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The transition to integrated care

Why population health management is critical to the future sustainability of health and social care

The growing demand for health and care, rising patient expectations and increasing costs in the face of substantial budget constraints call for innovative solutions.

There is a growing consensus that if healthcare is to be sustainable, there is a need for a fundamental shift from treatment of ill health, when it occurs, to prevention. This week we launched our report The transition to integrated care: population health management in England, with findings derived from extensive literature reviews and our experience working with health economies internationally. It highlights key challenges and potential solutions that, if adopted at scale, could deliver a more cost-effective approach to improving the health and wellbeing of a population.

The impetus for PHM

Over the past few decades most health systems have seen impressive improvements in health outcomes due, in part, to, scientific and technological advances and a better understanding of how our behaviours affect our life expectancy.

However, today, for many people a longer life means living longer with multiple chronic conditions. Furthermore, while life expectancy continues to improve for the most affluent ten per cent of the population, it has either stalled or fallen for the most deprived ten per cent. At the same time, the costs of providing care are escalating with many provider organisations facing serious financial challenges, and social care in crisis.



Critical Success Factors:


  1. Improved shared technology and Infastructure
  2. Leadership maturity and good governance
  3. Having a shared vision, mission and understanding of the journey
  4. Robust monitoring, advanced analytics and insight processes
  5. Focused population targetting and segmentation
  6. Delivery of primary care at scale
  7. New approaches to delivery and workflow
  8. Aligned incentives across the system
  9. Population engagement and patient activation
The building blocks and critical success factors for PHM

Historically, a lack of robust patient data that provides a holistic and longitudinal view of all patients has hindered the adoption of a more integrated approach to population health. Our report identifies four key building blocks for PHM: Infrastructure, Insight, Interventions and Impacts and nine critical success factors which we see as key requirements for achieving PHM


The need for a suitable governance, leadership and technology infrastructure is essential for PHM to succeed. Indeed, a fundamental requirement for PHM is a connected IT infrastructure, and adoption of a shared, interoperable, electronic health record, to enable the collection, analysis and sharing of data among care providers. A robust Information Governance framework is also needed, including a citizen opt-out standard, and common interoperability, data and cyber standards. The establishment of five Local Health and Care Record Exemplars (LHCREs) to improve care co-ordination and provide a foundation for health analytics and PHM is an important step forward and should also help improve patient engagement and activation. Gaining the necessary trust in the appropriate sharing of patient data is a fundamental pre-requisite, requiring both clinician and patient engagement.


Advanced analytics and actuarial and informatics capabilities are key to designing effective, robust risk stratification methodologies, and for monitoring the health of the population over time. They also support demand management and capacity planning and enable constructive decision-making in response to population need. In the future, machine learning and cognitive analytics, together with risk stratification analytics and patient profiling, will provide additional insights and propel the implementation of PHM to new levels.

Interventions and Impacts

PHM requires changes to workflows to optimise clinical pathways and enable more cost-effective interventions in community settings. It requires proactive clinical involvement in the development of new care models to change ways of working. Importantly, as recognised in the LTP, PHM is contingent on strengthening primary care and delivering primary care at scale. PHM involves supporting patients to become more self-sufficient in managing and contributing to decisions about their care. Enablers include the adoption of digital and remote monitoring technologies and improving the health literature of patients. Enhanced evidence-based care management strategies and robust analytics are needed to measure the impact of interventions and outcomes for patients.


Implementing a PHM approach and moving the mind-set from reactive care to a model of proactive care for the population’s health is a huge challenge. The need for a change in mind-set and deployment of appropriate financial incentives and performance metrics shouldn’t be under-estimated. It also requires ‘smart’ investment in technology and for staff with new skills and talent. The solutions and enablers discussed in our report provide a framework and set of tools for STPs and ICSs to use in the design and implementation of PHM programmes. For more information read the full report.

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