Population Health Management by William Shakespeare

For reasons that will become obvious by the end of this post, we at Sollis has recently been thinking quite a lot about Shakespeare. In particular, the moment in As You Like It when he has Jacques summarise the human condition as follows:

All the world’s a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts,
His acts being seven ages. At first, the infant,
Mewling and puking in the nurse’s arms.
Then the whining schoolboy, with his satchel
And shining morning face, creeping like snail
Unwillingly to school. And then the lover,
Sighing like furnace, with a woeful ballad
Made to his mistress’ eyebrow. Then a soldier,
Full of strange oaths and bearded like the pard,
Jealous in honour, sudden and quick in quarrel,
Seeking the bubble reputation
Even in the cannon’s mouth. And then the justice,
In fair round belly with good capon lined,
With eyes severe and beard of formal cut,
Full of wise saws and modern instances;
And so he plays his part. The sixth age shifts
Into the lean and slippered pantaloon,
With spectacles on nose and pouch on side;
His youthful hose, well saved, a world too wide
For his shrunk shank, and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.

As You Like It, II, vii, lines 139-166.

Shakespeare here seems to be acting almost as an early modern exponent of population health management.

Speaking through Jacques he divides the population — both men and women — into seven age bands.  He notes that throughout their lives, people move across segments (‘play many parts’), and he describes some of the characteristics of the people in each cohort. This has some interesting features.

There is a concentration on the mental health problems associated with some segments. For example, the ‘whining’ schoolboy; the lover ‘sighing like a furnace;’ the soldier ‘jealous in honour, sudden and quick to quarrel;’ and of course the aged regression to childishness.  Elsewhere he focuses on physical problems.  The ‘mewling and puking’ baby and the obese justice come particularly to mind.

Of course, it is well understood that segmentation purely by age is often less than helpful. And it seems that Shakespeare knows this too; his seven-part segmentation model isn’t created by considering the individual’s calendar age.  His ‘ages of men’ are rather the stages that all will pass through, should they live long enough. It might also be argued that his use of extreme stereotypes (not all in the fourth segment will be a soldier, and not all in the fifth a justice- and some justices will not be tubby) suggests that he also recognises that his cohorts aren’t actually that well-defined. This is signalled by his reference to the theatre in the first line. He’s offering telling examples, not detailed segment definitions.

There remain a number of real criticisms of the whole population model that the bard puts forward.

  • Firstly, where are all the women? Having asserted that he intends to speak of men and women, most of the exemplars of his seven-segment model are clearly men.  It would be good to include some female exemplars.
  • It’s also quite middle class. There is no sense of how deprivation, or other social and environmental factors, might impact on individual life stories and stages.
  • Nobody seems really happy, and well-integrated in their community (the justice may be an exception here). Ideas of wellness and social cohesion are missing.
  • Finally, there is no sense that these segments have been designed to produce homogeneous cohorts for whom preventive, curative or palliative action can be designed, in the shape of new care interventions. They are descriptive, but fail the tests of utility and impactibility.

To be scrupulously fair, several of these weaknesses may arise because Shakespeare is speaking with the voice of the melancholy nobleman Jacques. As he is described in his Wikipedia entry:

Jacques’ distinguishing characteristic is his unmitigated cynicism. He is the only purely contemplative character in Shakespeare. He thinks, and does nothing.

With that in mind, perhaps Shakespeare doesn’t do all that badly, for a segmentation analysis written in 1599, when population health analytics were very much in their infancy.

Fast forward to today, and we like to believe we know a little more, so we are pleased to announce a workshop on advanced population health management on November 29th.

Advances in Population Health

This all-day event is taking place in the Balcony room at the Swan, part of the Shakespeare’s Globe Theatre complex, with fantastic views over the river Thames.

We hope to catch up on new developments in understanding and improving population health, including:

  • Case studies from practitioners and planners
  • Presentation of recent new analyses and analytical techniques
  • Discussion of the role of new technologies in furthering population health

The keynotes will be given by Dr Steven Laitner, a GP with a Public Health and Clinical Leadership background, and a clinical advisor to the National Association of Primary Care (NAPC) Primary Care Home (PCH) Programme, and Jeremy Taylor, the chief executive of National Voices, the national coalition of health and care charities for England.

The workshop will cover four main areas:

  • Whole population analyses. Exploring the different techniques for segmenting and managing whole populations, their strengths and weaknesses, and measures of success. This includes a range of new benchmarking techniques.
  • Targeted interventions. Surveying many ways in which local care economies have identified specific patient cohorts for new interventions, and how effective delivery, monitoring and evaluation can be assured.
  • Personalisation. Examining how care can be tailored for the individual in a population health management environment. This includes self-management of care, social prescribing, and the importance of the patient’s voice.
  • New analyses and technologies. Looking at some of the latest analytical approaches and technologies supporting the health and care of populations. The Sollis team and several partners will discuss their latest innovations.

There will be opportunities to network and discuss ideas, and for those who are interested, the day will end with the opportunity for a free guided tour of Shakespeare’s Globe Theatre. Places for this will be strictly limited, so please book early.

Sollis will also be launching a new Introduction to Population Segmentation at the event, a companion to last year’s Understanding Population Health, authored with Johns Hopkins Healthcare. This new guide distils our experience of delivering population health solutions over the last nine years. Those attending will be the first to receive this new reference guide.

If you’re free, and interested in coming, please register using Eventbrite at https://www.eventbrite.co.uk/e/advances-in-population-health-tickets-51544125868.

Note: This event will include a free buffet lunch. If you have any special dietary requirements, please let us know by email to claire.mcfadyen@sollis.co.uk  or calling 01372 847 525.