Our response to the Hewitt Review: Call for evidence into the oversight and governance of Integrated Care Systems (ICSs)

Our submission to the consultation, January 2023

Optometrist at work

The Rt Hon Patricia Hewitt was appointed in 2022 by the Secretary of State for Health and Social Care to consider the oversight and governance of integrated care systems (ICSs). The review considers how the oversight and governance of ICSs can best enable them to succeed. It has a particular focus on real time data shared digitally with the Department of Health and Social Care, and on the availability and use of data across the health and care system for transparency and improvement.

A call for evidence invited views from across the health and social care system, as well as from patients, the public, and the wider voluntary sector.

Our response to the call for evidence

Optometrists are part of our NHS primary care workforce who provide skilled clinical care examining a patient’s eyesight (refraction) to detect the need for spectacles and eye health ‘screening’ to detect eye disease as well as underlying health issues such as diabetes, hypertension, high cholesterol and some cancer or tumors. Optometrists will prescribe glasses or contact lenses based on the outcome of a patient’s sight test.

Given our aging population and increasing long term conditions associated with lifestyle and health inequalities the role of primary care optometry as the first point of contact across the whole of the eye care pathway into secondary care is vital for both early detection and prevention.

Q1) Please share examples from the health and care system, where local leaders and organisations have created transformational change to improve people’s lives.

There are many excellent examples of where local health leaders have worked across the sector to design and deliver new pathways of care and service models. In eyecare two examples include the Minor Eye Condition Service (MECS) and the COVID-19 Urgent Eyecare Service (CUES).

The MECS service provides optometry led assessment and treatment for people with minor eye problems without the need for a GP referral (self-referral).

During the COVID-19 pandemic the CUES service was created to offer diagnosis and treatment for patients with urgent eye conditions, again without the need for a GP referral or appointment.

Where commissioned both these services support the aim of delivering more care closer to home, whilst also reducing pressure on general practice and secondary care as well as improving workforce productivity.

Both services clearly demonstrate the untapped opportunities for utilising the clinical skills of optometrists to greater effect in order to reduce backlog in secondary care and freeing up appointments in general practice.

Greater Manchester have been at the forefront of developing and rolling our urgent eye care services, engaging and involving local leaders in design and decision making.

In 2020 the National Eye Care Recovery and Transformation Programme was established to create a new integrated primary eye care service. Through this Optometry First was designed and developed as part of the wider eyecare delivery framework with the aim of reducing pressure on secondary care services and providing more responsive care closer to home ie led through the ‘optimal use’ of high street or community based optometry practices. Optometry First is currently being tested, with the view to national role out in three ICS sites and it will be important for ICSs to review these test sites to determine impact and national roll out.

Q2) Do you have examples where policy frameworks, policies and support mechanisms have enabled local leaders and, in particular, ICSs to achieve their goals? This can include local, regional or national examples.

Local Optical Committee (LOCs), are the formal representatives for all GOS contractors to work with primary care on matters relating to NHS optical services. LOC’s will continue to be crucial at ICS and place level to ensure consistent, safe and high quality delivery of primary eye care services as well as advising and leading innovation and transformation at regional/local level.

ICBs have only become fully operational recently so impact and performance is yet to be determined. However the strategic aims of ICS – broadly (health outcomes, health inequalities, productivity and value for money, prevention, wellness and independent living and supporting social and economic development), are all themes where primary eye care providers can contribute to these objectives.

Furthermore, the intent of the ‘Triple Aim’ to ensure greater collaboration and decision making is welcomed to help ICSs achieve their objectives of greater integration, more emphasis on preventative care and better utilisation of primary care. Again, all of which optometry plays and important and arguably are currently under utilised role.

It is our view that primary care optometry has a key role to play in working with ICSs to deliver against the 2023/24 NHS Operating Framework and planning guidance and the 2023/24 national NHS objectives including:

  • Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals
  • Continue to reduce the number of patients waiting over 62 days
  • Increase the percentage of patients that receive a diagnostic test within six weeks in line with the March 2025 ambition of 95%
  • Increase percentage of patients with hypertension treated to NICE guidance to 77% by March 2024
  • Increase the percentage of patients aged between 25 and 84 years with a CVD risk score greater than 20 percent on lipid lowering therapies to 60%
  • Continue to address health inequalities and deliver on the Core20PLUS5 approach

Q3) What do you think would be the need for ICSs and the organisations and partnerships within them to increase innovation and go further faster in pursuing their goals?

The COVID-19 pandemic signalled new opportunities to innovate at pace and scale that we must make sure are not lost in terms of learning, best practice and flexibility. ICPs should ensure that innovation and research is clearly visible within their integration plans and that ICSs see design, adoption and public and patient participation in research as a priority, utilising existing networks and systems such as AHSCs, AHSNs and specialty based networks as well as exploring and developing new opportunities to innovate and conduct ‘firsts’ in research and ensuring there are pipelines to scale innovation and communicate research outcomes for the benefit of all.

One of the main barriers to innovation in eyecare is the lack of IT connectivity, prioritising a IT strategy is something we feel is crucial for ICSs to deliver much of the local transformation and improvement programmes.

Q4) What policy frameworks, regulations or support mechanisms do you think could best support the active involvement of partners in integrated care systems? (250 word limit) Examples of partners include adult social care providers, children’s social care services and voluntary, community and social enterprise (VCSE) organisations. This can include local, regional or national suggestions.

There are already a number of formal and informal mechanisms and networks through which ICSs can engage with the wider system, sector bodies, stakeholders, staff, patients and the public. In eye care, as previously mentioned the LOCs provide a useful ‘go to’ platform through which to engage on eye care issues. In our view the role of Primary Care Networks (PCNs) and Local Medical Committees (LMCs), both are well established will continue to play an important role in ensuring effective and appropriate representation and co-design.

However, we are concerned that there will continue to be lack of parity of representation and voice within the system. Historically optometry has often not been represented and it is important that ICSs ensure effective representation across all parts of primary care not just general practice.

The recommendations from Clare Fuller Stocktake, are in our view a really important to both the future-proofing of successful locally managed systems and evolving PCNs into integrated neighbourhood teams. We welcome the involvement of Ruth Rankine and her team at NHS Confederation in supporting ICSs the delivery of much of this work and particularly in the development of a clear plan to support the sustainability of primary care and the translation of the recommendations around a effective integrated primary care into a reality across all neighbourhoods, tackling those gaps in provision in communities are certain patient groups.

The mechanisms and frameworks are in place already for ICSs to fully engage with partners and wider stakeholders. As before, we urge full ICS engagement with the full spectrum of primary eyecare organisations, and in particular LOCs and their associated primary eyecare provider organisations.

Q5) What recommendations would you give national bodies setting national targets or priorities in identifying which issues to include and which to leave to local or system level decision-making?

There are clear national targets set at a national level that remain highly relevant to local decision making and service delivery.

The recent Government Plan for Patients is, in our view an important policy document that ICSs can use as a means to measure impact, success and share best practice, reducing variation of care and clearly demonstrating better patient outcomes and improved performance and productivity through better partnership working. It is important to ensure the aims within the plan, are not lost and form a visible part of local priority and target setting.

The 2023 NHS Long Term Plan refresh will also be a key to informing local objective setting. Secondly the themes contained within the NHS operating framework are themes that we would welcome ICSs taking into account during its planning processes. For example:

  • How local systems and providers be enabled to improve the health of patients and their communities and reduce health inequalities though the reduction of variation and a focus on prevention
  • Better use of best practice and evidence?
  • Working collaboratively to ensure our healthcare workforce has the right knowledge, skills, values and behaviours to deliver accessible, compassionate care?
  • Optimising the use of digital technology, research and innovation?
  • Delivering value for money and ensure NHS resources are used effectively and appropriately for the greatest impact?

In our view it is vital that ICSs focus on examples of clinical practice and service design that already work with the view to wider implementation rather than the development of more pilot or proof of concept initiatives. The eyecare example already given around MECS and CUES is a prime example of tried and tested good practice that has been rolled out at scale.

The General Ophthalmic Services (GOS) is a good example of a service that works best when delivered on a national basis. Sight testing is performed by optometrists and provides around 13 million episodes of NHS funded care per year. This service provides excellent value for money and provides the key role in the early detection, diagnosis and prevention space as the service covers both the testing of sight and the ‘screening’ of eye health. GOS is responsible for the identification of nearly all patients with glaucoma, an often-symptomless disease that otherwise would not be detected until the disease was very advanced. It also ensures those eligible patients receive NHS funded sight tests and vouchers towards spectacles.

Q6) What mechanisms outside of national targets could be used to support performance improvement? (250 word limit) Examples could include peer support, peer review, shared learning and the publication of data at a local level. Please provide any examples of existing successful or unsuccessful mechanisms.

It is important that ICSs don’t lose the ‘library of knowledge’ and best practice realised through CCGs. It is also important that local systems have a good understanding of local stakeholders and influencers to ensure a collegiate approach to service redesign and improvement. Mechanisms could include:

  • Appropriate information and reporting flow between ICS and ICPs
  • Feedback from sector speciality bodies such as LOCs, PCNs etc
  • Effective utilisation of social media and networks (virtual and physical)
  • The use of charities and patient forums to socialise ideas and co-design
  • A ‘hub’ or portal for case studies, best practice and patient stories such as NHS futures
  • A strong commitment to education and training opportunities utilising existing CPD and training packages available from system partners

Q7) Do you have any examples, at a neighbourhood, place or system level, of innovative uses of data or digital services? - Please refer to examples that improve outcomes for populations and the quality, safety, transparency or experience of services for people; or that increase the productivity and efficiency of services.

At present primary eye care services are not universally part of the national NHS electronic referral system. This continues to cause issues for not only patient outcomes but efficiency of the system due to the lack of connectivity between primary and secondary care. It also puts unnecessary clinical and administrative burden on general practice. Lack of connectivity can lead to delayed diagnosis, unnecessary referral and lack or patient information when the patient comes back into primary care. In summary it is one of the main barriers to addressing the long standing issue of Ophthalmology backlog and the delivery of outpatient transformation as it hinders the safe transfer of care between professionals.

Whilst there are a few pockets of good practice it is our view ICSs need to push the issue of electronic referrals in eye care at a national level.

Q9) How could the collection of data from ICSs, including ICBs and partner organisations, such as trusts, be streamlined and what collections and standards should be set nationally?

In eyecare the lack of IT connectivity is one of the most significant issues as it impacts negatively on the ability for optometrists to effectively treat patients as there are gaps in knowledge of the patient’s referral and treatment journey.

Secondly, the current process for the collection and sharing of data across the system is complicated. There are no measures that set out what data is collected, reported and what data is omitted. Given the wealth of data collected in healthcare there seems so be a lack of consistency and understanding of the type of data that is collected, what is useful data or not and why and how it is used in terms of performance monitoring and academic research.

ICSs need to ensure with secondary care there is appropriate proportional data collection using a set of predefined measures and metrics that allow meaningful comparison between ICSs. Without these two key elements we are unclear how success and impact could be accurately benchmarked and measured.

Q10) What standards and support should be provided by national bodies to support effective data use and digital services?

There a number of key measures we feel ICSs should deliver to be effective including:

  • Standardisation of data collection and reporting processes
  • Standardisation on the metrics and measures collected to ensure validity of outcome reporting and avoidance of local variation
  • A limitation on the type of data collected (linked to improvement priorities and standard outcome reporting) that are required to enable meaningful comparison between ICSs and ICS areas
  • Avoidance of unnecessary data collection
  • A plan for utilising data more widely eg for academic research
  • Ensuring the roll out of digital services are standardised across the system to ensure connectivity, interoperability etc
  • Ensuring digital systems procured are affordable in terms of maintenance and renewal

Q11) What do think are the most important things for NHS England, the CQC and DHSC to monitor, to allow them to identify performance or capability issues and variation within an ICS that require support?

ICSs are still relatively new and still in the process of establishing their priorities and process. Within this we also recognise there is currently some variation in capacity, capability and performance between ICSs exacerbated by the same variation in local trusts and local authorities.

It is important therefore that an appropriate balance is achieved between regulation, national accountability and autonomy to act at local level. We are keen to explore whether there are any principles we can identify to help set that balance.

Q12) What type of support, regulation and intervention do you think would be most appropriate for ICSs or other organisations that are experiencing performance or capability issues?

As per the current role of NHS England, it should continue to support NHS organisations to work in partnership to deliver better outcomes for our patients and communities. Alongside the DHSC should continue to set the direction of UK health services as well as acting as the legislative and policy guardians of our health and care system. Both bodies should be there to provide an experienced supporting hand if ICSs run into difficulties with access to acknowledged experts in the field and in the shorter term support ICSs until they have established their own expertise at the highest level.

We would expect there to be a continuation of the collection and reporting against national data sets to enable regional comparisons and targeted support. Patient feedback should also continue to be held nationally as should financial reporting data.

Key policy priorities specifically workforce recruitment and retention (inc training), IT strategics and research and development should be covered by some degree of national oversight.

Q13) Is there any additional evidence you would like the review to consider?

AOP response: No