Article

Population health management: an introduction

What is population management and what are the benefits, particularly in primary care?

27 November 2023

Crowd of people walking streetCrowd of people walking street

This explainer offers an overview of population health management (PHM), answering key questions and highlighting the benefits of successful adoption. It is intended to provide an introduction for primary care teams looking to develop and strengthen PHM in local systems.

Understanding population health management

To tackle the current widening health inequalities in the UK and stagnating life expectancy, there is a need to consider all levers and drivers of health across our population, that is beyond the health sector. Our health is directly and indirectly influenced by the physical, economic and social contexts (wider determinants) in which we live, and this underpins population health as a concept. While definitions may overlap or vary, it is generally agreed that population health is an approach that aims to improve the health outcomes of an entire population.

Our health is directly and indirectly influenced by the physical, economic and social contexts in which we live, and this underpins population health as a concept

Population health management (PHM) is a methodology for understanding patient populations, their state of health (and some of the factors that may drive this) and supporting re-design of care for ‘at risk’ groups.

As a way of working, PHM drives the design and delivery of proactive, personalised healthcare models, which can help us to reduce health inequalities, make better use of resources, and sustain health and care services.

There should be a system-wide outcome focus, driven by need and not by existing services

A PHM approach uses qualitative and quantitative data and insights to identify local ‘at risk’ cohorts and create the evidence base for the targeted action needed. PHM means using data, evidence and knowledge in all forms to create local intelligence that aids decision-making.

There should be a system-wide outcome focus, driven by need and not by existing services. This could mean using a different approach and different skill sets, rather than following the way services have traditionally worked.

By enabling needs-based re-design, PHM can facilitate sustainable healthcare transformation by targeting interventions that prevent ill health, improve care and support for people with ongoing health conditions, and reduce inequalities in health outcomes. A PHM approach can lead to better outcomes, experience and value for patients while also offering wider operational improvements in health systems.

NHS England’s ‘4 Is’ approach

The foundations of PHM are its four core capabilities described below. The infographic below sets out key actions to take in building these capabilities, together with illustrative examples related to cardiovascular disease (CVD).

1. Infrastructure

The infrastructure is the set of basic building blocks that allow a system to manage the health of a population. This includes clearly defining the population, having effective leadership and agreement on information governance, and setting up basic digital and data infrastructure.

2. Intelligence

Once the right infrastructure is in place, we must understand population need and align this with effective interventions. The information gathered informs:

which interventions are needed
who within the population they will benefit
how outcomes will be measured.

System partners will need to work together to identify and develop local analytical resource to deliver the intelligence function. This provides an important opportunity for system working to align analyst capacity and capabilities with primary care networks (PCNs) and across wider teams including voluntary, community, and social enterprise (VCSE) organisations, NHS trusts and public health.

3. Interventions

The next step is to build on the learnings of the intelligence to make decisions about the services that should be provided to your population. Care models should focus on proactive, anticipatory care and interventions to prevent illness, reduce the risk of hospitalisation and address inequalities. This might not need to comprise wholesale changes to your local service provision, but rather could involve adapting existing services and resources to ensure they are most relevant for the population.

4. Incentives

Developing a shared understanding of payment reform and its impact can support greater integration and transformed care. An agreed payment and incentives framework can help integrated care systems (ICSs) deliver their purposes; a population-based payment model aligns payments and incentives around the needs of the population rather than organisational boundaries.

Population health in practice

PCNs have an important role to play in managing population health. They are key in assessing the needs of their local population and identifying who would benefit from targeted and proactive support. Healthier South Wirral PCN has placed high importance on access to examples of innovation strategies as an integral part of its PHM approaches.

Key takeaways

Enabling access to innovation through primary care-led PHM approaches
1. Focus on being local – Develop an approach that augments both ICS and local GP data with qualitative data and insight about the PCN as a geographical place where people live within environments and communities.
2. Grow PHM capacity – Develop a population health team with the ability and tools to use local and system data to identify cohorts across the PCN in need of intervention to reduce unwarranted variation, to provide intelligence for quality improvement efforts and to identify opportunities for outreach.
3. Adopt, adapt and utilise – Develop micro-teams within the PCN who can utilise off-the-shelf data tools within GP clinical systems and co-produced PCN-wide pathways to retrospectively identify cohorts who can benefit from healthcare interventions.
4. Inform and evolve – Develop PCN knowledge, skills and confidence to utilise population health data to improve process within the PCN so that individuals are proactively selected for interventions as they enter a specific cohort.

The Health Innovation Network (HIN) for the North East and North Cumbria (NENC) supports the health and care system to accelerate innovation which improves people’s health and the regional economy.
HIN NENC works closely with the NENC ICS and member organisations, including the NHS trusts and universities, across the region to help them identify, evaluate, adopt and disseminate transformative innovation. The HIN also collaborates with industry as a source of innovation and to support the testing and deployment of products and services that are the basis of the UK’s life sciences sector.
With a population of 3.2 million people, a mix of urban and rural areas and significant health inequalities in the region, there are a range of opportunities for collaborative working to improve health and care for local communities in NENC.
HIN NENC was appointed as the lead AHSN for the delivery of the national Lipid Management and Familial Hypercholesterolemia (FH) programme, [10] which started on 1 October 2020 and finished on 31 March 2023.
This was a programme looking at the evidence around lipid management across the whole clinical pathway. As a NICE-endorsed pathway, this brought together a range of evidence to optimise progression along the pathway in order for patients to access the right treatment at the right point in their journey.
HIN NENC and partners undertook initial pilot work to identify those with familial hypercholesterolemia from primary care searches, recognising the potential for achieving impact at scale from primary and secondary prevention of CVD. This was supported by the Clinical Digital Resources Collaborative, [11] which identified those across the lipid management pathway who would benefit from treatment and from progression along the pathway.
This pilot work created resources and tools which were then scaled to enable primary care health professionals to implement change at pace.
Partnership working
The collaborative work involved a range of partners including the Innovation for Healthcare Inequalities Programme (InHIP), the System Transformation Fund, and the National Lipids Programme Workforce Support Solution (NLPWSS) which was created as part of the collaborative working project between NHS England and Novartis Pharmaceuticals UK Ltd. This collaborative work led by HIN NENC to address lipid management demonstrates how novel therapies could be rolled out to populations in the future, and how industry funding can support innovation for the right populations to be reached with a focus on tackling health inequalities.
Key takeaways
- Harnessing existing relationships and infrastructure.
- Taking a tried and tested systematic approach to delivering change.
- Keen desire to do the right thing for the population.
- Enthusiastic and motivated clinical champions.
- Ability to scale innovation at pace with the right tools and information.
- Willingness to capitalise on opportunities to leverage funding to address population need.

Population health management: an introduction

Understanding population health management

NHS England’s ‘4 Is’ approach

1. Infrastructure

2. Intelligence

3. Interventions

4. Incentives

Population health in practice

Key takeaways

Enabling access to innovation through primary care-led PHM approaches

Partnership working

Key takeaways

Further reading

Related content

Care Closer to Home: Primary and Community Care Conference 2025

InFocus: Politics of the NHS with Dr Layla McCay and Daniel Reynolds

Demand unrelenting as Welsh NHS going into winter hot

'Finding new ways of providing care that can ease the pressure on hospitals is absolutely essential'