Understanding Population Health

With the challenges facing our health and social care services and the need to develop new care models — to improve the health of our populations, provide better patient experiences and reduce overall cost — the need for a comprehensive understanding of population health has never been greater.

This paper explores some of the resources, tools and opportunities that can provide insight from data, including:

• The data sets available to us, what is included in them, their benefits and their limitations.
• The added value of integrating data sets rather than only using one data source.
• Analytical tools and techniques to explore the data.
• Examples of the insights and intelligence we can derive using these techniques.

The paper is divided into two main parts. The first part explores some of the phenomena seen in populations. Some of these may be familiar but others challenge some common assumptions about population health. These phenomena include:

• The need for health care varies – a small percentage of people consume a large amount of resource.
• Multi-morbidity is the norm – it is more common for people to have multiple long-term conditions than to have just one.
• Co-morbidity impacts resource use exponentially – not in a linear way.
• Multi-morbidity is not distributed evenly across a population and casemix varies quite significantly between GP practices.
• Multi-morbidity, more than age, is a key driver of cost, activity and future risk, and multi-morbidity occurs across the whole adult age range.
• The top of the ‘risk pyramid’ is not homogeneous – there’s not as much overlap between different risk groups as people may think.

The second section explores a range of analytical techniques being used within the NHS, providing examples of how the insights these techniques reveal from integrated data sets are being used to inform clinical and commissioning decisions.

While most of the analyses provided in this paper have been derived from the Johns Hopkins ACG^® System and Sollis Clarity software, many of the techniques described can be generalised. The primary aims of this paper are to describe ‘the art of the possible’, share real life examples and to highlight the benefits of a greater understanding of population health.