At a macro level, Population Health Management (PHM) is about changing how health and care services are organized, funded and operated so that value, not volume, becomes the key objective and metric.

Many different industries globally are moving in a similar direction as businesses and governments begin to recognize that focusing on how well something is done (e.g. tracking quality, safety, sustainability and outcome metrics) is arguably more important than just getting more done with less (e.g. increasing throughput and reducing costs). In the NHS, services are intrinsically inter-dependent upon each other so reducing capacity in one area such as social care in-home services and residential care beds has knock-on effects in other areas such as hospital bed availability.

The advantage of a population health management approach is that it encourages whole-of-system thinking. People are challenged to think about how their daily work, processes and routines fit into the bigger picture so that transformation can be achieved at scale across a wide region or geography. Budgets and funding may be pooled which enables initiatives to be planned and managed across organizations and agencies.

Whole-of-system thinking has the potential to significantly reduce the demand curve in the health system. In places like Canterbury, New Zealand, where the shift towards integrated care began in earnest more than a decade ago, the results speak for themselves with The Kings Fund recognising them as a global exemplar and advocating for the introduction of place-based care in England.

Within the UK, the biggest barrier to greater uptake is the change management required to implement new ways of working brought about through population health. In whole-of-system thinking, collaboration, rather than competition, is the overarching goal, and the difficulty is that organizational structures, policies, funding mechanisms and incentives are not all aligned to encourage collaboration.

Defining pathways across care settings and providing more care remotely requires a shift in mindset, processes and responsibilities. Before meaningful change can occur for the better, new relationships and partnerships must be formed with high levels of trust established between people who often have never worked together before; this takes time. In order to safeguard patient safety and quality of care, healthcare providers often rely, and are reluctant to move away from, tried and tested evidence-based practices, but these must change in order to progress a place-based approach to patient care.

Public trust remains a key challenge and we have to address the confidentiality and information governance issues raised. It is crucial to ensure data is shared safely, securely and legally in any population health management solution.  The quality of data stored remains a major challenge because although it might be adequate to be used for direct care it may not be fit for purpose for any secondary use purposes. With PHM comes a greater volume of information related to a patient, through means such as wearable devices. Turning this data into reliable, actionable information is often a challenge and without understanding the patient’s medical history and wellness goals, data can be meaningless or misleading.

Within the last two years there has been a definite shift in customer understanding of the potential of population health, so much so that their thinking is sometimes outstripping their technical and organisational capabilities – for instance the interoperability of pathways that span different organisational business processes and boundaries. There is a strong desire for easier identification of, and more information around, population cohorts that should be targeted. The requirement is for broader analytics, specifically cohort tracking, to demonstrate which PHM programs and pathways are having the greatest impact on a patient’s care.

Potential customers are asking for the capability to provide a data layer for a longitudinal patient record for populations so that identifiable data sets about patients are available for the purposes of direct care, and de-identified data sets that are available for population health management. Secondly, they are asking for the capability to use analytics tools and techniques to discover, interpret, and communicate meaningful patterns across this data, and to support national initiatives for analytics and data services. And thirdly, they are asking for the capability and tools for patient empowerment and activation, that give patients the option to select from a wide range of PHR products so they can select the one that best meets their needs.

Several things need to happen if population health management is to become the new normal. When Dr Nigel Millar, former Chief Medical Officer of Canterbury District Health Board, toured the UK in 2016 and spoke at length with NHS leaders and managers, he said “The three enablers were vision, sustained investment in staff and how they are utilized”. He went on to say that investment in shared care records, electronic referrals and systems that provide guidance to providers on how clinical pathways operate within the local geography were “key in us making it better for the patient”.

There has to be strong support and commitment from all stakeholders to align collective and individual thinking. The funding of designated areas in England to introduce Local Health and Care Records (LHCRs) is an important step in the right direction because it comes with an expectation of collaboration, particularly in how information is safely and securely shared across organisational and geographical boundaries.

We can learn from the executive leadership of places that are further down the PHM road what is important and what has to happen to embed whole-of-system thinking in the wider heath and care eco-system, e.g. Canterbury DHB’s Chief Executive Officer, David Meates:

“Our health system has worked incredibly hard to make it better for people: to cut waste out of the system and improve the patient journey by putting people at the centre of everything we do. The mantra ‘one health system, one budget’ is firmly held by everyone who delivers care, whether in the community or a hospital setting.”

Engaging patients and their caregivers is also vital for population health management to be successful. Through their behaviours, patients are the single most important factor in influencing their own health, followed by their immediate caregivers and then the health system providers. Whole-of-system thinking reframes patients and caregivers as part of the team who are collaborating. Effective PHM requires strategies to reach the individual consumer or patient at all stages of life from early childhood through to old age, rather than just when they become sick.

Lastly, a commitment across all vendors and providers to adopt agreed medical record and interoperability standards such as the HL7 FHIR CareConnect profiles collectively defined by NHSX, PSRB and other members of the INTEROPen community. INTEROPen applies the principles of collaboration and whole-of-system thinking to all its activities, encouraging all people working in or benefitting from health informatics to get involved, so that the standards published are fit for purpose and can be easily implemented at scale. Events such as the recent Hack Day for LHCRs in London evidence this.