By Dr Jason Broch

Last month, I had the privilege of spending the afternoon with the first cohort of the Yorkshire & Humber Population Health Management (PHM) academy. As well as hearing about their projects and seeing the enriched thinking around PHM, we spent some time exploring current thinking about PHM, how it fits with current NHS strategy and the type of skills and capabilities we will need in the future.

The Five Year Forward View (2014) paved the way for integration to become a key objective; integration between Health & Care commissioning, integration of provision and development of New Models of Care.

This was further developed in the NHS Long Term Plan (January 2019), in which key priorities were identified along with 5 principles:

  1. Doing things differently
  2. Preventing illness & tackling health inequalities
  3. Backing our workforce
  4. Making better use of data & digital technology
  5. Getting the most out of taxpayers’ investment in the NHS

Emerging from these strategies is an enforced concept of ‘Place’ with the idea that this can be different for different functions. At a very local level, the development of Primary Care Networks (PCNs) – consisting of General Practices working together to support ‘Neighbourhoods’ of around 50k patients – developing new services based on local need as well as joining forces with other community organisations, both in the statutory and non-statutory sector. Groups of PCNs, maybe in a city, CCG or Local Authorities will work with the other statutory providers such as acute hospitals, councils and mental health trusts as part of a ‘place’ or  integrated care provider (‘ICP’). The ICP’s will work together on a bigger geography as part of Integrated Care Systems (ICS), which have been born out of the old STPs (sustainability and transformation partnerships). Citizen and system information will be used at each level differently with the aim of providing the best possible support and care for individuals.

The strategic direction is to develop a Population Health Management (PHM) approach to health and care. Although this sounds new, the approach builds on a range of initiatives already in place across many health economies such as risk stratification, integration of community teams, development of ‘Primary Care Networks’ and ‘Year of Care’ type approaches. The aim is to:

  • design health & care around the needs of people rather than their diseases, shifting to an emphasis on prevention;
  • connect better with people so they become proactive in their own care;
  • shared system understanding of how resources are used to promote integration and remove duplication;
  • And fully utilising informatics solutions to direct care interventions to where they are most needed, and better support professionals in joint working.

There are many definitions of PHM, but all involve using shared information better to ensure a proactive application of strategies and interventions to defined groups of individuals across health & care, to improve the health & wellbeing of the individuals within the group with the most efficient use of resources.

NHS England currently has a programme to help localities develop their understanding. The emphasis in PHM is to move away from different organisations providing different services and create a shared ambition within a place, focused on achieving outcomes for defined populations in an integrated manner.

This means provider organisations in health & care taking on more responsibility for shaping services and care pathways.

The whole approach is based on using information more effectively and is achieved through developing new capabilities.

The first stages are about defining and understanding the populations, using parameters such as ‘common need’, ‘deprivation measures’ and other attributes.

1.  Population Segmentation

In order to use intelligence effectively, it is important to understand the people in the cohort better. Evidence suggests that although people can move between segments, it is important that the way people are segmented is mutually exclusive i.e. people are only in one segment at a time.

Examples of segments could be:

  1. Health population (perhaps broken down further by age)
  2. People with long term conditions (again segmented further by age)
  3. Frailty
  4. End of life

At a high-level, a place will need to agree overarching outcomes that should be achieved for the different segments as well as understanding the capitated budget available for achieving them.

2. Population intelligence

There needs to be a more robust understanding of both the needs and inherent risks within a population segment. This will go beyond current methods of identifying health gaps and risk stratification. It will need to segment the groups further to help identify the type of interventions that will be of benefit. It is also important to appreciate that in terms of wellbeing / health outcomes, healthcare contributes about 20%, at best, to achieving this. For this reason, intelligence needs to go beyond traditional NHS information and must incorporate more holistic sources, including wider determinants data. The information needs to be used safely, so protecting it with robust information governance is essential in maintaining the public’s trust. The key is to use the information about individuals to identify needs and patterns, which in turn can be used to create insights that will improve the personalised care of individuals, including proactive measures to support prevention of illness or disease progression.

3. Manage Care with People

Care should be ‘planned’ wherever possible, so taking the approach of a ‘care plan’ in long term conditions with access to multidisciplinary professionals as appropriate. Best practice guidelines should help reduce variation in care provided and ideally care should be supported by decision support and knowledge management systems. The ambition is for ‘activated’ people to manage their own care and be supported to make better health and wellbeing choices and use a ‘Prevention approach’ to prevent disease or slow its progression. Care may be supported by newer technologies to improve access, e.g. patient held record apps, remote consultation technology or integrated medical devices such as activity trackers.

Key features of care under PHM are:

  1. Targeted programmes of care – this may include patient education programmes (egg in diabetes), smoking prevention or weight management that are designed in a way to have maximum impact based on the population segment targeted.
  2. Coordinated use of community assets – as opposed to a purely medical model, PHM requires a more holistic model, which may use local community assets such as local charities, places of worship or green space. Local assets may be used to support non-medical aspects of care such as shopping support or loneliness services.
  3. Case management – the coordinated management of people with complex needs is crucial in PHM. Those with the greatest risk should be provided with bespoke care packages and teams, including their carers. This should minimise unexpected events and allow planning for emergency situations.


4. Outcomes Measurement and continuous improvement

Moving towards outcomes-based systems means measuring the right things. Currently not all the components of outcome are measured in a patient record. These will need to be developed in areas such as patient experience and satisfaction. A robust integrated record will allow an understanding of care received along with associated costs. As outcomes are reviewed, providers will be in a position to understand how pathways and systems can be continually improved through quality improvement methods.

These ideas are permeated through the learnings in the Y&H PHM Academy, which is ensuring our ICSs have the people skills necessary for delivery of the Long Term Plan. The infrastructure provided by the Yorkshire & Humber Care Record will facilitate better care and provide the necessary information to support a PHM approach, especially using the PHM analytics system that we have created locally. The Academy is making sure that its fellows will know how to use the tool to ensure PCNs, ICPs and ICSs have the intelligence they need.