24th January 2023
Population Health and Population Health Management. I’ve worked in the NHS for many many years, and I’ve seen ‘consistently’ the latest newest, shiniest strategies emerge that will improve our quality, standardise our resources, and deliver our savings..
I probably sound pessimistic and I don’t mean to be, but the one thing consistent in the NHS is change, and while change is good, it often feels like we like change more than we like delivering change! That said, I jumped in, hands and feet first, the ethos of any NHS employee is no matter how pessimistic you may be, you give it your all!
A few years ago I was fortunate to be part of the New Models Vanguard in which we worked with Centene, a US based company who showed us how they utilise Population Health Management in the States. Cynical in the beginning I was amazed to see that PHM wasn’t about stopping services, charging patients or in fact the demise of the NHS. Population Health Management to them was about how do we treat the patient and improve their outcomes, when health can only influence a small percentage of their health and care needs… At its simplest they were talking about true integration. They highlighted that we could be giving the best respiratory care in the world, but if someone is going home alone to a cold, damp house, then our efforts, albeit admirable are futile! The light bulb went on! Now I’m sure you are all sitting here and saying, yep we know this… and so did I, but our previous attempts to integrate care had been tokenistic at best (cough cough, Better Care Funds)…
I knew we had to start somewhere but where? At this point in time, we were getting some feedback from the centre and had been given the PHM flat pack… This was a 150+ pages of how to implement PHM. My recommendation is it’s definitely worth a look. It’s long, but useful but we soon realised locally that sharing the ethos of PHM wasn’t enough… We needed a hook. You see when presenting PHM and the principles of it, I never had one person disagree with me or disagree with the principles of PHM… The challenge back was “so what!” Everything we were talking about made perfect sense, but how would we share our data? how do we define what a population or person needs are?, how do we transform a culture in looking at the data to drive change rather than finance? (Sorry finance peeps)… more importantly how do I download the 150+ page flat pack without my email inbox crashing because it’s full! (I kid you not!)
We took a step back and decided that PHM was too big to boil the ocean at once (you’ll see my colloquial terms, forgive me) and therefore thought it best to tackle the problem one step at a time, and it was during this time that we realised that for us to deliver PHM took 6 steps (this may differ in different areas). These steps were developed to breakdown each element of PHM, and within those steps there were masses of infrastructure and governance requirements so be prepared. The first approach and the one I’ll explain in this blog is how we approached Step 1 – Outcomes…
I’m often asked about what are some of the biggest challenges when delivering PHM. Apart from the obvious, analytical capacity, information governance conflicting policies; I have to say that in my personal opinion one of the biggest headaches I have come across has to be outcomes! l learnt early on in our PHM journey that in order to segment and stratify the population we need to have a collective and clear agreement on what outcomes we are trying to deliver!.. Simples I hear you say, Mmmm maybe not… you see if we are looking at a delivering a population approach, and inviting all sectors to the table, then with them comes their organisational outcomes and their interpretation of what an outcome is and more importantly; what their boards have signed up to! So how did we do it in Nottingham? We’re not sure we have it right, but I think my best advice to you is set your stall out before you embark on your analysis. In principle analytical modelling is the easy part. (Sorry analysts, I’m sure you will probably disagree with me). The difficult part is getting a system of independent entities (that are co-dependent on one another), signed up to not only being in the same outcomes boat, but also rowing in the same direction. This requires compromise, trust and sometimes even a little faith! Have we got it sussed? No of course not, it’s a massive task and I’m not sure any system can categorically say they have all their organisations signed up to using the same outcome objectives and principles and for your own sanity don’t try to boil the ocean at once! (I’ve worn the scars on this one). So what advice could I offer to make your life easier…? Well my first piece of wisdom (if you could call it that) would be to ensure that your system shares the same understanding of what an outcome is. Everybody, talks about outcomes, and the world and its mother talks about delivering improved outcomes, but when you get down to the nitty gritty and ask “what do you mean by outcomes” you will see that the word and the meaning gets interchanged between outcomes, performance metrics, interventions, enablers. Health has a beautiful outcomes framework; it’s comprehensive, clear and says the right thing! But the challenge is its health’s!! And not necessarily picking up local authority priorities. Some also argue that it has an undercurrent of performance metrics. So a priority in this step is ensuring you have a shared understanding of what outcomes means to your group…
To do this, I would suggest using a “test” area first. Get experts (clinical, transformational, and analytical) to create joint outcomes for a specific area, doing this aligns your outcomes bottom up and makes them meaningful. We did this with Diabetes (see our pack). It may be that once you begin these discussions you find you are all on the same page (let me know if this is the case, I’ll then go looking for the gold plated, singing unicorn)… or like us, we soon realised that we have different objectives that complemented each other, but required different data and sometimes a different approach. This is when the compromise begins, but getting this section right is the key to your success and is where we gained our valuable final lesson in this section. Hold you’re nerve! I cannot tell you how many times when we start to do a PHM review and discuss outcomes, the discussion goes straight to what interventions we want to deliver, or gets hung up on the variation in “must dos” ( This is often nationally dictated to be fair) but try not to let that shape your outcomes conversation. Holding your nerve will enable you to hold really important conversations with partners to understand what is important to them and their view of what’s important for their population. Then you can have the discussion on whether that is an outcome or an enabler. In the world of PHM it doesn’t matter. What matters is we are clear what we are trying to deliver… and does everyone share that view. Who we deliver it for comes next (step 2)!
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