What does improving population health really mean?

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Everybody in NHS policy seems to be talking about population health. New care models are being developed to improve population health. Sustainability and transformation plans (STPs) – the local plans for redesigning NHS and social care services – will, we are told, develop into partnerships to improve population health. And health care leaders in other countries, such as the United States, are also using the language of population health to define the aims of their health systems. But what does improving population health really mean? And what does it mean for the NHS?

Defining population health

People often mean different things when they talk about population health. Put simply, population health means the health outcomes of a defined group of people, as well as the distribution of health outcomes within the group. This means that health equity – the avoidable differences in health between different parts of the population – is a core part of understanding population health.

The health of a population is influenced by a wide range of factors and the interactions between them. They include the local environment – such as the conditions in which people live and work; social and economic factors – like education, income and employment; lifestyles – including what people eat and drink, whether they smoke, and how much physical activity they do; and access to health care and other public and private services. Age, sex and genes make a difference to health too, as well as social networks and the wider society in which people live (see Figure).

While health care services play an important role in keeping people healthy – particularly when they become ill – estimates suggest that wider social, economic and environmental factors play a greater role. Failure to address these non-medical factors can increase use of health services. On the flipside, investment in services to address the wider influences on health can, in some cases, reduce the burden on the NHS and provide returns on investment to society.

It is important to note, however, that investing in preventing ill-health is fundamentally about improving people’s lives rather than producing financial savings or reducing health care demand. In fact, successful prevention that means people live longer can lead to greater care needs in the long term.

Other terms, like population health management or population health care, are sometimes used interchangeably with population health. While the meanings of these terms aren’t fixed, they are typically used to refer to a narrower definition of population health than the one we have described above – focusing more heavily on medical services and particular groups of patients. Another closely related term is public health, which refers to the organised efforts of society to promote and protect people’s health and wellbeing, and to prevent ill-health.

Improving population health

Improving population health is not a simple task. The complex range of influences on health means that many different interventions and approaches are needed. This ranges from decisions about taxation, public spending and legislation at a national level, all the way down to the actions of individuals and the support they give to each other in their communities.

For the NHS, this means that improving population health depends on collective action with different services, sectors, and community groups – including the ‘assets’ found in local communities (like people’s time and skills, social networks and physical spaces like schools). Homerton University Hospital, for example, works with Positively UK, a charity, to provide peer support to people living with HIV. People are offered one-to-one support, group sessions and workshops with other people living with HIV in clinics across London. This has been associated with improvements in people’s mental health and emotional wellbeing, and reductions in social isolation.

Collaboration with local government is particularly important, given local government’s responsibility for public health spending and a wider range of services that influence people’s health. Priority areas for public health spending include giving every child the best start in life, helping people find good jobs and stay in work, and ensuring that people live in warm and safe homes.

The NHS also has a direct role in identifying people’s health needs and intervening early to address them. Data about people’s health can be used to identify groups of the population that would benefit from different types of support (an approach sometimes called population segmentation). Some population groups – such as people with long-term conditions, like heart disease or diabetes – require more intensive support than others to stay healthy and maintain independence.

In Somerset, for example, a new model of care is being developed for people with three or more long-term conditions. A single care plan is developed with people and their families based on their individual needs and preferences, health and care services are co-ordinated to meet these needs, and health coaches offer a combination of practical and emotional support to help people manage their conditions.

As well as providing relevant medical care, the NHS should also connect people with non-medical services – such as housing or employment advice – to address their social needs. GPs in Derbyshire, for example, work with the Citizens Advice Bureau to offer advice on benefits, employment, immigration and many other issues in primary care. This is sometimes called social prescribing.

Improving population health also means developing targeted approaches to improving health equity. Within the NHS, this includes action to reduce inequalities in access, quality and outcomes of care (and monitoring the results). Interventions by the NHS to encourage healthy behaviours must also take into account the role of social context in shaping people’s behaviour. People from more deprived backgrounds, for example, are more likely to engage in unhealthy behaviours. The NHS could also do more to tackle poverty through its role as an employer and in its spending decisions.

Where next?

The NHS has an important role to play in improving population health. But the complex range of influences on our health means that efforts to improve it face the ‘problem of many hands’, where no single organisation can be held responsible for the overall health of the population.

The NHS must therefore work with local government and other partners to develop more co-ordinated approaches to improving population health. At a local level, this should involve developing common aims for improving health, defining how these goals will be measured, and sharing resources to achieve them. It may also involve developing more systematic ways for NHS staff to identify people’s non-medical needs and work with others in the community to address them. STPs offer an important opportunity for the NHS and its partners to work together to achieve this.

But NHS and local government leaders can only do so much. A major factor outside their control is the political decisions made by government – for example, on welfare spending or housing policy –which have a major impact on people’s health. Short-sighted cuts to local government and public health budgets at a national level will make ambitions to improve population health harder to achieve.

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