The Hewitt Review re NHS in England: Little or nothing on Public and Patient Involvement!

Posted on 26th April, 2023

This is Blog No 25


Former Minister Patricia Hewitt had a tough assignment.


Her task was to examine how the oversight and governance of integrated care systems (ICSs) in England can best enable them to succeed. Her terms of reference were published in December and, please could they have her interim findings by the end of January, and the full report before April!

I have just read her final report and given the almost impossible circle she had to square, she has produced a remarkable piece of work.


Why is it so difficult?  Because the Government – and others, to be fair - want to pursue rather contradictory goals. They want to liberate local Integrated Care Boards (ICBs) to be able to determine and manage the system to meet locally agreed priorities, with fewer top-down targets and interference. On the other hand, they also want them to be ‘more accountable’ for performance and spending.


Another formulation is to call for “a shift from a top-down, centralised system of managing the NHS to a bottom-up system responsive and responsible to local communities and engaging the enthusiasm, knowledge and creativity of staff along with patients, carers and volunteers.” (Hewitt review at Par 1.15)


Broadly, her sensible recommendations will address some of the well-known barriers to the true integration of health and social care. But the true nature of accountability is still elusive. For those of us focused on NHS patient and public involvement, we saw in this Review a real opportunity to clarify and re-invigorate the essence of public engagement. After all, the wording of the legislation has scarcely changed in 20 years and has always been the triumph of optimism over precision. (Anyone who thinks it is easy or straightforward hasn’t yet been on one of my consultation law courses!)

In terms of engagement, what Hewitt has recommended is basically about stakeholder engagement – probably intended as a proxy for direct public/patient involvement.

  • Recognising Health Overview & Scrutiny Committees (HOSCs - or Joint HOSCs) as having an explicit role as System Overview & Scrutiny Committees. In my opinion, the best HOSCs thought they already were!
  • Continuing the NHS Assembly. This is a curious one. Its website reveals a fabulously representative group of relevant and highly informed stakeholders, though with its heady collection of professors, Knights of the realm, Dames, and umpteen Chief Executives it sounds more like the text of a Gilbert & Sullivan patter song. It seems not to have done anything since 2019, so difficult to imagine what impact it can have.
  • Establish a Health, Wellbeing and Care Assembly. Now this could be interesting provided they are adequately resourced to do the consultative job at which they can be effective, and not be another ‘pretend they can take decisions when they can’t' exercise

And that’s it. Seriously, that is it!


There are a handful of references to the need for public and patient involvement, as in the recommendation to develop a new framework and contract for GP Primary care. But unless the Dept of Health and Social Care has been asleep at the wheel, they are surely onto that one anyway.

This is just one big missed opportunity.


One example is the Review’s approach to data and information. It is rightly a major focus, as the ease of working with data and information flows lies at the heart of the accountability conundrum.


It states (at par 2.44) that “There is a shortage of skilled professionals, including those who are expert at the cultural change that underpins digital transformation.” and recommends that NHS England should develop in-house skilled teams and help grow a greater capability at local levels.


Now these are the people who need to be brilliant at public and stakeholder engagement – who know how to involve users before designing systems and processes that won’t work, and who should work with NHS and Council Communications Teams to ensure internal staff as well as public/patients are helped to understand and work with new digitally enhanced services. Sadly, there is little recognition of the need to skill-up in such aspects.


Another example is the Review’s statement that there should be a “common approach to co-production” (Par 3.113). Excellent. But, unfortunately, this seems to be in the context of service providers and the ‘stakeholder’ community, whereas the opportunity to co-produce with patients and public is an even greater priority.

But enough of criticism. My focus on public engagement is a specialised one, and, for balance, we should acknowledge that the health establishment has given a warm welcome to the Hewitt Review. 


Of note is the support of the Health Devolution Commission - an independent cross-party and cross-sector body working to champion and support the successful implementation of devolved and integrated health and social care services across England. The box shows the impressive list of Hewitt recommendations it welcomes.


The Health Devolution Commission ‘welcomed’:-

  • six key design principles to underpin the new system 
  • a shift of NHS resources ‘upstream’ to support prevention 
  • a broad-based national Health, Wellbeing and Care Assembly 
  • a cross-government National Health Improvement Strategy 
  • a limit of 10 national health and care priorities for ICSs 
  • local ICS priorities to have equal weight to national targets 
  • subsidiarity, autonomy and self-improvement 
  • a Strategic Alliances for Children and Young People 
  • a new strategy for the social care workforce 
  • a new NHS financial framework for local accountability 
  • clarity on the oversight/accountability re CQC and NHSE 
  • new measures of ICS maturity to support development 

The Hewitt Review is clearly a step forward for the new system of NHS and Social Care in England, and its reluctance to acknowledge or tinker with the current arrangements for public and patient involvement may have arisen from one of two different perspectives:

  1. That it has little or no relevance or makes little contribution to the accountability of ICSs to local people.
  2. That current arrangements are working brilliantly, are well resourced and consistently securing successful public engagement.

I leave you all to decide which applies.



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