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Ginger Root June 8, 2020

Top ten tips for Population Health Management (PHM)

Maria Principe, PHM Programme Director for the Nottingham and Nottinghamshire ICS, gives her top tips for anyone working to deliver population health management.

Population Health Management (PHM) is one of the key ways that we at the Nottingham and Nottinghamshire Integrated Care System (ICS) are working to develop the most effective and efficient system integration across our patch.
The city and county both have areas of high deprivation and the PHM approach will help us to focus on reducing inequalities and to work together across health and care to improve wellbeing for everyone.
PHM requires health, local authorities and other stakeholders to come together in new ways and we are proud of what we have achieved together so far. Here are my top tips for developing a successful PHM programme.

  • PHM is complex, but you don’t need to do everything at once. Create a simple approach. Choose little steps to achieve big transformations.As a relatively new way of working, PHM can seem a little overwhelming. However, by thinking big but starting small, you can show the impact of PHM and get everyone behind it with some relatively quick wins. Use the segmentation methods available to select a group you’d like to target, such as the frail elderly, and start with just one intervention. Measure the results, share the learning and take it from there.
  • Begin the information governance (IG) process as early as possible. There is a lot of data out there that is useful. Start the conversations within your system (and don’t forget wider determinants!).Get started on information sharing agreements and shared IT systems as soon as you can – with the best will in the world, it will take time to iron out all the IG issues. Information sharing across health, local authorities and the voluntary, community and social enterprise sector will be essential in the long run to maximising the opportunities offered through PHM.
  • Be clear on your outcomes. If you don’t have clear outcomes, you cannot target your interventions.Working through the PHM approach – Joint Strategic Needs Assessment (JSNA) analysis, population segmentation, risk stratification and impactibility – will help you to decide on the most appropriate, measurable outcomes and to pick an appropriate evidence-based intervention.
  • Don’t get hung up on the segmentation process. It is a means to an end, and can be sliced any way your system feels is relevant.There are a number of different ways to segment a population and some are more straightforward than others. A new guide has been published by the NHS, produced with a range of partners including ICHP, that makes it clear that while some methods need integrated data, there are some we can all have a go at today. It doesn’t actually matter which method you choose as long as it gives you the information you need to get started.
  • Pilot PHM on a test area, but ensure you have an integrated membership. Health only influences up to 11 per cent of an individual’s health and wellbeing, so it’s imperative to involve wider stakeholders in PHM projects. PHM is an area for all the partners whose work affects our health and wellbeing to focus on, and it will live or die depending on the ownership across a system. It’s crucial that ICSs engage with partners to get them on board and see the benefits to everyone of working together in this way.
  • We cannot afford to buy fish from our own pond! Use and develop local resources wherever possible by utilising your own teams such as researchers, analysts and public health – you want a rod, not a fish!You don’t have to buy in external support, although you could to get started. Your own data teams can be trained to carry out new kinds of analysis, and your clinical leaders can help support work on the ground, once they are on board with what you’re doing.
  • Make sure the data you produce is meaningful. Commissioners and providers want to do the right thing, but at the moment financial pressure is on. Use PHM to help, not hinder.Don’t think of PHM as an additional task – it’s actually a facilitator to you achieving what you want. By carefully targeting the groups where an intervention will have the greatest impact, resources can be better allocated to where the biggest difference can be made.
  • Leave finance until last. This way you will sustain clinical engagement, and will be focusing on where variation is, not where the money is! (Hold your nerve; money will follow improvement.)Again, clinical engagement is crucial to delivering a successful PHM programme and new ways of measuring outcomes and innovative ways of working may mean you need to develop new contracting agreements. Getting bogged down in the finances will just hold you back.
  • Have a clear 12-month plan and ensure your PHM decisions support group is updated on a regular basis.Keep everyone engaged and informed so people can see the progress being made. Make sure PHM is shown to deliver real results so it’s not just a concept or a ‘nice thing to do’.
  • Be prepared to be ignored. It’s not personal. Your system has a million priorities. You are one of them, but lower down the food chain. The nudge theory works… slowly, slowly.By starting small to get the evidence of the difference a PHM approach can make, and sharing the learning across the system, you should be able to demonstrate its value and get people interested in how it can help them.

Find out more about Nottingham and Nottinghamshire ICS at You can also read a blog ( from Dr Andy Haynes, Executive Lead, on why PHM is essential to system integration.