More than 30 years ago Rose set out the importance of focusing on population factors and not just individuals. We’ve not really made good on the hypothesis yet.
Population health is still all the rage, if not properly defined. I’ve had a few gos at defining.
Firstly trying to distinguish “public health” and “population health”.
Secondly trying to set out my take on some essential components of “population health”
Thirdly, describing some specifics in renal care
And finally setting out some thoughts on an outcome framework pertinent for “population health”
Here I will try to distinguish terms within the concept. Specifically – population health as a pursuit, population healthcare, and population health as a metric of how healthy a population is.
1. Population healthcare
Population healthcare or population medicine is well described in the literature by Muir Gray and others it could be characterised as a systematic approach to the management of healthcare problems with populations as a starting point.
Muir Gray and others had developed similar concept around other single disease groups for e.g. AF, pelvic pain or more broadly falls & fragility fractures, and frailty. Excellent reflections on this journey can be seen here and here.
See here for some thoughts around this in the context of renal disease.
“The 20th century was the century of the bureaucracy. The 21st century is the century of the system.”
Essential lessons for healthcare leadership
“The aim of population healthcare is to maximise value and equity by focusing on populations defined by a common symptom, condition or characteristic – e.g. breathlessness, arthritis, or multiple morbidity. The focus should not be on institutions, specialties, or technologies.
In other words: achieving population healthcare is the outcome of the necessary shift towards systems thinking within healthcare.”
In each clinical team at least one healthcare professional needs to move from a principal focus on a referred population to a broader, population-wide view.
System of care for population with a condition
It is essential to think through and design how population health care systems would look in the context of the burden of morbidity and death, based on WHO estimates.
Instruction manual is here:
High risk v individual
Managing risk in whole populations rather than only focusing on “high risk” individuals is the critical thing we most often forget. As Rose pointed out, and regularly reinforced by others including this uber classic by Martin Roland. Key points here.
Population healthcare and multimorbidity
The big challenge is obviously population healthcare applied to multimorbidity. We have a good system for multi morbidity, it is called ‘general practice’. I’m not sure we have fully nailed the whole system approach to multi morbidity yet, especially one that incorporates the full spectrum of approaches across many different sectors and stakeholders.
2. Population health as a metric.
Population health as a metric to describe the healthiness of the population is best described by healthy life expectancy full stop I’ve written plenty on this before
As we know the route to improving life it’s the life expectancy only partially involves more or better healthcare. The real improvements will come from upstream interventions as partially described in this diagram
the reality is rather more complex and includes things that aren’t even represented in diagram
3. Population health and risk factor management
Lastly population health would also be characterised as a systematic approach to managing risk factors for poor health across a given population as we all know there isn’t a single risk that will make a significant improvement. According to the WHO burden of disease studies the risk factors for both death and disease are represented below in proportionate terms.
Obviously these may be characterised as lifestyle drift in their nature.
Most know my views that the term lifestyle implies free choice’ our choices are moulded by our environment and more readily coined “lifestyles” as “commercial determinants of health”, although there is still not gain from addressing these in a behavioural sense with a service delivery offer.
Take care to understand the differential in efficiency and equity between making improvements individual by individual compared to population approaches, as described here and here in the context of diabetes prevention.
Clearly then it’s also necessary to go upstream and consider how to make improvements in social, economic, environmental and other issues that may impact on the mental and physical health on the population.
This is the main story business of social policy and linked to population health full stop if one was really thinking long term and in a societal actuarial sense improvements in school readiness and educational attainment are probably more valid as population health and prescribing statins.
when we use the term population health
• we ought to be clear and what we mean and how we organise our interventions. Interventions might not be only clinical service delivery, they might also be service or system design, analytic or other in their nature.
• We need to think about managing risk in whole populations, with actuarial thinking
• We should distinguish health and health care, or at least not conflate them
• We won’t make much progress if we act with institutional approaches.
Al three components are essential