15 January 2025
Our recent Population Health Management (PHM) reviews with several Integrated Care Boards (ICBs) have provided valuable insights into evaluating and adopting best practices across the wider healthcare system.
During a recent workshop with ICBs, we explored different approaches to addressing existing gaps and challenges in PHM, examining new ways of working and delivery models. Key opportunities discussed included identifying patient needs, leadership and system working, supporting patient outcomes, and addressing infrastructure requirements. We asked attendees what resonated with them, and notably, many stakeholders highlighted the importance of using PHM to inform resource allocation, as well as evaluating PHM interventions to demonstrate their benefits, and bringing together system analytical resources to support PHM.
Common PHM themes we identified
Fostering a whole-system culture of PHM
Adopting a whole-organisational approach to PHM is crucial, rather than assigning responsibility to a select group of individuals. Embedding PHM ‘top-down’—including in commissioning, resource allocation, and governance—encourages organisational responsibility. Simultaneously, a ‘bottom-up’ approach is essential to drive local population health improvements, such as through neighbourhood teams implementing population health improvement cycles. Decisions around resource allocation and commissioning should be driven by a deep understanding of the population's needs. This whole-system approach ensures optimal resource use and effectively addresses the unique needs of underserved populations in each area.
Making sense of PHM analysis
Developing a concrete definition of PHM that is adopted by the entire system can be challenging and resource-intensive. Instead, making the insights from PHM analysis as clear and understandable as possible ensures they can be effectively acted upon by those on the ground. A narrative-based approach, rather than simply presenting a list of statistics, can help achieve this. Additionally, staff should invest time in accurately defining the questions that need to be answered, potentially using tools such as logic models to guide the process.
Multidisciplinary working is key
While training staff in data analysis has its merits, equipping a large workforce with these skills alone is unlikely to fully address the challenges of advancing PHM approaches. Instead, data analysts and those operating on the ground should work together in multidisciplinary teams, with analysts providing clear and actionable insights, and those on the ground working to action those insights. This requires well-defined roles for all team members, alongside clear lines of accountability. It is also important that all analysis and actions are tied to the agenda of the system as a whole.
Evaluation is essential for cost-efficient resource allocation
Embedding an evaluative approach and mindset throughout the whole healthcare system is essential. Given the current financial pressures faced by ICBs, evaluation is often one of the first elements removed from project proposals to reduce costs. However, this practice is not in the long-term financial interest of Integrated Care Systems (ICSs), as it can lead to inefficient resource allocation due to a lack of necessary information. Evaluation should be built into any service or initiative from the outset, ensuring there is a solid evidence base to inform resource allocation decisions and promote cost-efficiency.
Data collection is not for performance purposes, but for improving the lives of patients
It is crucial to communicate to staff that data collection is not just for measuring performance, but ultimately to improve patient outcomes. By emphasising this, those responsible for data collection would be more motivated to adopt a rigorous approach. This shift in perspective could also spark greater interest across the healthcare system in how the data could be used and the insights it could generate, thereby increasing engagement with PHM as a way of working.
How we can help support your healthcare organisation
Our health and care research, evaluation and analytics team has extensive experience working within the healthcare sector to generate evidence for change, aiming to improve health and care outcomes. From a PHM perspective the team offers a comprehensive review of population health maturity for ICBs through a tried and tested progress matrix, as well as solutions to support assessment, modelling, monitoring, and evaluation. Our approach focuses on using data and evidence to drive meaningful change.
For more information or to discuss how our tailored solutions can support your healthcare organisation, please get in touch with Steve Hodgson.

