How to manage population health across an integrated care system

Claire Fuller profile picture

25 August 2023

Claire Fuller
Chief Executive
Surrey Heartlands Integrated Care System

Integrated care boards (ICBs) have been set a huge challenge: to change the way health and care is delivered. To do this, ICB leaders need to act decisively, and with confidence. One of my non-executive directors has described the need for "discontinuous change" – that is, change that is wholesale, rapid and significantly different from what came before.

The introduction of population health management has been a requirement of integrated care systems (ICSs) since their inception in 2022. As well as helping frontline teams better understand health and care needs, population health management can help predict what local people will need in the future – helping to reduce inequalities. At Surrey Heartlands, we've been making progress. Here is our approach:

Demystify the concept

There are lots of definitions of population health. The King's Fund's is pretty comprehensive: it's broadly about improving the health of our population, at a national, regional, local and place level. It's also an approach that encompasses the wider determinants of health, since only 20% of a person's health outcomes can be attributed to health and care (but of course, high-quality care is still very important).

Population health management should not be a tool that sits in the corner, only used every now and then. Not only is improving population health one of the ICS's four core purposes, but for us, it also runs through the other three as our common methodology and way of working. It needs to be understood and discussed by the board. ICB leaders need to develop a common language for population health. This is especially true because we're now joining up approaches with those outside of health and care. Data must underpin all the change we make.

Define the scope of your approach

Delivery can feel daunting. At Surrey Heartlands, we focused on three areas to begin with: we simplified our shared care record to make it easier to use and be understood by clinicians. With our partners at Graphnet, we built a population health management platform from our existing Thames Valley and Surrey Care Records programme. We then looked at the raw data from our record and turned this into insight, which involved risk stratification. This meant segmenting our population and understanding risk and the impact of different interventions to support our decision making. This begun to provide our staff with meaningful information upon which they could act.

Now we've begun to build a community of practice across the system to these changes. This has involved identifying best practice and sharing it across the ICS.

As an ICB leader, my role in a lot of this is to provide sponsorship and focus. You need to build a high-trust environment that enables teams to work together. Think about who needs to be in the room to make decisions. At Surrey Heartlands, we appointed a joint director of public sector reform to bridge NHS and local government, allowing us to streamline decision-making. We also have a neighbourhood board that brings digital, clinical and local authority leaders together. This is making it easier for NHS analysts to talk to their counterparts in public health and the county council.

Build on success

Having a population health management platform is good, but the benefits will only materialise when people use it properly. That's why, at Surrey Heartlands, we're investing in skills, such as predictive analytics, as well as data science, to help with its delivery.

Leaders have to remember that a population health management platform may not be as good as you expect. In my experience, successful integration will generally highlight another area for further integration. The job is never finished, but you can build on your learnings and successes.

We are also aware of the scarce resources across the NHS at the moment. In Surrey Heartlands, we're looking at how we further share roles with other organisations. For example, how we strengthen our relationships with universities in our system.

Finally, it's worth emphasising that population health management is fundamental to reducing health inequalities. We need to remember to follow the data, rather than follow the narrative.


Professor Claire Fuller explored using digital to deliver population health management at Surrey Heartlands at an event held as a part of the Digital ICS programme. At the event she was joined by colleagues James Palmer, population health programme lead at Surrey Heartlands ICB, Lynette Nusbacher, non-executive director at Surrey Heartlands ICB, and Professor Edward Kunonga, director of population health management at NHS North East and North Cumbria.

About the author

Claire Fuller profile picture

Claire Fuller
Chief Executive

Professor Claire Fuller, a practising GP, is chief executive of the Surrey Heartlands Integrated Care System. Prior to that, Claire was senior responsible officer for the integrated care system, a role she held since 2017, alongside that of interim accountable officer for NHS Surrey Heartlands Clinical Commissioning Group (from 2020).

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