The great Population Health Management opportunity is here and now

PHM is a data driven approach to planning and delivering proactive care to achieve maximum impact within available resources.

While PHM is not a new concept, its application to here and now (as opposed to long term challenges like smoking cessation and such) is a fresh approach to solving some of the NHS’s most immediate challenges. By proactively anticipating and managing undesirable events, such as emergency hospital admissions, Emergency Department attendances or falls we can help to prevent admissions in the first instance and improve resource planning and capacity when admissions are necessary.

We share three key steps to adopting PHM as the methodology to address some of the NHS’s most immediate challenges:

1. Use data to anticipate unplanned care

The journey that led to a 999 call leaves a bank of clues for us to examine and address, and we have the data to be able to do that – some Places and Systems (where ‘System’ is an Integrated Care System (ICS) of approximately 500k-3m people, and ‘Place’ is an entity within that System) are already underway with this analysis.

We recently worked with a Primary Care Network in the UK who found that a quarter of their elderly patients had been admitted to hospital in an emergency at least once over the last year, with an average cost of over £3,000 per admission.

By applying PHM data analytics methods such as segmentation and risk stratification, they found common factors that significantly increased patients’ risk of emergency admission, for example, living alone, suffering from frailty or dementia, or having an elderly carer.

These patients were prioritised for a clinical review ahead of winter to put individual admission avoidance plans in place. Engagement continues with the voluntary sector to see how they could support the elderly in the community to avoid hospital admission.

Other Places and Systems nationally could also apply PHM methodologies to identify patients that are most likely to be admitted to hospital and proactively manage this cohort to enable patients to remain healthier at home. In addition to decreasing pressure on hospitals, it also has a significant positive effect on the individual and their family, for whom being in hospital can be a stressful and miserable experience.

2. Involve partners across the system or place

Healthcare doesn’t start or stop with one organisation. Furthermore, the support and services provided by non-healthcare organisations can have greater impact on our health and wellbeing than seeing a doctor. Involving partners from across the wider public sector, voluntary organisations, and anchor institutions (such as schools and large employers) can help address this.

For example, a partnership of local secondary schools, primary care, children and adolescent mental health provider, and local voluntary sector organisations, focused on children and young people who are struggling with their mental health.

By working together and sharing data and insights between organisations, the partners could fully appreciate the extent of the crisis with children’s and adolescent mental health, get a holistic view of children’s and families’ needs, and come up with solutions that took into account multiple wider determinants of health.

Together they designed a number of local initiatives, including peer support in schools, counselling based in a youth café, and partnerships with private providers for children’s psychological support from the GP practices.

Building cross-organisational place-based teams that focus on population segments is an effective approach to improving patient care and efficiency of services. For example, regular touch points between Primary Care Children’s and Maternity Leads, Paediatric A&E Consultants, and Health Visiting teams are proving effective in improving quality of care for children and decreasing pressure on A&E in a London borough.

3. Ask people what they need

The current model of healthcare is focused on fixing immediate health problems. For many patients, these are not the top priority, especially now when the cost of living crisis is making things more difficult for many. Often asking people what they need and want, fundamentally changes the intervention.

We recently worked with a Public Health department in a Local Council who ran a PHM working group that was originally focused on obesity, mental health, and diabetes – traditional public health concerns.

Community engagement showed that what worried residents the most was food insecurity and cost-of-living challenges, which were directly contributing to poor health. One resident explained that they made a choice of buying cheaper frozen processed meat in bulk over better-quality healthier foods, for example a large pack of sausages rather than one small chicken breast. Residents also made it clear that they didn’t want to rely on free food.

The Partnership (which included the Local Authority, ICB and voluntary sector organisations, amongst others) secured funding for a Community Larder that ran in one of the more deprived areas until March 2023, which operated on a subscription ‘pay what you can’ basis with operational costs and procurement subsidised by the Partnership. The larder was also a hub for health and social care services, including diabetes management and mental health support, and cooking education to address the impact of nutrition on preventable illness.

By engaging directly with residents, the Partnership managed to address their concerns and build trust as well as put an intervention in place that would improve the health of the local population.

Other Systems and Places used resident engagement to manage waiting lists and optimise primary care clinic times to decrease the number of missed appointments – both key concerns for the NHS.

Opportunity lies in optimising collective resources

Using data to anticipate unplanned care, involving partners from across the wider system, engaging with key stakeholders, and asking the recipients of care what they really need – these are the key tenets of population health management.

By targeting the root causes, and securing stakeholder buy-in from the start, health systems can invest their limited resources into the activities that make the biggest difference.

Population Health Management is a key tool that can help to reduce the winter pressure and ongoing pressures on the NHS, and even disrupt the cyclical problems faced each year, paving the way for better and healthier winters to come.