There are five problems found in almost every health service in the world:
- Unwarranted variation in quality and outcome.
- Harm to patients.
- Waste, and failure to maximise value.
- Health inequalities and inequities.
- Failure to prevent disease.
Many previous NHS re-organisations, plans and initiatives have sought to address these problems and (particularly in the context of population health management) to increase the focus on population health, the prevention of disease and early intervention but have failed to have the scale of impact required.
The Covid-19 pandemic has highlighted the impact of preventable diseases and health inequalities and has once again shown the importance of the social determinants of health. At the same time, it has brought to the fore the strength of our borough-based partnerships and system relationships and has driven innovative practice of population health management focused on some of our most vulnerable residents (perhaps best evidenced by the work on Covid vaccination).
The shift into new Integrated Care Systems (with the Integrated Care Partnership a genuine joint endeavour between NHS and non-NHS system partners) presents an opportunity to create an aligned approach to improving population health across NHS providers, Local Authorities, the Voluntary Sector and our residents. It allows us to re-appraise our local and system priorities and encourages us to use the increasingly rich data available to target those in our communities with the greatest need, much of which is unmet. It also allows us to thoughtfully allocate resources to maximize value, in every sense. This is what is meant by ‘population health management’ (PHM).
This ‘Roadmap’ has been developed following a South West London (SWL) ‘PHM Stocktake’ which involved multiple partners across the system and captured examples of excellent existing practice, valuable distributed assets, high levels of aspiration for a range of uses of PHM as well as a variety of development needs. The Roadmap sets out the current context in South West London and the next steps required to improve our capability and capacity to enhance Population Health across our geography.
There is action required to improve the tools and skills available to those already working in our system, to target resource to support PHM but most importantly to change the way we think and behave across our system to move away from a predominantly reactive approach to those presenting at the doors of our services to a more reflective, proactive way of working that actively seeks unmet need across our population, reduces unwarranted variation, maximizes value and plans for the future.