Population Health Analytics: Run the Numbers

“You’ve got my number

Why don’t you use it”

You’ve Got My Number – The Undertones

Another day, another report.

The 15th June saw the publication of Stepping up to the place: The key to successful health and care integration. It is a joint publication from the Association of Directors of Adult Social Services, Local Government Association, NHS Clinical Commissioners and NHS Confederation.

Let me first say that it is a publication that demands to be read and the fact that it is jointly authored is significant and worthy of note. What I took from its pages was not necessarily any startling new insights, but a re-enforcement of thoughts and ideas that have been ‘out there’ for some time.

There is clearly a growing momentum for place-based systems of care and a recognition that the free flow of information, both at the individual and population level, is a prerequisite for any successful integration strategy. The report is at pains to point out that those health economies who are at the “cutting edge” of integration have designed their options around the needs of their population’s health.

For proponents of population health management — such as myself — this is music to the ears. There is clearly a growing consensus building that when designing new care models it is essential to understand the totality of a populations needs. Simple when you just say it.

As I have argued in previous blogs, the starting point has to be the data. No organisation worth its salt would undertake a large-scale transformation of its business model without first undertaking a forensic analysis of the data. It’s the data that provides the evidence for change. It is the data that offers clues as to where we should invest and disinvest. As in all of life, not all these bets will pay-off, but better surely to run the numbers first before reaching for our wallets.

When considering integration strategies much is made of how population health analytics can help us design and organise services around the demands of populations with more complex and chronic health and social needs.

And on the subject of ‘running the numbers’ it is instructive perhaps to look at what the evidence tells us from those who have gone before.

Recent work at Slough CCG has delivered some real insights, namely:

  • Multi-morbidity is the norm — it is more common for people to have multiple chronic conditions that to have just one.
  • Multi-morbidity is not distributed evenly across a population and case-mix varies quite significantly between GP practices.
  • Multi-morbidity more than age is a key driver of cost, activity and future risk.
  • Multi-morbidity occurs in the whole of the adult population.

The full report can be found here and I would urge you to take a look.

The results? The design and delivery of a primary care based intervention centred on complex case management. A sort of New Care Model, if you like, and proof that not all the ‘big brain’ innovation is being driven by the Vanguards.

None of the insights here could be attained without first doing some hard yards around the available data. Without the data and in the absence of the application of tried and tested population health analytics, service transformations strategies are at risk of failure.

Surely our citizens deserve better than that?