Population Health Management

People’s health is changing, and care needs are evolving. People are living longer, but with more years in poorer health and it is increasingly common for people to have two or more long term health conditions. We know that health is determined by an interaction between individual characteristics, lifestyle and the physical, social and economic environment – the wider determinants of health.

You can find more information in our population health management guidance document.

Population health management and integrated care systems

The health and care system will need to be more joined-up and proactive in responding to that change. Integrated care systems (ICSs), place-based partnerships and integrated neighbourhood teams offer a renewed opportunity for the NHS to focus on prevention and integrated care: integration between primary and secondary care, physical and mental health and between health and social care.

Population Health Management (PHM) will be a core enabler and function of integrated care systems in helping drive a data led focus on person-centred care.

It can help local integrated teams to reduce health inequalities and offer targeted proactive, personalised, and preventative healthcare for every community.

The use of joined up data across local health and care partners and techniques like population segmentation and risk stratification can offer deeper insight into the holistic needs of different population groups and the drivers of health inequalities. Embedding this approach across all integrated care systems will transform the way we work and the way we care for people.

You can find resources and case studies for health and care professionals in Integrated care systems on the Population Health Academy on Future NHS, sign up for free.

If you’re new to PHM, NHS England’s online learning course ‘Introduction to PHM’ offers accredited on-going professional development.

PHM is a way of working built around three key pillars: Know, Connect, Prevent.


Evidence and knowledge are fundamental to how we think differently about the care we provide for individuals and communities. The Global Burden of Disease study (2019) highlights the major conditions that are collectively the greatest contributors to ill-health and early death; things like cardio-vascular disease, musculoskeletal disorders, cancer, mental ill health, dementia and chronic respiratory disease.

There are commonalties between these conditions and they share similar causes: risk factors like smoking and obesity, lifestyle factors and living conditions like employment, housing, education and access to green space. If integrated care systems are to understand how best to focus on upstream prevention and address the causes of the causes, they will need to share data and insight across their partners to build a holistic view of people’s needs and identify the full range of risk factors driving poor health outcomes in different population groups.

This will help us to recognise where best to focus collective resources to accelerate prevention programmes, tackle health inequalities and deliver personalised care.


The shift from competition to collaboration, from silos to system working is fundamental to delivering a more joined up integrated care service. By connecting and coordinating care across health, social care, public services and the voluntary sector we can ensure people receive the right service at the right time, from the right people. The move towards population health management will offer insight into how multi-disciplinary teams can more efficiently work together to create a more personalised offering that responds to what matters to people, not what is wrong with them.


Population health management aims to shift the focus from reactive care to proactive, preventative care – an approach that informs new models of sustainable integrated care.  By understanding the drivers of ill-health and inequalities we can predict who might be at risk in the future. Effective prevention models in primary care, in hospitals and at home can help to improve the lives of people living with conditions such as respiratory disease, diabetes, heart disease and cancer and delay the onset of future ill-health.

By supporting people to live their healthiest lives, based on what matters to them, we can ensure that every contact counts and every intervention is tailored. This leads to greater job satisfaction for us all and better health outcomes for everyone.

Population health management is a critical function of our new integrated care systems and the foundation to building a healthier future together.

Health and care professionals such as GPs, community nurses, allied health professionals, social prescribers and public health specialists are already using population health management  to deliver proactive, personalised, preventative care.

Find out more about how you can use PHM in your work on the Population Health Academy.

Request access to the PHM Academy


    For more information on PHM please email england.phmsupport@nhs.net.

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