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“A single version of the truth is an essential part of aligning all partners around the same goals” – exploring the Hewitt Review

The Hewitt Review – an independent review of integrated care systems – has been published. At 89 pages long, there’s a lot to read – here we focus on the report’s key findings and recommendations around digital and data for you.

The Rt Hon Patricia Hewitt, previous Secretary of State of Health, chair of Norfolk and Waveney NHS integrated care board and deputy chair of its integrated care partnership, was commissioned to carry out the review to consider “how the oversight and governance of ICSs can best enable them to succeed, balancing greater autonomy and robust accountability with a particular focus on real-time data shared digitally with the Department of Health and Social Care”. In addition, the review examines the availability and use of data across the health and care system “for transparency and improvement”.

Enabling a shift towards preventative services

The report goes into detail on the role of data and digital tools to support the prevention of ill health, highlighting how the shift towards prevention “will be more impactful if we enable ICSs to connect data from multiple sources” whilst maintaining privacy and confidentiality. “This would transform their ability to accelerate their work around a whole suite of activity including improving individual care and outcomes; improving population health and wellbeing; tackling health inequalities; improving the wellbeing and engagement of staff; and, significantly, improving the productivity of the health and care system.”

Hewitt notes that many ICSs and partnerships are integrating data from multiple sources as a basis of integrated care and proactive population health.

Examples are provided, including Dorset ICS, where the team is working with residents and partner organisations to establish a live linked data set and using it as the basis for screening their over-65s population, significantly reducing the number of emergency hospital admissions as a result. Norfolk and Waveney ICS has established a GP-led collaboration using data analytics and risk stratification to identify people at risk of undiagnosed or poorly-managed Type 2 diabetes. North East and North Cumbria ICS is joining up healthcare and social care data to streamline and simplify processes to electively support discharge, with staff able to use it as a single version of truth in hospital and community settings to understand where patients are in the discharge process, highlight blockages and provide actionable intelligence through patient tracking and reporting modules.

“ICSs and NHS England need to work together to create a single view of population and personal health,” Hewitt states. “To deliver this there needs to be a strong working partnership between ICSs, NHS England, local government, providers, and the VCFSE sector, which will enable systems and organisations locally to collect and utilise high quality data. A strong partnership between different organisations locally and nationally will be vital for its success.”

The report welcomes the proposed data framework for adult social care outlined in Care Data Matters and emphasises that adult social care providers should be fully involved in finalising the framework. Input should involve those already making transformational use of digital and data tools as well as those less experienced in digitisation.

Building on this, Hewitt also recommends that NHSE, 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. She suggests that it should particularly focus on GP practices, social care provision and VCFSEs.

“I also recommend 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),” Hewitt writes. “This reform, already agreed in principle, is essential to allow local authorities and the local NHS jointly to plan and deliver support by accessing appropriate patient information.”

The Shared Care Record (ShCR) should be a priority for further development, the report states, with an “urgent need” to enable social care providers, VCFSE providers of community and mental health services and local authorities to access the ShCR on an equal basis with NHS partners. “As soon as possible,” it says, “the ShCR should enable individuals (and their carers where appropriate) to access as much as possible for their own data and allow them to add information about their own health and wellbeing.” It adds that patients should be able to access their hospital record as well as GP record, and should, for example, be able to check where they are on an elective waiting list and remove themselves if they have already had their diagnostic test or procedure.

Acknowledging that NHSE plays a “crucial role” in supporting ICSs with vendor management of large supplier relationships and ensuring accountability. “National user-groups should be established with strategic suppliers to leverage and aggregate demand, coordinate any need for changes, and ensure compliance,” the report states. “As part of the national framework, trusts need to adhere to international standards and the data dictionary for nationally mandated metrics and data submissions and ensure coding rules are not open to local interpretation.”

Hewitt highlights the shortage of skilled professionals, “including those who are expert at the cultural change that underpins digital transformation.” She suggests that NHSE should develop in-house skilled teams who can be embedded within a provider or system to train frontline staff and grow the local capability.

The report states that the Data Alliance and Partnership Board from NHSE’s Transformation Directorate has a “central role in the development of NHS digitisation and will therefore have a significant impact upon the ability of ICSs to succeed.” As an immediate measure, Hewitt recommends that NHSE should invite ICSs to identify appropriate digital and data leaders from within ICSs to join the board, to develop the board into an Integrated Data Alliance and Partnership Board.

Hewitt comments upon the need for public support and trust and notes that it is “vital” that national and local systems engage with the public continually to ensure “a data-literate population that we can draw upon.”

Empowering the public to manage their health

On how ICSs can empower the public to manage their health, Hewitt writes: “The democratisation and personalisation of data and digital tools has created a population that both expects and is able to use digital tools and data to support their health and manage their care and treatment. Equally, the effort to improve the nation’s health can only succeed if we support people to become active and engaged partners in their own health, wellbeing and care.”

Hewitt highlights how “most people rely on increasingly sophisticated digital devices to support almost every aspect of their lives”. However, she says, “it is vital to recognise that many NHS patients and social care clients are among those least able to use digital solutions… their voice needs to be heard, within ICSs and nationally, to ensure that the design of digital and data solutions is as inclusive as possible.”

The report recommends that 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”. Additionally, a national user group should be established for the NHS App to ensure public involvement in future developments.

Hewitt also recommends that the government should set a longer-term ambition of establishing Citizen Health Accounts, which would require all providers to publish relevant data they hold on an individual into an account that sits outside health and care systems, which would be owned and operated by citizens themselves. “This should go further than just EPR data and should become a mechanism to enable people proactively to manage their own health and care,” Hewitt writes. She adds that this would need to be linked into the NHS App functionality and should receive information from sources such as NICE, and could also be a gateway into clinical trials and improving health outcomes.

The right skills and capabilities for ICBs

Exploring the skills and capabilities required within integrated care boards, Hewitt writes, “All ICBs need to work with their partners – including place boards, provider collaboratives and local government – as well as their own staff to establish and develop people in the roles that are needed in the ICB, to facilitate acceleration of and depth of performance improvement and wider transformation across the system”.

She notes that “everyone” participating in the review’s engagement process was “acutely aware” of the intense pressures upon the nation and population’s finances, and the stress upon VCFSE partners, social care providers and local government, as well as the NHS. Organisations need to “work together within individual ICSs to share corporate services and other functions, create single teams and make better use of digital tools to improve productivity,” Hewitt states. “Neighbouring ICSs need to consider similar arrangements” as “such collaboration helps strengthen ICSs while achieving better value for public funds.”

Relationship between DHSC, NHSE and ICSs

Considering the relationship that should be in place between NHSE, the department and ICSs, Hewitt writes that prior to conducting the review she expected to find broad agreement on the availability and use of data across the system for transparency and improvement. However, “this proved not to be the case. DHSC and its ministers are frustrated by their inability to get data that they want. NHS England itself has changed its stance on sharing data and information with DHSC, with automated data-sharing feeds updated regularly. ICB and trust leaders themselves are increasingly concerned about multiple requests for data and information, often extremely detailed and at very short notice.”

Effective alignment can be never be found solely within legislation, she continues; “it depends on building relationships of trust and on mutual understanding.”

Digitisation of the system, alongside rapidly growing use of smart data analytics tools, “will help to provide the single version of the truth that is an essential part of aligning all partners, locally and nationally, around the same purpose and goals,” Hewitt states.

In order to strengthen alignment between these bodies, the report recommends a rapid stocktake, potentially to be led by the No. 10 delivery unit, which would assess data flows for timeliness and usefulness. Conclusions should then be shared with systems, NHSE and the Secretary of State “as a basis for agreeing actions for using data” to further support the work of all three.

The role of data for system accountability 

Here, Hewitt emphasises that in order to develop integrated care “with timely, relevant and high-quality performance data, it is essential to ensure that there is a two-way flow between systems and national bodies.”

The new Federated Data Platform (FDP) should make a “significant difference”, the report adds, with automation of data in real-time to drive consistency, free up administrative burdens and enable effective benchmarking. Hewitt recommends that work begins at the same time to “build a close partnership with NHS England, the FDP developers, and appropriate colleagues from ICSs, local government and the provider sector” to ensure that full benefits of the platform can be realised in the future, with all parts of the system involved in its development.

The strategic objective should be to “create a unifying digital architecture across the entire health and care system, with the FDP itself helping to support local systems to address key challenges while also offering the opportunity to share and scale innovative tools and applications.”

In particular, the report recommends that NHSE and DHSC should incentivise the flow and quality of data between providers and systems by taking daily situation reports and other reported data directly from FDP and other automated sources, replacing both the daily reports and additional data requests. Data acquired in real-time should be taken from automated receipt of summaries to drive consistency, the report continues; data collection should increasingly include outcomes, and data held by NHSE about performance within an ICS should be made available to the ICS itself and to the national government. In addition, DHSC and NHSE should work with nominated ICS colleagues to conduct a rapid review of existing data collections to reset the baseline, and remove duplicative or unnecessary requests. This piece of work, Hewitt says, should be completed within three months.

Hewitt states: “it is essential that information-gathering itself does not distract senior leaders and their teams (including the scarce resource of digital and data experts themselves) from the key priority of actually improving performance. Given the scale of improvement required, the present manual reporting burden placed on providers and partners in ICSs is unacceptable… Continuing automation of data provision, shared between NHS England, DHSC and No. 10, will itself improve matters.”

Primary care

“In order to enable the kind of integration, collaboration and autonomy we want to see ICSs embody, we need to pull down some of the barriers that currently exist for primary care, social care and the way we train health and care workforce,” Hewitt writes. “Breaking down these boundaries will be fundamental to unlocking the potential of system working and reinvigorating the much-needed focus on prevention and early intervention.”

With regards to primary care, Hewitt’s recommendations are based on Dr Claire Fuller’s stocktake from last year, covered by HTN here.

The report notes that ICSs should “play a greater role in driving primary care transformation” and recommends that NHSE and DHSC should “convene a national partnership group to develop together a new framework for GP primary care contracts”. The group should include a diverse range of GP partnership leads currently delivering excellence across different regions and demographics, ICB primary care leaders, local government and patient and public advocates. This framework should then be used to “enable systems to find the right solutions to fit their circumstances”.

In particular, Hewitt writes that this group should consider the outcomes desired from primary care as a whole; how to incentivise and support primary care at scale; and the need for clear expectations around digital and data.

The digital and data workforce

The report emphasises that it is “essential that we level up basic digital infrastructure in all parts of the system” instead of expecting busy staff to spend their time manually inputting data.

Hewitt recognises that as digitisation of the sector continues, staff at every level must feel equipped and confident to use the tools available.

“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,” she writes.

Acknowledging that the Agenda for Change framework for NHS staff poses a challenge in terms of paying competitive salaries for these skilled professionals, Hewitt makes a recommendation for ministers and NHSE to work with trade unions to resolve this issue “as quickly as possible”.

She notes that national workforce planning “needs to include steps to ensure that systems can build digital capability, upskill their current workforce and develop clear pathways for progression.” ICSs can create new routes into digital roles, she adds, by working with local schools and further education providers.

The report also states that as NHSE completes its own reorganisation, it would be helpful if skilled staff could be seconded or transferred directly to ICBs most in need of support, with a specific focus on data science, cyber security, and analytical skills.

Resetting the approach to finance to embed change

“Instead of viewing health and care as a cost, we need to align all partners, locally and nationally, around the creation of health value,” the report says, adding that good health has a wider value to society and the economy. “Recent analysis finds that every pound of public money invested in the NHS can generate £4 on average through gains in productivity and increased participation in the labour market.”

At present, Hewitt continues, “we are not creating the best health value that we could from the current investment in the NHS.” She notes that within each element of healthcare, there are opportunities to improve technical efficiency by enabling people to work more effectively, such as replacing paper systems with shared digital records.

Hewitt highlights that one of the main themes in submissions to the report’s call for evidence was the “perverse effects of ‘penny packets’ of funding”, with concerns raised around the investment in digital transformation.

She recommends that as far as possible, the use of small in-year funding pots with extensive reporting requirements should be ended, and instead funding should be largely multi-year and recurrent.

Ensuring efficient delivery of care

“Across all parts of the health and care system, there are many opportunities to use digital technologies to reduce administrative burdens on both clinical and other staff,” the report says, providing the example of moving to real-time data dashboards rather than paper-based data collection.

There are opportunities to ensure that staff are spending the maximum possible time on care and treatment, it continues, for example through use of smart scheduling; and there are also opportunities to support multidisciplinary working, such as using decision management tools to support a wider range of clinical staff in providing safe and effective care.

Hewitt highlights an example from the emergency ophthalmology service at Moorfields Eye Hospital NHS Foundation Trust, in partnership with the London Central ICB. She calls this a “striking example of digitally-enabled, consultant-led transformation that has effectively eliminated waiting times for emergency care in one speciality.” Another example can be found in University Hospitals Birmingham, where they have transformed their skin cancer pathway by using telehealth tools in the community and AI support for diagnosis, leading to a significant reduction in the need for hospital appointments.

“By connecting primary, community, intermediate care and acute hospital teams through high-speed broadband networks, digital stethoscopes and similar smart diagnostic tools, we can bring the NHS to its patients,” the report states.

Fundamental to this, Hewitt adds, is improved data sharing, accompanied by an “actuarial approach to data and risk to understand how money is being spent and how effectively it can be spent across a system.” Whilst there is already “considerable” benchmarking data available, this should be expanded to more areas, in particular areas with notably poor data such as mental health, community services and primary care.

“Given this data, system leaders must feel empowered to work with partner organisations to drive improvements in productivity,” she says. “Alongside such benchmarking and reflecting the fully integrated approaches of leading systems referred to earlier, it is also essential to adopt clean sheet design approaches or zero-based budgeting to set out what best practice care or processes should look like and calculate what different interventions should cost.”

Strengthening and embedding a culture of research and innovation 

As care pathways are transformed across systems, the report states that it is essential that ICSs build a culture of importing and exporting ‘what works’, and that they innovate and transform in partnership with academia and industry. Academic Health Science Networks (AHSNs) should be an integral part of this, it adds, and ICBs should ensure that AHSNs are aligned with local strategic priorities.

“Rather than each of the 42 systems to be constantly reinventing the innovation wheel locally, each investing relatively small individual budgets, ICBs can mobilise this expertise as a cost-effective and productive part of their contribution to system infrastructure,” Hewitt states.

Regional AHSNs should work together and with the national AHSN Network to identify and spread best practice and to innovate pathways, enabling each system to import proven interventions from elsewhere in the country whilst ensuring that their own innovative approaches become part of the wider pool.

System should feel empowered to engage with AHSNs and the National Institute for Health and Care Research, along with regional and national academic communities, Hewitt adds, in order to proactively draw upon their skills and support. “This should align and support ICBs with the duty placed on them to facilitate and utilise research for the improvement of health and care services. Therefore, it is vital that we build a thriving research community which can easily access and utilise the wealth of data that systems collect to undertake well-developed and valuable research to support systems to drive transformation and enable wider economic growth.”

To read the Hewitt Review in full, please click here.