The role of social determinants in health is a field of research stretching back more than 150 years. Sir Michael Marmot put it succinctly in his landmark 2010 review Fair Society, Healthy Lives: ‘the more favoured people are, socially and economically, the better their health.’
This message has crystalised in the years that followed, with the Covid-19 pandemic putting a spotlight on widening health inequalities that saw the disease disproportionately impact those on low incomes, people of colour and those with disabilities and long-term conditions.
As the cost of living crisis deepens, members of the public are already reporting an adverse impact on their health.
Policymakers see integrated care systems as a key weapon in the battle against health inequality. It’s hoped that bringing together organisations responsible not just for healthcare but for services like housing and education should enable holistic pathways that address the social as well as the medical. Indeed, many systems see the goal of reducing inequalities as a ‘golden thread’ running through all strategic decisions.
Proactive approaches like population health management, which involves analysing data to pinpoint the patients most likely to benefit from targeted interventions, are considered a key tool for tackling health inequalities.
Although systems remain at different levels of maturity when it comes to data sharing and collaboration, 39 out of 42 have been involved in a population health management pilot as part of a three-wave programme.
Often led and delivered by a single PCN the 22-week pilots have involved the creation of new pathways for patients at risk of preventable disease and those with complex social and medical needs. In many cases, they’ve included input from organisations and experts from across a system: GPs, local councils, hospitals and voluntary groups.
In theory, they’re the first tangible step towards a much greater milestone. NHS England wants all systems to have the ability to transform and create new multidisciplinary pathways informed by data by next April.
By 2025, each is supposed to have a fully embedded population health platform.
But as the final pilots draw to a close, those managing them aren’t certain what the future holds.
Pre-diabetes pilot
At Loxford PCN in Redbridge, London, Dr Shabnam Ali and her colleagues are coming to the end of a 22-week population health management pilot focused on young adults with pre-diabetes.
Type two diabetes is a major issue for the PCN, which serves a population of around 68,000 people. Given its onset can often be delayed and even prevented with certain lifestyle changes, it seemed like a perfect area of focus for proactive intervention.
More than 80% of the PCN population is a member of an ethnic minority group, with many younger people living in multilingual, multigenerational households. Dr Ali and her colleagues believed the changes these individuals made had a good chance of rippling through to the whole family, maximising their impact.
The patient cohort — all aged between 20 and 39 — were chosen following an in-depth analysis of GP, local authority, public health and hospital data performed by health services firm Optum and what was then North East London CCG. Eventually, the cohort was whittled down to around 80 people, roughly 45 of whom were fully involved in the pilot.
Interventions themselves were co-produced with patients, each of whom was asked what terms like ‘prediabetes’ meant to them, and what changes they could and would want to make to improve their health.
GPs, dieticians, social prescribers and a health and wellbeing coach then worked with representatives from the local authority, public health department and CCG to create culturally specific menus, a tailored exercise programme with different tiers of intensity, a meditation programme and a step counting app.
These elements were used to create personalised plans for each patient that would slot easily into their lifestyles.
‘If you want to make a behaviour change, it if it becomes something that you find onerous, you’re not going to do it,’ Dr Ali said. ‘If it’s something that sort of gaps into your lifestyle, you can sort of tailor it into the way you’re living. It becomes a habit as opposed to becoming, ‘this is what I have to do.’’
Although Dr Ali and colleagues will use some quantitative metrics to assess the success of their scheme, she says improvements to the patients’ quality of life are already clear. She gives the example of a young woman with prediabetes and arthritis who avoided going out for walks because they caused her pain.
Ali said: ‘On one of our follow up calls, she says ‘Guess what? I’m in the park. I’ve actually managed to walk and I’m not having any pain.’’
Even though the benefits of personalised, preventative interventions seem clear, Dr Ali is concerned about their future beyond these kinds of pilots.
Initially believing Loxford’s pilot would be fully centrally funded, she was surprised to find out this pot only stretched to the consultancy work provided by Optum. The interventions themselves were delivered entirely by system partners, putting extra pressure on already overstretched resources. In the long term, this would not be sustainable.
Still, Dr Ali and system colleagues are determined to build on the progress achieved by the pilot. They want to continue providing activities like walking groups and cook-alongs.
‘One thing it does is it strengthens your relationship with your system partners,’ she said. ‘You work with them in a way you haven’t before. As a PCN, we are going to make an active effort to keep that going.’
But without funding for the analytics used to identify cohorts at such a granular scale, she says there is only so much the PCN can achieve.
‘Anything we do again, it will be at a much smaller scale. It won’t be as effective, because we won’t be able to do drill down [on the data] as much. I think that that’s probably one of the biggest risks with all the population health management.’
Data driven
The importance of data is no surprise to Arden and GEM CSU Chief Clinical Information Officer, Dr Nick Pulman. A GP and former CCG chair, Pulman works closely with the organisation’s analytics service on several systems’ population health management projects.
‘PHM is rooted in data but it’s what we do with that data that matters,’ he told Pulse PCN. ‘Segmenting and stratifying populations, modelling changes and identifying appropriate evidence-based interventions enable us to take targeted action to improve health and wellbeing.’
Similar to the work performed by Optum for Loxford, CSUs like Arden and GEM develop tools that help GPs ‘explore and identify opportunities’ for intervention ‘in ways they could never do with conventional practice-based data searches.’
The organisation compiles data from a wide range of national and local sources, including secondary and, where possible, primary care. Social data can be a great asset when it’s available but Pulman says it presents a technical challenge from a coding and systems interoperability perspective.
Following a national pilot focused on linking adult social care data to health records, the CSU now receives data from 35 local authorities, ‘enabling both councils and integrated care boards to better understand their services and the impact on clients.’
Depending on what data is available, the CSU produces different population health-focused models. A model developed for CCGs in Bedfordshire, Luton and Milton Keynes, for example, was used in specific initiatives focused on frailty, weight issues, diabetes and chronic obstructive pulmonary disorder.
Although it’s receiving more attention today, population health management schemes have existed for some time. Before Dr Pulman joined the CSU himself, he and other primary care colleagues worked closely with the organisation on a proactive care scheme. The CSU helped identify patients with multiple long-term conditions and frailty.
GP practices and other organisations across the system tried to work in multidisciplinary teams, sharing care plans for at-risk groups of patients. “For many practices it was the first time they had worked so closely with their social care colleagues and I think it helped put Leicestershire in a great place to take on the challenges of ICS integration,” Dr Pulman said.
Data limits
Andrew Fenton, Transformation Director for PHM at South, Central and West CSU, says it’s also important to recognise the limits of data when it comes to population health management projects.
‘Often this gold standard, the linked integrated dataset, doesn’t yet exist,’ he said. “And data insights aren’t enough on their own.’
Like Loxford’s Dr Ali, he recognises that quantitative data can’t capture many aspects of the ‘wider social dimension’ of health and care.
In addition to data analytics, his CSU provides services such as community asset mapping to PCNs and other groups: documenting the resources that already exist in a community and figuring out where there might be potential for development.
‘I think we need to move beyond [the data] and think about, well, where’s the patient insight? That’s why understanding community development issues and community engagement is important — particularly connections with the voluntary sector and local community groups.’
His CSU have worked closely with the Growing Health Together programme in Surrey: a series of PCN-led collaborative schemes targeting health inequalities. As well as performing health data analytics to inform the projects, the CSU has worked with an external supplier on baseline community asset mapping for the programme.
This involved working with local stakeholders to ‘map the key sort of people and organisations in a neighborhood’ and understand ‘the strength of those relationships in a community context.’
Originally commissioned by Surrey Heartlands CCG, Growing Health Together sees five East Surrey PCNs work on a diverse range of interventions including community gardens, walking groups, coffee mornings, dedicated wellbeing spaces and support groups for those with specific needs.
The projects are, as far as possible, coproduced with the local community and the specific groups they target.
Some of the programme’s more innovative schemes include multigenerational music sessions for older people in care homes and school age children, and bike repair training aimed at those from disadvantaged groups. It’s hoped projects like these will both foster a sense of community and help empower individuals.
Programme leaders have also been keen to improve the lived environment for their population, improving access to green spaces and redecorating wellbeing rooms in schools.
PCNs involved in Growing Health Together give their clinical leads a small amount of dedicated time to work on the programme. Dedicated funding for each project varies, with some projects run — like the PTA-funded school room refresh — on tiny budgets.
Assessing the success of these kinds of programmes is a crucial step in ensuring they continue, but this can be tricky when their benefits are considered wider than metrics like BMI and Hba1c.
In Loxford, Dr Ali and her colleagues are using indicators like patient activation scores, which assess a patient’s confidence in self-managing their health, to try and better quantify the impact of their pilot.
Fenton’s CSU is has been evaluating quantitative indicators for Growing Health Together based on the King’s Fund Population Health Model.
Growing Health Together co-founder Dr Gillian Orrow told a recent webinar: ‘It’s been really helpful to have that quantitative data insight to be able to triangulate with our own experiences working in the patch.
‘This can really help us to make sure we’re taking this proportional universalist approach that Sir Michael Marmot advocates, so that we’re putting greatest resource in the areas with the most to benefit.’
Programme leaders want to supplement these insights with qualitative data. As well as applying for funding for such research from the National Institute of Health and Care Research, the group is performing surveys on community connectedness and self-rated health, and assessing the environmental impact of its work.
Fenton says it’s important to look at population health management beyond data analysis itself. Not only does the term sometimes grate on those at local authorities, but it risks siloing work that by its nature needs to be collaborative.
‘Management suggests a kind of bureaucratic process — that one is being managed, something is being managed – when it’s not, it’s much more.’
PHM is viewed by some as a solely data driven approach — an element he describes as ‘to technocratic and too heavily medicalised’ — and something that ‘limits its impact.’
His CSU is involved in a wide range of schemes beyond PHM pilots that all work towards the same goal of reducing health inequalities, often at a PCN level. As well as PHM schemes, ‘you’ve got personalised care, social prescribing, people in communities, health inequalities,’ he said.
Especially at an NHS England level, he says it’s important for leaders to recognise that ‘all of these things are kind of overlapping and sometimes mutually supportive sometimes, you know, not divergent.’
Whether they’ve considered PHM or projects or something else, leaders need to ‘more closely integrate these different strands of thinking.’
