Population Health

In terms of population health, what this really describes is the make-up and demography of the local population and using that knowledge and information to understand the services that should be provided and in place, as opposed to what actually might be in place.

By risk stratifying the population it is possible to see and establish the gaps in services, and in so doing ensure that any service redesign delivers what the population needs rather than what may currently exist.

If we take diabetes as an example, much of my work has been in areas of significant deprivation, where the prevalence of diabetes – particularly in Type 2 diabetes – has been two, sometimes three, times the national average, yet services, especially those for patients with more complex needs, are generally not adequate to meet the needs of those patients. We would, therefore, expect to see the ICS in those areas to be working closely with their PCNs to prioritise services to meet those needs and looking at complete pathway redesign as a consequence.

By re-designing pathways, with the organisations that make up the ICS working in a collaborative and integrated way, and by ensuring that patients are seen in the right place, at the right time by the right healthcare professional for their needs a proactive approach can be taken to meeting the needs of the local population. Key to this is a proactive pathway approach, and not the reactive approach that is so often seen.

By understanding the make-up and demographics of the population, and by understanding prevalence of disease within the population, where disease cannot be prevented it can be diagnosed and treated at a much earlier stage, so preventing disease progression, unnecessary complications and reducing the impact on health and social care. This can be achieved by using such as wearable technology that is easy to access and gives rapid diagnosis, so that treatments can commence as quickly as possible. An example from my work would be the use of 24, 48 and 72-hour ECGs to diagnose arrythmias and ensure patients are quickly anti-coagulated to prevent stroke – the downstream consequence of not taking a proactive approach.

A further example is around frailty which, with an increasingly aging population often living with multiple morbidities is a challenge for both health and social care. Where primary, community and voluntary organisations collaborate and integrate in a proactive way it is possible to manage disease and keep people independent for as long as possible, again reducing the burden of cost and reducing workload on a stretched system.

So, whilst understanding population need and taking a proactive approach may be challenging to achieve in a system that is largely reactive currently, this key element of the Long Term Plan is vital for the sustainability of our health and social care system.

This is another area where your budget impact models and data can play an important role; you often have better data available in a usable format that we can get inside the NHS. However, you will need to tie your approach, data and budget impact models to the prevention agenda and at the same time link that to the key agenda of positively impacting the workload and the workforce (please see earlier article on this topic).

Next time, we will explore how you start to work on the NHS agenda and move beyond your molecule, device or technology to deliver something remarkable within the disease or therapeutic area you work in. In the meantime, if you have any questions, please make contact.

Scott McKenzie is an independent management consultant supporting GP Practices, GP Federations, Primary Care Networks of 30k-50k structure correctly to then deliver high quality patient outcomes with financially viable solutions. Scott is working to support the Pharma, Med Tech and Device Companies better engage and access the NHS. For more information on how we can support you please contact Frances on 0845 388 0302 or email


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