Implementing Population Health Management across Primary Care in a UK Integrated Care System (April 2022-2024)

Background: Population Health Management (PHM) is pivotal for England’s 42 Integrated Care Systems (ICSs) to transition from reactive to proactive, preventative, and person-centred care. By integrating health and social care datasets, including health determinants, ICSs aim to redesign and target services in order to use resources more effectively, improve population heath and reduce health inequalities. However, there is no agreed definition of PHM internationally [1], with scant evidence on how best to link and use historic datasets effectively in the UK [2] and Europe [1,3,4] or engage key system partners, such as primary care [5].

Approach: To support the implementation of PHM across 31 Primary Care Networks (PCN) a series of 6 multi-stakeholder Action Learning Sets were facilitated in each of the ICS’s 4 localities over a 12-month period, using a linked dataset to identify local health (service) issues to work on. The programme was evaluated by embedded researchers, utilizing systems thinking to foster innovation through real-time data analysis and feedback. Qualitative and quantitative data was collected from 25 ALSs, 16 governance meetings, 10 interviews, 4 workshops/events, 10 webinars, 1 conference, and document reviews, with 110 participants consenting to the study. Data were coded using Excel and NVIVO software.

Results: While most PHM infrastructure and resources (incentives and workforce) were established, challenges remained in PCN signup, data governance and data access issues. Resource constraints led to delays in ALS initiation, reduced support and analytical capacity and loss of momentum. All localities engaged in ALSs, identifying issues, gaining insights, and developing 6 innovations focused on vulnerable populations: children in families with a history of drug and alcohol misuse, rural male populations at risk of suicide, deprescribing of Z-drugs, and frequent attenders in primary and secondary care. Data literacy, trusting relations, use of intrinsic motivation and formal evidence facilitated those PCNs making most progress towards implementation. Engagement reached 198 individuals from health and social care, statutory and voluntary sectors, with encouraging evidence of capacity building for PHM through knowledge and relationship brokering. Involvement of patients, caregivers and community voices was largely absent.

Implications: The PHM programme demonstrated substantial engagement and conceptual understanding among stakeholders. However, challenges in infrastructure readiness, strategic integration, data governance, and resource allocation hindered full implementation, insight generation, innovation implementation and impact. Nevertheless, the evaluation highlighted the potential of PHM in improving health outcomes through strategic stakeholder collaboration and systems thinking.

References:

1. Steenkamer, B.M., et al., Defining Population Health Management: A Scoping Review of the Literature. PHM, 2016. 20(1): p. 74-85.

2. McShane, M. and K. Kirkham, Making it personal – population health management and the NHS. JIC, 2020. 28(3):243-252.

3. van Ede, A.F.T.M., et al., How to successfully implement population health management: a scoping review. BMC HSR, 2023. 23(1):910.

4. Steenkamer, B.M., et al., Implementing population health management: an international comparative study. JHOM, 2020. 34:3(1):273-294.

5. Alton, D., et al., Population health management in primary health care: a proactive approach to improve health and well-being. Primary care policy paper, 2023. World Health Organization European Region.