How population health management helped save lives during the pandemic

Focusing on the needs of our most vulnerable residents has helped us save lives during arguably the biggest health crisis of our time. So, I'm always surprised when I hear people say they haven't been involved with population health management (PHM).

At the start of the COVID-19 pandemic each one of us was involved in PHM.

Mike Bell    Chair

At the start of the COVID-19 pandemic each one of us was involved in PHM: from chairs and chief executives to consultants, nurses, hospitals managers, data analysts and social prescribers. In Croydon, we compiled a list of 5,500 people we knew would be vulnerable to the virus. By week five, the list was at 12,000. We built up that cohort using linked data overlaid with demographic data giving us a 360-degree picture of the community. A virtual ward model was then introduced to monitor up to 800 people at home quickly actioning clinical interventions before they became acute. As we interacted with this community, we began to understand the holistic support they needed to keep them well, be that loneliness and isolation, debt issues or mental health. This is PHM in action.

Wave three of the PHM programme is currently underway, and most integrated care systems (ICS) have done it or are on it now. The challenge, however, is to bake it into our day-to-day commissioning and provider structures. While preventative strategies won't reduce the elective list today, they'll certainly stop it from growing. But with all the pressure we're under – can we prioritise sustainability now?

As ICSs move to become statutory bodies it's important that both commissioners and providers understand the opportunity of a PHM approach.

Mike Bell    Chair

The Long Term Plan makes it clear that PHM must be the catalyst for system planning, particularly at place level where a community's health will be mostly influenced. As ICSs move to become statutory bodies it's important that both commissioners and providers understand the opportunity of a PHM approach. It's crucial for example that the thousands of staff engaged in contracting activities – 8,000 alone in London – are upskilled. It will be in their gift to shape the future of services and looking at the demographics of a population will yield the best results. That goes for providers too.

There are people on waiting lists with multiple health needs and their secondary problems are becoming tomorrow's primary problems. We can use our linked data analysis to address some of those problems exacerbated by socio-economic factors. In Croydon, the key has been engaging with clinicians from the start. Croydon's virtual wards were generated by the clinicians delivering the service. Engaging with the provider side and releasing talent and ideas on the ground makes interventions far more likely to succeed.

We've prioritised co-production of care models; the PHM approach brings frontline colleagues to the table early. If we are to avoid the provider side being left with stranded costs in five years' time we need to be in on this now. It's great that the Place development programme will support providers to become more involved over the coming year. It's also crucial that we think about our communities as people as well as patients. Links with local authorities and public health colleagues will be vital to ensure we remember we're dealing with lives not just life. We must understand those lives properly to be able to create impactful well-being interventions as well as just treatments. Without this focus at place level we cannot possibly address health inequalities.

The next six months will be vital to ensuring senior and local buy-in to the PHM approach at system and place level.

Mike Bell    Chair

One module of the PHM development programme for example is on place based working. Ours took place in Sutton where we were able to really focus on the very specific needs of that community highlighted to us by the data. The next six months will be vital to ensuring senior and local buy-in to the PHM approach at system and place level. It will also be an important tool in addressing the needs of communities post-COVID and reducing the elective wait and the health inequalities gap.

We must make every effort across both provider and commissioner sectors to make PHM business as usual, to provide appropriate, personalised care as well as reducing future pressures and build sustainability for the years to come.