A journey in population health management

by Gary Raphael

30 October 2019


Population health management may hold key to better outcomes and sustainable services

HCF - OctoberOne of the highlights of October was picking up my copy of Healthcare Finance to see population health management on the front cover.

Having been part of the NHS England PHM development programme over the last year I was delighted to see its prominence (see Under scrutiny, Healthcare Finance, October 2019). In the 38 years I’ve worked in the NHS, I’ve never been as confident about its future as I am now.

With colleagues in the Lancashire and South Cumbria Integrated Care System we were very keen to see what this approach could mean for the future of our population.

Across our health and care partners we used actuarial modelling to crunch data on demographic and activity trends to forecast population demand on our health system over the next five years for an unmitigated financial scenario.  

We looked at the evidence for anticipatory care models to target health risk within different population groups and displace activity to more cost-effective settings. This gave us a mitigated financial scenario, effectively flattening the cost growth gradient curve.

It was a different way to look at financial risk within the system. Rather than thinking about current activity and utilisation in providers and commissioners, we were starting to look at the risks driving health deterioration in different population groups and what this would mean for the future if we did nothing and if we implemented the new anticipatory care models and services changes in the NHS long-term plan.

We supported five out of our 41 neighbourhoods to pilot an approach to developing health improvement plans at that level. The five neighbourhoods, supported by analytical, finance and commissioning teams developed insights about their neighbourhoods that they’d never had before.

Instead of a set of complex, unusable spreadsheets, they developed sets of ‘actionable data’. For GPs in particular this a better way to target clinical and other resources on cohorts of patients with different sets of conditions and be able to develop genuine prevention programmes for the different population groups they serve.

We need to do something different to make our health and care system sustainable. The great thing about PHM is that it gives us that actionable data about specific patients and groups of patients – we can help our neighbourhoods find the exact issues that need to be fixed.

That’s just the start. If we can understand cost drivers in cohorts of patients, we can think about how to realign risk and reward incentives and create capitated budgets for these groups across primary, community and secondary care alliances. And we can begin to address the underlying risks in a proactive and anticipatory model of care.

We can then look at what this means for contracting for outcomes, tied to what we know about the current and future health needs of a group of patients.

There’s huge potential for this approach when coupled with the latest technology. For example, algorithms are available now that can predict the existence or progression of conditions for specific patients. This can enable interventions to be planned by professionals working within neighbourhoods.

If we can find those patients and get to them early enough, we stand a chance of preventing or delaying the onset of complex and debilitating conditions. This not only improves that person’s health and well-being outcomes but it avoids cost increases in the NHS and social care sector.

For many years we’ve spent time trying to move the bulk of spend into prevention to relieve pressure and cost on acute services, but demand is still high and we’re not succeeding.

Instead of financial planning for individual organisations, the PHM approach allows us to look across the whole system and think more effectively than ever before about displacing secondary care activity and making spend effective at a neighbourhood level.

The long-term plan has called for higher investment in primary and community services and in Lancashire and South Cumbria (LSC) we’re taking that commitment seriously.

While we’ve finished the PHM programme, we’re taking it to the next stage using the data insights we’ve gained to see what the impact will be of higher investment in our neighbourhoods.

As finance directors across the patch, we’ll be using that data to see the bigger picture over the next four years. We plan to explore how implementing new evidence-based programmes will reduce growth in demand and cost for general and acute services. 

Of course, the question is how to scale up this work from the pilots – it’s not going to be easy with wider workforce challenges. But once we have a clear view of where the resources should be focused, working with the community and voluntary sector services already available, then it’s about the art of the possible.

Creating energy across neighbourhoods will be key and, alongside system-wide evidence, could change lives person by person as well as by system.

Many will ask: if there are clinical and financial sustainability problems in acute services, how do we justify spending more in primary, community and mental health services at the expense of growth in those acute services? This will surely have an impact on the ability of the acute providers to manage rising demand in the short term.

However, what we really need is cover from regulators to give the new ways of working a chance of success, while we collectively manage the difficult agenda faced by acute services.

The journey of Lancashire and South Cumbria on the population health approach has been an eye-opener with the potential for healthier patients, a sustainable health and care service and job-satisfied clinicians.

It might be 38 years since I joined the NHS, but what happens in the next 38 depends on our choices today.