What is Population Health Management (PHM)?

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.

Population health is one of our core strategic aims for integrated care systems (ICSs); to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population, with a specific focus on the wider determinants of health (things like housing, employment, education).

Population Health Management is a way of working to help frontline teams understand current health and care needs and predict what local people will need in the future.

This means we can tailor better care and support for individuals, design more joined-up and sustainable health and care services and make better use of public resources.

PHM uses historical and current data to understand what factors are driving poor outcomes in different population groups. Local health and care services can then design new proactive models of care which will improve health and wellbeing today as well as in future years’ time.

Population Health Management and health inequalities

Population Health Management focuses 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. Local health and care systems have started to use data to design new models of proactive care and deliver improvements in health and wellbeing which make best use of their collective resources.

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 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 future years because their lungs are affected by the mould 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, helping to reduce health inequalities.

How PHM has helped during the pandemic

The coronavirus (COVID-19) pandemic has further highlighted the known link between poorer health outcomes, ethnicity and deprivation. Integrated care systems, working with the local authority and the voluntary sector, have used PHM to identify people who need more support and those with the most complex needs within their localities, so that efforts can be targeted to protect certain populations through personalised care models, public health advice, testing and vaccination programmes.

As services restart after being paused during the pandemic, health and care systems are using PHM to identify those with the greatest needs who have been waiting for appointments and procedures.

How PHM is helping to reduce the elective wait

In Surrey, the ICS worked with health services in Guildford and Waverley using a PHM approach to identify almost 3,000 patients who were aged over 65 and on four or more elective waiting or follow-up lists. With multiple teams and providers caring for these individuals in a fragmented way, the estimated cost of care for these individuals was £19 million per year.

The ICS partners, including GPs and the hospital, worked together to restore services in a more joined up way for these patients who needed long-term specialty care and mental health support post-COVID.

After identifying that the care provided to this group who had complex health and care needs was often uncoordinated, a proactive integrated care hub was established to offer a wide range of services. This meant people could be seen by multiple specialists at one time, often virtually, improving their patient experience, reducing the need for multiple visits to hospital, reducing their risk of picking up infections and reducing NHS workload.

The team included social prescribers, special interest GPs and geriatricians. New technology also helped patients recognise when their condition is getting worse and set up follow-ups to reduce the chances of this happening. Read more about this case study here.

The Population Health Management Development Programme

The NHS England Population Health Management Development Programme has been running for over three years. It aims to develop leadership, knowledge and skills around using data and analysis for decision making. During the programme, multi-disciplinary teams focus on a specific group of the local population to tailor health interventions to ensure they have better access to health, better engagement, a better experience and better outcomes.

In East Milton Keynes, analysis pinpointed poorer diabetes management and higher risk of cardiovascular disease in South Asian communities, and those in unskilled jobs or unemployment. The primary care network offered advice from the Wellbeing Team, which included information about diet, nutrition and exercise including cultural cooking, free gym membership and use of community facilities, such as local allotments. People were encouraged to monitor their weight and diet by directly inputting to their medical records using a health app.

Find out more through our case studies, short films and podcasts about how integrated care across the NHS is changing and developing to better meet people’s needs.

Sign up to the Population Health Management Academy to read specific case studies about PHM in action.

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.

See above a short clip from patient Laz Udubuisi from Sussex who was contacted after his doctor identified him as someone who could be high risk. He was diagnosed with Type 2 diabetes and at risk of heart attack and stroke – he has since checked his lifestyle and says “if it hadn’t been for that phone call – who knows.

What does it mean for people working in systems?

For doctors, nurses, social care, therapists and other frontline staff, this should mean greater support and insight from integrated care systems to enable care and support to be designed and proactively delivered to meet individual needs – it should mean less duplication and a reduction in workload pressures as it ensures the right care is given at the right time by the right person.

Integrated care systems are putting in place support to empower health and care professionals to redesign their services, reduce the reactive episodic nature of their workload and take a more proactive approach to supporting their local population to 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. As health and care providers work together and take collective responsibility for the care and support offered to improve outcomes, they can use their resources to keep people healthier.

Why is PHM important for integrated care and systems?

PHM is becoming increasingly important as systems move to formally establish integrated care systems and will be pivotal to the way systems will work together to improve the health of their populations.

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 local health and care partners to deliver 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.

Working together in integrated care systems, we have a better chance of using all our public resources to innovate solutions together instead of in isolation.

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 and efficiently by encouraging care in the most appropriate setting.

How can I get involved?

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

The PHM Academy is an inspirational hub of information around PHM techniques and resources, as well as ongoing PHM work within the health and care sectors.

Any staff member within a health and care system can register.

It can help systems:

• Get started with PHM
• Learn about the core PHM capabilities – Infrastructure, Intelligence, Interventions and Incentives – to support maturity in line with the PHM Maturity Matrix
• Use online 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 Programmes
• 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 weekly reading and remote learning for the PHM development programmes.

Request access to the PHM Academy

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

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