Demystifying Population Health Management (PHM) aka. We Can Do It.

In recent months Sollis have been providing data and analytics support to a number of Primary Care Networks (PCNs) nationally. These work programmes have varied in scope and nature ranging from:

  • Managing People with Complex Needs / Anticipatory Care (South West London)
  • Frailty Transformation (South West London and Surrey)
  • Chronic Disease Management/ Long Term Conditions (South West London)

Clinical engagement/input is at the heart of all these engagements and the energy in the room to make things better for patients has been palpable. One of the most striking aspects of the engagement is that – without exception – this energy has been focused on ‘doing’ as opposed to ‘talking’.

The discussions that underpin the various work programmes have never once centred on the theory of Population Health Management (PHM). During the many virtual meetings I have attended, I struggle to recall a single time when the concept of PHM was referenced at all.

In these meetings, the total absence of vast swathes of PowerPoint slides embroidered with the latest and greatest iteration of the risk pyramid and process charts has been liberating. It is my experience at least that the clinicians and wider Multi-Disciplinary Team (MDT that we are working with just get the fact that they can make things better for the patients they serve. Moreover, there is a real passion to do so.

My clients don’t talk in terms of service transformation; they talk in terms of making things better and they well understand that making things better extends beyond the patient sat opposite them in the consulting room. They instinctively know that if the team – and this is absolutely a team endeavour – can get it right at an individual level then they can get it right at a population level.

In short; they get it so spare them the slide deck!

And when it comes to the data and supporting analytics, they don’t need lecturing that better decisions can be informed by better data. They also understand that when it comes to data, ‘perfect is the enemy of the good’. The PCNs and GP Practices that I work with are in a hurry and they haven’t got time to wait for the launch of the latest iteration of the world beating Data Lake, Electronic Patient Record (EPR) System or Data/IT Infrastructure Strategy Document.

If they haven’t all seen Waiting for Godot then they sure as hell know how it ends.

They – more than anyone – recognise the power of the data assets already in their grasp. The core data set here of course is the primary care. Give them a linked secondary care and primary care data set, then better still.

And whilst they are happy to be guided by the data, they are never slaves to it. Clinical judgement is always front and centre.

In a future blog I will write more about how these various work programmes are making a difference to the people they are designed to serve.

For the time being I felt compelled to document the fact that in addition to battling a global pandemic, in Primary Care good people are busy doing great things.