General Practice Transformation Champions, 28th March 2019, Novotel Hammersmith, London

1. Population health management in practice
Dr Karen Kirkham
National Clinical Advisor Primary Care NHSE
Jackie Chin, Deputy Head of PHM, NHSE
March 2019

2. 1www.england.nhs.uk
National context: what is population health management?
Population Health…
… is an approach aimed at improving the health of an entire population.
It is about improving the physical and mental health outcomes and wellbeing of people,
whilst reducing health inequalities within and across a defined population. It includes action to
reduce the occurrence of ill-health, including addressing wider determinants of health, and
requires working with communities and partner agencies.
Population Health Management…
…improves population health by data driven planning and delivery of proactive care to
achieve maximum impact.
It includes segmentation, stratification and impactabilty modelling to identify local ‘at risk’ cohorts
- and, in turn, designing and targeting interventions to prevent ill-health and to improve care and
support for people with ongoing health conditions and reducing unwarranted variations in
outcomes.

3. 2www.england.nhs.uk
Strategic commitments on PHM
Long Term Plan
ICSs will cover all of the country making shared decisions with
providers on how to use resources, design services and improve
population health. Each ICS will be required to implement integral
services that prevent avoidable hospitalisation and tackle the
wider determinants of mental and physical ill-health
Primary care networks will from 2020/21 assess their local
population by risk of unwarranted health outcomes and working
with local community services make support available to people
where it is most needed…..using a proactive population health
approaches to enable earlier detection and intervention to treat
undiagnosed disorders.
During 2019 we will deploy population health management
solutions to support ICSs to understand areas of greatest health
need and match NHS services to meet them. These solutions will
become increasingly more sophisticated in identifying groups of
people at risk of adverse health outcomes and predict which
individuals are most likely to benefit from different interventions.
We will be able to routinely identify missed elements of pathways of
care for individuals. In 2021/22 we will have systems that support
population health management in every ICS.
GP Contract 5 year Framework
Through their Integrated Care Systems,
NHS England will also ensure that
predictive analytical tools are
available to Primary Care Networks.
These will help them identify those
groups of people who are most at risk of
adverse health outcomes and
increasingly predict which individuals
are most likely to benefit from
different health and care
interventions. This is an important
enabler for the new Anticipatory Care
requirements

4. 3www.england.nhs.uk
There are three core capabilities for Population
Health Management
Infrastructure
• Integrated data architecture –
primary, secondary and social
care
• System wide Information
Governance arrangements
• Digitised health & care providers
and common health and care
record
Intelligence
• Advanced analytical tools and
multi-disciplinary analytical teams
• Actionable insights supporting
providers focus on population
health
Interventions
• Design and delivery of new care
models and anticipatory care
interventions which support an
integrated approach to physical,
mental and social care for target
patient groups.
• Building and utilising strong
partnerships with the voluntary and
community sector, with a specific focus
on reducing health inequalities
• Workforce and incentives
development based on population
health analysis.
Underpinning it all is the cultural shift required to put data at the heart of decision making across an ICS

5. 4www.england.nhs.uk
High risk
• Complex care management
programmes, intensive case
management and supported and
quicker transitions of care
Emerging risk
• Proactive risk based case finding and
management
• Prevention programmes, social
prescribing and community initiatives
• Improving access to extended MDTs/
primary care teams
Low risk
• Wellness and self care programmes
• More convenient access and digital
tools
Longtermconditioncomplexity
Wellness
Segmentation and stratification Impactability Tailored interventions
• Lifestyle factors
(diet / exercise)
• Social and
community
networks
• Genetics
• Money
• Education
• Housing
• Work /
unemployment
• Pollution
We want to help systems explore more advanced ways to
target and tailor clinical and non clinical interventions
Data supplemented with information
on social determinants and wider
influences

6. 5www.england.nhs.uk
PHM can be illustrated as an ongoing cycle of
intelligence-led care design

7. 6www.england.nhs.uk
All tiers of a system use population health information for
different purposes

8. 7www.england.nhs.uk
NHSE’s PHM Development Programme is supporting four ICSs
to adopt data-led approaches to delivering proactive care
The programme has been designed to build capability and accelerate adoption of population health
management, with two overall aims:
1. Demonstrate proactive care delivery through Primary Care Networks using population health management
approaches
2. Advance population health management capability and infrastructure to enable sustainability across all tiers of
the system
Evaluation and impact System
roadmap
System Actuarial model
Tactical cohort (high risk, high utilisation)
Strategic cohort (rising risk, proactive care)
Upstream cohort (influencing wider determinants)
Cycle of learning
Identifying
the key lines
of enquiry
Data and
analytics

9. 8
This linked data enables health and care professionals to view the whole integrated system through the
lens of a single patient. This data can then start to be supplemented with information on social
determinants and patient reported data (eg through apps and wearables) to give a richer, more holistic
view of patient well-being.
Common
pseudonym
Registered People
List incl. disease
registries
(from GP systems)
General
Practice
(consultations
& prescribing)
Acute
CommunityMental Health
Adult Social
Care
Linked patient level data is the engine of PHM
Analytical
Approach
Description
Segmentation A method of dividing a population into smaller, more
coherent pieces, in order to better understand a specific
patient cohort. Simple segmentation involves analysis using
only a single dimension, but segments can be displayed in a
matrix format as well.
Intelligent
segmentation
The process of creating segments using statistical models.
Unlike simple segmentation, many dimensions, or variables,
can be used, and we can assess their validity and predictive
power with confidence in their statistical significance.
Risk
Stratification
A method of ascribing the likelihood of some adverse event
to a patient or group of patients, based on demographic or
clinical factors.
Intersegmental
Drift
The process whereby patients do not remain in a single
segment, but instead move between segments, based on
changes in demographic and clinical factors over time, such
as growing older, more complex, or developing specific
conditions.
Theographs Cross-sector patient timelines, showing a person's contacts
with health and social care over time
Population Health analytics glossary

10. 9www.england.nhs.uk
Systems are exploring how to use their local linked data to
understand their populations needs in different ways to
design and target interventions
Pounds per Person per Year
Total spend for cohort
Number of people in cohort
Step 1 – segmentation
By understanding different segments
of the population, systems can
understand where investments and
interventions may have the biggest
impact on the system as a whole.
This complexity model goes beyond
standard age-based or disease-based
segmentation models to truly look at
what makes a whole person ‘complex’
to treat, including multi-morbidity,
mental health issues, and social
demographics and determinant.
Each segment is Mutually Exclusive
and Collectively Exhaustive.

11. 10www.england.nhs.uk
For example, Leeds is exploring how to better meet the needs
of people with moderate frailty – using linked data to identify
who is most likely to benefit from interventions
Next stage is focusing in on
high risk and rising risk
patients within these
segments using risk
stratification to design and
implement proactive
interventions.
Step 2 – stratification

12. 11www.england.nhs.uk
Example of a COPD PHM cycle at Primary Care Network level
Clinicians and managers are aware
of Population Level Health Needs
Analysis and how that translates
to the population they serve
COPD prevalence identified as high
in GP practice and admissions to
hospital for COPD patients are also
high
Population is segmented
based on the need
identified
Patients on practice register
who are diagnosed with
COPD and at risk of COPD
(those who smoke) are
identified
Population risk profiling
of segmented population
Primary and secondary care
utilisation of those who are
identified is reviewed. High
users of services are
identified
Transformation using design and
implementation of effective
Interventions for the identified
need
Implementation of targeted smoking
cessation services. Referral to
pulmonary rehabilitation pathways
and MDT care planning for those
multiple conditions in addition to
COPD
Impactability modelling
Targeting care towards those with
the greatest ability to benefit
Of those who are high service users
which of those have care that is not
optimised? E.g. smoking cessation
advice not given, pulmonary
rehabilitation not offered, care plan
not in place/ in date, medication not
optimised
Evaluation of impact of
change against proposed
outcomes
Patient and practice level
impact on COPD
prevalence, related
emergency hospital
admissions and smoking
prevalence.
Knowledge of available effective
interventions to influence segmentation

13. 12www.england.nhs.uk
By linking data across the system, it is possible to track an
individual’s journey, spot gaps in care and streamline future care
Theographs…

14. 13
NHS England is developing support for systems
• PHM Maturity Matrix diagnostic sessions (infrastructure and intelligence)
• Data and Information Governance Network (being established) and PHM Data Governance Tool
• PHM Network and access to international learning webinar series
• ‘Flatpack’ guidance – an introduction to PHM
• Population Health Analytical Skills Audit – online tool
• Population Health Intelligence and Data Function Specification
• Library of good practice interventions and care models
• Access to accredited external transformation, digital and analytical support through HSSF
• PHM Dashboard co-design sessions
• To come……what does PHM mean for PCNs guidance and learning from ICS development
programmes
Email us at england.stgphm@nhs.net to get access to the PHM network

15. 14www.england.nhs.uk
Discussion
• What does population health management mean to you?
• What are some of the key barriers and solutions to making PHM business as
usual within Primary Care Networks?
• What support do you need to make this happen?