Population Health - The Critical Questions Ahead

MAINSTREAMING POPULATION HEALTH MANAGEMENT:

The critical questions ahead

By Bec Richmond, September 2023

In the final Perspectives blog from our roster of speakers at NHS Confed Expo 2023, Optum UK Director Bec Richmond describes some of the fundamental issues that need to be answered to take population health management (PHM) forward.

Having said my goodbyes to Manchester (and the last reported sighting of the British summer), I left this year’s NHS Confed Expo carrying a rather unsettling feeling – the uncomfortable realisation that so many of the shining examples of PHM on display were the result of exceptional individuals succeeding despite the system rather than because of it.

No more heroes

Whether it’s in the brilliant examples of workforce and service transformation articulated by Sheinaz Stansfield and Rupa Joshi, or the gritty and pragmatic application of data to support patient need reflected in the projects described by our very own Peter Milmer and Jim Forrer, what was often left unsaid in these sessions was the huge burden of discretionary effort, the isolating battles against inertia and cultural resistance, and the personal risk and sacrifice carried by them to push these programmes forward: not all heroes wear capes, but in the NHS they often have to wear crash helmets.

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

The problem is that if we want PHM discipline to be embedded at scale, as per Claire Fuller’s and Patricia Hewitt’s respective visions, then 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

It certainly isn’t hard to spot the barriers, which were eloquently described throughout the conference. One delegate spoke about the difficulty of replicating the necessary “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 then we need to be asking the right questions and framing the debate in the right way. Here are some of the big challenges I’ve been thinking about.

First: 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 within an Integrated Care System (ICS), an Integrated Neighbourhood Team (INT) or a Primary Care Network (PCN), the big issue people are facing is how you keep yourself and your teams focused on what really matters – that is, improving health and care outcomes for the community – at a time when the resource and headspace to do so simply doesn’t exist.

PHM can act as a way of lubricating this process because it gives you the objective 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 apply it in this way?

Second: 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 fundamental 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 the application of PHM can start to “democratise” decision-making and bring to the table a wider range of voices (i.e. community leaders, religious institutions, people with lived experience etc.) in finding the right answers. However, 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 preventative healthcare.

For PHM to flourish, we need to ensure people genuinely “leave their lanyards at the door” when entering discussions, become less fixated on who owns the project or intervention, and allow the data to 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 resolve if we are to take the next steps forward.

Third: how do we secure the protected time and resource to allow 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 data. If we’re to get beyond the current reality whereby a lot of the momentum and drive for PHM too often ends up being carried by individuals having to fit this in around their day job, then we need to reconsider 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.

And fourth: how do we cultivate lasting belief in and commitment to PHM across all parts of the leadership community, including the political sphere?

Most people would accept the NHS’s job has been made harder by political churn and resulting cycles of different reforms and initiatives coming out of Whitehall over the last 25 years. Population health is uniquely vulnerable as very often the benefits of upstream investment can only be measured over the long term.

So while it’s encouraging to see ex-ministers and other luminaries calling for a cross-party “covenant for health”, it’s essential that this has PHM at its core. More than ever, we need the data and the evidence showing the value that different interventions bring in order to build trust and confidence that investing in preventative health truly works. And that means ICS leaders backing PHM strongly for the long term – not because it’s written into the latest tranche of national policy documents, but because it’s their best hope of establishing a stable, long term, evidence-based approach to managing their population’s needs.

There’s also a sense – still – 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, and something that has the potential to impact so much of what’s being addressed by Integrated Neighbourhood Teams, Places, Integrated Care Boards and ICSs – from waiting list management to tackling inequity of access to services.

Conclusions

So there you have it: my ‘big four’ reflections from NHS Confed Expo, which I hope add a little to the wonderful ‘can-do’ examples of PHM practice we’ve showcased throughout this Perspectives series.

Now we want to hear yours.

What do you think are the pragmatic solutions that will help PHM flourish and make a valuable contribution within a deeply challenged health and care system?

What’s working now and where should we be pushing harder in the future?

We would love to hear from you. Please get in touch.

This article was prepared by Bec Richmond in a personal capacity. The views, thoughts and opinions expressed by the author of this piece belong to the author and do not purport to represent the views, thoughts and opinions of Optum.