How do you measure the success of population health approaches?

In 2018 we published The King’s Fund’s Vision for population health calling for urgent improvement of health and care and tackling of health inequalities across UK.

Four years on, the Covid-19 pandemic, the stark insights about inequalities that came to light, and profound realities about UK poverty and the worsening economic situation have served to be a compelling call to action. The NHS Long Term Plan, the Digital Health and Care Plan, the 2022 Health and Care Act with statutory establishment of integrated care systems across England this month, and numerous initiatives by local, regional and national teams have helped set a healthier trajectory for change. But it is still early days, and there is much work to do.

'Success of health and care transformation will require review, refresh and refocus of measurement approaches with much more focus on population health.'

A common theme highlighted by health and care leaders we support in our leadership programmes is how best to measure success for population health. We hear there are already far too many metrics, so people are ‘drowning in data’, and that existing data reporting processes can create additional work for already under-staffed teams. We hear worries that central bodies will increasingly use performance measurement to tackle immediate pressures such as waiting times and elective lists rather than focus on population health approaches as a whole. And we hear about the need for greater data competency of leaders and boards, particularly in the new ways of working needed for population health. Success of health and care transformation will require review, refresh and refocus of measurement approaches with much more focus on population health. These are some thoughts about how this can be achieved:

First, focus on purpose. At whatever level you work, be clear that the purpose of measurement is to act as an enabler for creating an improved health and care system that is better able to meet the needs of the people it serves. Done well, measurement is a powerful tool for improvement. But done badly, it can act as a barrier and make it harder for positive change. It will take courage to see that this will mean reviewing existing metrics and making necessary changes to make them more population-health focussed. This includes getting rid of metrics that are no longer helpful.

'...we regularly find it is important to bring diverse groups of people together to have honest conversations about what is required and to co-create steps towards a healthier future.'

Second, collaborate for quality. In our work to support people to develop their population health approaches, we regularly find it is important to bring diverse groups of people together to have honest conversations about what is required and to co-create steps towards a healthier future. We know this is not easy – and indeed we often hear that our role at The King’s Fund is necessary as an independent broker to overcome challenges of history, personality, perspective, and power dynamics to try to build confidence in a new way of working across boundaries. For example, powerful conversation resulted when we recently brought together leaders from NHS England and NHS Improvement, local systems and ICSs to help join the dots across key programmes for population health. A similar approach will be needed to agree the best metrics to use across England with enough detail for consistency and enough flexibility to meet local needs.

Third, understand that expertise for this collaboration lies across a range of people – especially the lived experience of communities, powerful insights of the voluntary sector, the technical skill of public health teams, and insights from data and intelligence teams across a range of partner organisations. It takes skill to resist the urge to focus on the loudest voices or those with traditional forms of power or succumb to the pressure of only focusing on immediate pressures (which are often the result of missed population health opportunities previously). Success requires leadership skill to bring together the many different perspectives and enable a choice of metrics that count, and to measure what matters – to the public, and not just to the health and care system.

Fourth, seek a healthy balance of metrics in any population health dashboard. One metric alone will not suffice. There are several ways to consider this balance – for example using the four pillars of our framework to guide selection.

The four pillars of a population health system

There are many metrics to choose from, and many tools to support efforts. For example, Public Health Outcomes Framework, Marmot indicators, value measures, and more. Existing priorities can help – for example Core20plus5 for health inequalities improvement, Population Health Management for monitoring, personalised care to aid delivery. But these need to be part of a more comprehensive population health approach rather than seen in isolation. Ensure that the range of metrics enables all partners to contribute. Include a range of short-term (up to 1 year), medium-term (1-3 years), and longer-term (over 3 years) measures to create a full and phased approach. Short-term measures help partners take immediate steps, generate early impact, and help enhance confidence and motivation for people to persevere. Medium-term measures can help address deeper-seated issues that can have more impact than short-term steps for local people. Longer-term measures are key to creating sustainable approaches for population health. To select metrics that matter, working in partnership with patients, communities and the wider public is key.

Finally, continually review and challenge yourselves to ensure efforts are as aligned and streamlined as possible across all parts of the health and care system. Create simple data collection and reporting mechanisms to minimally impact on staff and maximally aid population health efforts. Agree funding and a commissioning approach to support your population health approach. Short-term steps may fit into existing funding cycles, but the longer-term change needed is likely to require longer-term contracts and different commissioning processes. In addition to process change, training is required to help staff at all levels feel more comfortable with this new way of working and to see that central to their efforts, regardless of their role, seniority, or sector, should be purpose (population health) and not process.