ICBs share their approaches to population health management, how they are targeting issues in their own population, and the preventative proactive work they are undertaking. Learn about approaches in Lincolnshire, Suffolk and North East Essex and Bristol, North Somerset and South Gloucestershire Kathy Oxtoby reports.
In England, and every other country committed to universal healthcare, need and demand are outstripping resources, says Professor Sir Muir Gray, a healthcare systems expert who established the UK national screening committee, and former chief knowledge officer of the NHS.
‘By resources, I mean not only money, but also staff, time and carbon,’ says Sir Muir, who is founding director of the Oxford Value and Stewardship Programme, which seeks to train healthcare professionals on delivering value to populations and patients.
There is also an ageing population, economic inequality is increasing, and new conditions are emerging, including real diseases like Covid, and new concepts like monoclonal gammopathy of undetermined significance (MGUS), which is a condition just created based on an abnormal lab test, says Sir Muir.
Then there is what has been called ‘the relentless increase in the volume and intensity of clinical practice,’ with doctors doing more and more and more, he says. Clinicians are doing more and more tests. ‘Doctors are sometimes ordering CT scans before they have even spoken to the patient.
‘Or a hospital blood test may be giving many different results because laboratories are testing for issues that are not relevant to the patient’s condition, which were not requested by the doctor who sent the blood sample in,’ he says.
Sir Muir says many of the factors affecting population health ‘are not within the scope of NHS leadership to get a grip of – they are broad social factors that need to be tackled’.
Factors affecting population health that are out of the control of the NHS include isolation, housing problems, employment problems, deprivation, and low levels of education, he says. ‘The team at the Oxford Value and Stewardship Programme have been saying we should be putting more money into education, for example, because wellbeing problems, which the NHS cannot prevent, are overwhelming the NHS.
‘The NHS does wonderful things in diagnosis and clinical treatment, but it is having to deal with a much broader range of issues such as the sickness absence epidemic.’
Population health management (PHM) or Population Healthcare – the terms are used interchangeably – is an approach that can help deal with these issues. Sir Muir describes it as: ‘delivering health services focussed on populations, and subgroups of populations defined by need’.
‘We emphasise the need to think about, and focus on the third dimension of healthcare, “3D healthcare”,’ he says. The first dimension is self care, family care, primary, secondary, and tertiary healthcare, the second dimension is the bureaucracies, and the third dimension is population subgroups – people with symptoms such as back pain, diagnosed conditions such as rheumatoid arthritis, or people in certain situations, such as in the last year of life, says Sir Muir.
Currently, the way the healthcare budget is divided up means that, for example, while it is clear to the ‘nearest pound’ what is being spent on health centres and car parking, it is not clear what is being spent on, say, respiratory disease, cardiovascular disease, or mental health, he says.
Taking a PHM approach could mean, for example, allocating a budget for respiratory care to those in charge of providing services for people with, or at risk of respiratory disease in a particular population. The respiratory physician responsible for, and to, the population would then be given a budget for respiratory disease, which would also cover such costs as drugs and smoking cessation services, says Sir Muir.
‘And we would say to those in charge of healthcare, and the people with respiratory disease in that area: “Are you sure this money is being used in the best way, or are there things you’re doing that are of lower value and using resources which could be used differently?”’
‘We’re starting to manage healthcare in that way,’ he says. ‘At the Oxford Value and Stewardship Programme we’re trying to develop clear systems for, say, asthma or COPD within the respiratory disease segment of the population.’
Under this system, ‘you would have a network of GPs, patients, and specialists who would feel responsible for making the best use of those resources. These would not be hospital or NHS resources. These would be resources for the people living in a particular area with respiratory disease.’
Sir Gray has seen 20 reorganisations of the structure of the health service ‘most of which have made no difference’. But with the current structure he says, ‘at least we’ve got the words “system”, “place based partnerships”, and “primary care networks”. This is the century of the system and the network. I see ICSs as a step forward. And I’ve also worked with a lot of great primary care networks.’
Regarding how ICBs are tackling issues in their own population and the preventative proactive work they are undertaking, ‘I’m seeing good things taking place in different populations,’ says Sir Muir.
‘We’ve seen some places where football clubs, for example, are getting involved in prevention and improving wellbeing.’
He says ICBs are also ‘looking at the health of their population as a whole, not just the use the population is making of their service’.
But clinical services are ‘not moving to population healthcare and population based clinical services at the speed that needs to take place’, he says. ‘The clinicians need to be given the responsibility for the resources.’
And ‘we need a much more radical approach, where the ICBs tell the local authorities and local businesses: “We can’t do it all”’.
With a PHM approach, ICBs need to look at their population and the problems of their population. He says ICBs could put a map of their area on the wall, showing the places, neighbourhoods, and the primary care networks. And they need to consider ‘how they could involve the community in the development of a health and wellbeing service that will allow the NHS to do the things it can do best – diagnosis, acute care, and starting the right treatment’.
ICBs are ‘bringing health prevention and health promotion up the agenda’, he says. ‘They are focussed on the population, not on the real estate. They now need to move to a much more formal approach to population healthcare.’ He says this requires programme budgeting, which is budgeting based not on institutions, but on segments of the population defined by need, for example budgets for people with cancer, or people with bone and joint problems, or people in the last year of life.
This requires training, and Sir Muir says that with every ICB there are about 500 people, from GPs to those working in finance, who need to be trained to think in a different way and to be ‘involved in a cultural revolution’.
This training should include: how to think about population health management, how to design systems and build networks, how to help individuals get personal value, and how to create a culture of stewardship, says Sir Muir.
Challenges to taking a PHM approach include people being ‘too focused on primary, secondary and tertiary care, and we need to change that focus to looking at the population subgroups – and that’s a leadership role, a cultural role’.
Sir Muir says the changes that population health can bring about are big enough, and fast enough to make an impact on the “broken NHS”.
‘About 15% of what is done on the NHS doesn’t do any good. We need to get clinicians to shift resources from things that are not adding value, to things that do add value, not just by increasing efficiency, but by shifting resources from, say, prescribing to promoting physical activity. And the public needs to understand this too.’
He says responsibility for the future of the health service lies ‘not just with ICB chairs and chief executives. It’s every clinician, and the public too. The public needs to be informed about things they can do for themselves.
‘That’s the culture of stewardship – we all feel we are responsible for making the best use of the NHS resources. It’s a key culture for the coming decades.’
NHS Lincolnshire ICB
How Lincolnshire ICB Is targeting issues in its own population ‘comes down to the root of the population health management (PHM) infrastructure that we have built within Lincolnshire over the last four years’, says Vic Townshend, programme director – population health management, for Lincolnshire Integrated Care System.
‘To be able to target and identify issues with your local population you need to understand how local people are interacting with your local services, to start to understand where opportunities for improvement can be recognised,’ she says.
In 2019, the CCG, and later Lincolnshire ICB, committed to adopting a PHM infrastructure and approach on behalf of the system.
This included executive sponsorship and funding for a strategic partnership with health intelligence and analytics company Optum UK. The independent consultancy ‘offers the capability and capacity to build population level linked dataset and develop local capability to utilise that intelligence appropriately’, says Ms Townshend.
The ICB, in an ‘equal and equitable partnership with Optum, rapidly developed a population level linked dataset for 100% of GP registered people within the Lincolnshire system, linked to their activity in acute hospitals, community services, mental health and social care, so that the ICB and the wider system can see how people are interacting with our services and where there are opportunities to target improvement’, says Ms Townshend.
‘Leveraging the power of the intelligence infrastructure we have built in the PHM programme, we are able to identify, very quickly, health inequalities in access and outcome, rising risk within a cohort of the population with shared characteristics, and groups of people experiencing sub optimal outcomes and treatment pathways,’ says Ms Townshend.
‘This enables us to support our programme and organisational colleagues to consider opportunities for preventative initiatives for earlier intervention and improved outcomes,’ she says.
A core part of the PHM programme is upskilling the programme and organisational workforce to feel comfortable with these methods, which ‘has been a key outcome for us. And that allows them to do the prevention and proactive care’, she says. ‘We’re calling it “democratising intelligence.” It’s about accessibility of intelligence.’
It is also about working with populations themselves. ‘We champion co-production and personalisation. We have had patients and relatives in a room with multidisciplinary care teams exploring this linked dataset with an analyst for a project, talking about what that intelligence is showing them and co-produce new solutions,’ she says.
The High Intensity Use (HIU) service shows how the ICB ‘leveraged all its professional population health tools to change outcomes for those people’, says Ms Townshend.
The service, piloted at Trent PCN, focuses on people over 18 years old that have attended A&E seven or more times in the last 12 months and are not on an end-of-life pathway.
It looks at supporting people who use a significant amount of urgent and emergency care resources compared to the average population.
This service, costing £80K annually, provides flexible, non-clinical support through two dedicated HIU link workers. They focus on the holistic needs of individuals in their preferred settings, aiming to uncover the root causes of frequent emergency visits.
People supported by the service include those with untreated physical or mental health conditions who have ‘fallen through the cracks’ of health services. There are also some with learning disabilities, or who have experienced trauma or addiction issues and housing issues, says Ms Townshend.
‘By collaborating with key partner organisations, the HIU link workers co-produce personalised care plans that emphasise asset-based recovery and align with the individual’s goals.
The service engages the entire community, working with voluntary sector organisations, social prescribers, and the council to develop tailored support solutions that meet each person’s unique needs.
An evaluation, using retrospective control group methodology, revealed that an annual investment of £80K in two link workers achieved a nearly 3:1 potential return on investment within six months.
This relationship-based intervention supported emergency admission avoidance worth £230K versus the control group.
This sort of robust evaluation requires a linked data model to demonstrate the value and return on investment of the intervention across the whole integrated system, the ICB says.
After six months, emergency admissions had reduced by 58%, A&E attendances by 41%, GP encounters by 4% and mental health activity by 37%.
The service has ‘empowered individuals to take control of what they can and be supported with what they need’, says Ms Townshend.
‘It has empowered the local team to work more closely with the voluntary sector in their local community.’
‘It has also made the case for investment in rolling out this service to other areas of Lincolnshire, and proven to our boards that this methodology works.
‘And it has enabled us to have a measurable impact,’ she says.
Ms Townshend says the HIU project’s success was not just about intelligence infrastructure, but also ‘a personalised approach, having the right people in the right place, and a diverse team coming together with a “can do” attitude’.
‘It’s the infrastructure, the culture, a way of working together as a multidisciplinary team, and the intelligence that gives you that magic sauce for success,’ she says.
Key to the success of the scheme were the ICB’s primary care transformation team, the Trent PCN team, clinicians, local voluntary sector organisations, analysts, and HIU link workers, she says.
A PHM approach provides ‘a framework for resource allocation decision making, which is a core objective of any ICB or ICS. PHM enables you to make decisions about where to most effectively place your resource, whether that may be money, workforce or estates’, says Ms Townshend.
With PHM, ‘you need to invest in the right people in the right roles with the right agency to act with freedom across the system’, she says.
‘You also need the buy-in of your boards. For PHM to really have an impact you have to adopt it at whole system scale,’ she says.
One of the benefits of PHM is that it provides ‘the framework in which the ICB can assess its effectiveness in commissioning services for local people, and within that we can understand where there is inequity and inequality and target that for improvement’, says Ms Townshend.
‘It also enables us to make far more informed decisions about what change to drive forward and where to allocate resource.
‘It empowers programme leaders to be ambitious in their drive for change and improvement, and to be confident in their decision making when they propose doing something differently.
‘PHM also provides the evidence and the arguments to support frontline teams to drive forward their own change and improvement initiatives like High Intensity Users – it gives them confidence to do things differently,’ she says.
Currently, ‘we are leveraging PHM infrastructure and methodology in our whole system planning’, says Ms Townshend.
‘We are embedding PHM methodology in our decision making around investment. And we are embedding population health understanding and outcomes framework for the whole population into system and board assurance so that our governance understands population health outcomes for our people,’ she says.
‘Whilst we’ll always have a focus on delivering constitutional standards, we can use population health intelligence to target our resources more efficiently and to affect a larger change for both those targets and outcomes for people.’
She says PHM is being used in Lincolnshire ‘in all programmes of work now, as part of the annual planning cycle, including organisational clinical strategy’.
‘We’ve built foundations, some confidence and interest in PHM, and are comfortably starting to upscale, but that isn’t going to be easy when changing things across the whole system. We need two years to get PHM embedded as our “business as usual” at scale. We’re not there yet, but that’s the next phase of it for us,’ she says.
To ICB and ICS leaders looking at PHM she says: ‘It needs to be a priority for resource, because it’s going to help you make decisions about finance and sustainability, whilst trying to improve outcomes. And it’s important to invest in the right people to drive the work forward.’
‘You leverage PHM to understand the needs of your local people. And when you can gather together as an ICB or ICS and say: these are our people, these are their needs, it can really change and drive the conversations you have as partners to make different decisions to improve outcomes.’
NHS Suffolk and North East Essex ICB
Suffolk and North East Essex (SNEE) ICB has a joint forward plan to address and align with the diverse health needs of the local population.
‘To support this effort, the ICB has placed a strong focus on commissioning healthcare services by using a population health management (PHM) approach,’ says Charlotte Minns, senior PHM programme lead, NHS Suffolk and North East Essex Integrated Care Board.
‘PHM is about using linked data to provide new insight, and then taking linked action to improve the social, physical and mental health outcomes and wellbeing of people within and across a defined population, while reducing health inequalities,’ she says.
The PHM Programme is funded by SNEE ICB.
In partnership with general practices across SNEE, the ICB has developed a PHM linked dataset. ‘This brings together anonymised data from across the ICS and allows us to understand how healthcare need varies across our population,’ says Ms Minns. This data is being used to inform plans at all levels of the ICB, with a particular focus in reducing health inequalities and enabling an integrated care approach in local areas via the ICB’s integrated neighbourhood teams.
Ms Minns explains that in SNEE, PHM approaches are used to identify opportunities for new services, for example, where to geographically put a new service.
They are also employed to identify opportunities for improvement and embed initiatives that improve health and care outcomes, such as designing and embedding new ways of working to improve outcomes.
And PHM approaches are used to target high impact initiatives towards groups of people that will benefit most from that care.
The ICB has a variety of proactive and preventative work being carried out, that draws upon population health management approaches. These projects are in different phases of delivery.
For example, PHM data was utilised to determine the optimal locations for Sisu Health Stations. These stations provide digital self-service health checks in easily accessible areas, along with personalised, local signposting to follow-up support.
‘To identify suitable locations, we focused on risk factors associated with hypertension. Collaborating with alliance partners, we then pinpointed specific sites within those communities that would attract the highest footfall. The approach has allowed us to integrate health checks into people’s everyday lives and activities. We have received positive feedback from users of the Sisu machines,’ says Ms Minns.
PHM data has also been used to identify priority areas for delivering mental health training in Ipswich and East Suffolk. ‘By analysing risk factors associated with male suicide, we pinpointed the locations where the training would have the greatest impact. As part of this initiative, we are equipping barbers in the region with the skills and confidence to engage in conversations about male mental health and suicide,’ says Ms Minns.
The ICB is currently investigating the relationship between poor-quality housing and health conditions in north east Essex. ‘As part of this effort, we are aiming to integrate data from a social housing provider, with health information, such as respiratory needs. Once the data linkage and analysis are complete, we will design targeted interventions and potentially target high-risk cohorts,’ says Ms Minns.
West Suffolk Foundation Trust led a project in West Suffolk to identify individuals at moderate risk of emergency admission within the next 12-months for frailty assessments. ‘The approach combines specialist assessments with local, asset-based interventions. It focuses on delivering proactive, personalised care through social prescribing, health coaching, and patient activation strategies,’ says Ms Minns.
The primary challenges with this work on population management ‘have revolved around embedding PHM at scale, as a shared responsibility across all stakeholders and securing the resources needed to achieve this’, says Ms Minns.
To address this, the ICB has appointed a PHM transformation manager for each alliance in Suffolk and north east Essex. These managers are tasked with enhancing PHM capabilities within their respective alliance area by providing training, specialist advice, and ongoing support. These transformation managers are also aligned to a long-term condition area too and bring PHM methodologies to bare within these programmes.
‘This dedicated resource, alongside comprehensive training, and guidance is beginning to build the system’s confidence in driving PHM approaches forward,’ says Ms Minns.
She says SNEE’s Integrated Care System PHM strategy talks to five key areas that PHM is seeking to deliver: enhancing the experience of care, improving the health and wellbeing of the population, reducing the per capita cost of health care and improving productivity, improving health and care inequalities, and increasing the wellbeing and engagement of the workforce.
In 2023/24, the PHM programme established ‘the right foundations and enablers under the infrastructure and intelligence pillars of the ICS PHM Strategy’, says Ms Minns.
In 2024/25, ‘the PHM programme will focus on using our enablers to deliver PHM interventions. SNEE has adopted some PHM interventions; however, these interventions have not all yet delivered an evaluation to evidence the full impact’.
On a quarterly basis, the PHM programme undertakes a self-assessment ‘to review the maturity and capability of PHM under the four programme pillars’, says Ms Minns.
These programme pillars are:
- Infrastructure: establishing robust foundations.
- Intelligence: gaining insights into the population.
- Interventions: applying PHM strategies.
- Impact: promoting the adoption of best practices.
Each PHM pillar is scored against a national maturity matrix as “emerging”, “developing” or “mastering”. ‘SNEE has made excellent progress on infrastructure and intelligence and is making good progress in the intervention space and general visibility of PHM and training,’ says Ms Minns.
The ICB works closely with all organisations in the Integrated Care Partnership, including a diversity of organisations across the VCFSE (Voluntary, Community, Faith, and Social Enterprise). Partners include general practices and pharmacies, Suffolk County Council, Essex County Council, district and borough councils, University of Suffolk and the Integrated Care Academy, acute and community hospital trusts, and mental health trusts.
‘These are strong and broad partnerships that improve coordination across these critical programme areas of health inequalities, prevention and PHM,’ says Ms Minns.
‘We also have an Integrated Care System Intelligence Function, which is an analytical collaboration of analysts from across the system that provides insights from PHM data to inform strategy and delivery.’
SNEE’s key focus areas for the next 12-24 months are likely to centre around ‘empowering the workforce to confidently apply PHM methodology in commissioning and service delivery, and making PHM standard practice to scale projects and implement evaluation methods to assess impact’, says Ms Minns.
The ICB’s plans will also involve expanding strategic partnerships to enhance engagement with ICS partners and clinical experts crucial for prevention and health determinants, including VCS and district and borough councils.
It will also focus on ‘identifying, planning, and delivering PHM-informed transformation opportunities within each of the long-term condition areas and alliances, cardiovascular disease, diabetes and stroke, respiratory and neurorehabilitation’, says Ms Minns.
And she says the ICB ‘will be looking to address health and care inequalities, ensuring PHM governance aligns with national and ICB priorities’.
NHS Bristol, North Somerset and South Gloucestershire ICB
NHS Bristol, North Somerset and South Gloucestershire ICB investigates issues in its population ‘using insight from clinicians who are on the ground delivering services, as well as system leaders who are setting our strategic objectives’, says Nick Hassey, head of population health management and insights at the ICB.
‘We then take a person-centred approach to find solutions. For example, we approached the question of what could be done about long A&E waits by using linked data to find out if certain groups of people were more likely than others to wait a long time in A&E.
‘And we found there were, which led to the F-ACE work, which focuses on the assessment and coordination for emergency and urgent care support to frail patients who would otherwise be admitted or conveyed to hospital,’ says Mr Hassey.
Equally, national datasets show the ICB where there are opportunities for improvement. ‘For example, our NHS England cardiovascular monitoring tool showed we have opportunity for improvement on the management of cardiovascular disease in our system. We’re then able to use this insight to drive our inequalities work,’ says Mr Hassey.
Funding for population health management (PHM) is from core ICB funds and limited and focused purely on the staff costs within the team.
The ICB ‘works closely with clinicians across our system partners, as well as the commissioning support unit who provide the mechanism for the data we need to flow to us’, says Mr Hassey.
Preventative proactive work regarding PHM being carried out by the ICB includes F-ACE and pro-active admission avoidance schemes ‘where we helped GPs identify patients at risk of admission and who were missing evidence-based interventions – such as vaccines – to avoid those admissions’.
The ICB has also run successful projects on cardiovascular disease and heart failure, he says.
This includes the ICB’s Healthy Hearts group, which identified people in Bristol Inner City who were at risk of heart failure. They were offered a range of support options, including attending a Healthy Hearts group, where people met with specialists and peers to discuss health issues and find personalised solutions. Through this group, support from a nurse, a dietician, a physio, and a social prescriber was provided. Follow up evaluation revealed this group had improved heart health metrics over time than the comparison group.
‘A big misconception is that population health management is just analysis – the verb is important,’ says Mr Hassey. ‘By its nature population health management work involves lots of different organisations working together from analysis, to new service design, piloting, and then fuller roll out. That takes a long time and is hard to get and keep everyone involved. We’ve not solved that either, we’re still really at the early stages.’
It can also be difficult to carry out the patient and service user involvement required at the scale needed. ‘Again, by its nature, population health management involves quite large groups of people, and you need to understand their lives if you’re to help them improve their health. But that requires more than a “token” patient representative on a project board, which presents challenges in funding,’ says Mr Hassey.
PHM ‘shows you where the real issues are’, he says. ‘For instance, through our work we were able to show that the people who generally use a lot of emergency care are also using lots of primary care capacity too.
‘This helped move the understanding of where unsuccessful patient interactions were and address the challenges in providing support to the same groups of people, working together more effectively.
‘We’ve also been able to tweak services following feedback from local people and communities, for example, offering heart advice clinics and sessions in different settings and different times to suit our communities,’ he says.
The ICB has lots of plans moving forward, particularly as we further develop our data’, he says. This includes ‘how we can get more relevant data into the hands of frontline teams, and understanding of how local people use, or don’t use, local services’.
