Enlightened policymakers have moved beyond just looking at health and social care integration, and are looking to population health management to safeguard the future of the people they serve. Population health management recognises that people's lives involve more than health and social care. Education, housing, and employment all have an impact on how people use those services. Integrated care is striving to achieve person-centred care, but the current approach is only looking at health and social care. Population health management sees the bigger picture.
This means delivering targeted services based on the specific needs of patient populations. Frail elderly populations are growing, for example, and the number of people available to look after them is falling. We need to identify the care needs of such groups and develop health systems that meet those needs effectively and efficiently.
Other countries are aiming beyond integrated care and looking at population health management. The UK could learn some valuable lessons.
The Counties Manukau District Health Board in New Zealand has identified specific groups of the population, and tailored health and lifestyle services, including a healthy housing programme for such groups. Smoking cessation and immunisation rates have increased, and hospital usage is below expected growth rates. Such an approach could help with the pressures facing UK emergency departments.
Spain's Balearic Islands have integrated primary, secondary and social care services for people with chronic conditions such as Chronic Obstructive Pulmonary Disease. The NHS calls these 'frequent flyers'; in Spain, hospital visits are down by 70 per cent. For a small proportion, hospital visits have increased, but patients are using hospital when appropriate.
Involving people in care planning can reduce the pressure on primary care and GPs. The Electronic Blue Book in New South Wales, Australia, sees parents take control of many care activities for their children. This helps to encourage positive health behaviours, and cuts unnecessary appointments as clinicians intervene only when needed. The NHS could draw from this experience for its own digital Personal Child Health Records.
Ontario, Canada has developed its Integrated Assessment Record, which joins up information across community care. This helps providers understand the needs of specific populations, and adapt services to meet those needs. If UK regions are to take on health and care budgets, such an approach would act as a foundation.
Information sharing is crucial for care coordination and population health. But sometimes the fragmented nature of health and social care can act as a barrier. The devastating 2011 earthquake in Canterbury in New Zealand meant that policymakers, clinicians, technologists, and patients had to quickly ensure wider access to a patient's information. Individuals needed access to appropriate care from a range of providers. Different agencies came together to take the necessary steps to share information between them. This has helped both service delivery and design.
It has not taken a disaster for Northern Ireland to start doing something similar with its electronic care record. Two Northern Ireland Trust diabetes specialties have created a shared diabetes care pathway and are using this in a discovery phase of diabetes population management. Rather than focus on institutional barriers to collaboration, clinicians are developing a patient-centred approach to care.
Such relationships are essential steps on the journey to population health management. Financial incentives are part of this journey, and are often the most difficult to align. There is no perfect system in place.
But lessons from around the world can show the UK how to move beyond integrating health and social care. Policymakers and professional should look ahead now, rather than look back on opportunities missed.