Population health, prevention and the power of improvement

Penny Pereira

Hello and welcome to Leading Improvement in Health and Care.

Matthew Taylor

In this episode, we're exploring how improvement can play a role in public and population health.

Penny Pereira

Joining us on today's episode are Dominique Allwood, director of population health at Imperial College Healthcare and Ruth Glassborow, director of population health and wellbeing at Public Health Scotland.

Matthew Taylor

Yeah, I'm really looking forward to this conversation because when we talk about improvement, Penny, we tend to talk about kind of marginal improvements within organisations, particularly within hospitals. This is a very, very different kind of focus. So anyway, first up, Ruth Glassborow on the approaches needed to achieve change when we're seeking to improve population health.

Ruth Glassborow

Public health is very much focusing on that wider system level improvement. And one of the things I've learned since transitioning over is just the level of importance around addressing some of the wider structural key contextual factors for impacting on population health. I think within quality improvement, we would tend to focus more on the processes. And then we did in the latter years really move up to systems level transformation. 

But we wouldn't, for instance, look to legislation changes really to make an impact. But when you're talking about population health, because what surrounds you shapes you, because the context and environment you live in is so important, you are drawing much more, or focusing much more, on issues such as looking at the legislation changes. So if you take for example, the no-smoking-in-public-places ban, which had a major impact on population health, you look at things like the legislation around seat belts that again dramatically reduced deaths from accidents. 

So there's this whole other area of intervention that complements, I think, what we traditionally would do in improvement.

Penny Pereira

I guess one of the things that I kind of associate with improvement is being able to think really clearly about your theory of change, so how you're going to achieve impact. And from what you're saying, I guess you do get into different territory when you're talking about population health. 

Do you find the methods of improvement useful when thinking about that overarching theory of change?

Ruth Glassborow

So public health are already very well disciplined about thinking about theory of change and actually working in quality improvement, I was taught about logic model approaches by public health colleagues. They've been using them probably for longer than quality improvement have. 

So it's great walking into an area that already has that discipline. I would say the theory that I tend to draw on most in the work is actually the basic one around if you want to see change happen in practice, you have to align the will, the evidence-informed ideas and the ability to implement change. 

And it was one of those key theories that we learned from the Institute for Health Improvement, it underpinned a lot of our work in Scotland around the Scottish Patient Safety Programme, and I found it incredibly useful moving into population health. I think in particular because there is such a strong focus on evidence-informed ideas in public health, really good there. 

There is a risk though that we don't put enough emphasis on that ability to implement the change and hence we talk a lot about the implementation gap and what we need to put in place there to really support implementation. 

And there's also this whole issue as well about will for change that is so important in both service level change and legislative because there's a lot we know we could do that would impact population health on the legislative side, particularly around the food environment and the alcohol environment. 

But we need to get the public opinion in a place where it's acceptable for the politicians to make those changes. So yes, I would say that set of thinking in particular is really important.

Penny Pereira

And here's Dominique Allwood with her perspective.

Dominique Allwood

That’s what I really like about improvement, it helps to focus on what are the things that are important? What are you trying to achieve? What methods are you going to use to get there and how are you going to know that you've made a difference? 

I think sometimes with some of the population health challenges we're facing around prevention, multimorbidity, rising demand, and then those things impacting on healthcare can feel very big and difficult to grapple with.

And then nested around all of that are all the things that then shape why all of that is going on around health behaviours, around society, around the wider determinants of health. So you could end up with your head in your hands thinking, is so complex, where to start? And I think what I really like about improvement is that it starts to give you a way in to do that through methods and approaches. 

One of the, I guess, common sayings in improvement is think big, but start small. So you definitely need to think about the whole system as you're trying to understand a problem. For example, obesity, there's so many facets that make up the challenge that is obesity, but you can't boil the ocean and particularly if you're sitting in a health service thinking, well, where do I start to tackle that with my service or my patients? 

Thinking big, but starting small, what are the things that we can control in the space in which we're seeing patients around? The way in which we deliver our services to focus or tackle that problem or support our patients starts to become, I think, much more manageable. And then the other thing I really like is using logic to understand what we need to do and why. And I think there's this magical thinking that says, we've got these problems out here and we want to achieve these impacts and we don't always know that path. 

So having that logic model of understanding what will be the things that will make a difference, how do we prioritise them and how will we understand they really are making a difference and then make those changes if they're not.

So I find improvement approach is really helpful in being systematic in the way in which we can think about big complex challenges.

Penny Pereira

What's exciting you most in terms of either practical work that you've led or that you've seen in this space? 

Dominique Allwood

I guess things that are exciting me are that we've got this policy context now that really focuses strongly on three shifts. And the first one about focusing much more heavily on prevention is something that's very much music to my ears as someone who's interested in population health and public health. 

And I think for too long, people have understood that that is important, but not really understood perhaps how to go about it. And I think that's shifting and changing now. 

It's hard because how do you measure things that you're trying to prevent, but I think that's where things like improvement can come in because you're looking at data over time, you start to be able to see those shifts and changes. 

So it's exciting to me that we're starting to join up now and think more as systems as to how we do that work because one organisation can't solely be responsible or one service for trying to tackle prevention. If you think about taking a systems approach, you make a change in one place, but you've got to make sure you understand the impact in other places.

Sometimes you're just squeezing one thing to move it into a different problem space. So taking a systems approach and really understanding how partners can work across integrated systems is exciting to me. It's challenging at the moment because it's complex and there's lots of change going on in the system. 

But there are also really great strides that we've made to work more as systems to try and take more collective approaches to say these challenges are things that we need to tackle ourselves.

Matthew Taylor

So yeah, really interesting, wasn't it? Let's just start with that point I raised before we heard from Ruth and Dominique, which is population health, it's not a natural kind of ground for improvement, it's not what people, when people do improvement in health service, they're not normally talking about these big complex population societal changes, are they?

Penny Pereira

No, and yet, in fact, the work that we've done with the Q community over the last ten years has shown a real shift from… I when I started doing improvement, really the focus was on incremental changes at frontline services. Now we are seeing as many people seeking to tackle kind of big population health challenges. The work naturally is at a slightly earlier stage. There are some different kinds of approaches, as we're hearing in this episode. But in fact, improvement approaches have been across the waterfront of change for some time. 

As you say, they're much more visible and familiar when we think about incremental service change within provider organisations. 

Matthew Taylor

So Penny, look, you're really, my enthusiasm for improvement grows every day, but you're really the expert. So let me ask you a couple of questions about this. 

So the first is that improvement has this kind of test and learn, test and learn kind of rhythm to it. There's a lot of, in recent years in particular, this sense of kind of the speed of the feedback loop, you learn, you try, you learn. 

It's hard when you're talking about a change that, you know, an obesity strategy that might take a generation or two generations to pay off. How do you get that kind of feedback that you need that is normally a part of the improvement process?

Penny Pereira

Yes, I mean, in some ways, some of that bias towards incremental immediate change that we associate with improvement makes it helpful to help make things like population health feel tractable to change and show momentum, even though they might seem initially like approaches that are very difficult to use to structure changes, which will kind of span many years.

As I think we hear from Dom and from Ruth the kind of principle of testing and incremental learning, that holds an improvement that is really valuable, whatever scale of change that you're doing. When you're thinking about kind of population health, you need to recognise that there will be multiple levels of types of change that you'll be seeking to achieve. 

So for example, Ruth talks about the need to get into addressing the big structural policy drivers of health. And some of those things will take some time to address. But at the same time, you can have a theory of change, a way of simply laying out how those changes will sit alongside changes that are much more immediate and incremental, but all pulling in the direction of overarching kind of population health goals. 

I think improvement approaches by their very nature, they can help us move from feeling like we've got these big overwhelming changes to actually thinking you can take some action.

Matthew Taylor

Yeah, so that's really interesting. And that kind of time span feedback loop is one part of this. But the other is that in some senses, improvement owes some of its kind of intellectual foundations to a kind of experimental mindset. Now, the thing about experiments is that, if you think about scientific experiments, you try to shut out all the noise, and so you can focus on the specific thing you're experimenting. Again, you can't do that with population health. The noise is society. It is always continuously going on.

That's another challenge. And in all of this, that kind of timescale challenge, that complexity challenge, when we hear Dominique, I think it was, talking about sinking big and starting small. How important is that as an idea, Penny?

Penny Pereira

I mean, it feels kind of critical. And when we think of the kind of big shifts in the ten-year plan and equivalent strategies elsewhere, there's a real risk that some of those big changes never get beyond the kind of conceptual analysis change into actually making changes in practice. 

You talk about that need for a kind of experimental, this scientific test and learn approach. I think when you're addressing population health issues, we do get more into complexity-informed approaches to improvement and change. So you would expect to see a kind of much larger kind of system analysis with a wider range of drivers and data that you're taking into account. 

So the art and the science of improvement in this territory is about at the same time reaching out and understanding the totality of that complexity and then moving to use kind of brief and accessible methods that help think about, and what step do we take next? 

And potentially in the context of population health, you're talking about like many, many actors taking different approaches to change, either through a mission approach or a kind of larger overarching strategy, which you then break down into different strands. 

So in some ways, it's a world away from helping reduce falls on an individual ward, that kind of mode of improvement. In other ways, actually, there's some common themes and principles across different scales of change.

Matthew Taylor

Fascinating conversation. 

Let's get onto a different dimension of this, Penny, which is the question of inequalities. Nobody talks about population health without talking about inequalities, partly because the NHS is universal service, we care about it, but also because there's just no way of being successful about prevention unless we are more successful on health inequalities. So we're going to talk now to Ruth about this kind of relationship between inequality and population health improvement.

Ruth Glassborow

I think one of the critical issues for us is around the inequalities lens on everything that we are doing on the health and social care side. There are major differences whether or not you're looking through a lens of deprivation or you're looking through a lens of ethnicity, but we know that access to healthcare is not equal. 

And I think if I was to go back the other way now, I would have a much stronger focus on the measurement side of making sure that we are looking at the impact of what we're doing broken down by that inequalities because you might actually be delivering an improvement for the population as a whole, but widening health inequalities at the same time because you're delivering the improvement by shifting people who already have longer life expectancy or better health outcomes. 

So, I think for me, that's a really important area where we need to make progress in terms of improvement across health and social care, looking at it through that inequalities lens. And if I say Penny, as an example in Scotland, and this often surprises people, there were two really critical numbers for us, which are  ten and 25. So ten, is the difference in average life expectancy between the richest and the poorest in Scotland. 

That's ten years, a whole decade, that you will live longer if you're living in the richest areas. 25 is the number of years that you will live longer with healthy life. So you'd have to go back to 2001 to imagine how long that is. That's a massive gap between the richest and poorest. 

And hence making sure that we are doing everything we can to close that gap in the improvement work in health and social care alongside the critical work on the determinants because that's where we'll have the greatest leverage or be the wider determinants of health. It's really important to keep a focus on those inequalities.

Dominique Allwood

The equity challenge is not to be understated and I think something that listeners will be very familiar with, but it can often feel difficult to think about where to start tackling those inequities around outcomes, experience and access. 

I think improvement method can be really helpful in that because if you take a lens of trying to understand it through equality lens, which is that there is variation that we are seeing. How do we then try and think about what needs to happen to reduce that variation? 

And that would include some of the approaches that we've traditionally employed in improvement, which is look at the data, understand where it is and go and investigate why those problems are there. 

I think where it differs is some of those methods and approaches to how you then go and understand those issues and working very much with those communities who you are finding those areas and pockets of inequity is really important to be able to understand the problems from their perspective, work with them, not do to them and co-design those solutions. 

And often those are really challenging areas to work in. These are groups who have often felt marginalised, not listened to, not interacted with, that the services aren't designed for or by them and they don't work for them. 

And so that requires quite a lot of different thinking, different relationships, engaging with others to help do that work, but doing it through a sort of genuine commitment to want to make those changes. 

And I guess sometimes it requires difficult conversations. For example, if you start to look at your waiting list to say, well, who's not turning up? Who's DNAing in your clinics? Who's waiting longer? And you start to cut those through different lenses of ethnicity or gender or age or other demographics or other equity angles and aspects and start to find problems. 

You suddenly can't unsee them and you've got a duty really to think about, how do I act? Am I required then to do things differently to potentially channel resources in a different way and to prioritise and that requires difficult conversations and ultimately leadership decisions around that.

Penny Pereira

I mean, that was a fascinating and really important description of the kind of rich focus on kind of inequality that has always kind of run through population health efforts. I think this is an area that a bit like I was saying at the start, overall improvement has moved from mainly focused at the clinical micro system to now addressing business system issues. 

I think in the earlier days of improvement, we didn't pay enough attention to inequities and we may at times have ended up improving things for some and then increasing the gap. Whereas I think this agenda, the people who are working on population health are often kind of setting the way in terms of a systematic approach to inequities. 

Some of the insight work that we've done with Q has highlighted just how challenging that can be because, for example, you are often dealing with incomplete data. You feel at once a moral obligation to act with incomplete data so you're not paralysed by the need to have a complete and perfect picture. 

And yet at the same time, there's a real sense of wanting to make sure that you're acting in a way that is properly informed by the needs of people who have typically not been well understood in terms of their needs and requirements. 

So, we've talked a lot about measurement in this episode, as we indeed do in all of the episodes around this work. And I think there are a kind of particular combination of challenges when it comes to measurement in relation to population health when you're taking seriously inequalities.

Matthew Taylor

To your last point, Penny, and this is a matter of degree, but if we're talking about improvement in a kind of clinical process in hospital, there is, of course, an important element of that, which is around kind of patient experience and patient satisfaction. 

But it is, in a sense, a kind of consumer service. Now, when we talk about population health, the attitude of the community, the engagement of the community, the behaviours of the community are all critical. And so you've got this challenge, haven't you, Penny, of the kind of technocratic, well, that the evidence says we should do it this way versus the public saying, well, no, actually this is what it feels kind of matters to us. 

So, you might go to the community and say, well, look, we've got this great initiative to encourage you to be healthier or whatever. And the community might say, well, no, that's not the biggest challenge for us. The biggest challenge for us is GP access or fast food shops or whatever. 

So how do you get the right balance between a kind of technocratic evidence-based approach to how it improved population health and responding to the community and the importance of community buy-in.

Penny Pereira

Yes, and in some ways we talk about the community and there will be some kind of issues like changes in policy, like there'll be some issues where you are consulting with the community and the population overall. An additional layer of complexity is that if you're really going to take inequality seriously, then you're probably talking about understanding the distinct needs and priorities of the multiple communities that make up the society in which we're seeking to operate as a health service.

And then within that, it's the dynamics within those communities. So rather than think about the health service or a health service engaging with a particular patient group or if it wants to reconsider services, we have an attitude in the NHS of consulting the population. 

Actually, it's much more about understanding the nature of the dynamics between different communities and kind of family groups and the way in which that will influence kind of individual behaviour. 

Matthew Taylor

That's great, Penny. And of course, one of great things about Q and one of the reasons we're so glad that we're now working with you is that you work across the UK and in the Republic of Ireland. And often on this programme, you talked about Scotland and I found it fascinating to find out more about how they think about improvement in Scotland. 

So in the last section of your interviews with Ruth and Dominic, we're looking at some of the kind of practical Implementation to population health improvement and we're starting in Scotland with Ruth talking about work that she's done with colleagues in schools.

Ruth Glassborow

The bit we're really excited about in Scotland is an initiative we call the Public Health Approach to Learning. But this is where we have got some really exciting stuff around data linkage. We're linking data across education, health, social care. We've got data on vaping shops, alcohol shops, everything geographically. And we're linking it all together at a school level. And it is giving us this phenomenally rich data set to then be able to say and understand where are the key opportunities for improvement here. 

But we know that it's not enough just to have the data to diagnose. Alongside that pillar, we have three other pillars. So we are, at the moment, working on the evidence toolkit. So how do we pull together all of the evidence for the common issues so that we can then support local systems around once you identified your key issue, here's some evidence-informed ideas. 

We know knowledge into action really matters, so it's that practical implementation support. We would call it ‘model for improvement’; Population Public Health call it ‘knowledge into action’. It's basically, it's the same thing. And then the final pillar is that systems leadership, because again, the solutions to the challenges that our school-aged children are facing are not just sitting with the schools and the teachers. 

This is about how we wrap the wider system, including health services, including wider community services. How do we get that community-level ownership? And we're working together at a local level. 

So, we're currently live at the moment in Edinburgh doing the work with one school system, primary and secondary. And we're about to expand that into two other local authority areas and then at the same time looking at what a scale-up approach across the whole of Scotland might look like. And we just think that has so much promise for transformation. 

And Penny, we've had phenomenal buy-in from teachers, head teachers and the education community to this as well, because I think there's that absolute understanding that educational outcomes and health are so inter-related that you need to be working on both together.

Dominique Allwood

One of the other things that's excited me about the work that I've been doing in the Health Innovation Network at Imperial College Health Partners is taking a mission-based approach to improving health and outcomes. 

And that really starting to say, we need to think over a longer period of time and more ambitiously about the changes that we want to see and bring all of our partners on board with that. 

So it starts to move us away from more traditional programmatic focus and within year cycles of funding or resource. And we started that mission-based approach with saying, in the next time scale of X years, and the one we had was over five years, so between 2024 and 2029, we want to see a reduction in strokes and heart attacks. 

And we put a figure on that around a reduction that we wanted to see. And what that did was really set and focus the mind of people to say, right, that's a big goal across that system that we really want to see improvements in those outcomes. 

But clearly the day-to-day management of that work can't just be focusing in five years’ time on what's going on. And so how do we think about what are the things that will get us there and how do we measure the impact of those? So we've been doing quite a lot on looking at the process versus the outcome measures. 

So, for example, point-of-care testing for lipids and making sure that we have equitable uptake across some of our most marginalised populations and taking that as a measurement that will help us get to our bigger population health goal has been really exciting to see some of that progress and motivates people. 

So, I guess it comes back to that sort of think big, start small. How do you find the areas that you can celebrate progress as you say, but make sure that ultimately you're going to try and achieve that bigger goal.

Matthew Taylor

Well, that was fascinating. I have to say hearing that there's enthusiasm in amongst schools in Scotland. I very often do hear in England, I'm afraid, that there's quite a big gap between the health service and the education system. When you think about issues like, for example, the scale of mental health challenges amongst young people, we've really got to close that gap between those systems. 

So, it's great to see that's happening. That takes us, doesn't it, Penny, to this question we've also talked about a lot, which is this issue of how we get collaboration between different agencies to work on things. 

I've become I have to say utterly obsessed by this issue in recent weeks. I've discovered the whole literature around relational coordination. What that literature says is collaboration is critical to solving complex problems and building services around people with complex needs, but it also says you've really got to invest effort in this stuff. You know, just hoping that people will get on with each other and trust will naturally kind of emerge isn't good enough. There are a whole set of things that you need to do. 

And we've heard about some of those things, haven't we, from Ruth, you know, the importance of a shared vision, the importance of data and all of that. 

This question, you and I've talked about it a lot, improvement in the context of multi-agency collaboration. That does add to the excitement of it, but it certainly adds to the challenges as well, doesn't it?

Penny Pereira

Well, many of the cultural, professional, personality differences that you can even see within a single ward or a single department in one organisation are kind of writ large when you're then trying to work across kind of multiple sectors. 

I guess I would say that having spent the majority of my career working in the NHS, just before I joined the Health Foundation, I had the responsibility of working with the local authority on the public health agenda and being the kind of NHS rep into that work, and it was a salutary reminder about how people who are working in other public services and working across local authorities have a much longer history and tradition of working across sectors. 

So in some ways in the improvement world we can tend to think that's most mature, it's most developed in the NHS. We understandably struggle with some coordination and collaboration issues between individual NHS departments. In some ways when you're working across a much bigger canvas and across sectors that is building on a longer standing kind of set of relationships. 

So I guess that's an interesting, an interesting reflection when we get into things like neighbourhood health and indeed the kind of wider shift to prevention is not assuming that we're thinking about sharing learning and models from the NHS because often the rest of the public sector will have a lot to teach us.

Matthew Taylor

That's all we have time for in this episode. Thanks again to our guests, Dominique Hallward and Ruth Glassborow. It's been great, as always, Penny talking to you. I look forward to our next conversation. 

If you liked what you've heard, please share it with other people or get in touch. Let us know what you think. Share an example of improvement you're involved in feature on a future episode.

Penny Pereira

Thank you and there's lots more information on health inequalities and approaches to implement population health on the Health Foundation website. We'll include the specific tools and examples we referred to in this episode in the show notes.