Prof. Jim McManus DIRECTOR OF PUBLIC HEALTH Hertfordshire County Council Vice-President, Association of Directors of Public Health UK
Population Health as a concept and a title has become the flavour of the month. Up and down the country, there has been an awful lot of talk, the publication of many “think papers” on how it will make the NHS more sustainable (for example here https://www.good-governance.org.uk/wp-content/uploads/2018/03/GGI_IBM_PHMwhitepaperFinal.pdf ) and a great deal of events, conferences and seminars.
And everyone has a varied take on it. The King’s Fund have a take on population health https://www.kingsfund.org.uk/publications/vision-population-health which seeks to include wider determinants. Other takes are much more focused on the use of data stratification tools for already unwell patient cohorts at local level.
All in all, it’s easy to conclude that this feels a bit like some bits of the debate around that other much confused term “wellbeing”: everyone thinks they know what they mean, nobody seems to mean the same as anybody else, and everyone has a different set of priorities and focus on what needs to be done.
Wittgenstein famously articulated that we all play language games every time we speak and think, and it seems that the whole issue around population health is a classic example of people knowingly or unknowingly playing language games. Wittgenstein would be vindicated. Or possibly just incredibly confused. And this can be confusing. It also doesn’t help us get to where we need to be.
It seems to me that we need to take some time to exercise a good old-fashioned discipline of going back to first principles, and defining our terms, our engagement and our understanding. So here goes one attempt.
Population Health is really a family of terms not a single term. By it we mean a range of efforts and activities to improve and protect the health of a given population. So what’s the difference from Sir Donald Acheson’s famous definition of Public Health as “the art and science of improving and protecting the health of the population” – to my mind, none at all on one level. Depending on your viewpoint you could see the term as an updated term for public health, or you could see population health as the goal with public health being one of the specialist skill sets which helps us get there. What doesn’t help is that nobody has really made very clear when they’re using which term, whether either of them are interchangeable and what they really mean. So whichever we plump for, I think we need to be careful and consistent in articulating.
NHS England, working with Public Health England, have come up with some common definitions they use. (see figure below.) The trouble is, even those agencies don’t use these terms consistently, because they are new terms. And The King’s Fund and many others don’t mean the same thing necessarily as NHS England and PHE do, either. A recent blog from the King’s Fund seems to be aware of this and tries to address some of it. https://www.kingsfund.org.uk/publications/what-does-improving-population-health-mean
False dichotomies – upstream and downstream together
Seen in light of the NHSE definition above, Population Health Management could be seen as one approach within population health. (The linear relationship of the diagram above risks sending the unintended and untrue message that it’s the only one or indeed the most important.) Population Health Management becomes a subset of public health or population health approaches, where we keep strong focus on wider determinants, place and upstream actions. This definition I can sign up to.
What I can’t live with, and what flies in the face of decades of evidence, is the idea that data driven, clinical prevention efforts in and of themselves will solve the significant health problems of our population. They will be a part. But without addressing wider determinants, we will fail to build a healthier society. The evidence for that in my view is overwhelming.
But equally, it’s not only about wider determinants either. We have an already ill population for whom many things could be done, including reducing persistent unwarranted variations in care. That’s one of the things the NHS Long Term Plan seeks to address. And Population Health Management within that should, in principle be welcomed – alongside a nuanced view.
If we don’t get the balance right we risk becoming too “downstream” after the problems happen and failing to do the upstream. A recent Milbank Quarterly blog highlighted this risk, and the need to stay upstream. https://www.milbank.org/quarterly/articles/the-medicalization-of-population-health-who-will-stay-upstream/
The NHS Long Term Plan, welcome though it is, seen in isolation could unwittingly drive us to a technologized, clinicalised prevention logic which, while it has its place, is by no means the whole story. This is precisely the risk of medicalisation of population health which the Milbank quarterly, among others, warn of. The corrective to that is to welcome the Long Term Plan but emphasise the need to keep wider determinants in focus too. Good education, good jobs, solid foundations for early years, good resilience and a healthy environment are all crucial, and not just in the long term either.
Language and tension
Language matters here, because the concepts and actions and policy frameworks behind them matter. We need to know what we are engaging with, because not being precise risks ignoring the upstream and prioritising the downstream, not achieving the right balance between them.
But so does keeping a dynamic tension. One of the problems with Population Health is that there are in reality multiple discourses. The discourse of place and the discourse of clinical management, and the discourse of intelligence led work, need to be held in dynamic tension as a “both…and” not an “either…or”.
Since my name got onto some list somewhere of people leading population health management approaches, I have been inundated with companies offering me tech solutions to the issues of how we get the population health management bit of this. Important though it is to get data, analytics and systems right; if we don’t get language right we won’t get culture right, and if we don’t get culture right we won’t get systems for managing people right, and if we don’t get that right we might as well not bother with kit. No amount of analytics and IT solves a system that doesn’t articulate and think and commit to a purpose.
The watchwords for public health leadership
So, what can those of us who are public health leaders or engaged in this do as we go forward. Here are my starting points:
- Mind our language – if we don’t confusion is certain
- Articulate the complexity –
- hold on to wider determinants AND downstream measures as being required.
- develop and articulate clearly that Population Health Management is the clinical end of a continuum of work which at the other end starts at addressing wider determinants, addressing risk factors across the lifecourse, place-based and social approaches and the clinical approaches.
- Keep these in tension. We need them all.
- Articulate that this complexity needs a range of skills – from social and behavioural sciences, planners, politicians at one end to informatics specialists, epidemiologists and clinicians with good people skills at the other
- Articulate the culture change we need to deliver for population health across this continuum.
- To narrow down onto one level, there’s no point delivering a pile of analytic software if clinicians don’t have the time, culture and systems around them like ability to refer to non clinical services, which will put that in context.
- Stop buying kit, start building systems and cultures.
- Deliver what we can with what we’ve got now.
- Stop articulating a beautiful future which won’t land without incremental steps to get there. How do we do this now while building the next stage? To take an analogy, how do we still operate a creaky tube station while building Crossrail?