By Karen Taylor, Director, Centre for Health Solutions
The growing demand for health and care, rising patient expectations and increasing costs in the face of substantial budget constraints call for innovative solutions. In the UK, there is a growing consensus that if healthcare is to be sustainable, there is a need for a fundamental shift from treatment of ill health, when it occurs, to prevention. This week we launched our report The transition to integrated care: population health management in England, with findings derived from extensive literature reviews and our experience working with health economies both in the UK and internationally. It highlights key challenges and potential solutions that, if adopted at scale, could deliver a more cost-effective approach to improving the health and wellbeing of a population.
The impetus for PHM
Over the past few decades most health systems have seen impressive improvements in health outcomes due, in part, to, scientific and technological advances and a better understanding of how our behaviours affect our life expectancy. However, today, for many people a longer life means living longer with multiple chronic conditions. Furthermore, 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 (see Figure 1). At the same time, the costs of providing care are escalating with many provider organisations facing serious financial challenges, and social care in crisis.
Figure 1. Key facts and figures about life expectancy in the UK
Population health brings together a deep understanding of population need, through big data, patient engagement and new health and care delivery models. While population health is not a new concept, to date, attempts to tackle it have been fragmented, with health policy still largely focused on treatment rather than actions to address the wider social determinants of health.
Population health management (PHM) is the concept of gathering data and insights about population health and wellbeing across multiple care and service settings, with a view to identifying the main health care needs of the community and adapting services accordingly. Today, the increasing capacity and capability of technology to generate, collect, analyse and transmit data, together with major advances in data analytics and machine learning, provide powerful tools to make PHM a reality. Such tools can identify risks and stratify patient populations, improve the speed and accuracy of diagnostics, and support the design of personalised treatment plans.
However, if PHM is to be embedded, there are numerous barriers to overcome, such as: linking previously disparate datasets and developing models of leadership that embrace new integrated, ways of working and a shared culture and mind-set. Importantly, there is a need for health economies to build collaborations, especially engagement with patients, and for clinical and care teams to be organised around the people in need of care.
The transition towards a PHM approach
For more than 40 years there have been numerous policy attempts to develop an integrated approach to health and social care, with limited success. In 2016, NHS England mandated that all health and social care organisations should form 44 (now 42) geographically-based Sustainability and Transformation Partnerships (STPs), providing a new impetus for integration and collaboration.
However, since 2012, the NHS in England has operated under the legal framework of the Health and Social Care Act 2012. This encourages competition between organisations and champions the commissioner/provider split. This has led to funding, accountability and governance challenges for STPs and undermined progress towards vertical and horizontal service integration - even in the most advanced partnerships. However, during 2018, a new form of partnership emerged - an Integrated Care System (ICS) – to take collective responsibility for managing resources, delivering NHS standards, and improving the health of their population. For an STP to become an ICS it has to agree to take on a budget for the health provision of a defined population and demonstrate, system leadership, a shared culture, and that it is capable of implementing an integrated PHM strategy, efficiently. By the end of 2018, there were 14 ICSs.
The NHS Long Term Plan (LTP), published in January 2019, cements the policy shift towards integrated care and gives a strong boost to the PHM model, reconfirming the need for the NHS to move from reactive care towards a model that embodies proactive PHM. ICSs are seen as the main mechanism for achieving this. Indeed, the LTP requires every NHS organisation and their local partners to become part of a geographically-based ICS by April 2021. Reforms to the payment system will move funding away from activity-based payments and ensure that a majority of funding is population-based.
The building blocks and critical success factors for PHM
Historically, a lack of robust patient data that provides a holistic and longitudinal view of all patients has hindered the adoption of a more integrated approach to population health. Our report identifies four key building blocks for PHM: Infrastructure, Insight, Interventions and Impacts and nine critical success factors which we see as key requirements for achieving PHM (see Figure 2).
Figure 2. The four key building blocks - Infrastructure, Insights, Impact and Intervention - and nine critical success factors enabling population health management
The need for a suitable governance, leadership and technology infrastructure is essential for PHM to succeed. Indeed, a fundamental requirement for PHM is a connected IT infrastructure, and adoption of a shared, interoperable, electronic health record, to enable the collection, analysis and sharing of data among care providers. A robust Information Governance framework is also needed, including a citizen opt-out standard, and common interoperability, data and cyber standards. The establishment of five Local Health and Care Record Exemplars (LHCREs) to improve care co-ordination and provide a foundation for health analytics and PHM is an important step forward and should also help improve patient engagement and activation. Gaining the necessary trust in the appropriate sharing of patient data is a fundamental pre-requisite, requiring both clinician and patient engagement.
Advanced analytics and actuarial and informatics capabilities are key to designing effective, robust risk stratification methodologies, and for monitoring the health of the population over time. They also support demand management and capacity planning and enable constructive decision-making in response to population need. In the future, machine learning and cognitive analytics, together with risk stratification analytics and patient profiling, will provide additional insights and propel the implementation of PHM to new levels.
Interventions and Impacts
PHM requires changes to workflows to optimise clinical pathways and enable more cost-effective interventions in community settings. It requires proactive clinical involvement in the development of new care models to change ways of working. Importantly, as recognised in the LTP, PHM is contingent on strengthening primary care and delivering primary care at scale. PHM involves supporting patients to become more self-sufficient in managing and contributing to decisions about their care. Enablers include the adoption of digital and remote monitoring technologies and improving the health literature of patients. Enhanced evidence-based care management strategies and robust analytics are needed to measure the impact of interventions and outcomes for patients.
Actions to realise the benefits of PHM
Evaluating health economies against the nine critical success factors, and deploying the maturity frameworks identified in our report, can help monitor progress towards PHM. We feature eight good practice case examples and highlight a number of enablers, including the need for: a common language for PHM; clarity around data sharing, privacy and interoperability standards; funding to create the infrastructure and leadership support needed for STPs to become ICSs and for ICSs to succeed; prioritising primary care as the asset that is closest to the local community; and PHM to be seen as a change management initiative requiring clinician and wider community engagement in identifying and adopting PHM solutions.
Globally, policy initiatives have promoted the role that PHM can play but, to date, PHM in the UK remains largely underdeveloped. Implementing a PHM approach and moving the mind-set from reactive care to a model of proactive care for the population’s health is a huge challenge. The need for a change in mind-set and deployment of appropriate financial incentives and performance metrics shouldn’t be under-estimated. It also requires ‘smart’ investment in technology and for staff with new skills and talent. The solutions and enablers discussed in our report provide a framework and set of tools for STPs and ICSs to use in the design and implementation of PHM programmes. We will explore these further in subsequent blogs.