What’s the big deal about population health management?

What do we mean by ‘population health management’ or PHM for short? Some in the health service describe it as an ‘emerging’ technique, one “involving using data to design new models of care across organisations” to improve outcomes for patients. 

It is generally thought to be a more effective way of planning health services locally. The general understanding is that data is used to identify specific groups within a population which may have similar characteristics and similar needs. Once identified, programmes can be designed to increase the health and wellbeing of these cohorts.

Building a shared understanding

In the context of the NHS Long Term Plan, PHM is becoming more commonly discussed, but clinical commissioners have had this on their radar for some time. Clinical commissioners always seek to understand the health needs in their population and how best to meet them, drawing on both managerial and clinical expertise. 

There’s no simple way to introduce any new model of care. With the complexities of local health and social care, any new approach needs to build a shared understanding and the willingness to navigate complex issues around sharing data. To find out more, we have spoken to a number of our members at NHS Clinical Commissioners to see how they using PHM approaches to better care for their populations. 

We have had conversations with commissioners in ten areas of England: from Dorset to Lancashire and Solihull to Leeds. The result is a report published today. It shows that progress is being made in making PHM work and that challenges are being overcome. It also shows that clinical commissioners are often well placed to build the coalitions necessary for success. 

A key enabler

In our conversations, we have found clinical commissioners are often a key enabler of population health management approaches, because they are well-connected across primary care and secondary care, and already have expertise in information governance and data issues. 

In many instances, patients are already benefiting from the use of PHM approaches. It is clear from speaking to our members that the shift to using PHM is a ‘journey’: some are at the beginning and others are further down the line. In West Berkshire, for instance, a group of people living with type 2 diabetes and weight problems has been separated out into two distinct groups – and different programmes introduced for each. Early results indicate improved health for both.

In North West London, the eight clinical commissioning groups (CCGs) have been on a PHM ‘journey’ for some time, building a data dashboard which is now being used to improve care for people living with a number of long-term conditions. Among them is diabetes, which affects 45 per cent of the local population. Clinical leaders have been able to take the data and introduce new styles of intervention. One initial innovation has been the creation of virtual clinics, held in GP surgeries to discuss patients whose condition is considered cause for concern, and involving specialists from community and secondary care teams. 

Better patient outcomes

The obvious roadblock remains data-sharing issues and information governance. Those clinical commissioners who have navigated their way through problems are actively sharing their expertise. But population health management relies on consolidating and analysing data from a variety of sources – both inside and outside the health service. Current processes are often proving unequal to the task. We heard that one planned PHM project in Birmingham and Solihull has been stymied by issues around information governance and data sharing. The West London CCGs told us that getting data-sharing agreements in place took two years – but those agreements are freely available online for other commissioners to use. 

Where PHM approaches have been implemented, or the PHM journey begun, the benefits are not only better patient outcomes. Leaders in Dorset report real enthusiasm among clinical staff for the approach. Indeed, several of those interviewed for our report say that an unexpected benefit of PHM is increased satisfaction among frontline clinical teams. The members of these teams are being empowered to make changes based on the data they have been given as well as their ‘on the ground’ knowledge. Discussions around population health as a concept also seem to be an enabler of closer collaboration between separate organisations and separate sectors. 

Our conversation with clinical commissioners across England shows they are all at different stages of the PHM journey and may be approaching it in different ways. What is clear is that those who are going down this route are seeing the benefits and providing useful learnings for others to follow.

Read more in our PHM report published today.

Julie Das-Thompson is assistant director of policy and delivery at NHS Clinical Commissioners, a part of the NHS Confederation. Follow NHSCC on Twitter @NHSCCPress