Population Health Systems Kingsfund Feb15

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Populationhealth systemsGoing beyond integrated care

Authors

Hugh AlderwickChris HamDavid Buck

February 2015


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Population health systems

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Contents 1

Contents

Summary 2

From integrated care to population health 3

Integrated care 3

Population health 4

Joining up the dots 6

Examples o emerging population health systems 11

Kaiser Permanente, United States 11

Nuka System of Care, Alaska 14

Gesundes Kinzigtal, Germany 15

Counties Manukau, New Zealand 17

Jönköping County Council, Sweden 19

Summary of these approaches 20

Implications or England 23

Where next? 27

Re erences 29

About the authors and acknowledgements 3 6

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Summary 2


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1 SummaryIntegrated care has become a central part o the language o health service re ormin England in recent years due to the challenges posed by an ageing populationand the changing burden o disease. Policy initiatives introduced by the coalitiongovernment have sought to accelerate integration o services both within the NHSand between NHS and social care, and some areas are making progress in co-ordinating care or older people and those with complex needs.

While this shif marks progress rom the ragmentation that has come tocharacterise the NHS and social care system, these efforts have not typicallyextended into a concern or the broader health o local populations and the impacto the wider determinants o health.

Just as with integrated care, there is a long history o public health policy initiatives

in England. Yet the paths o integrated care and public health have rarely crossed.

Te central purpose o this paper is to challenge those involved in integrated careand public health to ‘join up the dots’. Tis challenge recognises that populationhealth is affected by a wide range o inuences across society and withincommunities. Improving population health is not just the responsibility o healthand social care services, or o public health pro essionals. Instead, we argue that itrequires co-ordinated efforts across population health systems.

Tis means thinking o integrated care as part o a broader shif away romragmentation and heading towards population health. Making this shif will requireaction and alignment across a number o different levels, rom central governmentand national bodies to local communities and individuals.

Tere are a small number o examples rom other countries where organisationsand systems have sought to go beyond simply integrating care services to ocus onimproving the health o the populations they serve. Tese examples provide lessons

or us in England as the development o integrated care continues.


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2 From integrated careto population health

Integrated care

Tere is a long history o policy initiatives in England designed to promoteintegrated care, dating back at least to the 1960s. Most recently, amendments to theHealth and Social Care Bill ( ollowing the unprecedented ‘listening exercise’) createdlegal duties to promote integrated care, a programme o integrated care pioneershas been established, and the Better Care Fund has been set up to pool some o the

unding or health and social care. Health and wellbeing boards were created bythe Health and Social Care Act 2012 to provide a local orum or the developmento integrated care, and some areas are planning to go much urther than required

under national policy initiatives. Te Care Act 2014 also includes a duty or localauthorities to promote integrated working.

Tere are very clear reasons why integrated care has attracted growing attentionand support. Population ageing and the changing burden o disease (especiallythe increased prevalence o long-term conditions) require care to be co-ordinatedwithin the NHS and between health and social care. Nowhere is this moreimportant than in the case o people with multiple long-term conditions (multi-morbidity), many o whom are in regular contact with several health and social carepro essionals as well as receiving care rom amilies, riends and volunteers. Unlessthese pro essionals work together in responding to people’s needs, and treat theperson as a whole rather than the presenting medical condition, there is a risk thatcare will be ragmented and deliver poor outcomes.

Te experience o organisations and systems that have achieved high levelso integration illustrates the benets o this way o working or patients andpopulations ( Curry and Ham 2010 ). A well-known example in England is orbay,where health and social care services have been working together in the community

or more than a decade, delivering particular benets or older people ( Thistlethwaite2011 ). Many other areas o England have ollowed orbay’s example by creating

http://www.kingsfund.org.uk/publications/clinical-and-service-integrationhttp://www.kingsfund.org.uk/publications/integrating-health-and-social-care-torbayhttp://www.kingsfund.org.uk/publications/integrating-health-and-social-care-torbayhttp://www.kingsfund.org.uk/publications/integrating-health-and-social-care-torbayhttp://www.kingsfund.org.uk/publications/integrating-health-and-social-care-torbayhttp://www.kingsfund.org.uk/publications/clinical-and-service-integration


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integrated health and social care teams in the community aligned with generalpractices and, increasingly, with hospitals. A number o these areas are beginning torealise the benets o integration by helping people to remain living independentlyin their own homes or longer and reducing the use o somehospital services.

Similar experiences have been reported rom initiatives in other parts o the world,including Canada, the United States, Europe and New Zealand ( Timmins and Ham2013 ; Curry and Ham 2010 ). Some organisations and systems in these countrieshave sought to go beyond the integration o care or patients and service users toexplore how they can use their resources to improve the health o the populationsthey serve. Examples include long-established integrated systems such as KaiserPermanente in the United States (ofen re erred to as a health maintenanceorganisation), which is described in more detail later in this paper.

Population health

Efforts to improve the health o populations ofen use the language o public health

or population health. Like integrated care, population health means different thingsto different people, but can be broadly dened as ‘the health outcomes o a group oindividuals, including the distribution o such outcomes within the group’ (Kindigand Stoddart 2003).

While access to traditional health and care services plays an important part indetermining the health o a population, evidence suggests that this is not asimportant as li estyle, the inuence o the local environment, and the widerdeterminants o health – that is, the conditions in which people are born, live and

work (Canadian Institute or Advanced Research et al , cited in Kuznetsova 2012;Booske et al 2010 ; Marmot et al 2010 ; McGinnis et al 2002; Bunker et al 1995). Tismeans that improving population health requires efforts to change behavioursand living conditions across communities. It also means that accountability orpopulation health is spread widely across these communities, not concentrated insingle organisations or within the boundaries o traditional health and care services.

Following the lead o organisations like Kaiser Permanente and the inuence othe ‘ riple Aim’ – dened by the Institute or Healthcare Improvement (IHI) asimproving patient experience, improving the health o populations, and reducing

http://www.kingsfund.org.uk/publications/quest-integrated-health-and-social-carehttp://www.kingsfund.org.uk/publications/quest-integrated-health-and-social-carehttp://www.kingsfund.org.uk/publications/clinical-and-service-integrationhttp://uwphi.pophealth.wisc.edu/publications/other/different-perspectives-for-assigning-weights-to-determinants-of-health.pdfhttp://uwphi.pophealth.wisc.edu/publications/other/different-perspectives-for-assigning-weights-to-determinants-of-health.pdfhttp://uwphi.pophealth.wisc.edu/publications/other/different-perspectives-for-assigning-weights-to-determinants-of-health.pdfhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://uwphi.pophealth.wisc.edu/publications/other/different-perspectives-for-assigning-weights-to-determinants-of-health.pdfhttp://www.kingsfund.org.uk/publications/clinical-and-service-integrationhttp://www.kingsfund.org.uk/publications/quest-integrated-health-and-social-carehttp://www.kingsfund.org.uk/publications/quest-integrated-health-and-social-care


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the costs o health care – there has been growing interest in population health inthe United States in recent years rom accountable care organisations and otherintegrated health systems.

Because o the way the US health care system works, these organisations andsystems have typically ocused on improving the health o specic groups o peoplecovered by health plans rather than the whole o a population living within a denedarea (Noble et al 2014; Jacobson and eutsch 2012). Tey have also ofen ocused onimproving the health o these populations ‘one person at a time’ – with patients asthe primary unit o intervention rather than broader populations (Noble et al 2014).Tis means that these approaches can quickly lose their connection with populationhealth, ocusing primarily on medical interventions or patients and neglectingthe wider determinants o health and the distribution o health outcomes acrosspopulations (Shar stein 2014).

In England, there has been a succession o initiatives over the past 40 years designedto give greater attention to preventing ill health and rediscovering the role o publichealth. However, an important difference in the English context is the denition o

the population group whose health is being managed or improved. Unlike in theUnited States, where the ocus is on members or attributed patients, in Englandthe ocus is on all those who live in a dened area and who are served by the local‘health authority’ (to use the overarching term). Te importance o the widerdeterminants o health has long been recognised ollowing the analysis o healthinequalities presented in the Marmot, Acheson and Black reports ( Marmot et al 2010 ; Acheson 1998; Department o Health and Social Security 1980). From thisperspective, population health management ocused on individuals has a place ( orexample, through ‘making every contact count’), but needs to be underpinned and

complemented by interventions designed to tackle the underlying social, economicand environmental determinants o health across populations ( see Figure 1, p 8).

Approaches to population health are beginning to gain traction in different partso the world. In the United States, some accountable care organisations andother integrated systems are emulating Kaiser Permanente’s approach, and someo these systems are trans orming into accountable health communities basedon collaboration across sectors and geographies (Magnan et al 2012). Similarapproaches can be ound in New Zealand and the Nordic countries, where therole o regional and local government in unding and providing health care creates

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a avourable environment or partnerships across the public sector to promotepopulation health. Closer to home, the trans er o public health responsibilities tolocal authorities has led to renewed interest in their role in improving the health othe populations they serve. Examples o some o these systems are explored later inthis paper.

Joining up the dots

Returning to the English context, the main ocus o integrated care has been onbringing different parts o the NHS closer together, as well as building bridges betweenhealth and social care. Tese efforts have centred on co-ordinating care services orolder people and those with long-term conditions, in line with international evidenceand national policy initiatives. While there are some examples o this extending intoa concern or population health, most o the current initiatives have started with localgovernment (as in the case o the health commissions established in Liverpool andLondon), and the role o public health is not yet well articulated within work on theBetter Care Fund and the integrated care pioneer programme.

In view o the scale o the challenges involved in moving rom ragmented careto integrated care – both within the NHS and between health and social care –this narrow ocus is entirely understandable, but there is a risk o a much biggeropportunity being missed unless stronger connections are made between differentstrands o activity. Tis is particularly the case in the context o the NHS ve year forward view and its emphasis on the dual role o the NHS in prevention andli estyle support as well as developing new models o care (NHS England et al 2014 ).In writing this paper, our principal purpose is there ore to challenge those involvedin integrated care and in public health to ‘join up the dots’. Put simply, this means

thinking o integrated care as part o a broader shif away rom ragmentation andtowards population health.

Te need to make this shif is clearly articulated by the body o evidence about ourpopulation’s health, li estyles and the impact o the wider determinants o health.Tis evidence is well known and includes the ollowing.

• Te persistence o large and avoidable differences in health outcomes betweensocial groups, which are, in many cases, widening ( Marmot et al 2010 ). Tisincludes large differences in health outcomes within local populations.

http://www.england.nhs.uk/ourwork/futurenhshttp://www.england.nhs.uk/ourwork/futurenhshttp://www.england.nhs.uk/ourwork/futurenhshttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.england.nhs.uk/ourwork/futurenhs


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• Te prevalence o multi-morbidity increases with deprivation (Barnett etal 2012; Department o Health 2012 ). A recent study o patients in around500 general practices ound that 29 per cent o people with three long-termconditions were rom the most deprived quintile o the population, comparedwith only 14 per cent rom the least deprived (Charlton et al 2013).

• Te development o single and multiple morbidities is clearly linked to li estyle(Sabia et al 2012). Yet seven out o ten adults in England ail to adhere to twoor more government guidelines in our areas o behaviour that affect health(smoking, alcohol, diet and physical activity) ( Buck and Frosini 2012 ).

• Unhealthy li estyles are increasingly clustering and polarising within thepopulation. Between 2003 and 2008, the relative risk o men rom unskilledbackgrounds in England displaying unhealthy behaviours in these our areascompared to pro essionals increased rom a ratio o 3:1 to 5:1 (Buck and Frosini2012 ).

• Early li e experiences in the womb, home and school are critical to health andwellbeing over the li e course (Giesinger et al 2014; Allen 2011a , 2011b ; Marmotet al 2010 ). However, evidence suggests that child health and wellbeing may haveworsened in recent years, and in the current decade England is likely to ace therst rise in absolute child poverty since records began in the 1960s ( Social Mobilityand Child Poverty Commission 2014 ; aylor-Robinson et al 2014; UNICEF 2014 ).

Making this shif towards population health will require collaboration across a rangeo sectors and wider communities – between NHS organisations, local authorities,the third sector and other local partners, as well as patients and the public ( Foot et

al 2014 ), working together as population health systems.Tinking about this shif inrelation to systems rather than organisations is crucial because o the complex rangeo inuences on population health.

As outlined in Figure 1, what we are describing here as population health systemshave a wider ocus than most o the approaches to integrated care in England todate. While interventions ocused on individuals and integrating care services orkey population groups are important, these must be part o a broader ocus onpromoting health and reducing health inequalities across whole populations.

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216528/dh_134486.pdfhttp://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-timehttp://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-timehttp://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-timehttp://www.gov.uk/government/uploads/system/uploads/attachment_data/file/61012/earlyintervention-smartinvestment.pdfhttp://media.education.gov.uk/assets/files/pdf/g/graham%20allens%20review%20of%20early%20intervention.pdfhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.gov.uk/government/publications/state-of-the-nation-2014-reporthttp://www.gov.uk/government/publications/state-of-the-nation-2014-reporthttp://www.unicef-irc.org/publications/pdf/rc12-eng-web.pdfhttp://www.kingsfund.org.uk/publications/people-control-their-own-health-and-carehttp://www.kingsfund.org.uk/publications/people-control-their-own-health-and-carehttp://www.kingsfund.org.uk/publications/people-control-their-own-health-and-carehttp://www.kingsfund.org.uk/publications/people-control-their-own-health-and-carehttp://www.kingsfund.org.uk/publications/people-control-their-own-health-and-carehttp://www.kingsfund.org.uk/publications/people-control-their-own-health-and-carehttp://www.unicef-irc.org/publications/pdf/rc12-eng-web.pdfhttp://www.gov.uk/government/publications/state-of-the-nation-2014-reporthttp://www.gov.uk/government/publications/state-of-the-nation-2014-reporthttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewhttp://media.education.gov.uk/assets/files/pdf/g/graham%20allens%20review%20of%20early%20intervention.pdfhttp://www.gov.uk/government/uploads/system/uploads/attachment_data/file/61012/earlyintervention-smartinvestment.pdfhttp://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-timehttp://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-timehttp://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-timehttp://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216528/dh_134486.pdf


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Elements o this approach are already in place in some parts o England. A well-known example is the Bromley by Bow Centre in east London. Established in1984 and now serving around 2,000 people every month, its work is based oncollaboration across services and sectors to improve the health and wellbeing o vulnerable young people, adults and amilies across the local community – one o

the most deprived wards in London. Alongside GP services, the centre is home to arange o activities and services including social wel are and legal advice, adult skillsand employment programmes, money management services, social groups andother community activities, as well as healthy li estyle programmes. Local GPs re erpeople to these services and others like them in the borough.

Other areas have developed similar initiatives that connect the NHS to a rangeo local services ocused on specic aspects o people’s health and wellbeing. Tisincludes service models where social wel are, legal and debt advice are providedalongside traditional health and care services, and close links are made between the

Figure 1 The ocus o population health systems

Individual caremanagement

Care for patients presentingwith illness or for those at

high risk of requiring care services

Integrated caremodels

Co-ordination of care servicesfor defined groups of people(eg, older people and those

with complex needs)

‘Making every contactcount’

Active health promotionwhen individuals come

into contact with healthand care services

Improvingpopulation

health requiresmultiple

interventionsacross

systems

Population health(systems)

Improving health outcomesacross whole populations,

including the distribution ofhealth outcomes

Focus of intervention

Unit ofintervention

Populations

Individuals

Care services Health improvement


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two. In Derbyshire, or example, the Citizens Advice Bureau provides support toindividuals and amilies in 98 out o 102 general practices in the county. In 2013/14,around 6,500 people received advice through the service, dealing with nearly 30,000problems ( Buck and Jabbal 2014 , p 69).

Elsewhere, some pro essional groups are starting to play new roles in promotingpublic health and wellbeing. In Wigan, 70 community pharmacists offer smokingcessation and sexual health advice services, as well as re erring people to relevantservices i they spot early signs o issues like isolation, dementia or the risk o alls.Te approach is now being extended to dental practices in the area. Wigan Councilhas also established a community investment und to provide support or ideas romthe community sector that will improve people’s health and wellbeing.

In other parts o the country, programmes are being established that recognise theconnections between people’s health and their living environments. One exampleis Liverpool City Council’s Healthy Homes Programme, which uses targetedassessments o people’s health needs and the conditions in their homes to identi yinterventions to improve health and wellbeing. Interventions include ‘health-

proong’ homes rom damp and excess cold, removing hazards in the home toreduce accidents, and giving advice on uel poverty and keeping homes warm,as well as re errals to a range o local partner organisations. Te programme hasachieved reductions in the number o excess winter deaths and nancial savings orthe NHS, among other things ( Public Health England 2013 ).

A similar example can be ound in the West Midlands Fire Service, which delivers arange o programmes that recognise the links between keeping people sa e in theirhomes and the impact o poverty, deprivation and li estyle. Te re service works

with partners across the community to help make homes sa er, tackle anti-socialbehaviour, and support people to live healthier lives ( see www.wm s.net/ ).

As well as joining up local services, some parts o the country are also beginning toharness the power o local communities in shaping their health and care servicesand improving community health and wellbeing. In some areas, volunteers havebeen trained to become ‘community health champions’, supporting people in theirneighbourhoods and broader communities to lead healthier lives, as well as workingwith commissioners and providers to improve the quality o services available in theirlocal area (see www.altogetherbetter.org.uk ; NHS Con ederation and Altogether Better 2012 ).

http://www.kingsfund.org.uk/publications/articles/tackling-povertyhttp://www.gov.uk/government/uploads/system/uploads/attachment_data/file/268181/Health_and_care_integration.pdfhttp://www.wmfs.net/http://www.altogetherbetter.org.uk/http://www.altogetherbetter.org.uk/SharedFiles/Download.aspx?pageid=36&mid=57&fileid=89http://www.altogetherbetter.org.uk/SharedFiles/Download.aspx?pageid=36&mid=57&fileid=89http://www.altogetherbetter.org.uk/http://www.wmfs.net/http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/268181/Health_and_care_integration.pdfhttp://www.kingsfund.org.uk/publications/articles/tackling-poverty


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aking a broader ocus, various recent national initiatives have tried to encouragethe development o place-based approaches to unding and designing publicservices. Te coalition government has piloted whole-place community budgets inan attempt to bring together budgets and services or amilies with complex needsin different parts o the country. Despite a number o challenges, some o these areasare beginning to show progress in building partnerships across the public sector(House o Commons Communities and Local Government Committee 2013).Be ore that, the otal Place pilots established by the previous government alsosought to reshape resources according to local population needs rather than separateorganisational unding models ( Humphries and Gregory 2010 ).

At a city-wide level, the recently established Mayoral Health Commissions inLiverpool and London have ambitious plans or services to work together acrosstheir cities, boroughs and local communities to improve the health o theirpopulations and tackle the wider determinants o health ( London Health Commission2014 ; The Mayoral Health Commission 2014 ). Some health and wellbeing boards arealso growing into their roles and starting to design plans to join up local services toimprove population health.

By highlighting these examples, we are recognising some o the building blocks thatare already in place across the country to support the shif that we have describedtowards population health (and more examples can be ound in Local GovernmentAssociation 2015 ; Local Government Association and Public Health England 2014 ; Buck andGregory 2013 ). Te challenge or local areas is how to build on and join up theseofen small-scale initiatives to create a systemic approach to improving populationhealth across services and sectors. Tose areas that have already developed system-wide plans or improving population health ace a urther challenge: putting the

right oundations in place to make these plans a reality.

In the next section, we describe examples o organisations and systems in othercountries that have started to make this shif towards population health. Ten weexplore what needs to happen to support these developments in the English context.

http://www.kingsfund.org.uk/sites/files/kf/place-based-approaches-nhs-seminar-highlights-richard-humphries-sarah-gregory-kings-fund-october-2010.pdfhttp://www.londonhealthcommission.org.uk/wp-content/uploads/Better-Health-for-London-report-revised-November-2014.pdfhttp://www.londonhealthcommission.org.uk/wp-content/uploads/Better-Health-for-London-report-revised-November-2014.pdfhttp://liverpool.gov.uk/media/770697/healthcommissionerport2.pdfhttp://www.local.gov.uk/publications/-/journal_content/56/10180/6995080/PUBLICATIONhttp://www.local.gov.uk/publications/-/journal_content/56/10180/6995080/PUBLICATIONhttp://www.local.gov.uk/documents/10180/5854661/Public+health+transfornation+nine+months+on+-+bedding+in+and+reaching+out+-+publication/ce0b8b36-c81d-44f7-ba91-b0836a9b4822http://www.kingsfund.org.uk/publications/improving-publics-healthhttp://www.kingsfund.org.uk/publications/improving-publics-healthhttp://www.kingsfund.org.uk/publications/improving-publics-healthhttp://www.kingsfund.org.uk/publications/improving-publics-healthhttp://www.local.gov.uk/documents/10180/5854661/Public+health+transfornation+nine+months+on+-+bedding+in+and+reaching+out+-+publication/ce0b8b36-c81d-44f7-ba91-b0836a9b4822http://www.local.gov.uk/publications/-/journal_content/56/10180/6995080/PUBLICATIONhttp://www.local.gov.uk/publications/-/journal_content/56/10180/6995080/PUBLICATIONhttp://liverpool.gov.uk/media/770697/healthcommissionerport2.pdfhttp://www.londonhealthcommission.org.uk/wp-content/uploads/Better-Health-for-London-report-revised-November-2014.pdfhttp://www.londonhealthcommission.org.uk/wp-content/uploads/Better-Health-for-London-report-revised-November-2014.pdfhttp://www.kingsfund.org.uk/sites/files/kf/place-based-approaches-nhs-seminar-highlights-richard-humphries-sarah-gregory-kings-fund-october-2010.pdf


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Examples of emerging population health systems 11


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3 Examples o emergingpopulation healthsystems

o help articulate the shif described in the rst part o this paper, we now discusssome examples rom different parts o the world where systems are emerging thatare ocusing on improving population health. Rather than offering a comprehensivereview o the way these systems work, the examples simply aim to illustrate howpopulation health has been interpreted in different systems and the interventionsthat have been used or proposed. Tese examples were selected based on theauthors’ knowledge o developments in other countries and the views o a smallnumber o international experts. aken together, they provide a picture o the shif

being made towards population health in different countries and provide lessons orlocal areas in England as the journey towards integrated care continues.

Afer describing each example at a high level, we outline a broad ramework to helpinterpret the approaches taken by these organisations and systems to improve thehealth o the populations they serve. Te ramework explores similarities in theirapproach at macro, meso and micro levels.

Kaiser Permanente, United States

Kaiser Permanente started out in the 1930s as a prepaid health care system orworkers building dams in the Cali ornian desert, where there was a strong incentiveto reduce injuries through prevention. Te apocryphal story o Sidney Gareld (therst doctor who worked or Kaiser Permanente) hammering down rusty nails toavoid workers being injured and requiring expensive medical care illustrates whatthis meant at the time. oday, Kaiser Permanente is a non-prot health maintenanceorganisation serving around 9.5 million members, their amilies and widercommunities across the United States.


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Kaiser Permanente’s structure and its longstanding efforts to integrate servicesare well known and described in detail elsewhere ( Curry and Ham 2010 ; McCarthyand Mueller 2009 ). Key organisational eatures include its role as both insurer andprovider o care (within and outside o hospitals), and the use o capitated budgets

or members’ care across regions. Among other things, integration o care atKaiser Permanente is supported by population risk stratication, an emphasis onprevention and sel -management, disease management and the use o care pathways

or common conditions, case management or patients with complex needs,extensive use o technology and population data, and a model o multispecialtymedical practice where unplanned hospital admissions are seen as a ‘system ailure’.

Over the past decade, Kaiser Permanente has shifed its ocus rom people withlong-term conditions with the most complex needs ‘at the tip o the triangle’ toall o those or whom it has responsibility. It uses data about the population itserves, available through its system-wide electronic health record, to understandmembers’ health needs and the distribution o health outcomes. Using these data,Kaiser Permanente offers a range o interventions tailored to the needs o differentindividuals and population groups to support people to remain healthy and to

deliver the right treatments when they become ill.

One example o this is Kaiser Permanente’s approach to preventing and treatingheart disease. It has ocused heavily on preventive interventions like smokingcessation, promoting exercise and other li estyle changes to reduce the risk odeveloping heart disease across member populations. Between 2002 and 2005, inNorthern Cali ornia, Kaiser Permanente helped reduce prevalence o smokingamong its members by 25 per cent, compared with a 7.5 per cent reduction acrossCali ornia as a whole (Levine 2011 ). Smoking cessation interventions have been

combined with a range o other interventions – rom primary and secondaryprevention through to acute care and the management o chronic illness – to orm asystematic approach to the prevention and treatment o heart disease across KaiserPermanente member populations. Among its members in Northern Cali ornia,the rate o heart disease mortality decreased by 26 per cent rom 1995 to 2004,and members were 30 per cent less likely to die rom heart disease than otherCali ornians in 2004 (McCarthy and Mueller 2009 ).

Across Kaiser Permanente as a whole, the success o this approach to improvingmembers’ health is evidenced by the organisation’s consistent high per ormance

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in national Healthcare Effectiveness Data and In ormation Set (HEDIS) measures(Kaiser Permanente 2015c ; Kaiser Permanente 2014 ), as well as its strong per ormancecompared with other health systems across the world, including the NHS (Ham et al 2003; Feachem et al 2002).

As well as ocusing on improving members’ health, Kaiser Permanente has beeninvolved or a number o years in efforts to improve the ‘total health’ o the broadercommunities it serves. For example, to help improve the availability o healthy

ood, Kaiser Permanente supports ood stores in deprived areas to stock reshruit and vegetables, sets up armers’ markets at Kaiser Permanente acilities and

in the community, and works with local schools to offer healthier ood and drinkoptions or pupils. It also provides nancial support or ood banks and other oodassistance programmes. In schools and community centres, Kaiser Permanente runsa range o educational theatre programmes using music, comedy and drama to helpeducate children and adults about their health and wellbeing. Tese programmeshave reached around 15 million children over the past 25 years ( Levi et al 2013 ).

As part o these efforts, Kaiser Permanente has also established a range o

Community Health Initiatives to support the development o place-basedinterventions to improve population health. It has sponsored or co- ounded morethan 40 Healthy Eating Active Living (HEAL) collaboratives since 2006, typically

ocused on:

• ensuring that health is considered in local government plans and policies ( orexample, through creating bike paths or walking trails)

• improving access to green spaces and community gardens

• improving access to healthy ood in schools, workplaces and deprived areas

• promoting physical activity across the whole population

• utilising community assets to support and sustain initiatives ( seeKaiserPermanente 2015 b).

Tese initiatives involve collaboration between a range o organisations and groupsacross different sectors working in partnership with their local communities. Tey

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have had some positive results – or example, increasing levels o physical activityand improving aerobic tness among school-age children (Cheadle et al 2012; KaiserPermanente 2012 ). Evaluation o these place-based initiatives continues, and ndingsand key lessons are shared online ( Kaiser Permanente 2015 a).

Nuka System o Care, Alaska

Southcentral Foundation is a non-prot health care organisation serving apopulation o around 60,000 Alaska Native and American Indian people inSouthcentral Alaska, supporting the community through what is known as the NukaSystem o Care (Nuka being an Alaska Native word meaning strong, giant structuresand living things).

Nuka was developed in the late 1990s afer legislation allowed Alaska Native peopleto take greater control over their health services, trans orming the community’s role

rom ‘recipients o services’ to ‘owners’ o their health system, and giving them a rolein designing and implementing services ( Gottlieb 2013 ). Nuka is there ore built onpartnership between Southcentral Foundation and the Alaska Native community,

with the mission o ‘working together to achieve wellness through health and relatedservices’. Southcentral Foundation provides the majority o the population’s healthservices on a prepaid basis.

Te Nuka System o Care incorporates key elements o the patient-centred medicalhome model, with multidisciplinary teams providing integrated health and careservices in primary care centres and the community, co-ordinating with a rangeo other services (Driscollet al 2013; Graves 2013; Johnston et al 2013). Tis iscombined with a broader approach to improving amily and community wellbeing

that extends well beyond the co-ordination o care services – or example, throughinitiatives like Nuka’s Family Wellness Warriors programme, which aims to tackledomestic violence, abuse and neglect across the population through education,training and community engagement. raditional Alaska Native healing is offeredalongside other health and care services, and all o Nuka’s services aim to build onthe culture o the Alaska Native community.

Alaska Native people are actively involved in the management o the Nuka Systemo Care in a number o ways. Tese include community participation in locality-based advisory groups, the active involvement o Alaska Native ‘customer owners’

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in Southcentral Foundation’s management and governance structure, and the useo surveys, ocus groups and telephone hotlines to ensure that people can give

eedback that is heard and acted on. As well as building strong relationships withthe population it serves, the Nuka System o Care depends on collaboration betweenSouthcentral Foundation and a range o local, regional and national partners. Newcollaborations are being established each year as gaps in services are identiedand lled.

Since it was established, the Nuka model o population-based care has achieved anumber o positive results, including:

• signicantly improved access to primary care services

• reductions in hospital activity, including: – 36 per cent reduction in hospital days – 42 per cent reduction in urgent and emergency care services – 58 per cent reduction in visits to specialist clinics

• per ormance at the 75th percentile or better in 75 per cent o HEDIS measures

• customer satis action, with respect or cultures and traditions at 94 per cent(Gottlieb 2013 ).

Gesundes Kinzigtal, Germany

Gesundes Kinzigtal (meaning ‘healthy Kinzigtal’) is a joint venture between anetwork o physicians in Kinzigtal and a Hamburg-based health care management

company, OptiMedis AG. Gesundes Kinzigtal is responsible or organising care andimproving the health o nearly hal o the 71,000 population in Kinzigtal in south-west Germany.

Since 2006, Gesundes Kinzigtal has held long-term contracts with two Germannon-prot sickness unds to integrate health and care services or their insuredpopulations, covering all age groups and care settings. Around a third o thispopulation has actively enrolled in Gesundes Kinzigtal – ree to all those insured– which allows access to a number o health improvement programmes offeredby the organisation. Health care providers in Kinzigtal are directly reimbursed

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by the sickness unds or their services, but Gesundes Kinzigtal holds ‘virtualaccountability’ or the health care budget or this population group. I the sickness

unds spend less on health care than the population budget, Gesundes Kinzigtalshares the benets (Hildebrandt et al2010; 2012).

o help keep the population o Kinzigtal healthy and reduce care costs, GesundesKinzigtal contracts with traditional health and care providers as well ascollaborating with a range o community groups including gyms, sports clubs,education centres, sel -help groups and local government agencies. Trough thesecollaborations, Gesundes Kinzigtal offers gym vouchers to encourage people to stayactive as well as dance classes, glee clubs and aqua-aerobics courses. It also runshealth promotion programmes in schools and workplaces and or unemployedpeople, and ‘patient university’ classes to offer health advice to support preventionand sel -management.

As with many other integrated care systems, Gesundes Kinzigtal has developedtargeted care management and prevention programmes or particular high-riskpopulation groups, such as older people, those living in nursing homes, people with

specic conditions, and those with high body mass index. Health pro essionals aretrained in shared decision-making to ensure that patients are actively involved intheir own care when they do require input rom health services. Pro essionals alsobenet rom the availability o a system-wide electronic health record to ensure thatin ormation about patients is available across providers and care settings to supporteffective co-ordination o care.

External and internal evaluation has shown that this approach is improving healthoutcomes – most notably, reducing mortality rates or those enrolled in Gesundes

Kinzigtal compared with those not enrolled (Busse and Stahl 2014; Hildebrandt et al 2012). Tere have been improvements in the efficiency o services, as well as people’sexperience o care. Gesundes Kinzigtal has also been success ul in slowing the risein health care costs or the population it serves (not simply those who have activelyenrolled in Gesundes Kinzigtal). Between 2006 and 2010, it generated a saving o16.9 per cent against the population budget or members o one o the sickness

unds, compared with a group o its members rom a different region. One o themain drivers o this saving related to emergency hospital admissions. Between 2005and 2010, emergency hospital admissions increased by 10.2 per cent or patients


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in Kinzigtal, compared with a 33.1 per cent increase in the comparator group(Hildebrandt et al 2012).

Counties Manukau, New Zealand

Counties Manukau Health (CMH) is responsible or commissioning health and careservices or the whole population o 500,000 people living in South Auckland, NewZealand, and providing hospital and specialist services in the area. CMH works witha range o local and national partners to integrate services and improve the health othe population living in Counties Manukau.

As with many other integrated care systems, CMH has worked with local providersto develop locality-based integrated health and care teams aligned with networkso general practices and working in partnership with hospital services. Capitatedbudgets are allocated to primary care organisations to deliver care in their localities,and alliance agreements are used to share responsibility between locality partnersand CMH. Services are tailored to the needs o different population groupswithin each locality, based on population risk stratication, ranging rom primary

prevention services and li estyle support through to active case managementor patients with complex health and social care needs, with the emphasis on

supporting people to manage their own health. Each locality is served by a widersocial care network to provide help and support to amilies with complex needswhose living environments are impacting their health.

While these locality networks are relatively embryonic, early indicators reportedby CMH show improving trends in a number o areas. For example, immunisation,cardiovascular risk assessment and smoking cessation support rates have all

increased rom around 65 per cent to more than 90 per cent in the past two years,while acute hospital and care home utilisation rates are now below demographicgrowth rates.

Alongside these locality networks, CMH also runs a number o other well-established programmes with local partners designed to improve population health.One example is its Healthy Housing Programme – a joint initiative between CMH,neighbouring district health boards and Housing New Zealand, the government-owned social housing provider – which ran rom 2001 to 2013. Te programme


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was open to all people living in rented Housing New Zealand accommodation, andocused on:

• improving access to health and care services

• reducing the risk o housing-related health issues

• identi ying social and wel are issues and providing a link to relevant agencies.

Afer a joint visit and assessment rom local health and housing teams, typicalinterventions included educating amilies about their health and health risks,re errals to health and social care services, installing insulation to make houseswarmer and dryer, modi ying houses to meet health and disability needs, andtrans erring amilies to alternative houses in cases o overcrowding. Teseinterventions were tailored to the needs o different amilies and population groups– particularly the M ā ori and Pacic Island groups, which are disproportionatelyaffected by poor housing conditions. Te programme took a locality-by-localityapproach to ensure that every eligible household was reached systematically and to

reduce the potential or stigmatisation o amilies involved in the programme.

Te programme had a clear impact on the health o amilies involved. Anevaluation involving 9,736 residents in 3,410 homes ound that the programmewas associated with reductions in acute hospital admissions o 11 per cent (among0- to 4-year-olds) and 32 per cent (among 5- to 34-year-olds), while housing-relatedhospital admissions ell by 12 per cent and 27 per cent respectively or these agegroups (Jackson et al 2011). Qualitative evaluation ound strong links between theprogramme and tenants’ sel -reported household wellbeing (Bullen et al 2008).

Other interventions run by CMH and its partners include the Providing Access toHealth Solutions programme, which supports people in receipt o jobseeker supportand other benets to access appropriate health and vocational services to help themreturn to employment, and Smoke ree 2025, which involves action across multiplesectors to meet the national policy goal o being a smoke- ree nation by 2025.


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Jönköping County Council, Sweden

Jönköping County Council is an elected regional health authority serving around340,000 people in southern Sweden. Over the past 20 years, Jönköping CountyCouncil has pursued a population-based vision or its citizens o ‘a good li e inan attractive city’. It plans, unds and provides health services or this population,working in partnership with local government in the county’s municipalities. Ithas considerable autonomy and tax-raising powers by virtue o Sweden’s system odevolved government.

Jönköping County Council is best known or its work on quality improvement anddeveloping integrated health and care services ( Ham 2014 ). Staff and clinical teamshave been encouraged to work together to think about how they can deliver thebest outcomes or a ctional elderly resident, Esther, enabling them to map servicesthat people receive across different settings and explore how they can be improvedacross systems. Te benets o this approach have included signicant reductionsin hospital admissions, days spent in hospital and waiting times or specialistappointments (Baker et al2008).

Other services aimed at improving older people’s health include Jönköping’s Passionor Li e programme, which recently won the European award or social innovation

in ageing. It is based on a series o group meetings called ‘li e ca és’, where peoplecome together to collectively discuss how they can improve different aspects otheir health and wellbeing. Li e ca és are held in different locations depending onthe topics being discussed – or example, in a gym i the topic is physical activity, orin a restaurant i the theme is diet and nutrition. Some o these li e ca és have also

ocused on intergenerational activities and the specic needs o minority groups.

As well as integrating care and prevention services or older people like Esther,Jönköping County Council has taken a broad approach to planning and deliveringservices across the whole o the population it serves. It uses population-level datato understand the needs o different population groups, and uses a dashboard oindicators to monitor health outcomes across and within local populations. Teseindicators ocus on a range o areas, including rates o obesity, alcohol consumption,physical activity, quality o diet, social deprivation, violent crime, school truancyand educational outcomes, as well as a range o measures o people’s physical health.Te Council then works in partnership with local government in Jönköping’s

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municipalities to plan and deliver services to improve population health ineach locality.

In particular, Jönköping County Council has developed targeted strategies orour main population groups: children and young people, people with mental

health conditions, people living with drug and alcohol addiction, and older people.Pro essionals rom different sectors are brought together to design and implementnew approaches to improving people’s health across each o these groups. Oneexample is Jönköping’s collaborative programme or younger people with mentalhealth conditions, which involves primary care and social care services, schoolsand the police, as well as a range o other local partners. Public health is seen as acore part o designing and delivering interventions across each o these populationgroups, rather than a separate strand o activity.

o support people to manage their own health across the population, ‘learning ca és’(similar to the li e ca és described above) have been set up that connect people withsimilar conditions and draw on the expertise o ‘expert patients’.

Te impact o Jönköping County Council’s population-based approach is evidencedby its consistent high per ormance across a range o public health indicators whencompared with other parts o Sweden – including in relation to li e expectancy, sel -reported health status and emotional wellbeing ( Socialstyrelsen et al 2014 ).

Summary o these approaches

In their different ways, the examples described in this section paint a picture othe shif that is being made in different parts o the world rom integrated care to

population health. While they take a variety o orms and are at different stages odevelopment, these examples share a number o similarities in their approach andmethods. In particular, the approaches taken by these systems can be describedacross three broad levels: macro, meso and micro.

At a macro level , the examples involve organisations working together acrosssystems to improve health outcomes or dened population groups. Unlike typicalapproaches to integrated care that ocus primarily on groups that are requent userso health and care services, these systems aim to improve people’s health across thewhole o the populations they serve, as well as targeting specic interventions on the

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most deprived groups. Tis population-level lens is used to plan programmes andinterventions across a range o different services and sectors.

Key eatures that have supported these systems at a macro level include:

• population-level data to understand need across populations and track healthoutcomes

• population-based budgets (either real or virtual) to align nancial incentiveswith improving population health

• community involvement in managing their health and designing local services

• involvement o a range o partners and services to deliver improvements inpopulation health.

At a meso level , these systems have developed different strategies or differentsegments o the populations they serve, depending on people’s needs and level

o health risk. By grouping people with similar needs and tailoring services andinterventions accordingly, this approach recognises that improving the health oolder people and children, or healthy adults and those living with multiple long-term conditions, will require a different set o approaches, and involvement romdifferent system partners to be effective.

Key eatures that have supported these systems at a meso level include:

• population segmentation and risk stratication to identi y the needs o different

groups within the population

• targeted strategies or improving the health o different population segments

• developing ‘systems within systems’ with relevant organisations, services andstakeholders to ocus on different aspects o population health.

At a micro level , the examples deliver a range o interventions aimed at improvingthe health o individuals within the populations they serve. Tese interventions aremany and varied, and involve input rom a number o organisations and services


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depending on their ocus. In the examples described above they include housingsupport, education programmes, vocational services and employment advice,exercise programmes, smoking cessation services and other li estyle support, as wellas more traditional health and care services like care planning and individual casemanagement or people with complex health and care needs.

Key eatures that have supported these systems at a micro level include:

• integrated health records to co-ordinate people’s care services

• scaled-up primary care systems that provide access to a wide range o servicesand co-ordinate effectively with other services

• close working across organisations and systems to offer a wide range ointerventions to improve people’s health

• close working with individuals to understand the outcomes and services thatmatter to them, as well as supporting and empowering individuals to manage

their own health.

Across these three levels, the examples that we have described illustrate what theshif towards population health means in practice, as well as the range o benetsthat can be achieved rom pursuing this way o working. In the nal section o thepaper, we build on these ideas to ask how we can support the development o thistype o approach in England.


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Implications for England 23


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4 Implications or EnglandMaking the shif rom integrated care to population health in England requiresNHS organisations to work much more closely with local authorities, third sectororganisations and the private sector. It also requires alignment at all levels, startingin central government, cascading through local systems, and ultimately reachinginto localities and neighbourhoods. Previous attempts to prioritise populationhealth have met with partial success at best, and the challenges involved in acting onthe ideas set out in this paper should not be underestimated.

o help provide clarity in meeting these challenges, the government and othernational bodies need to develop a population health strategy or England that setsout goals or population health improvement, how these goals will be deliveredand by whom. In some cases, this will mean national action through legislationor regulation; in other cases, it will require action by NHS organisations, local

authorities and their partners.

While central government and statutory agencies must provide leadership orpopulation health, third sector organisations and community groups also havea critical role to play. As we described in the rst part o this paper, the health oa population is inuenced by numerous actors, many o which are outside thecontrol o the NHS and local government. Drawing on the expertise held withincommunities is there ore essential.

At a local level, the Mayoral Health Commissions in Liverpool and London illustratehow local authorities are embracing the enhanced role o local government inpublic health ( London Health Commission 2014 ; The Mayoral Health Commission 2014 ).Elsewhere, health and wellbeing boards are beginning to act as a orum throughwhich NHS organisations and local authorities can develop joint approaches tointegrating health and social care and improving population health. While the impactand inuence o these boards to date has been limited ( Humphries and Galea 2013 ;Humphries et al 2012 ), their role as a orum or local leadership should be encouraged.Tese initiatives are embryonic examples o local system leadership in which leaders

rom different organisations work together on issues o common concern.

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Te trans er o responsibility or public health rom the NHS to local governmenthelps to explain the growing interest o local authorities in population health, butequally it risks detaching public health expertise rom the NHS. Tis illustratesone o Leutz’s original laws o integration, to the effect that ‘your integration is my

ragmentation’ (Leutz 1999). Strengthening the role o public health in the NHS,while realising the potential o public health responsibilities being co-located withother local authority services, is critical in order to embed a population healthperspective at local level.

As these ideas are taken orward, there are lessons to be learnt rom the otal Placeand Whole Place community budget initiatives established under the currentand previous governments. Tese lessons include the need to overcome barriers(real or perceived) to data sharing between different organisations, as well as the vital role o leadership across local areas (House o Commons Communities andLocal Government Committee 2013; Humphries and Gregory 2010 ). Experienceo partnership working in public services is distinctly mixed, and the challengesin delivering results are considerable. At the same time, the potential gains aresignicant i the barriers can be overcome, especially when public services ace

urther cuts in unding. Tis is particularly relevant in the context o the currentgovernment’s plans to devolve greater responsibility or public sector spendingand decision-making to cities and other local areas – as in the case o the planneddevolution o powers to Greater Manchester ( Topping 2014 ).

Much will depend on visible and consistent leadership at a local level byelected mayors and others, programme management arrangements to supportimplementation o local strategies, and an ability to nd and retain the commonhigh ground o a shared concern or the health and wellbeing o the population,

regardless o organisational or pro essional loyalties. National bodies must also playtheir part by ensuring their actions do not create barriers to joint working at a locallevel and by aligning the requirements they place on the NHS and local government.

Aligning requirements means having a common outcomes ramework to whichdifferent central government departments are ully committed – especiallythe Department o Health and the Department or Communities and LocalGovernment – and which incentivises local areas to work to achieve common goals.Tis means trying not to place conicting demands on NHS organisations and localgovernment, and realising the links between the NHS, social care and public health.

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It also means developing new ways o organising budgets and paying or servicesat a local level to incentivise investment in population health and joint workingbetween organisations across systems.

Te same need or alignment applies within the NHS itsel , where ragmentationat the centre means that national bodies do not always work in a way that creates acoherent policy ramework to support partnership working at a local level.

Public Health England and the National Institute or Health and Care Excellence(NICE) have a specic contribution to make in providing advice and guidance to theNHS and local government on evidence to support local decisions – or example,on the interventions that will have the greatest impact on health improvement. Teycould play a similar role in identi ying ways in which central government can assessthe health impact o its decisions and promote health in all policies. As a result othe recent re orms to the NHS and public health system, there is a lack o clarityabout who is responsible or holding policy-makers across government departmentsto account or the impact o their decisions on population health ( Gregory et al 2012 ).

For NHS organisations, a key question they must consider when approachingpartnership working is what kind o business they are in. In this regard, thereis much to be learnt rom the trans ormation o the US Veterans HealthAdministration (VA) in the 1990s. Te man who led the trans ormation, Ken Kizer,has described to us how the VA was traditionally seen as a hospital system be ore itreinvented itsel as an integrated health and long-term care system. Subsequently,it aced the challenge o becoming a system ocused on promoting the health andwellbeing o the veterans it served.

Kizer’s reection on the experience o the VA is that all health care organisationshave to ask themselves what business they are in; are they running hospitals andother health services, seeking to deliver integrated care, or promoting health andwellbeing? His ormulation o the challenge in this way is directly relevant to thechallenges acing the NHS today and is, in essence, just a different way o deningthe shif in thinking we have described in this paper. Te answer to this questionwill determine the uture direction o the NHS and its partners at a time ounprecedented challenges, as set out in the NHS ve year forward view.

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Whatever the answer, it is increasingly clear that the uture depends on jointworking between agencies in different sectors to create systems that are capable otrans orming health and care in the direction set out in the Forward View. Systemworking is needed to achieve this because, to invoke Atul Gawande, we are in thecentury of the system(Gawande 2014 ). By this, he means that delivering high-qualitycare and outcomes requires systems that support those responsible or care to makethe right choices.

Particularly now, in the in ormation age, it is no longer possible to rely on skilledcrafspeople using their experience and pro essional judgement. System working isalso important in the case o population health, where improved outcomes can bedelivered only through collaboration between a variety o agencies and the manypro essionals who work in them. As Senge and colleagues have recently described,system leadership is critical or the times in which we live, and there needs to beactive support or its development (Senge et al 2014).

Without system leadership, the problems acing our society will remain asintractable as ever. In health care, these problems include persistent and widening

inequalities in health, the challenge o multi-morbidity, and increasing numbers orail older people who account or a high proportion o need and demand or health

and care services. Tere is little prospect that unco-ordinated action by multiplepublic and private agencies will be effective in tackling these problems, underliningthe arguments we have advanced in this paper.

In emphasising the need or a broad-based approach to population health, it isimportant not to overlook the wider contribution o statutory agencies themselves.As the Forward View argues, these agencies could do much more by supporting staff

to adopt healthy behaviours as a contribution to population health improvement(NHS England et al 2014 ). Beyond that, the NHS and local government need torecognise the signicant contribution (either consciously or unconsciously) thatthey, as major employers, already make to population health, and the impact this hason local economies. Te NHS is not only a treatment or prevention system; it alsoactively inuences the wider determinants o health through its massive economicand social power in every community ( Buck and Jabbal 2014 ).

As these ideas are taken orward in the NHS, the crucial role o primary care insupporting a population health approach must also be recognised ( Thorlby 2013 ).

http://www.bbc.co.uk/programmes/b04sv1s5http://www.england.nhs.uk/ourwork/futurenhshttp://www.england.nhs.uk/ourwork/futurenhshttp://www.england.nhs.uk/ourwork/futurenhshttp://www.kingsfund.org.uk/publications/articles/tackling-povertyhttp://www.nuffieldtrust.org.uk/publications/reclaiming-population-health-perspectivehttp://www.nuffieldtrust.org.uk/publications/reclaiming-population-health-perspectivehttp://www.kingsfund.org.uk/publications/articles/tackling-povertyhttp://www.england.nhs.uk/ourwork/futurenhshttp://www.bbc.co.uk/programmes/b04sv1s5


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Community-oriented primary care has been debated or many years, and thestrength o general practice in the NHS – notwithstanding recent pressures – offersan opportunity to show what this could mean in practice.

At a practical level, developing a population health systems perspective requires theollowing elements as a minimum:

• pooling o data about the population served to identi y challenges and needs

• segmentation o the population to enable interventions and support to betargeted appropriately

• pooling o budgets to enable resources to be used exibly to meet populationhealth needs, at least between health and social care but potentially goingmuch urther

• place-based leadership, drawing on skills rom different agencies and sectorsbased on a common vision and strategy

• shared goals or improving health and tackling inequalities based on an analysiso needs and linked to evidence-based interventions

• effective engagement o communities and their assets through third sectororganisations and civil society in its different mani estations

• paying or outcomes that require collaboration between different agencies inorder to incentivise joint working on population health.

Where next?

Te history o well-intentioned public health strategies that have promised muchbut delivered less – dating as ar back as Prevention and health: everybody’s business in 1976 (Department o Health and Social Security 1976) – suggests caution inclaiming that things will be different this time around. I there are reasons oroptimism, they can be ound in the major challenges acing public services in thenext parliament, requiring responses that go well beyond tried and tested initiatives.


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o help meet these challenges, the incoming government in 2015 should work withnational bodies and local areas to take orward the ideas described in this paper. Tepermissive ramework set out in the NHS ve year forward view, with its emphasison integrated care and health improvement, also provides a avourable policycontext or the ideas set out here. Acting on these ideas should be seen as part o thehealth and care system’s efforts to achieve the ‘ ully engaged’ scenario outlined byDerek Wanless more than a decade ago ( Wanless 2002 ).

http://webarchive.nationalarchives.gov.uk/+/http:/www.hm-treasury.gov.uk/consult_wanless_final.htmhttp://webarchive.nationalarchives.gov.uk/+/http:/www.hm-treasury.gov.uk/consult_wanless_final.htm


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