Defining Population Health

Population health management (PHM) is a patient-centric, data driven approach to optimise the physical and mental health of populations over individual life spans and across generations. PHM requires clinicians to address existing acute and chronic conditions, and to enlarge their focus beyond the care and treatment of patients with known problems, identifying all the individuals in their patient population who may have potential conditions. A proactive approach is needed to enable healthy patients to remain healthy and to monitor continually the status of at-risk patients.

Population health is increasingly relevant for today’s health and care systems. First muted in 2003, the term population health was used to describe ‘the health outcomes of a group of individuals, including the distribution of such outcomes within the group’. Population health has evolved to include a methodology for identifying people at risk of physical and mental ill health and those whose condition is unstable, and applying appropriate interventions for prevention or for care and rehabilitation.

Grouping populations according to their conditions, severity of illness, demographic qualities, or other parameters, to identify risk levels, can help in leveraging resources to improve care and outcomes while reducing health inequalities. The focus of population health is also on strengthening primary care and delivering care closer to home, which is consistent with the current UK policy of integrating care to address growing demand pressures.

Population health balances the intensive management of individuals in greatest need of health care, with preventative and personal health management for those at lower levels of risk. Accountability for a population’s physical and mental health is shared across health and care organisations and communities, with interventions targeted at addressing not only the health needs of the population but also the underlying social, economic and environmental determinants of health.

Current health challenges within the UK

Medical advances and improvements in health care have resulted in a significant shift in the patterns of disease among patients. Although average life expectancy has increased, there has been a slowdown in improvements. Despite having the same health and social care system, some English regions (South West England, East of England, and South East England) now have similar or better levels of health than the best-performing European countries, whereas other regions (North East England and North West England) are losing ground and have worse health outcomes. Moreover, inequalities are often greater within regions than between them, suggesting that deprivation rather than geography is the cause.

While growing numbers of people are living longer, extra life years are not always spent in good health due mainly to an increasing prevalence of long-term chronic conditions, such as coronary heart disease, chronic obstructive pulmonary disorder and diabetes. The Department of Health and Social Care estimates that over 15 million people in England have at least one long-term condition. In 2018 about 2.9 million people were living with three or more long-term conditions. Data from the Global Burden of Disease Study for England shows that there has been little or no improvement since 1990 in how long people live with illness and disease. While life expectancy continues to improve for the most affluent ten per cent of the population, it has either stalled or fallen for the most deprived ten per cent. Moreover, on average, older men now spend 2.4 years and women spend three years with ‘substantial’ care needs.

The UK’s obesity rates are among the worst in Europe. Rising obesity levels, especially among young people, are increasing the burden of disease caused by preventable conditions, including type 2 diabetes, cancer, heart and liver disease, stroke and related mental health conditions. The 2018 Health Profile for England shows the two largest health burdens are deterioration or injuries to the musculoskeletal system (such as back pain and arthritis) and mental ill health.

People with chronic conditions are intensive users of health and social care services, and the associated costs of care are much higher. The Department estimates that 70 per cent of total health funding in England is spent on services for the 30 per cent of the population with long-term conditions. This presents a growing imperative to identify these patients, treat them, and keep them healthier and independent for longer.

What drives good population health management?

Population health management (PHM), while just one of many levers to tackle health outcomes, is viewed increasingly as the key to ensuring the affordability and sustainability of care. PHM is a data-driven approach that guides the planning, resource allocation and delivery of care to optimise population health. It brings together big data, patient engagement and health care delivery and requires a combination of:

  • Behavioural change, from both health care providers and patients, with a greater focus on prevention and patient activation measures delivered in a tailored manner, using an array of analytics, technology and communication tools
  • Proactive identification and monitoring of high-risk patients, and equitable access to evidence-based medicine, focusing on prevention and treatment and on improving function and wellbeing for individuals
  • Realignment of funding flows and incentives to encourage staff to work differently across care settings, underpinned by an appropriate outcomes framework.

The successful improvement of population health outcomes also requires regular monitoring of interventions and frequent reflection and review by all stakeholders to increase impact and outcomes.

Experience across the world shows that there isn’t a single approach or ‘rule book’ for PHM; however there are several distinct building blocks and critical success factors to enable a health and care system to adopt an effective PHM approach. These building blocks and critical success factors are discussed here.

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