A population health management approach to ageing

In the latest in the series of blogs curated by the Clinical Policy Unit, a GP and freelance health consultant with a background in public health and clinical leadership, looks at the role of the GP in supporting people to live healthier lives, for longer:

Every GP rightly advises: “Don’t start with the solution, start with the problem you’re trying to fix”.

As we continue to look at ageing and society’s response to ageing, we should start by asking what exactly is the problem we’re trying to fix?  It’s not ageing itself, as that would require some rather tricky changes to the natural laws of physics or biology. It must be the effects of ageing on our minds and bodies and its impact on our daily lives we are seeking to address. So let’s work with that.

The good news is that while we currently can’t stop the physical or biological clock, there are things we can do to reduce the effects of ageing and its impact on our functioning and quality of life. We can maintain our health, fitness and resilience throughout life. We can significantly reduce the risk of diseases which are more likely to develop as we age. Lastly, once we develop diseases and disabilities during our life course, we can develop interventions which reduce the impact of those conditions on our lives and the services we use.

The trick here is recognising that while linked, these are fundamentally different problems, requiring different service responses.

In order to do this we need a population health management approach. To read more about this, see Greg Fell’s blogs: Population health management and Revisiting segmentation.

The National Association of Primary Care (NAPC) has developed a population health management approach as part of its Primary Care Home programme – a new care model that has over 200 sites across England and covers 16% of the population. The approach is based on two dimensions:

  • Life course – children and young people; working age adults and older people.
  • Need – generally well; long term conditions (LTCs) and complex needs.

Using this matrix we can identify three distinct population groups, with different needs and different models of care required to meet those needs:

People who are generally well

This cohort will benefit from primary prevention interventions to maintain mental, physical, cognitive and social health throughout their lives, such as excellent:

  • maternity care
  • childcare
  • education
  • family support
  • physical activity
  • employment
  • housing
  • social interactions
  • diet


  • avoiding smoking and drugs
  • safe alcohol consumption.

The actual interventions and delivery mechanisms will vary to some extent by life course and other social factors.

Identifying people who are currently well but at risk of developing LTCs will enable a more focussed response. This targeted approach might be at both the individual (known individual risk factors) and population levels (known risks in certain populations and communities).This approach will prevent or delay the onset of LTCs and their functional consequences.  For further information, see Sir Muir Gray’s blog A quest for clearer thinking on ageing.

People with long term conditions:

In addition to the primary prevention interventions above, this cohort will benefit from early identification and treatment of LTCs, personalised care planning, self-management support, medicine management and secondary prevention services.

For most, this will be a Disease Management type of care model with support to improve “activation” and self-management to stop or delay progression to complexity, frailty and functional impairment/ disability.

Older people with complex needs or frailty:

In addition to the interventions above this cohort require something quite special – integrated, holistic, personalised, co-ordinated care with a high degree of continuity.

Their needs are likely to be a mixture of physical, psychological, cognitive and social and will need to be brought together in the person’s own – according to their needs, values, goals and preferences –  care and support plan.

They are likely to require a Case Management approach with both proactive and highly responsive care when they have an urgent care need.

It is likely that a Multidisciplinary (Dream) Team (MDT) will be required at locality level (e.g. 30,000 – 50,000 population) which is both multidisciplinary and multiagency and involves non-professional peer support and voluntary sector support in addition to professional and statutory health and care staff.

This MDT would need to include an expert generalist clinician such as a GP or geriatrician who would work as part of the team specifically focussed on the holistic needs of the “older people with complex needs” cohort – likely to be about 1,500 people in a community of 50,000.

But while the clinical expert generalist is an important member of the MDT they are not necessarily the lead or the most important member. The MDT needs to be co-designed with users and carers, appropriately scaled and skilled, and commissioned to deliver the highest quality care which meets all the identified needs and priorities of this cohort.

Different challenges, different solutions.

I know we are up for the challenge, but are we up for the different solutions?

Dr Steven Laitner

Dr Steven Laitner is a General Practitioner with a Public Health and Clinical Leadership background.

As well as practising as a part time GP he is a freelance health consultant with his own consultancy company Programmes for Health which supports a range of healthcare commissioning and provider organisations.

Steven was one of the original architects of the Accountable Lead Provider model whilst working at the Department of Health, where he was also National Clinical Lead for Shared Decision Making.

He is currently supporting a range of organisations on developing accountable, integrated, programmes of care.

During 2016 Steven joined the National Association of Primary Care (NAPC) as a Clinical Advisor to their Primary Care Home (PCH) Programme.He has developed a keen interest in Population Health Management, in particular, Population Segmentation and Risk Stratification.

His work also covers new models of care delivery such as telephone triage, referral triage, self management support, care coordination, case management and care planning. He supports commissioners and providers to develop new programmes of care such as Musculoskeletal and Frail Elderly Programmes.

His clinical interests include primary care, frail elderly, care planning, self care support, GP access, patient leadership and shared decision making.


  1. Gerald Davies says:

    words, words, words. I am a 95 year retired and widowed aviator and over the last 2 years have developed heart problems, Meniers Disease, Nocturnal Problems with lack of sleep etc and all my medical requirements (apart from hospital) are provided my my G.P. His last home visit was over a year ago. NHS writes reams of ways it is improving services to war veterans like me, but what should have happened was an assessment of my healthcare needs and regular visits by the GP and his staff. Instead of which I have to write and telephone each time. I never get regular visits or any acknowledgement of my needs. Several NHS fragmented services are involved, apart from the surgery, but I FEEL FORGOTTEN, NEGLECTED AND DISCRIMINATED AGAINST and have to be thankful for the excellent family support. It isn’t more words I need but action in my own home and more prevention rather than attempted or failed cures.

    • NHS England says:

      Hi Gerald,

      Thank you for your comment. If you are unhappy with the care or service you have received it is important to let us know so that we can improve. There is information on ways to provide feedback or make a complaint about NHS services on the contact us page:

      Kind regards
      NHS England

  2. Julie McLean says:

    Why aren’t people visiting the UK using travel insurance to cover any medical treatments ?
    just like we do when needing medical treatments abroad.
    Surely this would help the nhs financial issues.

    JB McLean

  3. John King says:

    Developing a PCH centred funding bid for simulation-based Learning Health Systems at moment. Embodies all the key NAPC population health management principles and all cohort driven. Key is using LHS approach to ‘activate’ the whole community in driving integrated care. Interested to compare notes. (PS I do remember your ALP model at inception!)