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Four reasons population health management might not be working in your ICS

NHS England is driving all Integrated Care Systems (ICSs) to implement population health management (PHM) as a way of working; but for it to be a success, four crucial elements are needed. Our strategy team shares what they learned from working with ICSs.

For decades, the NHS has evolved its service offering slowly, based on human learning and experience. Now, the data revolution has provided a fuel to more rapidly understand the needs of a local population and pave the way for PHM as a much more effective and efficient way of serving patients with the services they actually need.

Four reasons population health management might not be working in your ICS

What is Population Health Management (PHM)? 

PHM, at its most basic level, can be described as a process of using data to formulate intelligence about population need and using the intelligence to transform care and create much more effective care interventions.

How does PHM work in practice?

PHM can perhaps be explained more clearly, in the context of an integrated care system, by using an example - reducing the risk of asthma in children. In this example, a digital infrastructure is needed to support access to integrated data, including data about air pollution, presence of children in a household, smoking in a household and childhood respiratory A&E attendance.



Using such data sources, intelligence can be derived, which allows identification of a target population, such as those children who live near busy roads with heavily polluted air or children who live in a household with a smoker and have attended A&E with respiratory issues. Using the intelligence, new interventions can be designed and delivered to better reach and reduce the health risk in the target population. The impact of such a new intervention can be monitored, with the findings feeding back in, as an additional data source

Achieving a PHM approach requires education and behaviour change across the workforce - here are the four key elements that you need to put in place to ensure a successful PHM approach: 

1. Leadership

Only by implementing the right leadership, oversight and governance can PHM develop and embed successfully as a way of working. This means: 

  • A senior leadership group is essential to collectively develop and implement a PHM approach.
  • The group must have membership from key teams that will enable PHM, including business intelligence, digital, use case teams and the senior leaders that will lead the change and secure resources.
  • Importantly, the group works together to steer PHM and learn as PHM evolves.
  • Ultimately, PHM must be led and governed from a system perspective, rather than siloed within individual organisations.



The leadership group must influence across the system and ensure strategic alignment with business priorities. 

2. Data Strategy (Digital Infrastructure and Business Intelligence)

Providing access to health and care data, in an IG compliant way, is critical to implementing PHM successfully. There is a requirement for digital infrastructure that is capable of storing integrated data safely and securely, and facilitates access for the people that need it. Key pieces of the data infrastructure jigsaw are:

  • Integrated care data 
  • Information Governance Plan
  • Near real time and historical data 
  • Data quality improvement 

The digital infrastructure must support the creation of business intelligence (BI). BI resources are likely to be short in supply and fragmented across an ICS, functioning in different organisations; by bringing the resources together they can be coordinated as one group to more effectively support PHM.

Demands for intelligence will sometimes be simple or common and other times more complex and bespoke; creation of BI self-service for simple and common intelligence demands reduces pressure on limited resources allowing them to focus on more complex and bespoke requirements.

Significantly, useful intelligence will be held by local communities and by an experienced workforce. Establishing systems to capture this intelligence will help to develop better interventions that meet the needs of local people and are deliverable by the workforce.


3. Interventions

Intelligence provides the basis from which a new care intervention can be designed to achieve improved health outcomes in a target population group. A better intervention is the tool with which population health can be improved.

This is the opportunity for health and care systems to be truly transformational; using intelligence, teams can understand new ways to intervene, and take calculated risks to move away from traditional care approaches to introduce new care interventions that can deliver better health across their population. 



An agile approach can be taken to plan, engage, innovate and implement new interventions. An agile and incremental approach is based on learning from digital transformation and supports iterative improvements, which helps fine tune delivery of the best outcomes for the local population.


4. Implementation of PHM through Use Cases


Use cases have been employed to facilitate implementation of PHM in a real transformational health and care environment. In this context, a use case is an existing health and care transformation programme that is used as a vehicle to implement change.

Appropriately selected use cases can drive PHM implementation in a way that helps the leadership group and wider workforce to experience PHM delivery and the associated issues that the system must address, through a transformational approach, enabling learning and ultimately helping an ICS to scale a PHM approach.

In our experience, a use case team can share their learnings on very real issues, unearthed when implementing PHM. Examples of learnings include: how to obtain the integrated data needed; how to make the leap from intelligence to a new intervention; and how to evaluate the impact an intervention has made in a population? Use cases can therefore act as early test beds for PHM to inform plans for scaling up across an ICS.

Phasing PHM implementation through small groups of use cases is a helpful approach in the early stages of PHM implementation; the approach helps with rationing limited expertise and resource and enables learning (and failure) on a small scale, before moving to a larger second and third phase of use cases as the PHM approach is scaled.



Ultimately, an ICS needs a PHM Operating Model, staffed with the right resources to support large numbers of use cases. The PSC has experience of establishing Operating Models that support PHM and mobilising them with Integrated Care Systems; we would welcome a conversation with you to support your journey towards successful implementation of population health management.


Author: Phil Clow, The PSC Strategy team 

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