- Sustainability and Transformation Partnerships (STPs) offer a route map for how a place based health and care economy might best utilise collective resources to benefit local populations. Meaningful programme planning is impossible without access to linked patient level datasets. These datasets and the insights contained therein provide the key to an understanding of how to best invest shared resources to produce the best health outcomes.
- When thinking about place based care, focusing on the top to 2 per cent of the population – as with the Avoiding Unplanned Admissions Enhanced Service – is not enough to ‘move the cost curve’. A recent report published by the Local Government Association (LGA) suggests that this 1 to 2 per cent of the population accounts for not more than 10 per cent of total system costs. Population analytics and segmentation should focus on the next 20 to 30 per cent of the population, which make up the majority of costs in the system. Population segmentation matters, but it needs to be targeted on populations where you can make a significant impact.
- Multimorbidity is the norm and it drives cost. Population health analytics needs to centre on the quantification and measurement of multimorbidity, as populations with complex needs consume a high use of health and care resources.
- Socially disadvantaged populations tend to exhibit higher illness rates. It is important to quantify and measure the degrees of multimorbidity that exist in socially disadvantaged population groups, as the scale of multimorbidity is strongly linked to socioeconomic deprivation.
- When embarking on a population health management approach, a whole system approach is needed. Think carefully about the datasets required for segmentation. Acute and primary care data are prerequisites, however more nuanced and sophisticated segmentation is possible once community data and adult social care data are added to the mix. What we seek is an understanding of health and care needs and the totality of costs that apply.
 The Journey to integration: Learning from seven leading local localities / Ben Richardson et al, Carnall Farrar