Population health aims to improve the health of an entire population. Dr Cornelia Junghans, Dr Maslah Amin, Dr Kathrin Thomas, Professor Azeem Majeed and Dr Matthew Harris discuss the challenges facing primary care and CSI.
Broadly speaking, population health is the “health of a group of individuals, including the distribution of those outcomes within the group”, with groups often defined geographically, but also according to socio-demographic or other characteristics. While the population might be healthy overall, the average might mask strong health inequalities in certain groups. Effective population health is an approach to improving the health of an entire population. It’s about making the best use of our resources to improve everyone’s physical, mental and social well-being and minimize health inequalities. To do this effectively, population health must include the broader determinants of health and requires working with communities and partner organizations.
Many people use the term “population health” interchangeably with “public health”. Public health is a medical specialty, although public health specialists can be non-clinical, as it is a discipline that uses evidence to effect change in practice, something that transcends clinical boundaries. Public health specialists are population health experts. However, the skills and mindsets needed to improve the health of the population are essential throughout the health and social protection system.
Recent years have seen an increasing burden of chronic diseases and growing health inequalities and a health system ill-equipped to deal with these challenges. We know that about a third of consultations are for non-medical issues and that GPs are unable to effectively address these broader determinants of health. We know that around 80% of a person’s health is determined by how and where they live, with only 20% of their health and well-being dependent on access to good healthcare services.
Primary care accounts for most patient consultations in the NHS and manages referrals to secondary care, so it is ideally placed to play an influential role in population health. Unfortunately, public health and primary care have worked together less than might have been hoped in the UK so far, with the latter largely focusing on clinical medicine. However, there are probably few GPs who haven’t heard of population health management (PHM), a real buzzword in recent years. The focus on population segmentation has been driven by the shift to integrated systems of care (ICS), which is in turn driven by the NHS long-term plan  focus on prevention.
As noted in a recent Pulse PCN round table, this approach of identifying groups with a common characteristic is something we’ve been doing for a long time: using data to know where resources should be concentrated, for example using QOF data or projects where you look at cohorts and invest resources to help improve their health. The MPS is essentially a subdivision of population health that focuses on data to drive change. So what’s up?
Rather than just examining clinical outcomes, the PHM aims to examine broader determinants of health and data gaps. Questions could include asking why certain groups of patients do not come for cancer screening? Who misses their vaccinations and why? Who hasn’t been seen by their GP for a long time? Are there particular groups of patients who do not benefit from the NHS and how can they be reached, creating services that meet their long-term needs. The MPS can also help us understand if there are local or regional levers to improve health, even if these are external to the health system. As such, PHM is an essential component of comprehensive population health approaches and fits very well with place-based service organization, responding to the particular strengths and needs of a specific place.
Services should focus on people rather than clinicians and address communities holistically. The ICS offer this opportunity and have been formalized from June 2022. The ambition is that they promote partnerships on the ground with local authorities, communities and health and social assistance, which will be collectively responsible for the management of resources and the health of local populations. These partnerships aim to integrate care across organizational boundaries and help connect hospital and community services for physical, mental and social issues. Other expected benefits of ICS are changes in the way services are designed and funded: removal of competition and separation of commissioners to facilitate effective management of population health. Although place-based and integrated approaches are evidence-based, there has been much skepticism about the ability of ICS to achieve these ambitions.
On the one hand, SCIs will need a large number of health and care professionals with population capacities to meet the challenges. We need workforce strategies that integrate population health at all levels. In 2020, Health Education England launched the first National Population Health Fellowship. An Advanced Clinical Practice Diploma will follow in 2022 as a workforce gateway to public health specialists, and a dual specialty training program between public health and primary care is underway.
Other challenges remain: the need for comprehensive, high-quality data from all agencies, used jointly and with the skills to interpret and use it as real intelligence. Whole Systems Integrated Care (WSIC) data in North West London, for example, is a first step. However, this data should be used to develop holistic, integrated, appropriately and sustainably funded solutions, and avoid overlapping initiatives by disease or demographic group.
Meeting the holistic needs of populations means working with and supporting community assets that improve broader determinants of health. Implementing community work by strengthening primary care with the Additional Roles Reimbursement Scheme (ARRS) roles such as Social Prescribing Liaison Workers (SPLW) are a step in the right direction, but currently a drop on a hot stone with an SPLW responsible for 50,000 patients in a typical PCN.
Creative solutions have emerged from the bottom up: Westminster City Council, Royal Borough of Kensington and Chelsea, Calderdale and Bridgewater have been pioneering Community Health and Wellbeing Worker (CHWW) initiatives, where local residents, recruits and employees , proactively visit households in deprived areas to dig up health and social care issues before they become bigger problems, building relationships in the community. Linked to both primary care and local authorities, they can support population health in a more integrated way, identifying our unknown unknowns in ways we weren’t able to before. Similarly, the power of primary care data to bring together people from the same locality or with the same condition to foster self-care and community support through group counseling for chronic conditions is a great example of how data works for the community.
ICS programs like Core20Plus5 attempt to redress inequities by focusing on the poorest 20% of the population around five areas that drive most health inequities: respiratory disease, hypertension , maternity care, mental health and early diagnosis of cancer. However, patient priorities often conflict with clinical priorities, creating clinically “hard to reach” patients. For example, GPs may approach patients around vaccinations and cancer screening, while patients’ own priorities are dominated by housing and employment issues that will need to be addressed first to enable conversations. on prevention. Moving from transactional to relational and from treating illness to creating health will require everyone working together and a significant cultural shift in medicine as we know it.
Dr Cornelia Junghansgeneral practitioner, senior primary care researcher at Imperial College London, epidemiologist.
Doctor Maslah AminGeneral Practitioner, National Clinical Lead in Population Health and Sustainability, Health Education England
Dr Catherine Thomaspublic health consultant, retired general practitioner, honorary lecturer Bangor University
Professor Azeem Majeedprofessor of primary care at Imperial College London
Dr Matthew HarrisClinical Lecturer in Public Health Medicine, Imperial College London, Honorary Consultant in Public Health Medicine Imperial College NHS Trust
The authors wrote on behalf of the Faculty of Public Health Special Interest Group for Primary Care and Public Health. More information is available here.