The importance of population healthcare in commissioning

Source: NHE May/Jun 2016

Sir Muir Gray, director of Better Value Healthcare, discusses the importance of commissioning for population healthcare.

As a veteran of twenty-two, or thereabouts, structural reorganisations of the NHS I have long lost faith in them. The reason why structural reorganisations fail is because the bureaucracies we organise are linear organisations, able to do linear tasks like the fair and open employment of staff.  Health and healthcare problems are complex or non-linear and, therefore, cannot be solved by linear organisations, important though they are. What is needed is to develop the other two bits of its organisation – its systems and its culture. 

Integrated care, another recent fashion, is a laudable initiative but it is much simpler to start not by looking at the bureaucracies that have to be integrated, but looking at the population served. Currently in the NHS we cannot answer simple questions such as those set out below: 

  • Is the service for people with seizures & epilepsy in Manchester of higher value than the service in Liverpool?
  • Who is responsible for service for all the women with pelvic pain in Birmingham?
  • Which service for people at the end of life in London provides the best value? 

It is often impossible to find people in a room full of highly committed and expert NHS professionals who are able to answer simple questions like: 

  • How many people are there with

   Type 2 Diabetes in Barsetshire?

  • How many people are there with complex needs in Coketown?

The aim of population healthcare 

Over the last four years, Public Health England working in partnership with the Right Care team has developed the concept of population healthcare whose aim is: 

“To maximise value and equity by focusing not on institutions, specialties or technologies, but on populations defined by a common symptom, condition or characteristic, such as breathlessness, arthritis, or multiple morbidity.” 

Work is progressing to develop system specifications for people at risk of stroke and vascular dementia because of atrial fibrillation and people at risk of falls and fragility fractures. There are about a hundred populations with problems like these two; populations in which we are probably spending about half a billion pounds a year.

Work is also focusing on people with even more complex needs. For example, people in the last year of life or the most complex yet tackled: single homeless people. 

Measuring value 

Population healthcare is of vital importance to Right Care and people working on commissioning in NHS England because it is only by using the population as the denominator that we can measure value. 

By comparing the outcomes with the resources used for the patients treated we can measure efficiency, but value requires us to think not only about the patients treated but also about the people who are not treated, and also the possibility of overuse even if the quality of care is high. Overuse can be of low value and can lead to patients being harmed.  

It is important to emphasise that population healthcare and personalised healthcare are two sides of the same coin. As we invest more resources in healthcare the benefits flatten off, the harms continue to rise in a straight line and the difference between benefit and harm is a J-shaped curve as first described in 1980 by Avedis Donabedian. 

From the point of view of the individual patient as we put more resources in people  who are less severely affected are offered treatment, and for each individual who is less severely affected the size of benefit will be less, but the probability and magnitude of harm will remain constant. 

For the future, therefore, we need to think of population and personalised healthcare. The new planning guidelines emphasise the importance of population-based planning, and the Right Care programme is developing its decision support and patient decision aid work. This is to ensure that every patient making a decision does so in full knowledge of the probabilities of benefit and harm and how these relate to their values.

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