Dr Jim Forrer Article - Population Health Management Is Not A Panacea

Population health management is not a panacea, but it can enrich and support the way general practice works for patients

By Dr Jim Forrer, July 2023

In our second Perspectives blog, Devon-based GP and Optum director Dr Jim Forrer explores how linked data has helped him gain a deeper understanding of his population’s needs and create a more personalised and proactive approach to care.

How well do we really know our patients?

Most GPs, almost reflexively, would say “pretty well”, particularly when it comes to those patients with chronic conditions or complex needs who we tend to see most regularly. We may feel we understand their condition, their clinical history, perhaps even their personal needs and preferences when it comes to their care. But is that enough?

The truth is every patient carries with them a deeper context and history that goes far beyond clinical parameters. It may extend to the nature of their housing or their support networks or wider cultural influences, for example. And 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 the best care and support for patients, it’s clear that we need to capture and act on a much richer understanding of our patients’ lives and experiences than we will ever get from their medical records. In my experience, population health management helps us do this in several ways.

Understanding people in a richer context

First, it helps us understand people in a richer context. 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, and rarely will I get to know the details about what's going on for them 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 us with an understanding of the wider determinants of a patient’s health. Knowing people outside a biomedical model can help you treat them medically in a much more informed, personalised and bespoke way. Population data gives us a way of interrogating what is happening to cohorts of people in their wider lives that may directly contribute to their health prospects. It changes the conversation.

Third, from this more informed position, we can be more proactive and targeted in the way we respond to people’s individual needs – looking not just at the brief touchpoints when they come to see us, but at the circumstances they may be affecting people’s health and lives long before they reach our front door.

And fourth, PHM can help us build the right relationships – the alliances between different services and organisations that can ultimately support people better across the full span of their lives. It provides a common understanding of what the challenges are and helps you come together to solve them on behalf of patients and citizens.

Once you look at your whole population using data like this, you get a better descriptive understanding of what your population looks like, where their needs are, and where the best opportunity for impact is. And you can be predictive too, forecasting how this may help patients and the way they use services into the future.

PHM is not a panacea

Of course, it’s important to say that PHM is not a panacea and the use of linked data is no substitute for basic human interactions and discoveries that are an essential part of medical practice. This is 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. He had symptoms that his friends were concerned about, and they sent him up to the practice using a taxi funded by a charity. He walked out of my consulting room saying there was no way he was going to go to hospital. I was able to reassure him that the symptoms weren't serious, although I would have preferred him to go to hospital and get checked out. He then went back to his previous existence.

I suppose my point is that there are some people that are not going to be found using the datasets we have. But with the data we do have, it is possible to paint a clearer picture of many people’s lives, understand more deeply what may be holding them back, and 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 exert a limited influence on a person’s wider health prospects. And, 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.

This article was prepared by Dr Jim Forrer 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.