Population Health

What is Population Health?

Population health has become a very popular term in recent years and has been used interchangeably with Public Health, although the two are quite different. 

Population health refers to the health outcomes for a population or group of individuals, including the distribution of such outcomes within the group. 

Public health is the act of improving health through health improvement, prevention of disease and improving quality of services. Public health specialists and academics have been involved in the applications of population health. This is true of the UK where there is a growing emphasis on improving health outcomes for patients and people rather than on outputs or targets (see the Public Health Outcomes Framework).

According to Wikipaedia, the concept of Population Health is to complement the classic efforts of public health agencies by addressing a broader range of factors shown to impact the health of different populations. In particular, there is a focus on the social determinants of health, i.e. social, environmental, cultural and physical factors that impact upon the health of human populations. By reducing the impact of these factors, you can reduce the health inequities and inequalities among different population groups. It is much more of a sociological approach rather than starting with the variations between groups and working backwards to determine the causes or reasons for the disparities.  

Arguably, population health is a broad concept but its value lies in its focus on the distribution of health (i.e. health will vary between and within populations) and the facilitation of knowledge across the many factors that influence health outcomes. This could enable different policy and decision makers to find a common language or interest in which to work together.  

What is meant by Population Health Management?

Population Health Management (PHM) is an approach that uses data to improve the physical and mental health outcomes and wellbeing of people, whilst reducing health inequalities within and across a defined population.  It takes into consideration the factors that impact upon health such as lifestyle and behavioural factors, environmental, societal factors, socio-economic and healthcare factors.   The idea is to improve health and remove inequalities by taking actions to reduce the occurrence of ill-health.  This is done using data-driven insights and evidence of best practice to inform, plan and deliver targeted, proactive anticipatory care interventions within a defined population.   

Action (population health improvement) is taken by a collective of partners working together (e.g. local authorities, NHS, voluntary sector, local people) who make best use of collective resources to achieve tangible improvements in health for people and communities and address the wider determinants of health. 

Uses of Population Health Management

Hospitals are using PHM to better manage their patient flow. This method places an emphasis on patient outcomes and quality of service, shifting hospitals from traditional reimbursement based on volume of procedures to improving patient experience of care, reducing costs and focusing on keeping people well in the community. This has led to the investment in telemedicine, community-based (urgent care) clinics in areas with high proportion of residents using the emergency department as primary care, and patient care coordinator roles to coordinate healthcare services across the system. 

Since July 2022, the  UK are delivering place based care through integrated care systems (ICSs).   PHM has become pivotal to the way that the new systems work together to improve the health of their populations.  Within the ICS model, hospitals have to meet specific quality benchmarks, focus on prevention, and carefully manage patients with chronic diseases. Providers are encouraged to keep their patients healthy and out of the hospital. The intention is that inpatient admission and emergency department rates will drop.  This builds upon the experience during the COVID-19 pandemic.  Primary and secondary care providers used PHM to risk stratify and proactively support key population groups with personalised care models.

On a GP practice level, I have heard conversations around helping GP practices to utilise a population approach to the planning and running of their services.  This effectively means helping them to think beyond the day-to-day management onto understanding who their population is, the variation in health conditions across the population and the patient outcomes they want to achieve.  

Useful links

Population Health Management - elearning for healthcare