In his latest column, Neil Paul, talks all things population health management, including why it can be a confusing and why is it important to local planning.

Partly in my PCN role and partly in my shadow ICP director role, Ive been spending a lot of time thinking about population health management, about big data, about risk profiling and about data quality in general.

Population health, to me, seems to be a confusing topic as it appears to mean different things to different people.

In its broadest sense it is about understanding that health is affected by many things, including the environment we live in, the choices we make, the choices that are made for us by politicians and officials and all the other socio-economic factors. This is very important and understanding the implications of policies and is vitally important if you are in a position to change or influence decision making.

Planning at a local level

There is also no doubt that planning in a broader sense is useful, interestingly I dont see much evidence of anyone doing it locally.

At a very high level, understanding how the population in an area is changing, what risk factors that population has and what problems they have or will get, should get health planners excited but they are much more focused on the now.

Most clinicians, in my experience, glaze over a bit at the mention of population health management.

Start collecting data

It seems clear to me we need to start upstream and start collecting more data. We need to take every opportunity to get basic observations as data including perhaps our other primacy care colleagues in this dentists/opticians etc.

Can we be clever and use tech without just targeting the worried well?

Going back to clinicians (whom I represent) they often want to know how to help. Just telling me Ethel is frail or is at high risk of admission is pointless as I usually know this. Yes, Id like more services to help her so mapping out numbers of people whats wrong with them and planning services to help is key however I really want to know who I can help perhaps as upstream as I can.

I dont what to know who is at most risk but whose risk I can most influence with perhaps the least intervention. Some say smoking cessation is the most cost-effective intervention, as even brief interventional advice can make a difference in year to peoples health. Yet do GPs do enough of it? Do we have enough smoking cessation services, alcohol services? Drug addiction services, weight managmenet services? Exercise on prescription, healthy lifestyle?

Do we know what medical interventions make a difference? Statins are meant to reduce your risk of a cardiovascular event by 20%. Do we think in terms of who on our list has the highest risk and have we reduced it? Have we treated to target? Have we maxed out the doses? Have we perhaps chased those that dont come and dont engage?

Should we be screening more? Should we be auditing more? Should we be harder on chasing people? Do we need to move away from just seeing people who think their sore throat needs antibiotics and give all that work to online doctors and concentrate on making people healthier?

Having the right tools

I think business intelligence (BI) and IT tools can help with a lot of this. We have some Quality and Outcomes Framework tools, but these arent perhaps enough to do this project management.

My clinical system allows me to bring up patients and see what problems they have; it doesnt easily allow me to bring up patients with groups of conditions or other characteristics and manage them as a group.

Locally my PCN is doing a heart failure project. The hospital started a heart failure clinic seeing people admitted with end stage heart failure and its been successful the readmission rates are down but to my mind its too late in the pathway. We are hoping to screen for risk factors but at moment we are making sure everyone thinks of it as a diagnosis in anyone presenting with compatible symptoms. Refers the patient for an echo and other tests, codes the ejection fraction and gets the diagnosis right, get the treatment right, record functioning in a standard way, audit our performance.

Heart failure isnt the only project Ive been working on. Ive been asking the BI people to play with what I call it the cohort problem. Effectively a multi-disciplinary team can manage 30-250 people in a year. (give or take find them, meet them, do things to them and see them again) What we need is groups where there is clear intervention that will make a difference that a team can deal with. The trick is finding these groups and putting the teams to work.

Delivering more outcomes

Collecting data and the presentation of it as useful information are key to new ways of working to delivering more outcomes with the same resources. I worry we arent spending enough time collecting good data and being agile in how we use and present it. I think as ICPs form they need to massively invest in getting people to record better data, think of innovative data sources and invest in BI teams.

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Another view: of population health management - Digital Health