The third major health reform
Health is on the eve of its third major reform: public health (drinking water, infection control) at the end of the Victorian period; the treatment of diseases (institutionalized reactive patient care) after the Second World War; population health (proactive care to support populations at risk) in the third decade of the 21stst Century.
Population health – which relates not only to health and care services, but also to the broader determinants of health, lifestyle and health-related behaviors – offers the potential to improve outcomes, with a reduced overall cost. Why? Because clinical care is only 20 percent of the factors explaining the length and quality of life of a population – much less than social and economic factors or health behaviors such as smoking.
To date, population health efforts in England have shown positive signs of impact, but there are no strong examples of sustained population health being achieved on a large scale. However, the covid has highlighted the need for more effort, highlighting health inequalities and showing that the NHS can move faster to covid speed. By building on the learnings of Covid and making disruptive change at a sustained pace, SCIs have a real opportunity to take a step forward in people’s health and genuinely tackle inequalities.
Figure 1: Measures of Covid Outcomes Disaggregated by Various Inequality Factors
How a bionic approach can unlock population health efforts
One of the main drivers of the transition to the ICS model is to remove the barriers related to competition and payments that will allow the health of the population to thrive. However, this will not be easy to do, especially given the competing demands of new governance, an unprecedented backlog and expected financial tightening.
The payoff to people’s health is potentially huge, but it will take investment – time, money and leadership – to have an impact. Given this, the risk is that population health efforts will continue to flatter to deceive, aside from the “core business” of partners within an ICS.
We argue that the investment is worth it – and that there are ways to tip the scales in favor of impact and sustainability. When we look internationally at health systems that have made sustained progress in addressing inequalities through population health, there is a common theme: they take a bionic approach.
A bionic approach combines the strengths of human and technological capacities to bring about lasting and lasting change. It’s engaging with people to support their own health – and using technology to make that easier. It stimulates clinicians and professionals to support population health – and gives them the tools to collaborate and share information to do so. It’s the leaders who set ambitious goals for their people – and the data and analytical capacity to target interventions to specific populations and track results that matter.
Too often, population health approaches do not give enough weight to each of these elements.
Eight steps for a bionic approach
We recommend eight steps for a bionic approach to population health, creating momentum for improving health and addressing inequalities:
1. Place the health of the population at the heart of our concerns. Develop a population health plan that is owned by all ICS leaders (including suppliers) – not just the ICS population health team. Share both the risk and the reward. Ensure that those charged with leading population health efforts have the right membership (including primary care and local authorities), feel responsible for delivery, but also have the resources to make it happen.
2. Go somewhere. Many pilots start with chronic illnesses such as cardiovascular disease. These populations are often easier to identify and track results. However, be aware of the need to holistically consider the needs of these populations – not just the primary condition – as well as the potential to gain momentum through early intervention. Kaiser Permanente, when developing population-based approaches, targeted breast cancer screening alongside chronic disease. Focusing on populations awaiting treatment so that they can “wait well” could be another initial priority.
3. Use the available data. Gather datasets to understand high impact opportunities and hidden communities. Data is starting to be gathered through local health and care records, but don’t overlook the right tools to help query the data for more. You don’t have to wait for a perfect dataset to get started: for example, Barts Health uses public health data to account for inequalities when prioritizing their elective covid backlog.
4. Find out where digital tools can improve care. Rather than applying one-off digital solutions, consider full journeys and how digital can enable. Swedish provider switched to digital preoperative assessment for urology patients. A large Danish specialist hospital has invested in an ultra-slim Holter monitor that can be displayed on patients, linked to their mobile and offering two-way communication in real time. There is a plethora of remote monitoring apps and technologies available – the question is less what to use and how to successfully apply it for these tools to be used.
5. Activate communities and encourage healthy behaviors. Consider the best routes for engaging with patients and communities. Consider social media – work on vaccine influencers has shown that the voices that impact a community may not be traditional community leaders. Join local social and community services. People’s health is about changing behavior in a simple and easy way: whether it is testing for diabetes during Ramadan to avoid having to fast separately in Qatar; or by offering discounts on healthier food using Apple Watches in Singapore – more than 150 governments and institutions around the world use nudges to influence behavior. The NHS and local partners can also do this.
6. Integrate population health into the working methods of clinicians and professionals. Create the correct prompts in electronic health records; monitor interventions; and buckle up – give visibility to impact. In primary care in Switzerland, doctors are given key indicators on the health of the population, which are tracked and shared weekly to help encourage positive behaviors.
7. Test and Evolve – Work quickly to identify and execute “use cases” that quickly deliver value based on available resources. Aim for impact in 12 months (not three years). Track metrics across the journey to understand the impact. Don’t get caught up in the governance, the process, or the search for the “perfect” system; be prepared to refine and change course without fear of failure.
8. Create a bionic hub to drive scale and continuous innovation. Scaling up best practices doesn’t just happen. It needs dedicated skills and resources to evolve effectively, even when the pilot is promising. Focusing analytical skills, building champions, improving staff skills, capturing results, codifying knowledge, adapting learning, and celebrating success all require special attention.
There is a clear opportunity to act on the lessons of the pandemic to address health inequalities by helping providers implement an intersystem population health approach. However, it will only bring the necessary systematic and lasting change through a bionic approach. The balance between human and technological factors is essential; people are leading change, but they need the tools to enable them to do so.
The authors would like to thank Cassandra Yong and Leonie Woodfinden.