Community health

Population health management: the time is now

By - Primary Care Journal

 Population health management: the time is now

This article is intended for UK healthcare professionals and relevant decision makers. This article has been funded and written by Novartis UK. Novartis has retained full editorial control.

Setting the scene

Though their origins date back at least 25 years1, the adoption of Population Health and Population Health Management (PHM) approaches are only recently on the rise. The terms have featured in recent NHS England policy documents2,3 and been the topic of a number of thought leadership publications and events from The King’s Fund. They are also emerging through the developing Integrated Care Systems (ICSs), with dedicated roles in Population Health or PHM. It’s clear that PHM is important, but what is it all about and why is it relevant now?

When we look at the NHS’ Long Term Plan2, we see it places a strong focus on the need for a PHM-based approach, using predictive prevention, to enable earlier detection and intervention to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population. To enable this, ICSs are, and will continue to be, key, as they provide a mechanism through which local organisations can partner with authority-funded services to work together, drive action and improve the health of a locality2.

More recently, the need for a PHM approach was further emphasised in the phase 3 response against COVID-19, evidenced in Simon Steven’s letter to NHS Trusts and CCGs3. In light of the stark healthcare inequalities highlighted in the pandemic, the guidance places utmost importance on protecting the most vulnerable members of the community, the need for collaboration with local authorities and other partners, and regularly updating plans to identify and protect people most at risk. As part of this ‘call-to-action’ by NHS England, it is going to be crucial for systems to consider just how they are going to approach this task and agenda. It raises many questions:

  • How can patient data be appropriately used to identify those at risk in society and address inequalities?
  • How can health risks associated with people’s relevant protected characteristics (such as age or race) be considered when care provision is being designed and delivered?
  • How can we accelerate the UK’s prevention agenda, proactively managing patient groups most at risk, while also improving the health of our population at present?
  • How can we work together to address the wider determinants of health that impact our communities’ health and wellbeing, such as social circumstances, environment and personal behaviours?

These questions highlight the need for PHM, and why it is more important now than ever before.

The PHM approach: what it all means

An evidence-based approach, PHM aims to investigate and address variation in health outcomes by using data and risk stratification as its starting point. With a strong focus on cross-organisational collaboration and sharing of insights, it allows better understanding of what is happening in communities, where the unmet needs are, and what you might be able to do to tackle them. If done correctly, it can truly help systems design care provision effectively around their own populations, as well as help eliminate health and care inequalities at the source.

For the newcomer, PHM can be broken down into the following steps:

1. Use available data and insights to segment a local population into groups, and identify those at risk of negative health outcomes, whether now or in the future

2. Engage and collaborate with the local population, councils, and services to investigate the issues 

3. Together, look for solutions

4. Implement these in the population, test, assess and refine

You can learn more on the NHS England website here.

Though new approaches may seem daunting, primary care, and in particular Primary Care Networks (PCNs), are in many ways well equipped to implement a PHM approach. Staff already have a solid understanding of, and unique insights into their community and its needs. Localities contain multidisciplinary teams deeply embedded in their communities and focus on defined populations of 30-50,000 people. And, for most of the population, primary care is the first and most common point of contact to the health system. Primary care is therefore the critical link to the populations we care for, and holds the strongest ability to create positive change.

Transforming patient outcomes with PHM

PHM requires a very proactive and integrated approach, and often significant changes, but the benefits in the long term (and often in the short term, too) will, arguably, be well worth it.

Andi Orlowski is a health economist and Director of The Health Economics Unit. Andi and his team believe a PHM approach led by primary care will transform patient outcomes throughout the UK, enabling healthcare professionals to identify key groups at risk, proactively intervene and deliver the best value for their local populations.

He and other experts in the field highlight how PHM can (and already has, as we explore later) help us to spot the gaps in our systems and tackle some of the biggest issues we face.

So far, PHM has helped to unearth some painful realities, which are deeply rooted in health inequalities; another key focus of the NHS’ Long Term Plan. It is thought that up to eighty percent of a person’s health outcomes are due to their social and economic situation, their home environment, and other determinants4. ‘Poor’ healthcare decisions by individuals are often the result of circumstance rather than choice, and those in minority groups tend to face bias, unfairly long waiting times, or follow different cultural practices than those our current systems are tailored towards (and which algorithms are based upon). Some services may simply not be convenient or useful enough for those they are targeted at.

However, seeing the problem is part of the solution and a big part of PHM too. By unearthing the key patterns in our communities, PHM helps us to move forward and drive change.

As the NHS faces one of its toughest challenges yet, PHM can be especially important, to help allocate resources appropriately and think beyond healthcare. If your practice is struggling for time, could the right discussions now reduce GP visits next year? Equally, how might choices that seem cost effective now impact the future?

In addition, PHM can also help to demonstrate that putting more money into healthcare is not always the best solution, and partnerships with organisations outside of the healthcare network, like social or community services could be invaluable. For example, if your area faces high levels of chronic respiratory issues, there may be a large percentage of damp housing. Could improving their housing situation help more than medication? Taking a step back, looking at the bigger picture, and addressing the wider determinants that impact our communities’ health is crucial, and it is this type of approach that a PHM strategy advocates.

Making PHM a reality

As mentioned, PHM in the primary care setting involves several key steps: segmenting a population into groups with specific needs (and these groups may be sick or well), engaging with them, and then addressing the issues – all while working with other community services to make support available when, where and how it is most needed.

Data is the backbone of a PHM approach, and the Nottingham & Nottinghamshire ICS is one district really taking the lead. With a GPRCC (a general practice repository for clinical care, a secure database of patient information) in place, they were able to design a workflow that compares successful patient groups to unsuccessful ones, and detects care opportunities and gaps in the community, which are assessed and recalculated daily. This approach has helped them to better reach their patients, by segmenting groups to stratify and overlay with inequality elements. For example, in a successful flu vaccination campaign, the team identified key target groups, based on factors such as age, deprivation and ethnicity, then commissioned research to understand how best to get each into the practice for their vaccination.

Working in partnership with other organisations can also help source crucial data. Primary Care Networks can request information – like population statistics, deprivation levels and use of services, as well as data from commissioning support units – from clinical commissioning groups (CCGs) and local authorities. The NHS and Public Health England are also useful sources, and groups like NHSRightCare are designed to advise local health economies on how to make the best of their resources5. With a phone call or email to one of these groups, you could kick start your own research too. Even GP records could be enough to make a start and help identify the cohorts that need help.

It’s important to think outside of the healthcare box, too, when sourcing valuable insights. Newport Pagnell Primary Care Home developed a list of local organisations and stakeholders, including the council, schools, youth clubs and social care staff. They set up one-to-one meetings with each to discuss PHM and their initial thoughts of the unmet needs of the local community. Since then, the team has held regular catch ups to work through segmenting the local population, to co-design services and share experiences and ideas that could benefit the community5.

Once the needs have been identified, it’s important to engage with those at risk, for example by setting up a simple survey or reaching out to a range of people in your target segment. This really helped the Berkshire West district after they uncovered two struggling groups of diabetes patients6. The team spoke to several members in each, and found two very divergent issues: one group was too busy to see a diabetic nurse and found previous education patronising, whereas the second was composed of a large Nepalese population facing language and cultural barriers. For the first group, the team developed a new service involving group consultations discussing the impact of stress, thereby helping patients to re-engage, whereas the second group benefited from a structured education system with a Nepalese nurse. This example shows that while the data helped to identify the at-risk populations, it was only by actually talking to patients that tailored solutions were reached.

PHM can also help with short-term needs too, for example in the response against the COVID-19 outbreak. Thanks to their PHM setup, CCGs like Berkshire West could react quickly during the first lockdown, identifying and reaching out to socially vulnerable people in the community and then harnessing volunteer groups and care coordinators to carry out specific tasks such as providing checking calls to those at risk of loneliness4.

Finally, for any locality to solve the needs identified, it’s crucial to engage with a range of stakeholders. Local stakeholders (which could include the community, community and mental health providers, commissioners, local Healthwatch and local authorities) may be necessary for designing the solution. Gather information on the interventions needed and make plans, together; design a multidisciplinary approach to meet the needs, connecting those who need to work together. There needs to be open dialogues, and resources to share information and correctly categorise the population. It’s important to hear from a range of voices, to keep measuring qualitative as well as quantitative outcomes, and to have learning systems that can get more evidence where needed, assess successes, and show areas for improvement.

Bringing it back to the Long Term Plan

We’ve shared some real success stories for PHM, and this is only a snippet of what’s out there. By building a movement to increase adoption of this approach could bring great benefits to the NHS and help it achieve the goals of the Long Term Plan. It could help us address inequalities, accelerate the agenda for prevention, and tackle some real health issues people are facing right now. PCNs are fully enabled to make this work; now is the time to make it a reality in your locality.

Where to begin?

While the adoption of PHM is still in its infancy, and there is a need for more evidence and better exchange mechanisms to share it, can localities really afford not to try?

It’s time to move forward, even if one step at a time. Set up a team in your PCN who can explore a PHM approach for your locality, contact your ICS, start gathering data to identify at-risk groups. Take a look at the PHM Academy on the Future NHS Collaboration platform too; it not only hosts a range of resources and inspiration, but forms a huge community with users from across the country, all experimenting with different ways of doing things.

Article developed by Novartis in collaboration with Andi Orlowski (The Health Economics Unit), and Maria Principe, Mike O’Neil and Jack Rodber (Nottingham & Nottinghamshire CCG).

UK | March 2021 |101473


  1. Kindig D and Stoddart G. What Is Population Health? American Journal of Public Health 2003; 93(3), 380-383. Avaliable at:
  2. NHS. The NHS Long Term Plan. January 2019. Available at:
  3. NHS. Implementing phase 3 of the NHS response to the COVID-19 pandemic. Last updated 18 September 2020. Available at:
  4. NHS Confederation. Alton D. NHS Reset: A running start – using population health management to rapidly respond to the challenge of COVID-19. 2 July 2020. Available at:
  5. NAPC. Primary care home: population health management. June 2018. Available at:
  6. NHS blog. Alton D. New Year’s resolutions and personalised care – any similarities? 8 January 2020. Available at:

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