Enabling Population Health

Critical success factors

From our work with health systems both in the UK and internationally, we have identified four building blocks (infrastructure, insight, interventions and impacts) and nine critical success factors for achieving better Population Health Management (PHM).

Historically, a lack of robust patient data that provides a holistic and longitudinal view of each patient has hindered the adoption of a more integrated approach to population health. Our report identifies nine critical success factors which form part of four key building blocks for PHM: Infrastructure, Insight, Interventions and Impacts. These are key requirements for achieving PHM:


  • A shared vision, mission, and understanding of how to implement PHM
    A key aspect of infrastructure of an STP or ICS is for its constituent organisations to develop a shared vision and strategy, underpinned by policies and principles that promote collaboration and consistency of purpose. Aligning the leaderships of organisations and, importantly obtaining the buy-in of clinical and other key professional staff groups, to a collective vision is crucial. Clinical engagement is particularly important, as is an understanding that any contact with the public is an opportunity to engage in improving population health.

  • Leadership maturity and good governance
    A common factor among successful integrated health systems is strong governance arrangements and system leadership that clarifies where responsibilities and accountabilities lie. System leaders, need to create a transparent structure of governance and accountability to support health and care systems, and deliver results at an appropriate pace.
  • Improved shared technology and infrastructure
    In order to achieve more integrated care, organisations need to prioritise automation and data sharing. Although data is critical, many people across health and care do not yet see it as an asset. This is largely due to concerns about consent, confidentially and cyber security. What is needed is an integrated IT infrastructure that complies with agreed interoperability standards and allows data sharing; supports cross-functional learning and collaboration; and, ultimately, better decision making.


  • Focused population targeting and segmentation 
    Growing numbers of patients have multiple care needs and varying levels of health literacy and engagement in their own care. This calls for a strategy that is attentive to diversity, based on a suite of person-centred action plans; which includes defining discrete population segments and developing an understanding of their requirements and the extent of co-morbidities and related risk factors. There is also a need to identify under-served populations and prioritise initiatives that provide the most value.
  • Robust systems of monitoring, advanced analytics and insight processes 
    The volume of health care data is growing by at least 48 per cent annually.39 With such vast quantities of potentially valuable data, crucial information may get lost and unused. Hence, appropriate governance and robust monitoring is required to ensure that ‘insight’ and not just data is being generated by the system.


  • Aligned financial model and funding incentives across the system 
    Current activity-based payment models encourage a revenue optimising behaviour by acute trusts. Conversely, the prevailing payment model for community and mental health services is a historical block contract, which restricts activity levels. This set-up is inconsistent with the need to deliver more care in the community and manage a population’s health closer to home, keeping people healthier and out of hospital for longer.
  • New approaches to delivery and workflow 
    Figures from NHS Digital show that demands on hospital accident and emergency departments in England has reached record levels with nearly 24 million attendances in 2017-18. This represents an increase of 22 per cent since 2008-09 and two per cent compared to 2016-17, yet the population rose by only one per cent. The percentage of people seen within four hours was only 88 per cent, well below the national target of 95 per cent. Over this time, hospital bed occupancy hovered around 95 per cent. These and other related factors are putting a strain on traditional health care models and increasing the imperative to identify new operating models.
  • Providing primary care at scale 
    Primary care has been widely acknowledged as central to a high-quality and cost-effective health system for many years. However, the provision of effective primary care at scale, requires choices to be made around the scope of the care to be provided, and the degree of care coordination.


  • Population engagement and patient activation
    The aim of population engagement and proactive health is to help people stay as healthy as possible, and to live independently in the community for as long as possible. It involves engagement by health and social care staff, working together in new ways to coordinate the care needed. Patient groups that could benefit by targeted engagement include:

    - Frail or older people with long term health problems, where care is often too fragmented and difficult to manage
    - Young or new parents, who often bring in their new-borns or young children on a ’just-in-case’ basis
    - Those with long term chronic conditions, such as diabetes and chronic obstructive pulmonary disease (COPD).

    While PHM places responsibility on health and care systems to manage care for their local population, it places even greater responsibility on the population itself to become more self-sufficient and engage in self-managing their care, through prevention, education and adherence to medication. Indeed, patient activation holds the key to improved health outcomes through gains in self-management and individual behaviour change.

Case study: The Wigan story – a shared vision for PHM

In 2010, Wigan council faced severe financial difficulties and needed to reduce running costs by £160 million within five years. In response it introduced the Wigan Deal, freezing council taxes in return for improved health and well-being behaviours. Wigan also gave staff permission to innovate. In the intervening years it has seen a seven year improvement in healthy life expectancy.

Accompanying the Wigan Deal was the ‘Be Wigan’ experience which is a place based organisational development tool, which includes reappraising how citizens are viewed, thinking how they can be helped, and building trust between citizens and health and care provider organisations.

The two largest sources of expenditure are social care and the NHS – the NHS and engagement of clinical staff has been pivotal in wrapping services around citizens and engaging with community and voluntary organisations. Wigan adopted a zero-based budgeting approach and adopted ‘best in breed’ solutions harnessing the passion and belief of the community (82 per cent of residents support the Wigan Deal).

While Wigan has saved £130 million it still has £30 million of savings to make. It has stopped things that don’t work – like expensive day centres – and focused on supporting local groups and local clubs. By 2018 its adoption and implementation of a shared vision between health and social care has helped it had one of best performing hospital systems (5th best on delayed transfers of care) had balanced its budgets for children and adult social services and had reduced the number of looked after children.

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