Population Health and the Population Health Management Programme

Population Health

Population Health is an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population.

This includes focusing on the wider determinants of health – which have a significant impact as only 20% of a person’s health outcomes are attributed to the ability to access good quality health care – and the crucial role of communities and local people.

Population Health Management is an emerging technique for local health and care partnerships to use data to design new models of proactive care and deliver improvements in health and wellbeing which make best use of the collective resources.

What is Population Health Management?

Our health and care needs are changing: our lifestyles are increasing our risk of preventable disease and are affecting our wellbeing, we are living longer with more multiple long-term conditions like asthma, diabetes and heart disease and the health inequality gap is increasing.

A new approach – called Population Health Management (PHM) – is helping us understand our current, and predict our future, health and care needs so we can take action in tailoring better care and support with individuals, design more joined up and sustainable health and care services, and make better use of public resources.

It is how we use historical and current data to understand what factors are driving poor outcomes in different population groups. It is how we then design new proactive models of care which will improve health and wellbeing today as well as in 20 years’ time. This could be by stopping people becoming unwell in the first place, or, where this isn’t possible, improving the way the system works together to support them.

PHM is a partnership approach across the NHS and other public services including: councils, the public, schools, fire service, voluntary sector, housing associations, social services and police. All have a role to play in in addressing the interdependent issues that affect people’s health and wellbeing.

For example, adults and children who live in cold, damp housing may be more likely to develop respiratory problems over the next 20 years because their lungs are affected by the mold spores in their home. If we improved their housing now by working with partners such as local councils and housing associations, they may not end up with various health conditions in the future which can result in poor quality of life (conditions like asthma, chest infections, and other respiratory problems) and could avoid the need for multiple health and care services.

In some areas PHM is already working well and we are currently spreading learning and development across the country in a Development Programme, run by NHS England. In Lancashire and South Cumbria for example, they linked data on people living with long term conditions and mobility issues, who have high numbers of GP and A&E appointments and are living in households with assisted bin collections. This enabled the team to find people living with frailty who were in need of more proactive personalised care to keep them living well at home. The team arranged visits, home adaptations were  made and social prescribers connected people into support groups in the community to reduce social isolation.

In Berkshire West, analysis pinpointed poorer outcomes in their Nepalese community with diabetes and a lack of uptake in the standard NHS offer. Primary Care Networks in the area are now offering longer consultations including group consultations in the evening, with more information about diet and nutrition, and social prescribers are connecting people into community health coaching. This is providing this population group with better personalised care to stay well, active and independent.

Read more about how PHM works in practice.

What does it mean for the public?

For the public, it should mean that health and care services are more proactive in helping people to manage their health and wellbeing, provide more personalised care when it’s needed and that local services are working together to offer a wider range of support closer to people’s homes.

Why is it important for integrated care and systems?

As set out in the NHS Long Term Plan, local NHS organisations will increasingly focus on population health and local partnerships with local authority-funded services, through Integrated Care Systems.

Therefore PHM is the critical building block for integrated care systems and enables Primary Care Networks (PCNs) to deliver with their local partners true Personalised Care.  Together, the three Ps (PHM, PCNs, Personalised Care) form a core offer for local people which ensures care is tailored to their personal needs and delivered as close to home as possible.

PHM enables systems and local teams to understand and look for the best solutions to people’s needs – not just medically but also socially – including the wider determinants of people’s health.

Many people need support with issues such as housing, employment, or social isolation – all of which can affect their physical and mental health – these solutions are often already available through, or better designed with, local people, the local council or a voluntary organisation.

Better partnership working using PHM to join up the right person with the right care solution helps us to improve outcomes, reduce duplication and use our resources more effectively.

What does it mean for people working in systems?

For doctors, nurses, social care, therapists and other frontline staff the PHM approach enables care and support to be designed and delivered to meet individual needs, it means less duplication and a reduction in workload pressures as it ensures the right care is given at the right time by the right person. Health and care professionals are being empowered to redesign their services, to reduce the reactive episodic nature of their workload and take a more proactive approach to supporting their local population live healthier lives.

For local councils, health care managers and clinicians who commission services greater understanding of the local population will ensure they can better predict what residents need and ensure health and care providers work together taking collective responsibility for the care and support offered to improve outcomes.

How can I get involved?

If you work in a system please sign up here to our on line PHM Academy to keep up to date with all the latest PHM information and resources.

The PHM Academy is the most up-to-date and inspirational hub of information around PHM techniques and on-going work for the NHS and its partners.

Any staff member within a health and care system can register to join by e mailing: england.stgphm@nhs.net.

It can help systems:

  • Get started with PHM
  • Learn about the core PHM capabilities- Infrastructure, Intelligence and Interventions- to support maturity in line with the PHM Maturity Matrix
  • Use on-line e-learning materials to support your PHM developmental journey, including: case studies, webinars, podcasts, videos, guides and toolkits
  • Read case studies from the national PHM Development Programme
  • Compare and contrast with PHM work in other countries
  • Link to the central NHS PHM team for help
  • Engage in peer learning by talking to other systems – sharing local best practice and asking practical questions to learn from elsewhere in the country
  • Access pre-reading and remote learning for the PHM Development and ICS Accelerator programmes.