In order to meet the vision of the Five Year Forward View (FYFV), local health systems will need to move to more proactive joined up care wrapped around patients, away from a reactive system where patients who don’t need to be in hospital are cared for in their own homes, where patients who frequently use A&E rather than waiting for a GP appointment can be seen more effectively in primary care and by pharmacists, and patients are empowered to look after and maintain their own health and independence. Population Health Management is an approach aimed at improving the health of an entire population and improves population health by data driven planning and delivery of care to achieve maximum impact for the population.
To truly understand the right intervention for patients, systems will need to deploy rigorous population health management to ensure that care is focused on what people actually need, not on what organisations can or want to provide, and that care is increasingly focused earlier in the patient pathway – less in the hospital, more in the community, and more targeted to prevention to achieve the triple aim and reduce health inequalities. In a nutshell to support systems transforming care for the population using data led approaches.
This proactive integrated approach to care will require health systems to deploy population health management capabilities, which enable them to have a deep understanding of their population cohorts across the life course, to better predict upstream activity, to enable the implementation of opportunity analysis and automate pathways. The data that flows from the patient record will also enable targeted and focused design care models and interventions that empower clinicians to target those who are most impactable.
The Health Systems Support (HSS) Framework provides a quick and easy route to access support services from innovative third party suppliers at the leading edge of health and care system reform, including advanced analytics, population health management, digital and service transformation. It can be used by any NHS organisation, including NHS Trusts, Clinical Commissioning Groups (CCGs), national Arm’s-Length Bodies, local authorities and a wide range of public sector bodies where they are supporting Integrated Care Systems (ICSs), Sustainability and Transformation Partnerships (STPs), or health and social care in general.
The Framework focuses particularly on services that can support the move to integrated models of care based on intelligence-led population health management. This includes new digital and technological advances that help clinicians and managers understand a population’s health and how it can best be managed.
ICSs and STPs can use the HSS to access innovative technologies and digital vendors as well as experienced development partners and coaches, to help develop and deliver population health management capabilities and drive forward system reform.
The framework has been structured around three areas:
- Infrastructure: encompassing Electronic Patient Records and place-based digitalisation; local health and care records across different care settings; and primary care IT support and cyber security;
- Intelligence: targeted population health analytics and digital tools for system modelling, actuarial assessment, planning, research, risk stratification and impactability modelling, and clinical decision support tools;
- Impact and Intervention: transformation and change support; patient empowerment and activation (including self-care support, personalisation, assistive technologies and remote consultations); demand management and capacity planning support solutions; system assurance and provider modernisation; and medicines management support.
The suppliers on the framework have passed rigorous selection criteria to ensure their products are of a high quality, their prices fair and their financial position stable. The framework will be refreshed regularly to ensure it stays current and includes the latest innovative products, services and suppliers.