by Sarah Parker, Surrey Heartlands Director of Transformation and PHM Lead

This week (24 February) is a key milestone for Surrey Heartlands Integrated Care System as we launch our Population Health Management (PHM) Wave Two programme.

Population Health Management  may only be three words but the scale of the task and the potential rewards are huge – an opportunity to build a long-term plan for people’s all-round health and wellbeing needs and, crucially, to collaboratively take a more preventive and proactive approach to their care.

 This isn’t just about statutory health services, it’s about working together with our local partners, from councils to voluntary groups, to better serve our communities. The PHM approach is a cornerstone of how we will build these partnerships and make sure our citizens remain at the heart of everything we do.

 Put simply, PHM is a way for local health and care partnerships to use data to design new care services and improve everyone’s health and wellbeing. It means we can predict future health and care needs and make sure we are using our resources, not just financial but our amazing staff, as efficiently and effectively as possible.

 This data is already collected by various organisations – the NHS, local authorities, housing associations, support groups etc. – and by joining the dots, we can see the bigger picture of what it is that people need to live healthy, fulfilling lives.

 For example, it is estimated that only 20% of a person’s health outcomes are impacted by clinical care alone. Factors such as employment, education and housing quality all have a huge impact, and that is why it is vital that all responsible organisations work together on keeping our local populations healthy.

 For residents and patients, existing local services can be tailored better to meet their needs and new approaches can be developed in partnership with them, listening and learning to the impact of poor health on their lives and focusing on what their goals are and how to achieve these. These might be things like seeing grandchildren, cooking for family or getting back to social sports – the real motivations for recovery or managing better. Local services, individuals and communities can then work together better to come up with better solutions that will result in less dependency, isolation or worsening health.

 There is no doubt that Primary Care Networks and the  teams within those networks will be key to the success of our PHM programme, forging a path that can then be spread across the whole of the Surrey Heartlands ICS and help us  predict better than ever before what the system needs will be in five to 10 years’ time.

 The programme is already supporting teams around our PCN footprints to work more closely together. Local councils, social care, public health, GPs, nurses and secondary care staff are coming together to discuss and plan patient care.

As we prepare for NHS England’s Integrated Care Week, Population Health Management is a great example of how systems can work more closely together around the needs of the population.

 Of course, a programme like this is not without its challenges. When it comes to pulling data together, there are so many different systems in place that this is definitely not a straightforward task.

 And then there are the issues of implementing a new approach when organisations are so busy just managing their day-to-day tasks. There is no doubt when fully up and running, the PHM approach should take some of the pressure of staff across the system, but those benefits won’t happen overnight.

 However, learning from the national Wave One pilots, as well as NHS England’s PHM Academy, has been invaluable and has really demonstrated the importance of building relationships at every level (neighbourhood, place and system) to achieve a fresh, data informed approach to health and care. 

 I am convinced that in the long-term, the PHM approach will help us reduce the health inequalities across Surrey Heartlands, through a shift of focus to wellness and targeted personalised care; making a real positive difference to the lives of over one million people in the Surrey Heartlands area.