Population Health Management

What is Population Health Management?

Our health and care needs are changing: our lifestyles are increasing our risk of preventable disease and are affecting our wellbeing, we are living longer with more multiple long-term conditions like asthma, diabetes and heart disease – and the health inequality gap is increasing.

Population health aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population, with a specific focus on the wider determinants of health (things like housing, employment, education).

Population Health Management (PHM) is a way of working to help frontline teams understand current health and care needs and predict what local people will need in the future.

This means we can tailor better care and support for individuals, design more joined-up and sustainable health and care services and make better use of public resources.

PHM uses historical and current data to understand what factors are driving poor outcomes in different population groups. Local health and care services can then design new proactive models of care which will improve health and wellbeing today as well as in future years’ time.

Population Health Management and health inequalities

Population Health Management focuses on the wider determinants of health – which have a significant impact as only 20% of a person’s health outcomes are attributed to the ability to access good quality health care – and the crucial role of communities and local people. Local health and care systems have started to use data to design new models of proactive care and deliver improvements in health and wellbeing which make best use of their collective resources.

PHM is a partnership approach across the NHS and other public services including councils, the public, schools, fire service, voluntary sector, housing associations, social services and police. All have a role to play in addressing the interdependent issues that affect people’s health and wellbeing.

For example, adults and children who live in cold, damp housing may be more likely to develop respiratory problems over future years because their lungs are affected by the mould spores in their home. If we improved their housing now by working with partners such as local councils and housing associations, they may not end up with various health conditions in the future which can result in poor quality of life (conditions like asthma, chest infections, and other respiratory problems) and could avoid the need for multiple health and care services, helping to reduce health inequalities.

How PHM has helped during the pandemic

The coronavirus (COVID-19) pandemic has further highlighted the known link between poorer health outcomes, ethnicity and deprivation.

Working with the local authority and the voluntary sector, we have used PHM to identify people who need more support and those with the most complex needs within their localities, so that efforts can be targeted to protect certain populations through personalised care models, public health advice, testing and vaccination programmes.

As services restart after being paused during the pandemic, health and care systems are using PHM to identify those with the greatest needs who have been waiting for appointments and procedures.

Why is PHM important for integrated care and systems?

As set out in the NHS Long Term Plan, local NHS organisations will increasingly focus on population health and local partnerships with local authority-funded services, through integrated care systems.

Therefore, PHM is the critical building block for integrated care systems and enables local health and care partners to deliver a core offer for local people which ensures care is tailored to their personal needs and delivered as close to home as possible.

PHM enables systems and local teams to understand and look for the best solutions to people’s needs – not just medically but also socially – including the wider determinants of people’s health.

Many people need support with issues such as housing, employment, or social isolation – all of which can affect their physical and mental health. These solutions are often already available through, or better designed with, local people, the local council or a voluntary organisation.

Working together in ICSs, we have a better chance of using all our public resources to innovate solutions together instead of in isolation.

Better partnership working using PHM to join up the right person with the right care solution helps us to improve outcomes, reduce duplication and use our resources more effectively and efficiently by encouraging care in the most appropriate setting.