Health and care needs have changed dramatically since modern healthcare systems were conceived. Different lifestyles, longer lives, long-term conditions and health inequalities increase the volume and complexity of demand facing health and care providers.

We need to prevent people from becoming ill in the first place.But how do we identify individuals and groups most risk of becoming ill, or unlikely to access services? How do we target interventions that proactively support people to manage their health and care in the community? And how do we protect secondary care services for those that need them most?

What Is Population Health Management (PHM)?

Population health management is the process of understanding the circumstances and health needs to develop tailored models of care that improve health outcomes, reduce inequalities and optimise resources.

Data quality, organisational challenges over data sharing and ethical concerns hamper effective PHM. Advances in cloud and analytics, integrated care systems (ICSs) in England, and the pandemic experience help to overcome these barriers, and, as a result, PHM is increasing in scale and success.

What are some of the challenges of Population Health Management?

  • Joining up data from disparate sources – across primary, secondary, social care, and local authorities.
  • A different approach to healthcare - helping citizens understand how interventions can improve their long-term health and wellbeing even if they aren’t unwell now.
  • Information governance – getting access to the right data and ensuring it is used safely, ethically, and in a way that increases public trust.
  • Digital exclusion – missing people who don’t feature in certain data sets could inadvertently exacerbate health inequalities.

 

Where can Population Health Management be effective?

Accurately identifying populations at risk of developing a specific illness and providing them with treatment and protection is vital in protecting their health and the capacity of the wider healthcare system.

A prime example of this is CGI’s work with NHS Digital, Oxford University and the Department of Health and Social Care in developing the COVID-19 Clinical Risk Assessment and Risk Stratification tools that identified an additional 1.7 million Clinically Extremely Vulnerable individuals to be added to the COVID-19 shielding list.

What are the benefits of Population Health Management?

  • Lower cost of intervention - intervening earlier in a patient’s journey reduces long-term costs.
  • Efficiency – providing tailored and proactive care leads to a more efficient use of resources.
  • Learning and improvements – use data to better understand impact to improve approaches.
  • Reducing health inequalities - informed decisions to focus new interventions on the groups where with the greatest needs.