Population health is aimed at improving the health of an entire population. Dr Cornelia Junghans, Dr Maslah Amin, Dr Kathrin Thomas, Professor Azeem Majeed, Dr Matthew Harris discuss the challenges facing primary care and ICSs.
Broadly speaking, population health is the “health of a group of individuals, including the distribution of such outcomes within the group” with groups often defined in geographical terms but also by socio-demographic or other characteristics. While the population could be in good health overall, the average might conceal stark health inequalities in certain groups. Effective population health is an approach aimed at improving the health of an entire population. It is about optimally using our resources to improve the physical, mental and social wellbeing of everyone and minimise health inequalities. To do this effectively, population health needs to include the wider determinants of health and requires working with communities and partner agencies.
There are many that use the term ‘population health’ interchangeably with ‘public health’. Public health is a medical speciality, although public health specialists can be non-clinical, because it is a discipline that uses evidence to effect change in practice, something that transcends clinical boundaries. Public health specialists are experts at population health. However, the competencies and mindsets necessary to improve population health are essential across the whole health and social care system.
Recent years have seen an increase in chronic disease burden and widening health inequalities and a health system ill equipped to struggle with these challenges. We know that about a third of consultations are for non-medical issues and GPs are unable to deal with these wider determinants of health effectively. We know that about 80% of a person’s health is determined by how and where they live, with only 20% of their health and wellbeing dependent on access to good health care services.
Primary care accounts for most patient consultations in the NHS and manages the referrals into secondary care, so it is ideally placed to have an influential population health role. Unfortunately, public health and primary care have collaborated less than may have been hoped for in the UK until now, with the latter focussed largely on clinical medicine. However, there are probably few GPs who have not heard of Population Health Management (PHM), a real buzzword in the last few years. The focus on segmentation of populations has been driven by the move to Integrated Care Systems (ICSs), which is in turn motivated by the NHS Long Term Plan  focus on prevention.
As outlined in a recent Pulse PCN round table, this approach of identification of groups with a common characteristicis something we’ve been doing for a long time: using data to find out where resources need to be focussed, for example through using QOF data or projects where you look at specific cohorts and invest resources to help improve their health. PHM is essentially a sub-division of population health that focusses on data to drive change. So what’s new?
Instead of just looking at clinical outcomes, PHM aims to look at wider determinants of health and the gaps in the data. Questions might include asking why some patient groups are not turning up for cancer screening? Who is missing out on their immunisations and why? Who hasn’t been seen by their GP for a long time? Are there particular groups of patients who are not benefiting from the NHS and how can they be reached, creating services that fit their needs over the longer term. PHM can also help us to understand whether there are local or regional levers to improve health, even if these are outside of the healthcare system. As such, PHM is a vital component of overall population health approaches and fits very well with place-based organisation of services, responsive to the particular assets and needs of a specific place.
Services must focus on people rather than clinicians, and address communities holistically. ICSs provide this opportunity and have been put on a statutory footing as of June 2022. The ambition is that they will foster place-based partnerships with local authorities, communities and health and social care, all of which will be collectively responsible for the management of resources and health of local populations. These partnerships aim to integrate care across organisational boundaries and help to join up hospital and community services for physical, mental and social matters. Other intended benefits of ICSs are changes in the way services are designed and funded: removing competition and separation of commissioners to facilitate effective population health management. Although place based and integrated approaches are evidence based, there has been much scepticism that ICSs will achieve these ambitions.
For one, ICSs will need a significant number of health and care professionals with population capabilities to meet the challenges. Workforce strategies are needed that embed population health at every level. In 2020, Health Education England launched the first National Population Health Fellowship. An Advanced Clinical Practice credential will follow in 2022 as a workforce bridge towards public health specialists, and a dual specialty training programme between public health and primary care is in progress.
Further challenges remain: The need for high quality complete data from all agencies, used in a joined-up way and with the skills to interpret and use this as real intelligence. The Whole Systems Integrated Care data (WSIC) in North West London for example is a first step. However, this data must be used to develop holistic, integrated, properly and sustainably funded solutions, and avoid layering initiatives by disease or demographic groups.
Addressing the holistic needs of populations means working with and supporting community assets that improve the wider determinants of health. Implementing community work by strengthening primary care with the additional roles reimbursement scheme (ARRS) roles such as social prescribing link workers (SPLW) are a step in the right direction, but currently a drop on a hot stone with one SPLW responsible for 50,000 patients in a typical PCN.
Creative solutions have emerged bottom up: Westminster City Council, the Royal Borough of Kensington and Chelsea, Calderdale and Bridgewater have been trailblazing Community Health and Wellbeing Worker (CHWW) initiatives, where local residents, recruited and salaried, proactively visit households in deprived areas to unearth health and social care issues before they become bigger problems, building relationships in the community. Linked into both primary care and local authorities, they can support population health in a more integrated manner, identifying our unknown unknowns in ways we were not able to before. Similarly, the power of Primary Care data to bring together people from the same locality or with the same condition to foster self-care and community support through group consultations for chronic disease is an excellent example of making the data work for the community.
ICS programmes like Core20Plus5 attempt to redress inequalities by focussing on the most deprived 20% of the population around five areas which drive most of the health inequalities: respiratory conditions, hypertension, maternity care, mental health and early cancer diagnosis. However, patient priorities are often at odds with clinical priorities, creating ‘hard to reach’ patients from a clinical perspective. For example, GPs might approach patients around vaccination and cancer screening, while the patients’ own priorities are dominated by housing and employment issues that will need addressing first to enable conversations on prevention. Shifting from the transactional to the relational and from treating disease to creating health will take everyone working together and a significant cultural change in Medicine as we know it.
Dr Cornelia Junghans, GP, Senior Clinical Fellow in Primary Care at Imperial College London, Epidemiologist.
Dr Maslah Amin, GP, National Clinical Leader in Population Health and Sustainability, Health Education England
Dr Kathrin Thomas, Consultant in Public Health, retired GP, Honorary Senior Lecturer Bangor University
Professor Azeem Majeed, Professor of Primary Care at Imperial College London
Dr Matthew Harris, Clinical Senior Lecturer in Public Health Medicine, Imperial College London, Honorary Consultant in Public Health Medicine Imperial College NHS Trust
The authors have written on behalf of the Faculty of Public Health Special Interest Group for Primary Care and Public Health. More information is availabe here.