Integrated care has become a key focus of health service reform in England in recent years, as a response to fragmentation within the NHS and social care system. Yet efforts to integrate care services have rarely extended into a concern for the broader health of local populations and the impact of the wider determinants of health. This is a missed opportunity.
This paper aims to challenge those involved in integrated care and public health to ‘join up the dots’, seeing integrated care as part of a broader shift away from fragmentation towards an approach focused on improving population health. Using examples from organisations and systems in other countries that are making this shift, the authors argue that improving population health is not just the responsibility of health and social care services or of public health professionals – it requires co-ordinated efforts across population health systems.
International case studies
The paper looks at examples from different parts of the world where systems are emerging that are focusing on improving population health. Read about the case studies in more detail:
The international examples described in the paper share certain similarities in their approach.
At the macro level, they use a population-level lens to plan programmes and interventions across a range of different services and sectors. Key features include: population-level data (to understand need across populations and track health outcomes); population-based budgets (either real or virtual) to align financial incentives with improving population health; and involvement of a range of partners and services to deliver improvements.
At the meso level, they have developed different strategies for different population segments, according to needs and level of health risk. Key features include: population segmentation and risk stratification; strategies targeted at different population segments; and developing ‘systems within systems’ with relevant organisations, services and stakeholders.
At the micro level, they deliver various interventions (including housing support, education programmes, employment advice and smoking cessation services) to improve the health of individuals. Key features include: integrated health records to co-ordinate services; scaled-up primary care systems; close working across organisations and systems to offer a wide range of interventions; and close working with individuals to support and empower them to manage their own health.
Policy implications
In England, making the shift from integrated care to population health requires NHS organisations to work much more closely with local authorities, third sector organisations and the private sector, as well as patients and the public. It requires alignment at all levels, from central government to localities and neighbourhoods.
At a minimum, developing a population health systems perspective requires greater pooling of data and budgets; population segmentation; place-based leadership drawing on skills from different agencies and sectors based on a shared vision and strategy; shared goals based on analysis of local needs and evidence-based interventions; effective community engagement; and incentives to encourage joint working.
Integration only adds real value and encourages ownership when built up around the individual or community and their needs, not down from large Public Sector organisations. Assessments done by professionals leave the responsibility for resolve in the hands of the state, while person-centred support plans facilitated for the person starts from the person's perspective and their social/community network to help prevent 'emergency' situations where professionals are needed. In poorer countries Social Workers are seen more as those who encourage Community Development. In this country, Social Workers have become 'soft police', highly standardised & regulated, implementing state interventions actually leaving the population dependent on the state! (learned dependency on the state) We need to move from Welfare State to Welfare Society.
As a commissioner now working with providers this is very interesting and relevant. Many providers do not think about delivery, design or performance monitoring through a population lens. Providers need to think more like commissioners (and vice versa). In a good health system you can do this. In Salford, we have worked with Public Health to develop a universal/targeted integrated wellbeing service. We have used population health principles to inform design and delivery and have integrated support around the individual and communities needs and assets with some encouraging results for individuals and our target population. www.beingwellsalford.com
One of the fastest ways of shifting to a prevention paradigm i.e. making the NHS a true health service rather than a treatment service is to commission and structure health and social care as a single entity on a geographical basis ( preferably single organisation provision) such that both commissioners as well as providers (of health, social care and all other services) can focus on long term aims, prevention and more holistic and integrated services.
Interesting article. I myself have noticed how marginalised the voluntary sector feels. So often they fill gaps in health/social care which gets taken for granted though it could be recognised and incorporated into a cohesive local care strategy. A good example is psychotherapy with staff numbers running into thousands mostly independent or voluntary. A
significant area of their work is behavioural disorder or autism which rarely features as a coherent part of any medically / nurse led CAHMS Service.
Interesting article, but a pity it has omitted some of the interesting developments coming from health and social care commissioners in England who are effectively tendering contracts to provide health and in some cases social care services to whole populations. These developments hold the promise of aligning incentives across an otherwise unconnected group of providers to deliver better outcomes for the whole population.
I like the population approach it shows risk stratification and directly connects with the available means to deliver care. It is utopia to believe that we can live without this kind of calculation and be based only to a welfare society and voluntary services.
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significant area of their work is behavioural disorder or autism which rarely features as a coherent part of any medically / nurse led CAHMS Service.
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