Population health management can help focus clinical resources

Population health management (PHM) has the potential to eliminate some of the legwork in health visits and help clinicians forecast patients of needs, a panel of clinicians and change management experts told a session of the NHS Confederation Expo 2023 on Wednesday. 

Dr. Jim Forrer, a GP from Devon and director at Optum UK, noted that visiting a patient in the home enables the doctor to learn about their culture, their family and provide information at a global health.

Integrating such information, including the wider determinants of health, into linked records, can allow a doctor to be reactive before the patient arrives in their surgery. 

“Through linked records, you can connect with other people through newly formed teams and understand them better,” he said, adding that PHM systems make it easier to make predictions about care demands for cohorts of patients.  

Citing the example of a group of 200 patients with COPD using steroids and antibiotics, he said a certain proportion are likely to end up in hospital at any given time. Through apps, special nurses or key workers, PHM can take a narrower look at individuals within the group and determine who is likely to need more support. 

“You can be very proactive if you consider differently the way you approach a cohort of people.”  

In highly pressured systems looking at financial and elective recovery, population health management systems have the ability to “bend the curve” by potentially providing cycles of data for anywhere between five and fifteen years, according to Vic Townshend, programme director for population health management in the Lincolnshire Integrated Care System. 

Yet, taking full advantage of PHM requires adaptation by clinicians as well as collaboration, said Dame Barbara Hakin, chair of the Health Tech Alliance and a former deputy CEO and chief operating officer at NHS England. 

“ICSs are better at technology, but this is about relationships,” she said. 

Lincolnshire is 100% covered by linked personal data encompassing adult social care, primary and secondary care, she said. The PHM reporting Suite covers a cohort of 840,000 people from “health to ill-health”, focusing widely on the determinants of health. 

“We’ve never been able to see the local population in granular detail before,” she said, adding that the program uses a strategically segmented model that allows healthcare providers to see high-level needs and look at outcomes and care ambitions more broadly. 

“You can use the shared information to see which stakeholders you need to have in the room,” she added.  

The most successful PHM systems have a framework and design that are supportive and empowering, the panelists said. 

Elsewhere at NHS ConfedExpo 2023, Health Secretary Steve Barclay said in a keynote session that the UK government will protect money for health technology from budget cuts.