population health Public Health

Population health – operationalising it

I’ve written quite a bit in this. each time I do so, I say never again. never say never. People keep asking me, but what do I have to do tomorrow please.

1. Operationalising it.

I’ve written quite a lot on that also. The stuff from the Advisory Board reference at the bottom of this is good. My own effort on operationalising concepts is here.

See this Excellent thread from @kinsonm giving practical advice on operationalising the concept:

• Imagine everyone in a certain locality was working together and pooling resources. Imagine they were all paid based on shared outcomes for the populations they served and not on activity through their services. Incentives for preventing and delaying diseases and poor outcomes.

• The thread focused on the right elements:

• COLLECT – the right info, including citizen generated data. (Big cultural change needed).

• AGGREGATE – that info, make it useable

• UNDERSTAND – Describe the need at neighbourhood level. Outcomes, map treatment pathways and monitor performance.

• Segment and risk stratify the population into groups.

• IMPROVE – Identify areas of focus for local quality improvement. Monitor in near real-time.

The thread went on further. It is excellent. Go see it for yourself.

And this one from Ben Gotland is also excellent

Steve Laitner’s response was also excellent

Form is the last thing to think about, if at all:

1. FOCUS (pop health management)

2. FUNCTIONS (new models of caring)

3. FUNDING (flows)

4. FORM (contractual/ organisational)

There’s something about coming back to Muir’s notion of population focused specialists. Being part of a job description, with planned activities.

one lead on population health in a specialty per xxxx pop. So a respiratory doc with focus on population for some or all of their job.

Must be built into a team of generalists.

2. But…….In your new found enthusiasm for population health, don’t forget what we already know

Things often missing from stuff I see on population health

Its what Chris Bentley has been telling us all to do for 20 years

His Christmas tree model etc. Born off back of HI NST, now reborn through PHE


Furthermore, there’s an easy argument to make that QOF = population health, or at least requires a focused effort to manage risks in populations.

Of course it maxed out years ago, and we all know it needs refresh.

The systematic methodology required to achieve targets still value, maybe need a new target

My own sense is a target based on neighbourhood and whole pop risk management. The money in QOF is a powerful lever to incentivise the right kind of change

3. Other Things to not forget.

Don’t loose an emphasis on inequality in your effort to address population health.

Inequality is a population issue, not “something about poor people”. Wont solve the population health improvement problem till solve the inequality in outcome problem

Scope – Health vs healthcare.

Needs a bit of narrative on this. Doesn’t quite come through strong enough on nearly all I read on population health. Those who come at this from an NHS backdrop will have mental assumption that “health” = “NHS”. those in local govt will use the word “health” to denote the sector that is NHS. and thus the muddle continues.

increasingly I say “NHS and Social care integration” not “health and social care”. “health” is equally applicable to “housing”, “economy”, etc etc

Alot of the pop health narrative focused on clinical care, technical and analytic

We need to get out of this and think more broadly. Population health without a focus on neighbourhoods, communities, good housing, poverty, access to green space and leisure will never go anywhere far, and never get beyond the health care bubble. See Chris Ham and Richard Murray’s long read on 10y plan. basically the analysis is that “population health” is the missing bit of NHS policy and strategy conversation.

If we we over focus population health on technical and clinical and forgets community / neighbourhood etc we will miss the point.

Of course analysis and segmentation is arguably backbone, but we forget interventions to improve outcome at our peril – depth and coverage of these matter, as does ensuring there is coverage in those with most to gain

system to deliver those interventions critical – back to points above re primary care at scale.

And Primary Care wider than “general practice” and wider than NHS. MDT sort of focus for high risk patients. Key working (not key worker – we cant afford an army of keyworkers) stuff

Probably within the NHS bit of this need to massively emphasise primary care and generalist care.

We all know its melting,

we all know the NHS as a system leads us to a default of more hospitals and specialists – which takes us in wrong direction.

Whether you call it primary care at scale, primary care home, neighbourhood, whatever….

More capacity for whole population NHS and social care, perhaps with addition of other non NHS / SC offers around VCS, housing services, leisure, benefits etc etc… this bit needs more emphasis??

We REALLY need to square population health with person centredness.

Missing in most of what I read. This requires some significant thought and effort! Currently I suspect population heath and person centred focus are ploughing different furrows, maybe in different fields. Of course maybe they are irreconcilable things, I don’t think so, but does need some careful thought. I’d guess it is a q taxing some very bright minds right now

Most of what I read needs a bit more oomph on the issues around functional impairment, multi morbidity and frailty (slightly different approaches as you know) and how to manage risk across those populations. Also a bit more emphasis on primary prevention + delay of movement from 1 LTC to 2 to 3 etc, then delay of complications

4. Training and competencies for population health.

someone ought to try to define what pop health looks like in curriculum terms

There’s a bit on skill sets here.

Many have contacted me  expressed a few concerns around poor or no training on population health. A lot of people popping up saying they are “population health” experts, without really much by way of competency. This competency framework is courtesy Ash Paul and prompted me to think. Reading the detail there are many striking similarities with the FPH curriculum. Im not at all being exclusive or closed shop on this, absolutely this is a skillset we need more of not less of, but we DO need people with the right sets of skills.

We wouldn’t let people practice as GPs who’d been to night school, ditto cardiologists, ditto senior leaders (tho to be fair we are not good at training senior managers with competency sets) so why don’t we try to ensure there’s some competency set definition here!

Of course it would need educational institutions to set it up properly

There is new found enthusiasm for this thing called population health, thus is excellent. It is in danger of being limited by skillset development (some call it public health, I wont split hairs), the extent to which the push for population health systems have driven actual changes in the way 1) managers operate (within system incentives available to them) 2) clinicians operate (ditto, mostly interested in person in front of them, often interested in shiny new things) 3) how system behaves… accepting its all very tricky…. Complex system etc

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