Leading for population health: clinicians’ perspectives

Context

Population health is a national, regional and local priority across UK health and care. It is one of the top four priorities for integrated care systems (ICSs) in England. It follows that population health is an area of interest for many people working in primary care, acute trusts, local government, voluntary and community organisations, and others who want to explore their role and that of their teams or organisations in improving the health of their local populations.

The term ‘population health’ refers to a whole-system approach to improving health outcomes and reducing inequalities of a defined population. The concept of population health is helpful because it recognises the contribution that many people across a range of sectors can have in improving people’s health and wellbeing and serves to foster a collective sense of responsibility. It also recognises that good health is not equally accessible for everyone in society, and places emphasis on tackling inequalities as part of this.

Since its inception in 2019, our Leadership for Population Health programme has supported more than 125 health and care leaders to develop their knowledge, skills and approach for population health. A question we are often asked is about the role of clinicians in population health.

The role of clinicians in population health

Clinicians have the opportunity to play an important role in driving a population health approach. As direct care providers, they are in a position to hear and understand the needs of their patients and may often share a close working relationship with people who access and use health and care services in their local area. The partnership between patients and clinicians is key to exposing the effects of health inequalities and the impact of the wider determinants of health. Clinicians can support patients in addressing how these inequalities impact their experiences of accessing and using services. This may include signposting and enabling access to a wider range of services, including those outside the NHS.

In addition to the ability to consider drivers of population health for individual patients, clinicians can also go a step further and act as leaders in suggesting wider population health interventions that are practical and relevant for their local communities. However, clinicians may feel uncertainthey may feel uncertain about their role in and relevance to population health.

To find out more about the realities clinicians face in leading population health work, we interviewed 10 senior clinicians from various clinical backgrounds (including primary care professionals, hospital physicians, allied health professionals and pharmacists) who had joined The King’s Fund Leadership for Population Health programme to explore their role in and potential contribution to population health. We wanted to know what helped and what hindered their efforts to incorporate this approach into their work. And where they encountered challenges, they also helped to identify a variety of ways to address them. We have set these out below along with some suggestions for action for clinicians, and system and organisational leaders.

Interest in and motivation for population health

We heard that the concept of population health is one that some clinicians already find helpful and compelling.

So it [population health] speaks to the fact that no matter where you are, what you do or where you work, there is an opportunity for everyone to be involved and I like that about it.
NHS education director

The Covid-19 pandemic further exposed the importance of population health by highlighting many aspects of the health inequalities that already existed within our society and how the wider determinants of health, such as poor housing, low income and discrimination, are some of the main drivers behind those inequalities. Our interviewees had read relevant reports and also seen first-hand the disproportionate effect of Covid-19 on certain groups of staff and wider communities. Many interviewees felt that there has been a post-pandemic shift in clinicians’ mindsets towards considering the wider factors affecting patients’ lives beyond their access to and use of health and care services, and a desire to reduce health inequalities and improve quality of life for people and communities through a population health approach.

And I think we actually understand the consequences of deprivation within communities because we've seen that in the death toll with Covid.
ICS chief clinical improvement officer

The people we spoke to saw that there is a pressing need for the health and care system in England to be more proactive, rather than simply reactive, when it comes to the population’s health – to prevent disease rather than focus on treating it – to ensure its sustainability. The Hewitt Review identifies prevention and population health management as one of five key workstreams in its independent review of ICSs. With the appropriate support and funding, this is an important opportunity for accelerating health and care transformation efforts. Below, we outline the themes interviewees highlighted as important for unlocking the power of clinicians to lead efforts for improving population health, including tackling health inequalities.

What can clinicians do?

Understanding what population health is

There is still a general lack of understanding among clinicians about what population health is and how it differs from the more familiar term ‘public health’. These definitions have been a topic of debate and exploration among national bodies, local government and health care professionals. This confusion can be further complicated by multiple other associated terms, such as ‘population health management’ (a data-driven tool or methodology that refers to ways of bringing together health-related data to identify a specific population that health and care systems may then prioritise for particular services). So, it is unsurprising that clinicians may struggle to understand the role of population health in the work they do.

What could help?

The King’s Fund has produced an explainer to clarify the distinction between these terms. Training to help clinicians understand population health and their role in contributing to it would be a great first step. This training should happen at a local, regional and national level. Most clinicians have some form of regular teaching and incorporating population health into these sessions would start to engage more clinicians in the approach and expand their awareness. A population health approach should be integrated within medical education. Increasing access for more clinicians to population health courses, conferences and events would further develop understanding of population health.

Knowing where to start

The King’s Fund’s vision for population health introduced a framework with four interconnecting foundation pillars of a population health system (see Figure). The clinicians we spoke to found having a framework was useful in breaking the broad concept of population health into achievable meaningful sections. Lived examples or personal experience were also seen as helpful ways to understand the key components of population health. For example, health care workers who are second-generation immigrants may have first-hand experience of supporting a family member through the health and care system and the issues that language barriers and cultural difference can have on accessing services.

I have been using that framework to educate other individuals that I work with. So, really importantly, I've raised awareness [of population health] with my colleagues and trainees.
Cardiology doctor.

What could help?

As laid out by The King’s Fund, awareness is the first step on the path to action and advocacy, both in terms of professionals’ interactions with individual patients and in advocating for the local community.

A more personal approach can help when it comes to raising awareness. It is important to appreciate that clinicians view population health with different lenses depending on their roles and backgrounds, and therefore are more likely to embrace any population health initiatives if they can relate to the proposed work on both a personal and professional level. Sharing experiences can help to raise awareness of population health work among colleagues: what has worked, what has not and what resources or support are available for them.

Developing relationships

Population health involves working across organisations and with people from a range of communities, professions and organisations. Clinicians we spoke to thought effective networking skills and meaningful partnerships were the key drivers to the success of their population health efforts. Clinicians need time to build these relationships with different stakeholders in a population health system (eg, health organisations, local government, communities, and the voluntary and community sector). In the health and care system, due to increasing workloads, time constraints and burn out, this can seem overwhelming, or a major hurdle particularly for the more junior clinicians.

I think there's a real issue with prioritisation. So everything is a priority. Everything is important. Urgent and emergency care systems that are toppling over and a really aggressive 30 per cent increase in elective recovery programme. And therefore the local data around population health sometimes feels a bit divorced and maybe that's what we need to be [prioritising].
Chief nurse

Interviewees also noted that such relationships can be repeatedly disrupted due to changes in leadership, personnel, policy and resources. However, with a clear goal in mind, partners are less likely to be distracted by emerging crises and side issues in relation to potential changes in political or organisational landscapes.

What could help?

Speaking to other clinicians who are already involved in population health work can create opportunities to learn from their experiences – both positive and negative. Formal and informal conversations to explore population health improvement ideas can also help. Talking to other stakeholders within a population health system, such as colleagues from local government, integrated care systems and the voluntary and community sector, can help clinicians to see things through a population health lens.

It was those informal relationships and not a formal hierarchy or governance… those informal relationships really helped, and still they’re helping and they’re just expanding. The relationships, that is the key bit.
GP

Working with colleagues across multiple agencies to develop a common vision and objectives with clear outcomes is important to forming strong multi-sectoral relationships. Clinicians often meet patients when they are presenting with specific medical concerns stemming from wider underlying health inequalities. Addressing the underlying health inequalities and wider determinants of health often requires professionals from other sectors, eg, a respiratory clinician may see a patient with severe asthma and recognise their housing situation is a contributing factor but they have a limited ability to directly address this. Communities and individuals within those communities are vital members of the population health ‘system’, and they should be active partners in conversations about approaches and solutions from the very beginning.

We're trying to work also with the community… to get participation from the people who actually use the services and we're trying to be quite holistic in what we want to achieve.
Paediatrician

Developing these multi-sector relationships can be challenging for those who are just starting out on their population health journeys. Cross-sector programmes, such as The King Fund’s Leadership for Population Health, can provide a forum for different partners to come together and share knowledge and learning.

At an organisational level, a clear population health narrative will provide a framework for clinicians looking to take a population health focus. As well as having a well-defined population health approach for themselves, organisations can support each other in highlighting their population health contributions. Senior leaders have an opportunity to showcase the importance of population health and ensure it remains on the agenda at times of competing interests, for example, population health plans should not be paused or stopped due to concurrent urgent care crises. The development of integrated care partnership and integrated care board strategies for population health may also provide a further structure to support clinicians in developing these relationships and implementing a population health approach. Some ICSs are appointing population health leads to spearhead this work and providing data and resources to allow clinicians to design effective care pathways.

Clinicians should reflect on their relationships with local communities to ensure patients and communities are truly valued as equals and are the focus of clinicians’ work. Care pathways must be co-designed with patients from the outset and continually reviewed to ensure they are still fit for purpose and remain relevant and important to the local community. This requires a fundamental shift in the way health and care is designed and delivered.

How do we shift the parity between hospital and community where people live?
Occupational therapist

What can national and regional leaders do?

Ensuring there is time and energy for population health work

Even with an understanding of and interest in population health, many of the clinicians we spoke to did not have population health responsibilities included in their formal job description. Many clinicians carry out work in population health on top of their ‘day job’ and an increasing clinical workload.

I think time is maybe one of the biggest challenges because of the pressures is, if it’s not in the job plan, how do you work on it? So I do a lot of this work outside of my normal nine to five hours because… it's just feeling also responsible for being part of the solution. So my way of responding to the Covid pandemic is not to go and tweet and not to make noise or to write letters to the government, but it's to actually run projects.
Community paediatrician

What could help?

Population health initiatives cannot rely solely on clinicians’ goodwill specially at a time of a health care workforce crisis. There is a need to prioritise the wellbeing of our clinical workforce – and to embody equality, diversity and inclusion in leadership approaches by prioritising staff health and wellbeing. Clinicians who are overstretched at work are at risk of burnout – which is a detrimental experience for them personally and would only further exacerbate the NHS workforce crisis

System leaders should review job plans and allow clinicians protected time for population health work. This might look like protected programme activity time for population health work, joint working with ICSs/local government, such as opportunities for fellowships or placements, or providing educational opportunities for further learning. This would ensure clinicians are renumerated for their work and can give the work the time it deserves.

Overcoming financial constraints

All the clinicians we spoke to recognised the financial pressures the NHS is facing, and acknowledged the implications for population health efforts. Current health spending is focused on acute services, with cuts being made to community-based and preventive care. The NHS is struggling to manage the elective backlog and is facing a worsening workforce crisis with large numbers of vacancies and several groups taking and/or planning strike action. Against this backdrop, clinicians have to prove the value of investing in population health and preventive care to commissioners and budget holders. Cost-effectiveness calculations for population health can be challenging, particularly given the time and labour involved in collecting good follow-up data.

What could help?

Budget holders and health care providers, from NHS England to ICSs and primary and secondary care services, should consider collecting data that is tailored to population-based outcomes and health determinant profiles. This would, in turn, help justify the redistribution of funding to improvement work aimed at population health and addressing health inequalities.

As well as focusing funds directly into population health and preventive medicine, all programmes and financial contracts within an organisation should be evaluated with a population health lens. For example, if prevention were treated as capital investment not revenue, returns could be looked at over a longer period. The Department of Health and Social Care could measure prevention spend consistently over time to ensure shared outcomes frameworks reflect drivers of population health, in this way ensuring systems are geared towards addressing them.

There’s a changing political landscape all the time and reorganisation in the health and social care sector is the norm really. So trying to have [a population health approach] that has legs to stand the test of time is quite difficult.
Psychiatrist

A cultural shift in financial planning around health care would enable the system to move from short-term budgeting based around political cycle towards long-term forecasting and preventive medicine, with appropriate spending on interventions that will best serve the communities, both in the short and long term.

Population health management (data and analysis)

Population health management is a data-driven tool that can help health and care staff to better plan and deliver care to achieve improved impact on the health of a population, and is being used across many ICSs and other health and care partnerships such as North Central London, Lancashire and South Cumbria and Hertfordshire and West Essex. We heard that using a population heath management approach helps clinicians identify areas of population health need, and acts as a measurement for preventive efforts. However, its accuracy does rely heavily on the availability of accurate data collection and clean data for meaningful interpretation.

Because, actually, I know that our systems are the very basic level. I mean we're struggling so hard to get data out of the system to even just be understood.
Paediatrician

What could help?

Sharing data between different sectors should be made easier, as the value of collaboration in data interpretation cannot be underestimated. For example, the NHS may hold health information about a patient, but have no data about their housing situation. Conversely, local councils may not hold data on hospital admission rates for people living in their area. Having this information available to clinicians will strengthen their ability to use a population health approach both for their individual patients and for their wider communities. Putting together data from both sources would generate a powerful interpretation on how and where population health improvement can happen. The Hewitt Review highlighted a need for a shift to investment in prevention as well as data-sharing.

Conclusion

Clinicians can play an important role in serving their local communities through adopting a population health approach. While there are logistical and financial barriers, with the right support and access to resources clinicians will be key partners in improving the overall health and wellbeing of local populations. Providing time and resources for clinicians to develop cross-sector relationships, exchange learning and develop ideas is key to success.