What does improving population health really mean?

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The King’s Fund’s vision for population health has put the spotlight on the importance of improving population health. But what does improving population health actually mean? And who is responsible for what?

What is population health?

Towards the end of the last century, health improvement strategies (such as the World Health Organization’s seminal Health for all by the year 2000) tended to use phrases like ‘protecting and promoting health’. In more recent years, the vocabulary has broadened out to place an emphasis on wellbeing as well as health. Today the phrase ‘population health’ is used to convey a way of conceiving health that is wider still. It includes the whole range of determinants of health and wellbeing – many of which, such as town planning or education, are quite separate from health services.

Referring to ‘population health’ rather than the more traditional phrase ‘public health’ also helps avoid any perception that this is only the responsibility of public health professionals. Population health is about creating a collective sense of responsibility across many organisations and individuals, in addition to public health specialists.

Confusingly, the phrase ‘population health management’ is also widely used, with a specific meaning that is narrower in focus than population health. Population health management refers to ways of bringing together health-related data to identify a specific population that health services may then prioritise. For example, data may be used to identify groups of people who are frequent users of accident and emergency departments. This way of using data is also sometimes called ‘population segmentation’. 

Throughout all these changes in vocabulary, one element has consistently been essential: an emphasis on reducing inequalities in health, as well as improving health overall. This continues to be important in population health.

There are several definitions of population health in use. The King’s Fund defines it as:

An approach aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people within and across a defined local, regional or national population, while reducing health inequalities. It includes action to reduce the occurrence of ill health, action to deliver appropriate health and care services and action on the wider determinants of health. It requires working with communities and partner agencies.
A vision for population health, page 18

What is involved in improving population health?

Our health is shaped by a range of factors, as set out in Figure 1. It is hard to be precise about how much each of these factors contributes to our health, but the evidence is convincing that the wider determinants of health in the outer ring have the most impact, followed by our lifestyles and health behaviours, and then the health and care system. There is also now greater recognition of the importance of the communities we live and work in, and the social networks we belong to.

Figure 1 - What affects our health?

Figure 1: social determinants of health
Dahlgren G, Whitehead M (1993). Tackling inequalities in health: what can we learn from what has been tried? Working paper prepared for The King’s Fund International Seminar on Tackling Inequalities in Health, September 1993, Ditchley Park, Oxfordshire. London, The King’s Fund, accessible in: Dahlgren G, Whitehead M. (2007) European strategies for tackling social inequities in health: Levelling up Part 2. Copenhagen: WHO Regional office for Europe: http://www.euro.who.int/__data/assets/pdf_file/0018/103824/E89384.pdf

The King’s Fund definition of population health leads to a focus on actions in four broad areas, illustrated in Figure 2. These are the four pillars of population health.

Figure 2 - Four pillars of population health

Four pillars of population health

Improving population health requires action on all four of the pillars and, crucially, the interfaces and overlaps between them. 

Understanding the interfaces and overlaps between the pillars is essential. For example, housing is well-known to have a powerful impact on health. Healthy New Towns are an example of how an understanding of the overlap between housing, lifestyles and behaviours can lead to housing developments that are designed to encourage physical activity, healthy eating and social interaction. Similarly, sugary drinks have been associated with childhood obesity. Understanding how lifestyle choices – in this case, the choice of drinks – overlap with wider determinants of health – in this case, the affordability of less sugary drinks – helped the government design a soft drinks industry levy (often referred to as a ‘sugar tax’) which has led to a reduction in the sugar content of many soft drinks.

The King’s Fund describes this way of thinking about population health as a ‘population health system’ in which the four pillars are inter-connected and action is co-ordinated across them rather than within each in isolation. This is illustrated in Figure 3.
 

Figure 3 - A population health system

Figure 2: a population health system

How should progress be made on population health?

The first step is to recognise that improving population health is an urgent priority. Over the last 100 years we have grown used to people living for longer and longer, but in recent years life expectancy has stopped increasing in England and in some areas has been reducing. Health inequalities are widening and England lags behind comparable nations of many key measures of health outcomes. Demand on NHS services has been increasing, but much of that extra demand is for treatment of conditions which are preventable. At heart, the NHS remains a treatment service for people when they become ill.

Importantly, action needs to be taken at three levels:

  • national – eg, government, arm’s length bodies, membership organisations
  • regional – eg, devolution areas, sustainability and transformation partnerships, integrated care systems
  • local – eg, individual cities, towns and neighbourhoods.

What needs to happen at the national level to improve population health?

In addition to The King’s Fund’s A vision for population health, national bodies in England have started to signal a will to prioritise population health. Notably:

  • the Department of Health and Social Care has issued a new strategy Prevention is better than cure which identifies population health as a priority. It includes a commitment for a Green Paper (consultation document) on the specific steps which the government will take to translate that priority into action.
  • NHS England has been increasingly vocal in its aim of reducing health inequalities, and has identified prevention as one of the key themes in the long-term plan for the NHS. The plan includes a welcome emphasis on population health which will be a key focus for integrated care systems as they are rolled out across the country.

National leadership for population health is essential but it needs to be co-ordinated across government. There are different options for how to do so. The last Labour government’s policies set targets for reducing health inequalities which went across government, with accountability through a cabinet sub-committee. The Welsh government has set statutory targets for improving population health, which go beyond the health sector and include requirements for translating them to the local level and for monitoring. The same legislation also set a requirement for health impact assessment of all policies.

At the moment, efforts to improve population health lack a common set of high-level goals and robust accountability for improvement. Although progress is being made in many local areas, responsibility for this is fragmented and unclear, rather than joined up as a concerted, nationwide approach. Improving accountability for contributing to national, high level goals is a priority. The King’s Fund has highlighted the potentially important role that Public Health England could have in monitoring and reporting on progress across the health and care system and beyond, if its role were more than only advisory.

At present, funding is skewed towards health services providing treatment, such as hospitals. There is good evidence that investment in prevention is cost-effective, but the benefits of that investment may not be realised until several years later and, in the meantime, hospitals need the funding now in order to meet people’s immediate needs. Breaking out of this cycle is fundamental to making progress. One of the challenges for national leaders is to lead a debate about how best to re-balance spending across the four pillars of population health.
 

What needs to happen at a regional level to improve population health?

Devolution areas and regional plans made by sustainability and transformation partnerships (STPs) or integrated care systems (ICSs) – which often include several local authorities and clinical commissioning groups – have great potential to improve population health.

Greater Manchester, for example, has a population health plan which is fully integrated into broader plans for economic development and growth and for public service reform. It is rooted in a set of principles and values which reflect the overall approach to devolution, and it sets out ambitious plans and programmes.

STPs and ICSs are using 2019/20 as a ‘foundation year’ to build up system-wide implementation plans for first five years of the NHS long-term plan, presenting a key opportunity to strengthen their focus on population health:

Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This will typically involve a single CCG for each ICS area. CCGs will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and long-term plan implementation.
The NHS long-term plan, page 29

It is implicit within this that although ICSs are being established through the NHS long-term plan, if they are to have impact on population health, they must not behave as just NHS bodies. At the regional level, a priority is to build on the cross-sector partnership approach that many STPs have started to establish.
 

What does a population health approach look like at a local level?

There is no single blueprint for a local population health approach: each place will need to work out what approach and – importantly – what arrangements for leadership and accountability will work best for their context. The four pillars of population health provide a framework that can be used for reviewing achievements and gaps, to inform the development of local plans and approaches.

The examples below show the different approaches taken by different local areas. 

  • Bristol is developing its approach to population health by building on an existing commitment to be a ‘Marmot city’, adopting the approaches advocated by Professor Sir Michael Marmot for improving health and reducing health inequality. The Marmot city infrastructure is the basis for creating partnerships between city planning and development, public health, the local NHS, the local university, the police and others.
  • Devon is using its STP as the framework for improving population health. For example, NHS commissioners and local authorities have jointly established wellbeing hubs.
  • The County Durham Partnership positions the health and wellbeing board as the vehicle for improving population health by bringing together economic development, services for children and families, health improvement, community safety and the environment. There is notable engagement of councillors and NHS chief executives.
  • Cherwell District Council is leading the Bicester Healthy New Town Initiative – a new development of 13,000 homes within the Bicester area – to bring together 20 partner organisations to ensure that the development actively promotes and improves residents’ health.

Local politicians – councillors and mayors – have an essential role in bringing different organisations and departments together to work as effective partnerships, and in ensuring a focus on what the local community needs rather than a narrow view of organisational accountability. The King’s Fund’s report on the role of cities in improving population health describes this in more detail. Involving local people and using their insight to draw up plans for improving health are key to population health approaches. The Surrey Heartlands Health and Care Partnership demonstrates a range of methods for engaging people at scale including a citizen’s panel, monthly online surveys, citizen ambassadors and rigorous use of focus groups and deliberative research methods.
 

Conclusion

Right now, a number of policy developments are causing population health to have an increasingly high profile. Some of these – such as the NHS long-term plan – are specific to the NHS, although population health is about far more than just NHS services. It is clear that a significant groundswell is building up, creating opportunities for progress.

Various secretaries of state for health have prioritised prevention when they first assumed office, only for that initial enthusiasm to evaporate over time. There is also a history of short-term thinking, resulting in prevention budgets being among the first to be cut at times of financial pressure. The key issue now is to ensure that the various commitments that have been made to improving population health go beyond rhetoric, to sustained effort at national, regional and local levels.

Comments

Deo Ekwamu

Position
TB/HIV Technical officer,
Organisation
Taso uganda limited
Comment date
06 October 2018

Looking forward to strengthening health system in my locality

Marcus Grant

Position
Director,
Organisation
Environmental Stewardship for Health
Comment date
20 February 2019

Population health is well defined in this document. However much of what the government, local and national, can influence in terms of improving it lies outside the NHS and even outside service delivery. Many sources I read are now rounding in on approx. 25% of the determinants of health being the spatial and physical environments and settings for life. To reduce the burden of preventable disease in the population, and hence its impact on NHS resources, we need to factor health into broad non-health policy areas. I would start with planning, urban policy (what elements we have), transport and housing. Then spread to energy, food systems, biodiversity and representation. Finishing off with population and planetary health in economic policy - as an input and an outcome. It's called Health in All Policies - and it will save the NHS a shed load - whilst supporting a healthier and more equitable population. Let's will leave the opponents to such an approach to state their own objectives . . .

Kenye Karemo

Position
Deputy to Chief Nurse,
Comment date
03 April 2019

Thank you for sharing your thoughts on this. Having spent most of my career in the acute sector, I found your comment very useful and agree with 'Health in All Policies' approach.

Ken Thompson

Position
Psychiatrist,
Organisation
Pennsylvania Psychiatroc Leadership Council
Comment date
06 April 2019

Lovely document that I think gets us almost all the way there. The piece that’s missing is something that makes the four pillars dynamic, that moves them in time and place. Perhaps the thought is that this dynamism is in the “wider determinants of health” but the word determinant is to concrete a word to capture any dynamism or any process. And it is too far away.
I would suggest a fifth pillar of “politics”-the relationships between people that determine how we act together.
How might we fruitfully talk about the politics of population health? Is the absence of the word or it’s synonyms a political act itself, trying to make population health more about reason than power?

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