Developing primary care leadership for population health and equity: how to begin

Lancashire and South Cumbria Integrated Care System (ICS), like many ICSs across England, wants to improve population health and tackle inequalities.

Having articulated this aspiration and set up a Population Health and Health Equity Academy in May 2022, in partnership with The King’s Fund, it has taken the first steps to making this a reality by developing its primary care workforce. In this long read, we outline key aspects of the approach taken in Lancashire and South Cumbria, and share reflections that may help others undertaking a similar journey.

The need for population health approach

This quote captures the overwhelming response among the primary care clinicians in Lancashire and South Cumbria we spoke to about why they wanted to spend time thinking about how to improve population health and tackle health inequalities, despite the widely publicised challenges facing primary care. It’s obvious, they said, population health and tackling health inequalities is key to a healthier, more sustainable, and fairer future.

Like these primary care leaders, many people are recognising that the challenges facing the health and care system in England signal the need for a fundamental re-think in how services are designed, delivered and organised to ensure the best possible health and care for all. The need for this is outlined in the Fuller stocktake report, The Hewitt Review, and other local and national policies and priorities. To create more effective and sustainable health and care systems, there needs to be much greater focus on preventing ill health, on valuing people (whether staff or communities) by understanding what matters to them and seeing them as the experts in their own lives, and on seeing health and care professionals as enablers rather than doers. For services to truly meet people’s needs, there needs to be a shift, not just in people’s thinking, but also in the distribution of power from national bodies and statutory organisations to people in communities and teams working to support them (for example, in voluntary, community and social enterprise (VCSE) organisations; public health, social care and mental health services; or via social prescribing).

Population health is an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population. It incorporates facets and enables the shifts mentioned above. People working in health and care increasingly voice the wish to improve population health and tackle inequalities. However, this work is less developed in practice. Improving health and providing high-quality care that meets people’s needs will require a focus on advancing this agenda.

Working across Lancashire and South Cumbria

As a system, Lancashire and South Cumbria has been working to build collaboration for population health, with a focus on improving the lives of people living in poverty. As an organisation, The King’s Fund has been working to support individuals and organisations to develop their knowledge, skills and approaches for population health. In autumn 2022, The King’s Fund and Lancashire and South Cumbria Population Health and Health Equity team joined together to embark on a year-long journey to develop primary care leadership for population health and equity across the region. The aim was to support the newly formed Lancashire and South Cumbria Population Health and Health Equity Academy to start to develop its workforce for improving population health and tackling health inequalities.

Implementing a new approach

We started our work together by agreeing its aims: to curate a programme of support for 44 primary care clinicians in the region to develop as a leadership community, to build skills for population health including for tackling health inequalities, and to lead improvements in practice.

We hoped that at the end of the year, the primary care leaders would keep working together, through the academy, to keep the work on population health and tackling health inequalities going. In addition, these leaders would also become a trained ‘resource’ and work with the local teams to cascade the ideas and approach to others to maximise its impact and help make it sustainable. In the future, the Population Health Team also hopes to use elements of the work to build a wider-reaching development offer to support the whole system including sectors beyond primary care.

We then finessed an approach built on the best of both our experiences; a process we realised would be the key to its success. The King’s Fund brought expertise and connections. During the year, partners across the local system – including the four directors of public health across Lancashire and South Cumbria – contributed to the work. There were also contributions from Professor Bola Owolabi, Director of Health Inequalities at NHS England, and other NHS England leaders, and teams and individuals The King’s Fund has worked with in the past, eg, West Yorkshire Health and Care Partnership or Oldham locality care organisation in Greater Manchester. The Lancashire and South Cumbria Population Health Team brought expertise on its local geography and communities, learning from work it had already done in this area, local connections and also an understanding of the realities local services and people were facing plus the power to influence this directly.

We agreed the following seven facets to our approach.

• We purposefully built a programme to model the behaviours and approach that we wanted to encourage across the system.

• We worked with participants on the programme to co-create the design.

• We sought to create conditions to enable the participants to feel safe, supported, connected to each other and to us, and valued by the system.

• We focused on assets already in existence both locally and around England – eg, examples of good practice in the local area, the skills and interests of participants, previous experiences, and insights from other sites.

• We stayed live to issues and responded in ‘real time’ using what we were hearing from the cohort to keep tailoring the programme, even if it took more effort to do this.

• We recognised their pressured roles and so used principles of servant leadership¹  to make it as easy as possible for the participants to lead change in practice.

In practice of this principle, our approach included:

• recognising the importance of protecting time for people to attend – eg, backfill arrangements were made so that people attending could focus on programme content during that time rather than daily clinical duties

• providing resource needed – eg, access to local data teams and a linked dataset, creating channels of regular communication with local leadership, building support networks through action learning groups, and providing funding where possible.

• We used a practical transformation-focused approach helping those we were working with to explore their population demographics and needs, their clinical work and approach for population health, the local system set up and priorities, and the wider landscape.

Early signs of progress

The cohort of primary care leaders on the programme have begun to develop an understanding of themselves as not only leaders in an organisation, but leaders across a system and to realise the need to shift power from statutory organisations such as the NHS to people working for and in communities, especially under-served groups. They are learning a range of skills including the art of hosting, community development, and having conversations for change, as well as understanding data for population health, prioritising needs, influencing skills, and initiatives to tackle health inequalities. They are learning the need to go into their communities to have different conversations and understand what really matters to people. They are making change happen in practice – aided by the data and evidence available. As a result of this work, 39 initiatives to improve the lives of people across Lancashire and South Cumbria have begun.

We are already hearing about improved care for women who have experienced domestic violence, enhanced health checks for people at risk of homelessness, improved connections with foodbanks, and development of population health skills in the next generation of primary care clinicians resulting from this work. The group has become a community of practice, supporting each other, sharing learning, growing initiatives, and generating momentum for the longer term.

Key reflections

The wish to improve population health and tackle health inequalities is easy to articulate, but harder to do in practice. It requires a new skillset that has not always been available as part of health and care training. But with the right development support, progress is possible and critical to bring about meaningful change. In England, we increasingly have systems (eg, integrated care systems) in place to work more in this way but efforts for population health practice are in their infancy and require more developmental focus.

For anyone wanting to develop primary care leadership for populations health, we’d offer the following reflections.

• Start well – understand what is required in practice to create change (eg, system buy-in, resourcing, support teams) and put that in place, to the best of your abilities, before starting.

• Place community at the heart – absolutely and without doubt this work cannot be done without a focus on community from the start and at its very core. Community needs to be front and centre of efforts – involving community leaders, lived experience members, hosting communities and adopting a community-centred approach.

• Create space – many leaders in primary care feel overstretched and possibly close to burnout. Enable them to see the work they are doing together as a gift that gives them the headspace to reimagine their work and rediscover joy.

• Be realistic – in the first year, give participants time to learn, to work with new concepts, to build relationships with their wider team and local community. Work like this to improve population health and tackle inequalities is likely to be new to them.

• Work with partners – this work is not possible alone or in an office but requires many conversations and willingness to really listen. Create the time and space to do this.

• Understand – that the step from clinical leader to systems leader for population health can be a daunting one. This is OK. As with any development step, it is a process of growth, learning and unlearning, refining, and flourishing.

• Resource this properly – especially in the time of such challenge, understand that this work will require resource, not just in funding (though this is important) but also in terms of commitment as leaders to truly invest themselves into this with a genuine willingness to journey with others as equals for improvement.

Improving population health and tackling health inequalities is key to the future of health and care. It is right that these issues are a priority for the health and care system in England. To move from aspiration to meaningful reality, health and care leaders need to focus on their approach on delivering this in practice. This will require work with staff, communities and partners over time, often working in a different way than many health and care staff are used to, to deliver on long-term improvements to people’s lives. Much is possible – but it will take courage to accept that much may need to change. We hope that these insights help others who are ready to start delivering change in practice. We will share further learning from this work later in the year.