Authors: Paul Corrigan, Care City Chair and Jenny Shand, UCLPartners, Care City and UCL

Health problems are complex and in most cases a single health issue may be influenced by interrelated social, environmental, and economic factors. Yet most medicine acts as if it alone is in charge of the processes that lead to health and ill health. But if the health service could  recognise the multiple influences on health status, and that the impact medicine  alone can have on health is limited, there is an opportunity for the NHS to collaborate with other sectors to create a more holistic approach and as such have a wider benefit. Population Health Management is a growing idea in the NHS and is accentuated in Januarys long term plan [1]. It aims to take a systematic, data-driven approach to improve the management of health risks in a population, and in turn reduce or delay the onset of health care needs. The Care City Cohort is an example of how this is working across Barking and Dagenham, but more about that later.

However whilst the leadership of the NHS in England may be arguing for the better management of the health of populations, the regulatory system for hospitals and NHS trusts requires them to break even on an annual basis. They are performance managed with vigour not to have a deficit on their annual budget. This makes upstream investments with benefits that arrive beyond that first year difficult to justify to Directors of Finance who are told to concentrate in year let alone implement. Whilst there is sustained system wide ambition for integration and whole system working [1] , the regulatory system run by those with that ambition still requires individual organisations to be stable and sustainable. If an organisation recognises that managing the health of the population requires  system wide collaboration, then that activity risks negatively impacting either clinical, operational, or financial performance of individual organisations. It will pose risks to meeting the obligations imposed through regulation. In addition, there is seldom the data in place to make the case for population based action.

However, the actions of different organisations and different sectors can have an impact on population health. If the regulatory system on individual organisations would allow it, the costs or benefits of the decision can be incurred by those other than the decision maker. The example of the reconfiguration of stroke services across London can be used to illustrate.

In 2006, one of the recommendations of Healthcare for London [2] was to reform the provision of stroke services across London, in part to implement research from 1995 that demonstrated the benefits of rapid access to thrombolysis for certain stroke patients [3]. This required immediate interventions 24/7 which the existing local hospital model could not fund. There needed to be a movement to all patients being initially treated in a Hyper Acute Stroke Unit (HASU) for the first 48 to 72 hours of care after a stroke. After that period those not ready to be discharged home are transferred to an Acute Stroke Unit (ASU). Across London, this required a reconfiguration of services from 34 hospitals appearing to be able to treat stroke patients at the moment of the stroke to eight HASUs supported by 24 ASUs.

There were extensive costs associated with implementing the new model. For London it was estimated that £10million was invested in capital and consultation [4], and that staff costs increased by £20million in the first year [5]. At 90 days, the model was cost effective, with £811 less costs per patient [4]. However, these savings were largely recouped in social care costs as patients were requiring lower levels of ongoing support due to higher levels of functioning and therefore lower social care needs.

However the cost benefit analysis when viewed at an individual hospital level would not justify the investment required to implement the service reconfiguration. However, from a system wide perspective, given the new model was cost effective at 90 days, and the investment required to implement the reconfiguration was recouped within two years, changing the configuration of services to achieve a new level of e.g., thrombolysis was achievable.

The benefits to patients were extensive, with reduced mortality and better levels of functioning. Therefore, the consequences associated with hospitals not implementing the new model of care would have been continued high levels of mortality from a stroke and poor levels of functioning for patients that survived. In this instance, hospitals were incentivised to implement the new model, by the NHS system investing the £10million required for capital investment, and a 50% increase to the tariff from £4765 to £7193 [5], to account for the increased staff costs.

In the stroke example, the full information on the cost and benefits of different courses of action was not known until after the implementation had taken place. However, delivering on population health management requires more than having the data to show the system wide analysis of cost and benefits of different courses of action. It also requires a system of implementation, clinicians, front line workers, organisation leaders to come together to commit to making changes for the benefit of the population.

The point of population health management is to actually better manage the health of the population and that needs health care and other interventions to be organised differently.

In Care City we have been working with a unique dataset, the Care City Cohort, of Barking and Dagenham residents from 2011 to 2018. It brings together data from local government, health providers and health commissioners that has been linked at the individual level to create a dataset for each individual of their own characteristics (e.g. age, gender, ethnicity, smoking status and body mass index, prevalence of long term conditions), information about where they live (e.g. levels of deprivation, household occupancy and household tenure), and information about their health and social care service use (e.g. Accident and Emergency attendances, GP contacts, social care packages, mental health inpatient stays), along with the unique property number to facilitate household level analysis. This dataset is due to be updated on a quarterly basis and be launched to the wider research community in January 2020.

We are excited about the potential this linked data has to inform and confirm opportunities for better management of the health of the population. We are even more excited about the potential to deliver real change if the insights from the data can be developed in partnership with the health and care workforce we collaborate with to confirm how and what we need to do to make population health a priority for all.

References

1. NHS England. The NHS Long Term Plan. 2019.
2. NHS London. Healthcare for London: A framework for action. London; 2007.
3. National Institute of Neurological D, Stroke rt PASSG. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581-7.
4. Hunter RM, Davie C, Rudd A, Thompson A, Walker H, Thomson N, et al. Impact on clinical and cost outcomes of a centralized approach to acute stroke care in London: a comparative effectiveness before and after model. PLoS One. 2013;8(8):e70420.
5. Porter M, Mountford J, Ramdas K. Reconfiguring Stroke Care in North Central London. Value in Healthcare Delivery; London: Harvard Business School and UCLPartners; 2011.