The Hewitt Review: What does this mean for Primary Care Networks?

As always, I write blogs for Primary Care Network leaders.

The long-awaited Hewitt Review has been released today, 4 April 2023, and the document can be found here. This is a strategic and political document versus operational guidance, which is helpful in enhancing our understanding of the context we work within.

In this blog, I share my initial thoughts and a summary overview of the document, highlighting how this review may impact Primary Care Networks and focusing particularly on the following key takeaways:

1. Increased data requests

2. Greater clarity

3. A revision to, or the ending of QOF

4. Further integrated workforce development

5. An increased focus on access

6. Reduced targets and smaller pots of funding (with complex funding rules)

7. A review of the GP Partnership model

Let's jump in!

Background

In February 2021, the policy paper; 'Integration and innovation: working together to improve health and social care for all' was released to set out the legislative changes for the Health and Care Bill.

This bill introduced Integrated Care Systems as:"a new and central vehicle to aid the delivery of integrated care, bringing together local organisations to redesign care and improve population health, creating shared leadership and action.

They [Integrated Care Systems] were designed to be a pragmatic and practical way of delivering the 'triple integration' of primary and specialist care, physical and mental health services and health with social care" and work to:

1. Improve outcomes in population health and healthcare

2. Tackle inequalities in outcomes, experience and access

3. Enhance productivity and value for money

4. Support broader social and economic development

The ICS model is built around the idea of place; meaning specifically that different health and care organisations should work more closely together to better meet the needs of people living in a particular area.

This includes sharing information and resources, aligning services around what people need (rather than organisational boundaries), and making joint decisions about how best to use limited resources.

Our ICSs should be ‘place-based’ and ‘bottom up’, with local clinicians, NHS managers, councils and other partners working together to design and deliver services that meet local needs.

In order to support the development of ICS’s, an independent review led by The Rt. Hon. Patricia Hewitt, Chair of the Norfolk and Waveney Integrated Care Board and Deputy Chair of its Integrated Care Partnership, was conducted to better understand what oversight and governance will best enable to them to thrive.

The review states that there are six key principles and thirty six recommendations which will enable the ICS to thrive and deliver.

I can only identify five principles which are listed below (please let me know if you interpret this differently):

1. Collaboration within and between systems and national bodies

2. A limited number of shared priorities, and the review specifically asks for a reduction in priorities

3. Allowing local leaders the space and time to lead

4. The right support, balancing freedom with accountability

5. Enabling access to timely, transparent and high-quality data

Whilst the statement I am about to make is obvious, as this review highlights, it's not about one part of the system.

Pressures upon the NHS and social care were already visible before the pandemic, but they have been greatly exacerbated as a result of it.

Waiting times need to be reduced across the board.

There is a growing number of people living with complex, long-term physical and mental health conditions, often associated with serious disabilities or ageing.

As a nation, we are becoming less, rather than more healthy, both physically and mentally. More people spend longer in ill-health and die too young, particularly the least economically advantaged and those most affected by racism, discrimination and prejudice.

Whilst I encourage you to read the full report, I believe Primary Care Network leaders will need to be mindful of the following. 1. Increased data requests

To help realise the ambition relating to achievement of timely, relevant, high-quality and transparent data, Primary Care Network leaders should expect to receive more data requests.

In the latest PCN DES, PCNs are now asked to join the General Practice Appointment Data (GPAD) Data Provision Notice and improve the accuracy of appointment recording. This is a new ask of networks.

I anticipate that this will be a process of trial and error, as data tools become ever more sophisticated and the interpretation and understanding of the data we have access to increases.

If you're not that way inclined it can be incredibly frustrating to submit regular requests for data, but it is necessary in building a better understanding of what is happening, why things are happening, where the gaps are, where the duplication is, and how things can improve.

2. Provision of greater clarity

In the review, some providers reported finding it difficult to navigate between different versions of ‘place’ within different systems. The review calls for greater clarity and transparency where relationships with different providers are concerned.

3. A revision to, or the ending of QOF

The review states that the Quality and Outcomes Framework (QOF) points, which were an important and useful innovation twenty years ago, are now out of date and are widely perceived (by GPs as well as ICBs) to be an inflexible and bureaucratic framework.

As we move forward, there is recognition that resources need to focus on prevention, rather than just activity that needs to be measured.

4. Further integrated workforce development

An integrated system requires an integrated workforce, and as a workforce, we should be able to navigate all areas of a health and care system which fully recognises our qualifications and experience.

Whilst many of us will be focused on the here and now, we must also consider the future and continue to embrace training and professional development beyond our current place of work.

All areas of the system should expect to see skills passports (if they haven’t already), integrated work placements and roles, shared funding for roles, integrated leadership, management and skills training.

PCNs have already begun to experience joint working in this way via the addition of trainee nurse associates, shared funding for mental health practitioners - and collaboration with other organisations when it comes to social prescribing.

I'm sure there are many more examples so networks are in a good position to build on this.

5. An increased focus on access

One clear and immediate priority relates to access. Access to primary care, urgent and emergency care, community care, mental health and social care services and elective diagnostics and treatment. Within 23/24, PCNs are set to receive a Local Capacity and Access Improvement payment, which should be made providing PCNs can demonstrate improvements in three key areas:

• Patient experience of contact

• Ease of access and demand management

• Accuracy of recording in appointment books.

Networks have also received a slight increase in the Enhanced Access payment. The level of interest in access is central to ICB accountability.

6. Reduced targets and smaller pots of funding (with less complex funding rules)

The review acknowledged that new targets and initiatives, non-recurrent funding or small funding pots with complex rules makes it impossible to plan new services or even recruit staff. These constraints also waste money and time and weaken impact and accountability.

So hopefully, networks should see reduced targets, smaller pots of money with less complex spending rules, and a greater appreciation of the length of time needed to mobilise new projects and services.

Primary Care Networks have already seen the removal of a significant number of Investment and Impact Fund indicators.

7. A review of the partnership model

The review recommends NHS England and DHSC should convene a national partnership group to develop a new framework for GP primary care contracts.

A review of the partnership model and how contracts are commissioned will affect how primary care at scale / PCNs / and integrated teams are organised and perceived.

With change, comes uncertainty, so PCN leaders need to be mindful of this.

Final Thoughts

Lastly, the review states….critically, all of us will need to change.

We will need to work more collaboratively than ever before.

We will have to be more accountable than ever before.

We should embrace change more than ever before (even when it may feel like we are going around in circles).

This is the nature of a complex adaptive system and one which we are not strangers to.

I hope this helps!

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About the Author

I'm Tara; I am the founder of THC Primary Care, an award-winning healthcare consultancy specialising in Primary Care Network Management and the host of the Business of Healthcare Podcast, where we have now published over 200 episodes.

I have over 20 years of project management and business development experience across the private and public sectors, and I have supported over 80 PCNs by providing interim management, training and consultancy.

I have managed teams across multiple sites and countries; I have an MBA in Leadership and Management in Healthcare, I'm published in the London Journal of Primary Care, and I am the author of over 250 blogs.

I have 3 children. My eldest has Asthma, my middle child has a kidney condition called Nephrotic Syndrome, and my youngest daughter has Type 1 Diabetes, so outside of work, healthcare plays a huge role in my life.