Sir Muir Gray, a healthcare systems expert who established the UK national screening committee, was former chief knowledge officer of the NHS and is currently founding director of the Oxford Value and Stewardship Programme, which seeks to train healthcare professionals on delivering value to their patients, talks to Healthcare Leader’s senior reporter Beth Gault about why population health management should be the future of the NHS.
Beth Gault (BG): How would you define population health management?
Muir Gray (MG): It’s thinking of the population as a database, not just the patients who reach the health service. We often use only patients as the database, which works alright for broken legs, but anything with clinical judgment involved we must use the population as a database.
For example, if there was a high rate of knee replacement in Oxford, is that right for the area, or is it possible that there’s overuse? If there’s a low rate of knee replacement, is that because there’s been a lot of hip replacements in the last 10 years, or is that underuse? And underuse is quite often combined with inequity.
BG: Why is it important?
MG: Unless you use the population as a database, you cannot see how you vary in the amount of care you provide. And therefore, you cannot ask if you’re overusing or wasting resources, or underusing resources which has an adverse effect on the population, particularly those in the poorest sections.
Simply looking at the quality for the people who reach the health service is not sufficient and we are probably wasting about 15-20% of all healthcare resources where there would be more value derived if they were switched to another purpose.
BG: How should it affect primary care service delivery?
MG: If you’re a GP or a nurse, you’ve got to get on with the job in front of you. But what we need is the PCNs to be thinking of their population and asking questions. For example, how many MRI requests have been made in the last year and how does that compare with other PCNs in similar areas in terms of age and deprivation?
However, ideally we don’t want to look at primary care on its own. We would want a single system for people with COPD, or type two diabetes. These would set out objectives and a standard set of measures per condition. Then the PCNs could compare outcomes with other networks.
But if you look at the budgets of hospitals or ICBs, you’ll not see words like heart or cancer or respiratory. You’ll see primary care, continuing care or long-term conditions. But we should be thinking of subgroups of the population and organising budgets by service line accounting, which is what we call it in business.
We’re very keen for one or two clinicians in primary care networks and someone in management to get involved in the place based partnerships and to have this population view.
BG: The recent contract encouraged PCNs to be using population health management techniques for service delivery. What does that mean?
MG: In something like type 2 diabetes, it means looking at how many people had been diagnosed with it in the PCN, the proportion of people in different parts of the PCN, because they all have different levels of deprivation, and then in terms of outcome how many people had it reversed. Then, how many new cases have been identified, and the proportion of those who have been given a prescription of diet and exercise before medication.
Population measures take into account inequity, the proportion of people in the most deprived groups who have been diagnosed.
BG: Has the development of PCNs and ICBs impacted population health management? If so, how?
MG: Oh yes. I’m a bit disappointed that I’ve seen 20 reorganisations of the health system which have made no difference at all. But in this one we have the word system, partnership and network. Healthcare is too complex for bureaucracies, it needs networks and systems.
The ICS strategies are quite good on prevention and deprivation, but one I read didn’t mention the word cancer, one didn’t mention respiratory or arthritis. They’ve largely ignored the huge amount of money being spent on clinical services.
But I do think that primary care networks are doing very well. I think it’s terrifically encouraging, the concept of a primary care network.
BG: What are the challenges with population health management?
MG: It’s a challenge to change culture, but I think the health service will not survive if we don’t move to a population approach, as well as carrying on evidence-based decision making, quality, safety, efficiency. They have to continue. But doing the wrong things more efficiently is madness.
BG: And what are the opportunities?
MG: It can free up resources that have come to be wasted and shift them to a more valuable activity by involving doctors, making them the stewards of the resource, giving them the responsibility of leadership and management of respiratory disease for Oxford, or wherever they are, or end of life care.
BG: What do PCNs need to deliver this?
MG: If they could identify one person – some have done this – with a particular population responsibility. Not just for prevention, but for service delivery. A population healthcare lead.
We have a training programme and a glossary at the Oxford Value and Stewardship Programme which can help.
BG: What about ICBs, what do they need to do?
MG: They need to introduce service line accounting and change the budgeting system, so we can see how much is being spent on cardiovascular disease or mental health, and they need to encourage the development of population-based systems.
A version of this story was first published on our sister title Pulse PCN.
