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