSs should work together to develop a long-term approach to system inspections and ensure that CQC develops the capabilities and skill sets needed to support successful development of ICSs. 
    • Reconsider Running Cost Allowance cut – The government should reconsider the further 10 per cent cut in ICBs’ RCA scheduled for 2025/26 (which adds to 20 per cent RCA reduction in 2024/25), before the 2024 Budget.
  • If fully implemented, the review’s recommendations offer a step change in enabling ICSs to deliver their four main statutory purposes: improving health outcomes and services, reducing health inequalities, delivering a financially sustainable health and care system and supporting our communitiessocial and economic development.
  • We welcome the commitment from government and NHS England to working in partnership with ICS leaders, reflected in the decision to commission the review itself and the collaborative approach from NHS England to developing the recent NHS Operational Planning Guidance. The review offers a clear roadmap for how to progress this work – something that must be done through continued collaboration and co-creation with system leaders.


  • The review draws on six key principles: collaboration; a limited number of shared priorities, giving local leaders space and time to lead; providing systems with the right support; balancing freedom with accountability; and enabling timely, relevant, high-quality and transparent data.  
  • The review argues that ICSs represent the best opportunity in a generation for urgently needed transformation of our health and social care system. It notes that, no matter how much money is invested in treating illness, unless we transform how we deliver health and care, we will not achieve the health and wellbeing we want for all our communities.
  • The review considers ICSs in their broadest sense as partnerships that bring together local government, the NHS, social care providers, voluntary, community, faith and social enterprise (VCSFE) organisations and other partners to improve the lives of people who live and work in their area, in line with their four core purposes set out in the Health and Care Act 2022. An ICS is not just an NHS ICB.
  • The review argues that the ultimate objective of health policy is that more people live longer, healthier lives. However, we have mistaken NHS policy for health policy. The care and treatment provided by the NHS only accounts for a relatively small part of each individual’s health and wellbeing. Significantly more important are the wider determinants of health. The creation of ICSs, with their four purposes and a strong statutory framework for partnership working, provides a real opportunity to build upon this approach and suggests a welcome recognition of the need for a more holistic approach to improving the nation’s health. However, empowering local leaders to work with and through their partners and local communities to improve outcomes for their populations can only happen at scale if the broader environment in which they operate is aligned to enable them to do so – something that is heavily dependent on policies pursued across government.
  • NHS England recognised the need to update its operating framework in line with the new accountability and oversight infrastructure contained in the Health and Care Act 2022. The review provides some examples of how this important work can be built on. The review argues that ICBs and ICPs should create the environment to support ‘mutual’ or ‘collective’ accountability, where system partners can, with mutual respect and transparency, support and challenge each other to deliver priorities they have agreed together, irrespective of where their statutory accountability sits. Increased availability of timely, transparent and high-quality data is vital to enabling local autonomy and supporting the move away from top-down performance management and towards self-improving systems.
  • Strengthening local leaders’ ability to have greater and more flexible decision-making in primary and social care, supported through a more joined-up national policy approach, will better enable them to deliver improvements in immediate performance and will be key to improving outcomes in the communities they serve. Some barriers to integration, collaboration and autonomy need to be removed to unlock the potential of system working and reinvigorate the much-needed focus on prevention and early intervention.
  • The review argues that, to achieve the best return from the current investment in the NHS, we need to consider health in terms of value rather than cost. To accelerate a shift in resource to where it is most needed – out of hospitals and into community and primary care settings – we should identify the most effective payment models and implement a new model with population-based budgets that will incentivise better outcomes and significantly improve productivity.

From focusing on illness to promoting health

Key recommendations:

  • The Prime Minister should personally lead a national health improvement mission.
  • 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.
  • We should empower patients through the NHS app and new Citizen Health Accounts.

Enabling a shift to upstream investment in preventative services and interventions

  • To achieve a decisive shift ‘upstream’, towards prevention, proactive population health management and tackling health inequalities, a baseline of current investment in prevention should be defined and established from which progress can be measured and benchmarked.
  • DHSC should establish a working group of local government; public health leaders; DHSC, including the Office for Health Improvement and Disparities (OHID); NHS England and ICS leaders, to agree a framework for defining prevention. As part of this work, the group should consider the guidance to local government on the use of the public health grant. The framework should be completed by autumn 2023. ICPs should establish and publish their baseline investment in prevention. This should be delivered through the ICP and include both NHS and local government spending on prevention and establish the baseline at place level. All ICSs should reporting on their prevention investment from 1 April 2024.
  • The government, NHS England and ICS partners, through their ICP, should increase resources going to prevention, including increasing the share of total NHS budgets at ICS level going towards prevention by at least 1 per cent over the next five years.
  • As public finances allow, the public health grant to local authorities needs to be increased.

Embedding health promotion at every stage

  • The government should lead and convene a national mission for health improvement designed to shift focus from simply treating illness to promoting health and wellbeing and supporting the public to be active partners in their own health. This should be led personally by the Prime Minister.
  • This new mission should be supported by appropriate cross-government arrangements, possibly including a revived Cabinet Committee that includes a senior minister from all relevant departments, as well as DHSC’s OHID, NHS England and the new Office for Local Government. An early priority should be the creation of a national health improvement strategy, identifying priority areas and actions.
  • DHSC should publish, as soon as possible, the proposed shared outcomes framework. This should develop a small set of clear, high-level national goals for population health, with appropriate timescales and milestones for action. The framework should consolidate current existing, fragmented outcomes frameworks to enable an aligned set of priorities across health and care.
  • A national ICP Forum should be established, including representation from DHSC, DLUHC (including the Office for Local Government) and, in the context of the national health improvement mission, the Cabinet Office as well as NHS England. This could be convened by government itself or alternatively by the ICS Network and the Local Government Association together.
  • The government should establish a health, wellbeing and care assembly, with a membership that mirrors the full range of partners within ICSs, including local government, social care providers and the VCFSE sector as well as the NHS itself. It would also be helpful for the assembly to be supported by a secretariat drawn from OHID and the Office for Local Government, as well as DHSC and NHS England.

ICSs’ role in embedding population health management

  • Every ICS should ensure that both their ICP’s integrated care strategy, and through it their ICB joint forward plan, include a clear articulation of the needs of children and young people within their population, and how those needs will be met through collaboration across the system.

Role of data and digital tools to support the prevention of ill health

  • Building on the Care Data Matters Strategy, NHS England, DHSC and ICSs should work together to develop a minimum data sharing standards framework to be adopted by all ICSs to improve interoperability and data sharing across organisational barriers, particularly focusing on GP practices, social care provision and VCFSEs providing health and care services.
  • 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).
  • The Shared Care Record, now established in all ICSs, should be accessible by local authorities, social care providers and VCFSE community and mental health services and enable individuals to access their own data and allow them to add information about their own health and wellbeing.
  • NHS England should develop in-house skilled teams that can be embedded within a provider or system to train frontline staff and grow the new local capability needed to ensure successful digital and data-driven transformation.
  • NHS England should invite ICSs to identify appropriate digital and data leaders from within ICSs to join NHS England’s Data Alliance and Partnership Board, within the transformation directorate of NHS England.

Empowering the public to manage their health

  • 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. A national user group should be established for the NHS app, including people with lived experience and VCFSE groups supporting marginalised or overlooked groups, to ensure public involvement in future developments.
  • The government should set a longer-term ambition of establishing Citizen Health Accounts by requiring all health and care providers to publish the relevant data they hold on an individual into an account that sits outside the various health and care IT systems and is owned and operated by citizens themselves. This would need to be linked into the NHS app functionality and should receive information from sources such as NICE. It could also be a gateway into clinical trials and improving health outcomes.

Delivering on the promise of systems

Key recommendations:

  • Each ICS should be enabled to set locally co-developed priorities or targets across health and social care that should be treated with equal weight to national targets.
  • NHS England and CQC should work together to ensure that their approach to improvement is complementary and mutually reinforcing.
  • A national peer review offer for systems should be developed, building on the LGA approach.
  • NHS England should work with ICB leaders to co-design and agree a clear pathway towards ICB maturity.
  • Ministers should consider a substantial reduction in the priorities set out in the new mandate to the NHS.
  • Support and intervention in relation to providers should be exercised ‘with and through’ ICBs as the default arrangement.
  • An appropriate group of ICS leaders should work together with DHSC, DHLUC and NHS England to create new High Accountability and Responsibility Partnerships (HARPs).


  • 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.

Local accountability and priority setting

  • 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 should be treated with equal weight to national targets and span across health and social care.

Self-improving systems

  • NHS England and CQC should ensure that their approach to improvement is complementary and mutually reinforcing.
  • NHS England should co-design and agree with ICB leaders a clear pathway towards ICB maturity, to take effect from April 2024. This should include self-assessment of maturity supported by peer review mechanisms.
  • A national peer review offer for systems should be developed, building on learning from the LGA approach.

Accountability relationships at the heart of system working

  • The creation of ICSs requires clarity about where accountability sits and the mechanisms should be effective and proportionate to allow ICB leaders the space and time to lead. Where an organisation has a clear responsibility for most or all of an issue and controls the resources to deal with it, accountability sits with them.
  • The review suggests roles and responsibilities between systems and providers:
    • NHS trust and foundation trust chief executives are accountable for what goes on inside their trust, including the quality and safety of the services they provide. Trust chief executives and boards are also accountable to system partners – within a provider collaborative or place partnership where appropriate, but also with and through the ICB. They are accountable to partners across the ICS (including the ICB) for their part in shaping and helping to deliver the ICS integrated care strategy and joint forward plan.
    • The ICB has a crucial role as the convenor of the NHS, as the statutory partner with the upper-tier local authorities that also form the ICP and leader and partner in the wider ICS. ICBs are accountable for the performance and financial management of the NHS in their area. ICB CEOs are accountable to their boards, to system partners and to NHS England for delivery of agreed priorities and plans, but not for the performance of individual trusts.
    • All system leaders collectively have a responsibility to challenge and support each other in relation to meeting their agreed system objectives.

ICSs develop their own improvement capacity

  • ICBs should be the first point of support for providers facing difficulties. The ICB should take the lead in working with providers facing difficulties, supporting the trust to agree an internal plan of action. NHS England should work ‘with and through’ ICBs as the default arrangement so there are ‘no surprises’ for local leaders.

High Accountability and Responsibility Partnerships (HARPs)

  • New High Accountability and Responsibility Partnerships (HARPs) should be created by an appropriate group of ICS leaders (including local government, VCFSE and other partners as well as those from the NHS) and DHSC, DHLUC and NHS England. These should start to operate from April 2024, with initially around ten of the most mature systems gaining greater autonomy. To reinforce the cross-government arrangements needed to parallel the broad partnerships of ICSs as a whole. These should aim to deliver:
  1. a radical reduction in the number of shared national priorities and KPIs
  2. agreed accountability for small number of shared priorities
  3. greater financial freedoms for local partners
  4. effective data sharing
  5. light-touch accountability framework.

The right skills and capabilities for ICBs

  • ICBs have a vital new role as convenors and catalysts for change. DHSC should reconsider the further 10 per cent cut in ICBs’ RCA scheduled for 2025/26 (which adds to a 20 per cent RCA reduction in 2024/25), before the  2024 Budget.
  • NHS England and central government should reduce the burden of the approvals process of individual ICB, foundation trust and trust salaries.

National organisations

  • NHS England should work with ICSs to co-design the next evolution of NHS England regions, to ensure that the regions can operate as effective partners, and the collective agent of the local NHS within ICSs.
  • 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.
  • The No. 10 delivery unit should provide a rapid stocktake of data flows to enable systems, the Secretary of State and NHS England to agree actions for improving timeliness and usefulness for all three.
  • Targets for ICSs set by DHSC and NHS England should be based on outcomes not outputs.
  • The national focus on reducing elective care waits should be matched by an equal focus on reducing waiting times for acute mental health treatment.
  • NHS England and ICBs should agree a common approach to co-production, including working with organisations like the NHS Confederation, NHS Providers and the LGA.

Enhanced CQC role in relation to systems

  • Greater autonomy must come with more effective accountability to patients and the public as well as to NHS England and ministers. The CQC will have an enhanced role in relation to ICSs, building on their core mission to inform patients and the public about the quality of care and the effectiveness of services based on their oversight and inspection of health and social care providers.
  • Once CQC has put in place arrangements to review systems, developing their approach and capability in partnership with a wide range of ICS leaders both from ICBs and ICPs, they should provide clear and transparent ratings on the quality of services within the ICS, across the key domains of care services.
  • CQC should also make an assessment of the level of maturity and effectiveness of each ICS as a whole, including a rating of the ICS leadership itself, based on an assessment of how far ICS structures are adding value. CQC should then use these different ratings and assessments to inform an overall judgement on the achievement, challenges and areas for improvement for each ICS. CQC should assess how the ICS itself (including the ICB, ICP, place partnerships and provider collaboratives) adds value, enabling the whole to be more than the sum of its parts.
  • 2023 to 2024 should be a transitional year, allowing CQC and ICSs to co-design the most effective approach to CQC reviews, sharing learning as both CQC and ICSs embed system working and enabling it to generate ratings that the public, as well as ICS partners themselves, can trust.
  • CQC should base its assessment of the maturity of ICSs on how partners assess the extent of engagement and relationships within the ICS, the strength of the system-wide integrated care strategy, the coherence, consistency and impact of arrangements at place and neighbourhood level and whether system partners are developing a framework of mutual accountability.
  • CQC and ICSs should work together over the coming year to develop a long-term approach to inspections and ensure that CQC develops the capabilities and skill sets needed to support successful development of ICSs, including investment in training for the CQC workforce to upskill staff and bring in colleagues with experience from systems, including where appropriate other system leaders.
  • In the first year, the CQC’s focus should be on calibration of its assessments, supporting improvement and sharing best practice among systems within its reports rather than assessment and rating. This should be driven by co-design between CQC and systems sharing learning as both CQC and ICSs embed system working.

The role of data for system accountability

  • NHS England and DHSC should incentivise the flow and quality of data between providers and systems. The Federated Data Platform (FDP), currently under procurement, can provide the basis for a radical change in oversight, to replace situation reports (SITREPS), unnecessary and duplicative data requests. NHS England, the FDP developers and appropriate colleagues from ICSs, local government and the provider sector should work together to ensure that the full benefits of the FDP can be realised in future, with the ultimate objective to create a unifying digital architecture across the entire health and care systems.
  • 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. Data required in real-time by NHS England and DHSC should be taken from automated receipt of summaries to drive consistency and without creating excessive reporting requirements.
  • 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.

Unlocking the potential of primary and social care and building a sustainable, skilled workforce

Key recommendations:

  • The government should produce a strategy for the social care workforce.
  • A national partnership group should develop a new framework for GP primary care contracts.
  • We should address how the Agenda for Change pay framework can allow for skilled data, digital and analytical staff.

Primary care

  • Through PCNs and place partnerships, ICBs can still consider the needs of their local population and determine the best use of resources for that population. The new responsibilities for ICBs provide an important opportunity, at place or system level, to integrate the whole primary care offer for communities, making the best use of both the staffing resource available and the premises.
  • The next stage of dental reforms, currently being developed and building on the incremental reforms made last year, must be implemented as soon as possible. Without this, ICBs are simply being handed the task of improving an unacceptable situation without sufficient tools to address this. The government has already made some welcome changes, giving ICBs some flexibility to create additional services where they are most urgently needed and announcing the first set of contractual reforms in July 2022 to support fairer remuneration for dentists and increase patient access to care.
  • The Quality and Outcome Framework (QOF) points should be updated with a more holistic approach that allows variation and recognising that in order to allow primary care to refocus resources on prevention, outcomes rather than just activity need to be measured.
  • NHS England and DHSC should, as soon as possible, convene a national partnership group to develop a new framework for GP primary care contracts. This partnership group should include a diverse range of GP partnership leaders currently delivering excellence across a range of different regions and demographics, as well as ICB primary care leaders, local government, patient and public advocates. Key stakeholders including the BMA and the RCGP should also be engaged. This group should consider in particular primary care outcomes, the balance between national specifications and local flexibility and decision-making, expectations around data and digital, how to incentivise and support primary care at scale and how to support struggling practices to improve.

Social care

  • If health and care are to be effectively integrated and delivered at ICS level, social care needs to be a national priority for investment and workforce development, enabling delivery of the reforms of the 2014 Care Act.
  • ICSs also have a vital role in supporting a more sustainable social care sector at system level, by taking an integrated approach to reducing the gap between demand for care and available supply. For example, by encouraging the adoption of personalised, preventative and proactive models of care.
  • The review recommends an acceleration and expansion of existing work on understanding both need and the fair cost of care, before the proposed cap on adult social care costs is implemented. This should include an expansion of the work on fair cost of care to capture working-age adults and potentially children’s social care.


  • Given the interdependence of health and social care, the government should produce a strategy for the social care workforce to complement the forthcoming NHS long-term workforce plan as soon as possible. This plan should set the strategic direction for a more integrated health and social care workforce. This strategy can then support local authorities, who have responsibility for adult social care provision, and ICSs, who will play an increasingly key role in joined-up workforce planning.
  • Investment in workforce development in social care should be longer term, as a minimum based on a three-year rolling planning cycle to support multi-year investment programmes.
  • There are also great examples of collaborative workforce planning across the country that should be built on. These include the Derbyshire ICS system workforce team working with Joined Up Careers, the Department for Work and Pensions, Jobcentre Plus and Futures for Business, to boost recruitment to the health and care sector-based Work Academy Programme (SWAP); and Suffolk University and the ICB working together to establish a joint venture community interest company to create a dental training practice.
  • Embedding the Messenger review’s call for systems to improve mutual awareness and provide opportunities for staff to engage beyond their professional environment, there should be a requirement that training and development budgets for both the NHS and social care should be used for shared training and development of staff with other parts of the NHS and social care.
  • DHSC should bring together the relevant regulators to reform the processes and guidance around delegated healthcare tasks.

The digital and data workforce

  • The skills needed to deliver data and digital transformation require a professional and highly skilled workforce at the system and provider level.
  • The health and care system urgently needs to develop, train and recruit more specialists in fields such as data science, risk management, actuarial modelling, system engineering, general and specialised analytical and intelligence.
  • The Agenda for Change framework for NHS staff makes it impossible for systems to pay competitive salaries for these skilled professionals, with the result that too many ICBs and providers recruit the necessary staff on short-term contracts. Ministers and NHS England must work with the trade unions to resolve this issue as quickly as possible.

Resetting our approach to finance to embed change

Key recommendations:

  • Systems should be given more flexibility to determine allocations for services.
  • There should be a cross-government review of the entire NHS capital regime.
  • Government should, as far as possible, end small in-year funding pots.

Financial accountability

  • NHS England, DHSC and HM Treasury should work with ICSs and other key partners to develop a consistent method of financial reporting that will give the public the information they need to hold their local systems to account, without creating burdensome new reporting requirements.

Funding settlements

  • The government and NHS England should end the use of small in-year funding pots with extensive reporting requirements.
  • DHSC, DLUHC and NHS England should align budget and grant allocations for local government, including social care, public health and the NHS.

Financial flexibility for intra-system funding

  • The NHS Payment Scheme should be updated to give systems more flexibility to determine allocations for services and appropriate payment mechanisms within their own boundaries. However, national guidance should provide a default position for payment mechanisms for inter-system allocations.
  • The government should accelerate the work to widen the scope of Section 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 Section 75 arrangements.

Ensuring efficient delivery of care

  • 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.
  • NHS England should work with DHSC, HM Treasury and the most innovative and mature ICBs and ICSs to identify the most effective payment models to incentivise and enable better outcomes and significantly improve productivity. This should include examples of pathway redesign where systems are moving to a ‘could cost or should cost’ funding model for a while, rather than what they ‘do cost’, based on efficient models of care and utilisation of staff or facilities.
  • 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.

Specialised commissioning or tertiary services

  • Joint committees between ICBs and NHS England, with delegated responsibility for commissioning some specialised services, should be kept under review.

The NHS Confederation’s role

The NHS Confederation has worked closely with Patricia Hewitt and the DHSC secretariat to support the review. Hewitt was clear from the beginning that she wanted to be a ‘catalyst for crowdsourcing.’ With support from us and our partners, she engaged with more than 1,000 stakeholders from across the health and social care system, including leaders and representatives from across the NHS, local government, VCFSE sector, those representing patients, and social care providers. From among our forums alone, she has met with over 300 people across 30 engagement sessions including leaders from ICBs, ICPs, acute, mental health and community trusts, primary care, public health, place and national trade union representatives, spanning every region and all 42 ICSs.

These engagements provided invaluable inputs to the review and its recommendations and resulted in an important debate that has wider value than the review itself. They also helped to generate support and buy-in from leaders from across the system and wider sector.

Several ICB leaders described the review’s recommendations as reflecting ‘why I chose to apply for the job’

Workstream groups were established and tasked with answering some questions and suggesting recommendations across five key areas: prevention and population health, accountability and autonomy, finance and productivity, integration and place, and data and digital. A mixture of ICB chairs, CEOs, ICP chairs and provider leaders were asked to chair the workstreams. The groups met regularly over two months, including one public meeting, to finalise their recommendations, many of which were taken into the final report. Representatives from the NHS Confederation worked closely with workstream chairs and a lead from DHSC on each workstream to support the process and evolution of the recommendations. The NHS Confederation also commissioned experts to write reports on areas of specific subject expertise, which helped focus the workstream conversations and shape the final report.

This high level of engagement and co-creation has been hugely beneficial to the substance of the review, the level of support for the principles guiding the review, and the review’s recommended changes. While some areas explored do not lend themselves to easy cross-sector consensus on either the issues or the solutions, there has been a high level of agreement on the broad shifts needed to improve life expectancy, population health and reduce health inequalities. Several ICB leaders described the review’s recommendations as reflecting ‘why I chose to apply for the job.’


The NHS Confederation welcomes the Hewitt review and the recommendations it sets out. While the foundations for ICSs were set out in legislation last year, what we now need to see is a cultural and behavioural shift to make the best of these new structures: something this review will help to instigate.

There is much in this review that leaders from all parts of the system – acute, mental health, community and primary care as well as ICB and ICP leaders – will welcome. The focus on prevention is crucial for the long-term sustainability of both the NHS and more broadly to increase health and wellbeing of the population, and something for which we have long been advocating. It is right to focus on the prevention agenda and to highlight the additional resource ICSs will need if they are to move away from constant firefighting, to looking at the bigger picture and doing more to support overall population health and wellbeing.

This review is a welcome recognition of the fundamental principles needed for success to become a reality

For ICS to succeed in their responsibility to reduce health inequalities and improve population health, they need to be given agency and support from national leaders. This review is a welcome recognition of the fundamental principles needed for success to become a reality.  Greater local autonomy and a shift towards shared outcomes is a sensible approach. Leaders have been asking for a move towards multi-year recurrent funding for some time, and a long-term capital strategy is key. The review also recognises how current primary care contracts can stifle primary care’s ability to innovate and integrate and incentivises activity rather than outcomes.

A wide range of leaders from across the NHS, local government and other system partners have been involved in the consultation process. That there is such widespread support for the review reflects how well they have been engaged in the process. Through our various networks, including the ICS Network and its members, we look forward to continuing to help enable joint working.

We hope to see the government endorse and accept all of these recommendations.

Next steps

  • The NHS Confederation and our members will make it a priority to support implementation of this landmark review, which builds on many of the priorities we have raised in recent months and years. We will work closely in particular with ICS leaders, NHS England, DHSC and wider government departments to support this.
  • In the coming weeks we will work with system leaders to discuss how we can help to implement the review’s recommendations and steps we will take to get there.

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