Population approaches

What are population approaches?

Policy decisions around health too often focus on treating ill health, and the structure, organisation and funding of healthcare. Health services are important but are not what drives health; the conditions in which people are conceived, born, grow, live, work and age are the prime determinants of future health.

BMA 2022

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.

Kings Fund 2018

Population approaches look at the big picture in relation to the health and well-being of local communities. Through building on available data sets, and engaging with local people and professionals, they seek to develop a comprehensive understanding of the quality of life and life expectancy of different localities, population groups, and those with similar health conditions and/or challenging life experiences. These data-based insights are used to stratify the needs of populations to make decisions on how best deploy available resources and co-ordinate activity with partners from public services, local communities, voluntary organisations, and private business.

Risk stratification or segmentation tools can be used to categorise people according to different needs.

A major focus is addressing inequalities in people’s health and wellbeing by tackling underlying causal factors. This means that population approaches not only look to improve direct health and social services through embedding more holistic and preventative practices, but also influence the broader determinants of health such as healthy eating, financial stability, physical activity, safe housing, and access to education and employment.

  • Video transcript Open

    Population health management describes an approach to identifying and managing the health and care risks of the local population, segmenting the risks based on needs, and designing services and other interventions to best meet these needs. 

    Building a complete picture of local population needs involves combining data about:

    • health behaviours;
    • health status;
    • clinical care access,
    • use and quality of available services;
    • and social and economic factors.

    There are at least four levels of increasing need that are identified through population approaches:

    • People who are generally well, and who will benefit from prevention interventions to maintain health and wellbeing
    • People who are currently well but who can be identified as being at risk of developing long-term conditions
    • People with long-term conditions who will benefit from early interventions and secondary prevention services to stop or delay progression
    • Older people with complex needs or frailty who require a multifaceted arrangement of integrated, holistic, personalised, coordinated care with a high degree of continuity.

    Population health management requires:

    • good and standardised local data
    • effective information management systems
    • and analytic capability for segmenting population groups by different needs.

    Delivering the benefits of population health management requires a delivery system where local partnerships are in place and working well, and where services are aligned towards the local vision for integrated care.

    The emerging evidence suggests that population health management and risk stratification contribute to:

    • A reduction in the demand for hospital care, including emergency admission
    • An increase in patient satisfaction
    • And an improvement in overall health outcomes.

    In addition, population approaches ensure local resources can be efficiently targeted, supporting people at higher risk to maintain independence, and preventing or mitigating the risk of their conditions worsening.

    Population approaches are an important enabling factor in achieving the ultimate goal of integrated care: the improvement of people’s care outcomes.

Explore population approach

Relationship to integrated care

Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate. Combining integration of care with the population health approach can be supported by a set of cohesive strategies and interventions aimed at preventing disease, addressing social determinants of health and improving health equity at both population-and individual-level.

International Journal of Integrated Care 2019

Services are able to achieve significant outcomes due to their direct impact with individuals - they must, however, be delivered with system, scale and in a sustainable way, and calibrated to deliver further and faster to the most disadvantaged communities.

Public Health England 2019

Population health management can assist integrated care through identifying the populations who will benefit most from person-centred and co-ordinated care due to the complexities of their health needs and/or challenging social circumstances. Integrated care is often intensive to embed, and it is therefore vital that staff and other resources are invested in those people and communities for whom it will add the most benefit. This includes reducing social and health inequalities and providing more preventative care which reduces the demands on expensive services such as hospital and long-term residential and nursing care. The data insights provided by population health management are further helpful in monitoring the impacts of integrated care programmes and reviewing how they can be implemented better.

Factors associated with success

Health and care systems are connecting people, place and power structures to establish partnerships that are sharing power and decision-making – creating healthier, resilient and empowered communities.

NHS Confederation 2022

Analysis should cover demographic patterns, the effects of health and wider inequalities, and the impact of local levels of deprivation as well as admissions, activity, service and provider data and trends. Triangulate quantitative data with qualitative data, such as people’s lived experience, care teams’ views, and feedback from staff, local Healthwatch and communities.

Local Government Association 2022

At the heart of population management is the quality of the data and the analytical processes which enable its interpretation. These data sources will not be help by any one organisation and will require accessing systems outside of health and social care such as the census or employment data. Bringing these data sets together is a complex process which will require joint teams of analysts with the right skills and sufficient capacity. Alongside formal data sets, population health management must engage with local communities and frontline professionals. They can provide further detail on health and wellbeing, the factors which result in better or worse health, and potential solutions to improve the health of a population. These insights should also influence how needs are segmented and resources invested.

Having identified what approaches should be prioritised and for which populations, it is then vital for local partners to collaborate on the implementation of associated programmes and practices. This requires systems-leadership in which the needs of local populations are priorities over organisational interests and robust but flexible governance to provide transparency over what plans are being made and shared accountability for their success. Commissioning and contracting arrangements are key enablers through removing financial incentives which reward single agency actions and instead look to fund joined up working between professionals and services.

Engagement with local communities and the voluntary organisations who represent and support them is key. Improving the health of a population will not only involve statutory health and social care services but also the informal resources and networks of communities. This will include helping them to recognise the assets which they currently hold and supporting them to build on these through providing relevant expertise and resources. This includes ensuring that relevant resources are available to all local people who could benefit and especially those who are often excluded from such supports.

Evidence of impact

“The most promising approach to improving population health is to continue to focus on the health and well-being of children. This is true, not only for the children themselves, but to weaken the intergenerational transmission of deprivation.

Institute for Fiscal Studies 2022

We identify evidence of a positive association between neighbourhood community life and several population health outcomes. Future research should define and conceptualize neighbourhood community life factors and health indicators to improve the comparison between studies and the process of evidence synthesis. This will also enable policy makers to take appropriate decisions.

Health & Place 2020

Population health approaches have been shown by some studies to positively benefit individual wellbeing and longevity of life, to reduce health inequalities, and to contribute to diversion from more expensive resources such as hospitals. However, it must be noted that other research studies suggest that they have had minimal measurable impact and that in the short term at least, approaches which uncover unrecognised needs and enable people to access support previously denied to them, can result in greater use of such services. This should still be seen as positive though if it leads to often marginalised groups receiving support which will ultimately improve their health and wellbeing.