How do we best serve the patients and populations with greatest need?

The challenges faced by the NHS today are in many ways those faced by health care systems across the world.

In the UK the task of ‘fixing’ the system has been given to Sustainability and Transformation Plans (STPs). Looking at those plans it is difficult not to come to the conclusion that, for the STPs at least, the ‘Triple Aim’ of better patient outcomes, better patient experiences and a reduced cost has been redefined as ‘reduced cost, reduced cost, reduced cost.’

Given a financial crisis in the NHS that appears existential in nature, this is perhaps understandable. However, when you put the plans themselves to one side for a moment and you look into the eyes of the people charged with delivery, it is clear that motivation and focus is very much centred on the delivery of better patient experiences and better patient outcomes.

The concern is a very human one; how best to serve the patients and populations with greatest need?

When we look across the world at how other health care systems address this question, what is telling is that pretty much everyone starts with the data. Data — and more importantly the insights driven from data — are seen as a critical element in delivering care models that better serve those populations in greatest need.

For example, if we think about the specific issues posed by the needs of complex patients — remembering that multi-morbidity is now the norm — then the starting point for those charged with service transformation has to be the need to understand who these patients are and how they currently use the health care system. There is a desperate need for insight that explains how healthcare resources are delivered and consumed. Only then can local health and care systems begin to adapt and transform in order to meet patient and population needs.

In the UK surely this must be the starting point for STPs and emerging Accountable Care Systems

When we think of the data the good news is that many of the advanced analytical systems needed to provide insight on populations in greatest need are available today. It is just that in the main, they are hopelessly underutilised.

So let’s return for a moment to the exam question set which is …how do we best serve the patients and populations with greatest need? If we accept that a logical starting point might be complex care patients who are multi-morbid, then I would humbly suggest that the following approach has some merit:

  1. Understand the characteristics of complex populations. Analyse the data to understand the breadth and scope of complex care populations within a ‘place’. This is consistent with the movement towards place based health and care systems centred on STPs and Accountable Care Systems. Use these analyses to set a vision for serving complex patients and use this vision to engage stakeholders and build intervention strategies.
  2. Identify and target specific patients. Use data analyses to determine which patients are most likely to benefit from intervention. The health and care system needs to understand which patients are likely to benefit most from targeted interventions. Who are the most impactable patients and patient groups? Population segmentation and case finding are the key to the development of strategies — often linked to intensive care management and coordination — that locate and engage individual patients.
  3. Ensure effective management and evaluation. Use the data to rigorously monitor and evaluate the impact of the intervention programmes deployed. The systematic use of data is the key to understanding whether or not intervention programmes are delivering better patient outcomes and a better patient experience at a reduced total cost for the population served.

If we accept that committing scarce resources to those patients and populations in greatest need is the right thing to do, then self-evidently our starting point must be the acquisition of knowledge that helps us gain a precise understanding of the scale and nature of that need.

Our work with a large number of NHS clients demonstrates that when you do the analyses, multi-morbidity is the norm and co-morbidity impacts resource use exponentially. We know this because the data tells us so.

To successfully answer the question how do we best serve the patients and populations with greatest need …start with the data.

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