By Cosima Pettinicchio, and Dr Eva de Brett, Deloitte MCS
Last month’s blog from our Deloitte healthcare practice provided an overview of the key challenges facing NHS and Local Authority organisations as they transition from Sustainability and Transformation Programmes (STPs) to Integrated Care Systems (ICSs); and gave a commitment to explore each of these challenges in more depth in a series of articles over the summer.1 This week’s blog explores the key building blocks of a comprehensive, target-oriented, Population Health Management (PHM) approach and outlines the ‘no-regrets’ decisions that system leaders need to consider when embarking on their transition to an ICS.
Population-level health management can seem a daunting task for new ICSs as they attempt to balance health and social care needs across a variety of providers and diverse population groups with the development of effective governance and infrastructure. The planning stage can be particularly challenging in understanding both where to start and the key steps needed to develop a robust PHM strategy.
Our recent report, ‘Population health management’ outlines the key building blocks and critical success factors to develop a comprehensive PHM strategy (see Figure 1).
Figure 1. The four key building blocks and nine critical success factors enabling PHM
In our work with aspiring ICSs, we have seen some systems investing significant leadership time and resources on developing their proposals for new organisational models, or in designing major IT platforms, that have not taken into account the needs of clinical and operational end-users. While we believe that clear governance and leadership arrangements alongside population health technology and analytics, are at the heart of an effective PHM strategy, these should not be prioritised above winning ‘hearts and minds’.
To truly make progress, ICSs will need to develop plans to improve performance across all of the above areas, in parallel. However, there are some ‘no regrets decisions’ and immediate areas that ICSs should focus on from the outset.
1. Obtain a clear understanding of the baseline
To transform at pace and scale, system leads need to understand their current level of maturity as an ICS and develop realistic milestones across domains such as: leadership and governance, culture and engagement, patient experience, data and analytics, technology, and financial and organisational models. The first step is to undertake a multi-domain maturity assessment. Our Population Health Maturity Framework (see Figure 2) can be used by system leaders to agree a pathway towards achieving a sustainable model, drive better performance and improve quality of care. In order to start thinking about a PHM strategy, a score at least ‘3’ is generally needed in each domain. As many systems will not yet be at this level, we will share further tips on achieving greater maturity in subsequent blogs, covering: system efficiency; system level governance and leadership capabilities; cultural and operational development (OD) change; data and analytics; and new models of primary care.
In conducting maturity assessments with aspiring ICSs, we stress that this should not be seen as a tick box exercise, but should use it as an engagement and developmental tool to alert leaders and managers as to the strengths that can be capitalised, and where further work is needed.
Figure 2. The domains within Deloitte’s Population Health Maturity Framework
Source: Deloitte LLP, 2019
2. Start engagement early
Staff and the public are the majority stakeholders in any health and social care economy and so early and sustained engagement is always going to be of value. This will be key to attaining early buy-in and a greater likelihood of achieving the ICS’s objectives and delivering improved outcomes. Where we have seen this work particularly well, is when early engagement has helped our ICS clients to build collaborative relationships and identify shared priorities for the system over the short, medium and long-term. When communications come late in the day, this can contribute to lost trust in system leadership and credibility.
3. Identify overall aims and objectives for the system
The aims and objectives for care will differ from ICS to ICS. ICSs, therefore, need to identify their individual priorities for care and use these to develop a population health outcomes framework that is specific to local needs. Any system-wide framework should provide a structure by which an ICS can: achieve consensus in how to improve health and care outcomes; align priorities and pool resources across the ICS footprint; recognise the different local needs and starting points; and enable commissioners and providers to achieve best value within available resources.
To support continuous improvement ICSs should:
- Define the vision for change and priorities for the population - Engage the public and staff in identifying the core priorities and outcomes for an ICS, underpinned by data analytics to ensure the focus is on the right areas. Measure outcomes and performance against constitutional standards to identify pinch points and population groups at risk and target interventions in the short and medium term (examples include emergency care services, diabetes care, and mental health support in the community). ICSs should also agree a manageable number of key performance metrics that define success, such as cost of care per episode, per bundle, or per patient, and create a meaningful clinical dashboard.
- Flex strategic aims to the needs of localities - ICSs need a flexible strategy that reflects their different localities and health and social care needs. For example, rural localities may want to focus on workforce mobility to support frail patients in the community, whereas urban localities may prioritise education in minority ethnic communities as a wider determinant of health. Equally, there may be ‘universal’ outcomes such as managing obesity and diabetes outcomes, which need tackling at a system level.
For example, Greater Manchester (GM) has a robust approach to identifying and communicating aims and objectives for the system and its 10 localities. GM uses a Single Outcomes Framework comprising a set of population health metrics that are tracked on a regular basis. Each of the 10 localities has an analogous framework that flexes the outcomes (within defined parameters) so that it is relevant for each locality’s population. Strategic ambitions and interventions follow five transformational themes designed and implemented across the 10 localities, and monitored through the Single Outcomes Framework, meaning all organisations use a common approach and language.
4. Focus on delivering improved outcomes
Finding the right interventions is vital to driving improved outcomes for the population. To achieve the greatest impact, these interventions should be underpinned by a strong evidence base (backed by research literature and outcomes derived from analogous national or global systems) and targeted to the right population groups via appropriate delivery methods. NHS England and NHS Improvement recognise the need to focus on the ‘impactability’ of population groups to identify who will benefit most from which intervention.2 For example, individuals with the highest clinical/social risk profile will benefit most from in-person interventions, whereas, lower risk, engaged, populations are more likely to benefit from app based self-management tools.
Evaluating your ICS against the nine critical success factors, and deploying the maturity frameworks identified in our PHM report, can enable health and care systems to monitor their progress towards building an effective PHM strategy. It can also help system leaders to understand where they are on their transition to a population health approach and how to progress to the next stage of development.
For further insights look out for our upcoming blogs including ‘System and Place-based decision making’ from Sara Siegel and Seb Zanker and ‘Population Health Analytics and Data’ from Jon White and Sunny Dosanjh.