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Population Health Management

Population health management (PHM) is a is a way to improve the current and future health and well-being of people within and across a defined local, regional and national population while reducing health inequalities.

It includes action:

  • To reduce the occurrence of ill health
  • To deliver appropriate health and care services
  • On the wider determinants of health.

The way in which communities and partner agencies connect and work together defines a population health system. This means:

  • Getting the right people to the right resources
  • Getting the right outcomes for the right people with the least waste
  • Doing the right things to protect resources for future generations (sustainability)
  • Ensuring fairness and justice (equity)
  • Supporting the whole population
  • Creating population based integrated systems.

Population health management is one of many tools using data to guide the planning and delivery of care to achieve maximum impact on population health. It often includes segmentation and stratification techniques to identify people at risk of ill health and to focus on interventions that can prevent that ill health or equip them to manage it.

The Social Care Institute for Excellence (SCIE 2018) describes PHM as a methodology to put together a comprehensive understanding of population health needs by joining up data about:

  • Health behaviours and status
  • Clinical care access
  • Use and quality of available services
  • Social determinants of health.

These four areas combine to provide comprehensive baseline information about the locality in terms of health and other challenges faced by residents. This is then analysed to gain further understanding about the levels of current and future need by segmenting the data broadly along the following lines:

  • Those who are generally well and who will benefit from health interventions to maintain their general good health – for example screening programmes for hypertension;
  • Those who are currently well but have been identified as being at risk of developing long term conditions – for example people who may have mobility problems;
  • People with long term conditions who will benefit from early interventions and secondary prevention services to stop or delay progression – for example people with diabetes or cardiac problems;
  • People with complex needs or frailty who need individualised co-ordinated care with a high level of continuity.

Factors associated with success are high quality local data and effective information management systems. The statistical analysis used to model future projections must be robust and supported by credible algorithms which incorporate tacit knowledge from service users and professional staff involved in care delivery. When modelling future demand, allowance must be made for levels of uncertainty and scenario plans should model the possible interactions of various parameters with audit trails of assumptions made.

PHM, if used correctly, is an important enabler to improve care outcomes for the locality population. The quality of the information produced is only as good as the quality of the data used, the way in which it is used and the extent to which information produced is regarded as credible and useful by both service users and front-line staff.

Resources to meet future current and future health and wellbeing needs depend on collaborative planning between health and social care organisations both for the day to day running of services and for workforce planning to ensure that the right numbers of appropriately trained staff are available at the right times to deliver care.

Planning involves thinking in different ways about physical characteristics (structure), services (function) and impact on the health and well-being of the local population (outcomes) and can be summarized using the Donabedian model (NHS England 2019) in set out below in diagram 1 below.

The structure relates to the legislative framework underpinning national health care provision as well as the location and design of the buildings where health, social and other care is delivered. The proposals for the new legislative Health and Care Bill published on 11 March 2021 draw heavily on population health, using the collective resources of the local systems, NHS, local authorities, the voluntary sector and unspecified others to improve the health of local areas. (UK Gov 2021)

The outcomes of care are more than the numbers of people treated, it refers to the impact of care given on the health and well-being of the individual receiving the care.

Diagram 1.

Why is it Population Health Management Important?

PHM is important because it informs how we design and implement Integrated Care Systems. It is fundamental to how health care will be delivered in community settings and enable Primary Care Networks (PCNs) to deliver care as close to home as possible in line with the NHS Long Term Plan (NHS England 2019).

PHM provides support for local teams to understand and look for the best way to meet the medical, social and wellbeing care needs of both individuals and communities within a defined population. It also provides a strong link to public health data to predict the likelihood of patterns of disease occurring. The recent COVID 19 pandemics is an example of where predictive data has been crucial to policy decisions about how services, diagnostics and treatment should be provided. One way of thinking about public health and PHM is to “join the dots” where dots is an acronym for duration, opportunity, transmission and susceptibility to understand risk and predict important consequences such as patterns of disease, impact of disease and service requirements. Ideally this should happen in a timeframe that allows for appropriate forward planning and resourcing. In the case of COVID-19,

The “D” in dots relates to the duration of contact with an infected person, as well as the duration of infectivity and illness.

The “O” in dots relates to the opportunity for transmission and has been a key driver policy decision such as lockdown and social distancing.

The “T” in dots relates to the transmissibility of the disease, which in the case of COVID 19, refers to the virus.

The “S” in dots relates to the susceptibility of people to the disease. Susceptibility may be linked to age, sex, existing health conditions or co-morbidities and social determinants of health. Deprivation issues such as poor housing, poverty or social isolation can have serious consequences for physical and mental health and often contribute significantly to co-morbidities (Kings Fund 2018).

How Does Population Health Management Work?

Data is the fundamental building block of PHM. Data is used to model current states of health care in given locations and, often by using modelling techniques, predict future demands and likely impacts of interventions (for example screening) or unexpected events (such as COVID-19) on given populations. This modelling helps to to identify local or national ‘at risk’ cohorts. The potential impact of interventions can be tested against the models to assess the likelihood of proposed interventions improving health outcomes of people already affected or preventing illness from occurring. Further details of how PHM can support healthcare can be found at the PHM Academy at (NHS England 2021).

Although, given current circumstances, COVID-19 has been the focus of a great deal of PHM work, it is not the only driver for PHM. Better partnership working using PHM to join up the right person with the right care solution helps us to improve outcomes, reduce duplication and use our resources more effectively. PHM means NHS staff will work more closely with colleagues from other disciplines and organisations including social care to redesign their services and take a more proactive approach to supporting their local population live healthier lives. This transformational change means that leadership styles need to focus on consensus rather than organisationally driven targets. It requires a new way of thinking about how to build and maintain relationships across organisations that are focussed on collaborative working to improve health and wellbeing in the locality. It also means thinking about how interprofessional teams can articulate their goals and share both knowledge and data from their different perspectives to improve their response to local needs.


In an integrated care system, NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve. PHM is a fundamental building block for integrated care systems because it provides the baseline information of local needs by joining up data about social determinants of health, health behaviours and status, access to services and ways in which existing services are used. This baseline information can then be used to model predictions about how current services can be better aligned and resourced to meet the needs of current and future service users.

Local services can provide better and more joined-up care for patients when different organisations work collaboratively in an integrated system. Improved collaboration can help to make it easier for staff to work with colleagues from other organisations to meet the needs of the people they are trying to help. PHM provides the shared data about local people’s current and future health and wellbeing needs. Joint care-planning and support addresses both the psychological and physical needs of an individual recognising the huge overlap between mental and physical wellbeing. Joint posts and joint organisational development are likely to become more commonplace and community nurses will have a vital contribution to planning and delivery of integrated care to improve health and care outcomes for their local populations.