The shift to a comprehensive population health management approach is a huge change management challenge. But there are tools and support available to help to make it a reality, write Rebecca Richmond and Alex Miller

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Population health management is a bit like world peace: most people would say it’s a good idea, but they’re not sure how to make it happen – or even what it means.

According to NHS England, population health management is “the critical building block” for integrated care systems. It says that “better partnership working using PHM to join up the right person with the right care solution helps to improve outcomes, reduce duplication, and use resources more effectively.”

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At Optum® we are working with integrated systems across the country to support them to embed a PHM approach. But while there is a lot of enthusiasm – passion, even – challenges remain.

Definitions remain a key issue. When we work with healthcare leaders, one question we always ask is how they would rate the degree of common understanding of PHM across their organisations, from one – indicating that PHM means something different to everyone, to 10, where everyone speaks the same PHM language. Without fail, they grade it at two or three. In other words, they can’t confidently say their system understands and agrees on what PHM means. This is quite illuminating when you consider that by April 2022, they are supposed to become part of integrated care systems built on the pivot of population health management.

Rebecca Richmond 3x2

Rebecca Richmond

That’s not to say they aren’t keen to do it – they are. There is a real appetite for using linked data to get a much richer understanding of a community so that we can start conversations with patients and citizens from a fundamentally different place. It is essential to get everyone using the new language with the same understanding.

Alex Miller 3x2

Alex Miller

So what do we need to do? First, we must agree what we mean by PHM: that definition must be shared at every level and in every part of an organisation and wider system – not just in healthcare, but in local authorities, third and independent sectors, and in the community more generally.

Next, we must ensure that a PHM approach is implemented comprehensively. That means taking stock of data assets, being able to link data, then using analytics to interpret it. Translating data from multiple sources into action is vital to pinpointing where a system’s efforts should go, whether the challenge is clearing the backlog or reducing health inequalities.

Trying to persuade an exhausted workforce that PHM isn’t adding to their burden, but will alleviate it, isn’t easy. But we sincerely believe – and the evidence supports this – that intelligence from PHM enables those working in healthcare to better prioritise how they spend their time to have the maximum impact. Working smarter not only saves time, but it means a better experience for clinicians and patients.

It is also critical that systems understand medicines optimisation is part of PHM and it mustn’t be siloed off or left out of the conversation. Using a PHM approach can transform a system’s medicines optimisation efforts, by ensuring that every prescription is the right one at the right time, and maximising the likelihood of effectiveness. Medicines data also plays a crucial role in building up a picture of a population’s health, so it works both ways. Effective clinical decision support tools are a key enabler to take PHM from a system view and translate that intelligence to a single patient on the GP desktop.

The shift to a comprehensive PHM approach is a huge change management challenge, and we’re not trying to minimise that. But there are tools and support available to help to make it a reality.

When you truly grasp the opportunities of PHM, and watch it take root and flourish across integrated systems, then you can make positive change happen. And that’s language everyone can get behind.


Rebecca Richmond, director of population health management, Optum UK,

Alex Miller, director of product (medicines optimisation), Optum UK