4 biggest challenges in population health management

Having said my goodbyes to Manchester, I left the 2023 NHS Confed Expo with a rather unsettling feeling — that so many of the shining examples of population health management (PHM) shared were the result of exceptional individuals succeeding despite the system rather than because of it.

A heroic battle to push programmes forward

In one session, Sheinaz Stansfield and Rupa Joshi shared brilliant examples of workforce and service transformation. In another, our very own Peter Milmer and Jim Forrer described the gritty and pragmatic application of data to identify ways to support patients' needs.

But what was often left unsaid in these sessions and others was the huge burden of:

• Discretionary effort
• Isolating battles against inertia and cultural resistance
• Personal risk and sacrifice involved in pushing these programmes forward

In other words, not all heroes wear capes, but in the NHS they often have to wear crash helmets.

What's been troubling me since is if the very thing that makes these projects so inspirational is that a) they're exceptional rather than mainstream and b) they’re grounded in a small number of people going above and beyond to make good things happen.

The problem is this: if we want PHM discipline to be embedded at scale, per Claire Fuller’s and Patricia Hewitt’s respective visions, this isn’t sustainable.

We need to start asking why these examples of intelligent, data-driven change so often manifest as a heroic battle against the odds. How do we make them a more instinctive and natural part of NHS practice? 

Asking the right questions to improve our communities

It isn’t hard to spot the barriers, which were eloquently described during the conference. One delegate spoke about the difficulty of replicating the “passion and leadership … in environments where people are feeling burnt out and lack the headspace to be innovative".

Another talked about the “frustration because when you’re face-to-face with patients, you can see what’s needed … but if the infrastructure and culture isn’t there, it’s very difficult to act”.

While I don’t pretend to have all the answers, I do know that if we want PHM to make serious headway in the years ahead, we need to ask the right questions and frame the debate in the right way. Here are some of the big challenges I’ve been thinking about. 

1. How do we (re)position population health management as a way of helping the NHS manage change during a period of intense disruption and operational pressure?

Whether it’s an integrated care system an integrated neighbourhood team (INT) or a primary care network (PCN), the big issue is how to focus on what matters — improving a community's health and care outcomes — when the resources and headspace to do so don’t exist.

PHM eases this process by providing the data and evidence to help lift your collective horizons and understand where you need to prioritise. Are we focusing enough on PHM as a mechanism for enabling change? And how can we do more to help teams use it in this way?  

2. How do we get a wider coalition of partners involved and create the right conditions for collaborative working across and beyond the NHS? 

There’s been a great (and many would say, long overdue) awakening within policy circles that the NHS can’t act alone in addressing the real threats to our long-term health. Yet the legacy of siloed working persists.

During our panel session on the first day, Lincolnshire ICB’s Vic Townshend described how PHM can start to:

• 'Democratise' decision-making 
• Bring to the table a wider range of voices (community leaders, religious institutions, people with lived experience, etc.) to find the right answers

But few would deny that narrow territorialism and other cultural barriers still permeate the NHS, affecting its ability to build the broad coalitions necessary to deliver preventive healthcare.

For PHM to flourish, we need to ensure that people genuinely 'leave their lanyards at the door' when entering discussions, become less fixated on who owns the project or intervention, and let the data define the solution.

As Vic herself would tell you, this isn’t an easy or short-term fix — especially at a time when so many organisations are in 'self-preservation mode'. But it is something ICSs need to decide if we are to take the next steps forward. 

3. How do we secure the protected time and resources to give staff the headspace and permission to experiment and innovate?

Another common theme running through many of our speakers’ presentations was the almost ‘extra-curricular’ nature of the work they were doing with population health management data.

To get beyond the current reality in which a lot of the momentum and drive for PHM is carried by individuals who fit it in around their day job, we need to think again about how we recognise and reward this type of activity.

The truth is we can only go so far with a ‘hobbyist’ approach to PHM. People need to be entrusted and given permission to invest the necessary time and effort to capture, interrogate and act on the data.

While lack of capability is often cited as a further barrier, it can be a slight red herring. My experience is that teams often have most of what they need. What they really lack is the protected time and headspace to deliver. 

4. How do we cultivate lasting belief in and commitment to PHM across all parts of the leadership community, including the political sphere?

Many would accept that political churn and the reforms and initiatives coming out of Whitehall in the last 25 years made NHS’s job harder. Population health is uniquely vulnerable in that the benefits of upstream investment can often only be measured over the long term.

While it’s encouraging to see ex-ministers and other luminaries calling for a cross-party 'covenant for health', PHM must be at its core. Data and evidence showing the value of interventions will build trust and confidence that investing in preventive health truly works.

That means ICS leaders backing PHM strongly for the long term, but not because it’s written into the latest national policy documents. It's because PHM is the best hope for establishing a stable, long-term, evidence-based approach to managing their population’s needs. 

There’s also still a sense that PHM sits only in the domain of public health. I’d unquestionably say that public health leaders and practitioners must be at the table as their expertise and data are invaluable.

But it’s much more than that. It's something that has the potential to impact so much of what’s being addressed by INTs, places, integrated care boards and ICSs — from waiting list management to tackling inequity of access to services.

Putting PHM into practice

So, there you have it — my ‘big 4’ reflections from the 2023 NHS Confed Expo, which I hope add a little to the wonderful ‘can-do’ examples of PHM practice.