Why population health management is not a panacea

How well do we really know our patients?

Most GPs, almost reflexively, would reply 'pretty well' if asked that question, particularly when it comes to patients with chronic conditions or complex needs who we tend to see most regularly.

We may feel we understand their medical problems, clinical history, perhaps even their personal needs and preferences when it comes to their care. But is that enough? The truth is every patient has a deeper context and history that goes far beyond clinical parameters.

This may extend to the nature of their housing or support networks or wider cultural influences, for example. It also takes in the many other barriers or challenges that may frustrate their ability to access services and live well. 

So, if we want to offer patients the best care and support, we need to capture and act on a much richer understanding of their lives than their medical records will provide. In my experience as a GP and director at Optum UK, population health management can help. 

Understanding people in a richer context

First, it helps us understand people more holistically. Patients are too often defined by which doorframe they’ve just walked through.

In my case, they arrive as a GP patient with a GP problem. Rarely will I get to know the details about what's going on in the rest of their lives, some of which may be extremely important. Linked data can help us break out and gain that wider perspective.

Second, it can provide an understanding of the wider determinants of a patient’s health. Knowing people outside a biomedical model can help you cure them medically in a much more informed and personalised way.

Population data gives us a way of interrogating what's happening to cohorts of people in their wider lives that may directly contribute to their health prospects. It changes the conversation.

Third, these insights help us be more proactive and targeted in how we address individual needs. It's looking not just at the brief touch point when people come to see us, but at the circumstances that may be affecting their health and lives long before they come to us.

Fourth, PHM can help build the right relationships — alliances between services and organisations that can better support people across the full span of their lives. It provides a common understanding of the challenges and helps you come together to solve them.

You'll gain insights into:

• What your population looks like
• Where their needs and challenges are
• Where the best opening for impact is
• How these insights could help patients and the way they use services into the future 

Using data is no substitute for human interactions

Of course, it’s important to say that PHM is not a panacea. Using linked data is no substitute for basic human interactions and discoveries that are an essential part of medical practice. It's simply another tool we can use in our practice.

For example, I remember seeing a patient who'd been living under a bush outside the library in the town where I work. This person had symptoms that friends were concerned about, so they sent this individual to my practice in a taxi funded by a charity.

The patient walked out of my consulting room saying there was no way they were going to hospital. I reassured them that the symptoms weren't serious, though I preferred that they go to hospital and get checked out. Instead, they went back to their previous existence. 

My point is that there are some people who aren't going to be found using the datasets we have. But given the data and analytics we do have, it's possible to:

• Paint a clearer picture of many people’s lives
• Understand more deeply what may be holding them back
• Make them feel more confident that the system knows what truly matters to them 

For me, that’s been a deeply powerful and humane thing. It’s enriched the way I work as a GP. It’s given me the humility to recognise that I can only exercise a limited influence on a person’s wider health prospects.

Above all, it’s shown that by joining agencies and services together under this common understanding of people’s needs and challenges, we can achieve so much more for our patients together.