Healthcare has more in common with the fashion industry than we’d like to admit. Concepts and phrases come and go and being ‘in’ is often determined by your ability to use the vernacular of the day.
It seems that this season’s fashion is population health management (PHM). This is a good thing, as without this simple approach to improve care delivery, integrated care systems just won’t work. PHM is basically service redesign for the whole population by targeting groups with similar needs. It isn’t rocket science. However, in our rush to appear current and ‘on trend’, there are three pitfalls to avoid.
1. Re-labelling activity
The first is simply re-labelling what you already do as PHM. It is possible to fit elements of PHM methodology to many of our existing healthcare activities. The danger is that by doing this we lose the guiding principle of system redesign based on group insights and fail to sufficiently align the essential enablers of PHM. Our financial systems, analytics and even strategic vision will become diluted and merely reinforce the status quo.
That improved way of delivering direct care against measured standards isn’t PHM – it’s still called audit. And performing analysis of disease burden and operational modelling isn’t PHM until it is translated into delivery via new models of care.
2. Entrenching the public health gap
PHM provides an opportunity to close the gap and connect the expertise of public health
The second is approaching the continuum of PHM from a polarised position. My career has witnessed a health system with public health (often deprioritised in funding allocations and marginalised by the 2012 Health and Social Care Act) operating separately from direct patient care (characterised by demand outstripping supply and enormous pressure to deliver). PHM provides an opportunity to close the gap and connect the expertise of public health, in shaping, designing, and measuring services, with the delivery rigour of the interventions and services of direct care.
Importantly, we mustn’t let the centre of gravity of PHM be pulled too much in either direction. Many of us will recognise the position of frontline pragmatists, who tend to describe PHM as being all about individual care and view the big picture with its trappings of analytics and incentive alignment, as remote and out of touch with the harsh realities of delivery. Meanwhile at the other end of the spectrum are those focused on whole-system strategy who risk becoming distracted by the act of planning and perhaps removed from ‘true’ care delivery. We need to call both these out when we see them.
3. Conflating enablers with the endgame
It is only when we use the best available insights to understand groups with common needs and design services around them that we are doing PHM
The third pitfall is that we confuse the enablers of PHM with the concept itself. Just as a car cannot be summed up by just the engine, the wheels or the chassis, critical though all these things are, they are not the car! NHS England and NHS Improvement has produced a great flat pack that establishes a definition of PHM and its key enablers. The data and technology, the analytics, the leadership, governance and financial drivers. All these things are essential components – but they are not the endgame. It is only when we use the best available insights to understand groups in the population with common needs and design services around them that we are doing PHM.
Some of the challenges of linked data, shared governance or financial risk are difficult and there is a danger that we spend all our time (and money) on trying to resolve these issues rather than just getting on with it and letting these things ‘flush out’. As my colleague Dr Steve Laitner puts it – focus, function, finance, then form – in that order. Identify the group you are going to focus on, use the best available insights, codesign with users the best care function or delivery model then establish what contractual model will drive the behaviours needed for success, then and only then formalise the governance structures needed for accountability and monitoring. This is the ‘just get on with it’ school of PHM.
Engaging and energising the workforce
It is rare to see health professionals excited about a competent governance framework, but a co-designed pathway that really delivers better care will hit the mark
In Calderdale we are working on the fundamentals of service design and managing the resulting issues of workforce and data and in the best way we can, with what is available. It can be messy and frustrating but in true Yorkshire style, we are getting on with the job. And, in doing so, we are achieving consensus and helping to clarify and prioritise the obstacles that need to be overcome. We are already seeing tangible benefits for population cohorts as we continue to co-design and deliver personalised care to the individual. These elements succeed or fail on their ability to engage and energise the workforce. It is rare to see health professionals getting excited about a competent governance framework but a co-designed pathway that really delivers better care will hit the mark. I say this with over 30 years’ experience at the sharp end of delivery.
I don’t believe population health management is a passing fashion but rather a style of approaching care and will become the established norm. We will wonder how we ever did it differently.
As the fashion designer Yves Saint-Laurent put it “Fashion comes and goes but style is eternal.“
Dr Helen Davies is a GP and community integration and PHM clinical lead in Calderdale. Follow her on Twitter @HelenDa21136593