In the space of just a few short weeks we have seen the NHS embrace and action change in a way that was perhaps unthinkable back in February this year. This is particularly important when we consider primary care and its role in the delivery of Population Health Management (PHM), because if Population Health Management is about anything then it is about change.
There are many lessons to learn from the Covid-19 pandemic and we are only at the beginning of that learning journey. However, something one hears a lot is that the crisis has provided us an opportunity to change the way we deliver health and care services centred on the person, the communities they live in and the population at large. Recovery of health services requires not restoration but the resetting of services that in a sense a pandemic led us to embrace.
Research across many health care systems has identified a cognitive dissonance between the critical strategic role assigned to the primary care system and its relative lack of investment, importance, or influence. When we speak of primary care here, we speak not only of the GP but of the wider Multi-disciplinary Team (MDT). A strong and enhanced primary care system with citizens accessing healthcare with a wide range of services in the community can enhance both the patient experience but also allow for local innovation and design delivering practical implementation of population health, centred around populations but delivered locally .
Humanising Population Health Management
At frequent points of our involvement in Population Health Management (PHM) we are told how difficult it is to engage General Practitioners in the endeavour. Some of this is attributed to workload, but often we were politely lectured that what really mattered to General Practitioners was not populations but the individual patients presenting in the consulting room.
In all the work Sollis has been doing we have observed that General Practice has its roots in the community and the wider primary care team are almost uniquely placed to improving the health of local communities beyond the consulting room. Because General Practice is at the heart of the community it is often best placed to understand and articulate the needs of that local population.
And whilst Population Health Management is often couched in abstract terms such as ‘stratification’, ‘segmentation’ and ‘impactability’, primary care teams instinctively know that in the end analysis everything comes back to the individual. Population Health Management needs humanising. Ultimately it is about the individual, their life and their holistic needs and preferences.
To illustrate; primary care has long understood the importance of personalised care and the need to include the patient at as part of the decision-making process.
This includes supporting patients to talk about the things – including outcomes – that matter most to them as individuals. Population Health Management strategies of course are designed to deliver better patient experiences and better health outcomes and therefore the needs of the wider population and those of the individual are part of the same story. Two sides of the same coin. For primary care there is no tension here. It is quite possible to focus at an individual patient level whilst at the same time being cognisant of needs, wants and desires at a community level.
Prevent and protect
It sometimes feels like a whole new language has built up around Population Health Management language that obscures something quite simple. At its heart Population Health Management is about prevention, identifying risk and carrying out an intervention that is personalised and actionable .It requires changing the narrative and debunking myths around Population Health Management delivered through wider partnerships and the multidisciplinary team.
The current crisis has placed prevention at the heart of the transformation agenda. During Covid primary care has shown itself in proactive mode and – given the headroom and the permissions to act differently – we have witnessed a discernible shift from reactive behaviours to activities centred on wider population needs.
Some of these activities have centred on an understanding of ‘at risk’ groups across the communities that primary care serves. Furthermore, insights driven from data have shone a light on the issue of long-term conditions and multi-morbidity.
Whilst the data is still coming in, we already know that a large proportion of the people who die from Covid have been suffering from one or more long-term conditions. This matters, because whilst Population Health Management strategies rightly consider the needs of whole populations, now more than ever the crisis requires us to pay even greater attention to those with complex needs, often characterised by the existence of long term conditions and multi-morbidity.
Primary Care: A Community response to crisis
The Coronavirus pandemic has cruelly exposed existing inequalities and inequity in society. We do not know when the next pandemic might hit, but we must ensure that those populations so devastated by this current crisis are afforded all possible protection in the future. Equally importantly is the question of how we intervene now in order that fewer people develop life limiting and threatening long term conditions and co-morbidities.
There is plenty of evidence that primary care is the right place to start to implement strategies to deliver population health management at a local level , building on community knowledge , a well-functioning patient record system and data insights from companies like Sollis. These actionable insights allow teams to segment amenable cohorts whilst considering risk within these cohorts. These evidence based insights will ultimately help improve outcomes for these populations and use innovative technology based interventions -new digital front doors to health and care which are finally seeing the light of day.
If this pandemic has taught us anything then it is that the vision, energy, and creativity that is the engine of change will ultimately action come from local communities who know their purpose and who are determined to act accordingly. Primary care – existing as it does at the heart of local communities – will be at the forefront of that change.
Now is the time to reset services. This reset should be data driven and led by innovative new service models based on the registered patient list. The agents of change will be primary care which has had a long standing commitment to the communities it serves; a commitment which goes back to the very foundation of the NHS.
Population Health Management delivered via world class primary care is an idea whose day has come.