Faye Wood August 27, 2020

Population health management. Outcomes: One small word – so many meanings!

Maria Principe, Nottinghamshire Integrated Care System population health management programme director.

This is the first of a number of blogs where I’ll be sharing the Nottingham and Nottinghamshire Integrated Care System (ICS) experience of delivering our six step population health management process. This time, I’m looking at step 1 – Outcomes.

I’m often asked what some of the biggest challenges are when delivering population health management (PHM). Apart from the obvious – analytical capacity, information governance and conflicting policies – I have to say that one of the biggest headaches I’ve come across has to be outcomes!

l learned early on in our PHM journey that in order to segment and stratify the population, we need to have a clear and collective agreement on the outcomes we are trying to deliver. ‘Simples’, I hear you say… Hmmm, maybe not…

When we are looking at delivering a population approach and inviting all sectors to the table, with those partners come their own organisational priorities and interpretations of what an outcome is – and, more importantly, what their boards have signed up to!

In principle, analytical modelling is the easy part. (Sorry analysts, I’m sure you will probably disagree with me.) The difficult part is getting a system of independent entities (which are nonetheless co-dependent on one another) signed up to not only being in the same outcomes boat, but also rowing in the same direction.

This requires compromise, trust and sometimes even a little faith. So, have we got it sussed in Nottingham? No, of course not; it’s a massive task and I’m not sure any system can categorically say that all their participating organisations are signed up to using the same outcome objectives and principles. For your own sanity, don’t try to boil the ocean! (I’ve worn the scars on this one).

Get on the same page

My first piece of wisdom (if you can call it that) to make your life easier would be to ensure that organisations across your system share the same understanding of what an outcome is. Everybody talks about outcomes, and the world and its mother talks about delivering improved outcomes, but when you get down to the nitty gritty and ask “what do you mean by outcomes” you will see that the word and its meaning get interchanged between outcomes, performance metrics, interventions and enablers.

‘Health’ has a beautiful outcomes framework; it’s comprehensive, clear and says the right thing. But the challenge is that this framework does just belong to ‘health’ and it doesn’t necessarily pick up local authority priorities. Some also argue that it has an undercurrent of performance metrics. So, a priority in this step of PHM is ensuring you have a shared understanding of what ‘outcomes’ means to your group.

I would suggest using a test area first. Get clinical, transformational and analytical experts to create joint outcomes for a specific area; this aligns your outcomes bottom up and makes them meaningful. We did this with diabetes (click here to find out more). It may be that once you begin these discussions you find that you are all on the same page (let me know if this is the case; I’ll go looking for the gold plated, singing unicorns). Or, like us, you might soon realise that you have different objectives that complement each other, but require different data and sometimes a different approach. This is when the compromise begins, but getting this section right is the key to your success and is where we gained our valuable final lesson in this section.

Hold your nerve!

I cannot tell you how many times when we start to do a PHM review and discuss outcomes, the discussion goes straight to what interventions we want to deliver, or gets hung up on the variation in “must dos” (although, to be fair, these are often nationally dictated).

Try not to let that shape your outcomes conversation. Holding your nerve will enable you to have really important conversations with partners to understand what is important to them and their view of what’s important for their population. Then you can have the discussion on what is an outcome and what is an enabler. In the world of PHM that technicality doesn’t really matter; what matters is that we are clear about what we are trying to deliver, and that everyone shares that view.

Who we deliver it for is the next step. Second blog to follow soon.