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It's time to do things differently

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It's time to do things differently

The increasing pressure on the NHS makes it clear that things must be done differently if it is to endure, says Dr Helen Davies, who suggests population health management holds the key...

Population Health Management (PHM) is about a radical shift in care delivery that starts with the needs of a population, not the capability and configuration of a string of isolated providers. It is a model for the planning and delivery of proactive, anticipatory care to achieve maximum impact from collective resources. It is an exercise in service design for the whole population, one cohort at a time, using data and analytics to guide us. 

There is an increasing body of evidence internationally that healthcare is delivered best if it’s done as an integrated care system across various health and care providers, with person-centred care at its core. 

Data also tell us that multi-morbidity is driving demand and cost within the NHS: more than one in four of the adult population in England currently lives with two or more conditions. Despite diversity in their disease profile and circumstances, people with multiple conditions frequently share common problems. They may have reduced mobility, chronic pain, shrinking social networks, incapacity to engage with work, and lower mental wellbeing. To date, these problems have not been well-addressed.

We tend to organise services around single conditions: doctors train in specialties, and research and decision support tends to be organised one disease at a time. This siloed way of thinking doesn’t reflect the real world. People with multiple conditions want greater service integration, more person-centred, holistic care, and better support for mental wellbeing. To address this, innovative ways of intervening are needed; a PHM approach is needed. 

PHM focuses on groups of people with shared characteristics (a cohort) and the design and delivery of holistic care for each person within that cohort. The concepts of integration are key. The PHM approach is anticipatory and proactive. It uses collective system resources to address wider factors such as environment (e.g. housing, transport and green space), social factors (e.g. education, employment, isolation and safety) and behaviours (e.g. smoking, diet and alcohol). It’s about using data, insights and evidence of best practice to co-design and deliver integrated models of care working with health, social, community, voluntary and private sectors and the public themselves.  

The implementation of the 2021 Health and Care Act puts in place enablers to make it easier for health and care organisations to deliver joined-up care for people who rely on multiple services. These include engaged leadership with aligned incentives, joined-up data and IT, facilitative decision making processes, lines of accountability and information governance.

“It’s about using data, insights and evidence of best practice to co-design and deliver integrated models of care”

Equally important, we must not forget that the workforce is key. People are the ones who are both delivering and receiving care, so we must ensure that we take people with us, that they are involved in and feel part of the journey.

We cannot use PHM to address the needs of the whole population in one go, but we can start with what we have.

Step one: is to prioritise, use data analysis or community stories to find priority areas – where there is unwarranted high cost or high demand, unmet need or inequality of care. The wider and richer the linked system data, the more informed this decision making can be, but you need to get on with it with what you have, using your ‘best available insights’. This can be cross referenced to compare against similar practices/areas, such as fingertips data and Joint Strategic Needs Assessment.

Step two: is the cohort. Use data analysis (stratification and impactability modelling) to identify a cohort within your priority area for whom there is the best opportunity to improve the quality, efficiency or equity of care. This may include a particular condition(s), or more likely a group of conditions or just ‘comorbidity’ or ‘complex needs’, within a geographic area, a particular demographic (age, ethnicity) or those at risk of a hospital or care home admission.

Step three: use a wide lens to include the broadest range of existing insights and include the patient and carer voice to understand your cohort. Seeing it from the patient/citizen side will address wider determinants of health and consider health inequalities. Use this broad view to get a clear picture of the existing resources and services.

Step four: designing. In designing a new model of care to deliver better outcomes, ask questions such as: What are the needs of the cohort? What outcomes do you need to see in order to meet these needs? What activities do you need to do to achieve the outcomes? What resources and skills do you need to invest to do those activities?

Step five: is implementation – the ‘how’, ‘who’ and ‘what’ involved in making it happen. You need to ensure buy-in from system leadership and stakeholder organisations for the support, co-operation and information governance processes to deliver the plan. From the outset, plan how you will measure the outputs and outcomes, including care provider and patient/user feedback. Keep the process agile, adapt as you learn.

Step six: is about evaluation and expansion. You need to evaluate the process and the outcomes, including: Did you reach the target group? Did you achieve the intended outcomes/outputs? What worked well and what can you improve? Do you need to make any changes based on your evaluation? How can you scale up/share your plan?

Trust in the process. Involve all relevant stakeholders and the patient/citizen at every stage. Make sure to combine best laid plans with pragmatic delivery.

Dr Helen Davies is an NHS general practitioner, Population Health/Digital Lead and member of Cegedim Healthcare Solutions’ Clinical Advisory Board

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