Reflections and future hopes for population health management

It's been a big couple of weeks for our health service. From tributes at Glastonbury to tea parties around the country, the way we’ve commemorated the NHS’s 75th anniversary shows the deep admiration people have for the NHS and its special place in our national story.

Yet these wonderful celebrations can’t mask the monumental tasks ahead for the service. One is managing the current challenges of wait times and soaring demand. Another is the long-term responsibility to reform and reshape our health and care system for the future.

In fact, looking back over the 50 or so years I’ve spent in the NHS, I’m not sure things have ever been as tough as they are now.

That said, the challenges we face are familiar to every developed nation. Specifically, how to support an ageing population with often more complex needs and an ever-increasing array of treatments, within finite resources. 

Whichever plan you look at, in this country or beyond, 2 basic things are seen as key to a solution:

1. Prevention, whether primary through a range of public health interventions or secondary, that is, treating people earlier and more proactively during a disease
2. Innovation, particularly so when it is enabled by technology and supported by data and analytics as the 'guiding hand' helping us make the right decisions 

Of all the recent advances in data analytics, population health management (PHM) is likely one of the oldest and most advanced. It can help us shine a light on what may be hidden, hear voices that may be missed and make sure our services reach those who need them most.

That’s hugely important when we need to ensure that every ounce of effort makes the biggest difference for our communities.

Critical lessons from the past

The application of population health management principles isn't particularly new. In the early '90s, I was involved in the introduction of community matrons within primary care. Back then, we didn't have the huge range of data or the analytics capabilities we have now.

But we were able to identify patients for whom you could do more to prevent a hospital admission or other episodes of ill health. It was an early precursor to the more sophisticated approaches available today, but it taught me a few things that feel just as relevant.

Success is decided by strong partnerships and collaboration

The first critical lesson I learned was that success will always be decided by the strength of the partnerships and collaboration you build. Put another way, change management is vital to getting new technologies and approaches adopted. 

For example, when we asked local practices to select and employ community matrons rather than have them recruited by the Primary Care Trust I was leading at the time, something noticeable happened. The impact generated by the matrons increased.

We talk a lot about ownership, empowerment, agency and choice when it comes to supporting patients. But we don’t always apply those concepts consistently to our own people in terms of how they approach their roles.

The raw insights and intelligence we can extract from our linked data will only ever be as strong as the conversations, coalitions and collaborative action they help to stimulate.

Less is always more

The second important lesson is that less is more. We made significant inroads with very limited technological firepower in the '90s. While having the infrastructure to deliver more advanced analytics is obviously desirable, you can start with relatively modest means. 

In other words, PHM doesn’t have to be complicated or all-encompassing. The value lies in identifying a specific cohort of patients you want to work with, then brokering conversations about what a ‘gold standard’ approach to care and treatment might look like.

From then on you can identify individual patients who would benefit and ensure they get that gold standard. And quite often, the best approach is to start small and build from there.

Looking to the future

Now that the NHS 75 celebrations are over, there will be plenty of discussions about how we secure the health and care system for the future.

But for all the talk of harnessing 'technological advances' and 'transformative change', the one thing the NHS must never lose is its enduring connection with its patients, which has always been founded on a deep and intuitive grasp of their needs. 

By strengthening our understanding of what works and providing a focus for collaborative action, my hope is that PHM can play a part in helping us strengthen and sustain this connection for the long term.

Because, as you’ll see throughout this new series, the impact this can have on services, best use of resources, workforce development and — most importantly — our patients is huge.