I mentioned in a past blog post that the word “population” in the term “population health management” is open to interpretation. The PHM projects I’ve worked on have mostly considered the word “population” to denote clinical populations, whether they be current or future patient populations. This approach has the advantage of viewing populations as somewhat captive and easier to define since they’re already entered into a system, in this case a healthcare system.
But there are other, equally valid ways of looking at populations, including on the basis of geography. It’s this viewpoint that’s at the foundation of National Health Service (NHS) England’s approach to PHM, namely its so‐called “Place‐Based Systems of Care” program or, as I’ll call it, PBSC. In my opinion this is a slightly more complicated and less straightforward vision of PHM in that, as visionaries of this approach will admit, people cross geographical boundaries all the time to receive medical care, so this formulation requires a somewhat less rigid definition of “population.”
In any event, a good starting place for exploring PBSC is to ask “why would anyone want to organize care delivery geographically as opposed to, say, based on clinical condition or insurance carrier?” Well, at least in the case of the UK, the idea is based on the duality of the “fortress mentality” versus the “system mentality.” This concept was put forward by the authors of a King’s Fund study that urged a collective approach to rationing of healthcare resources as opposed to a “war of all against all” (to quote Thomas Hobbes) in which every healthcare provider is out for themselves and some patient populations thrive at the expense of others.
To set the stage for this discussion, it’s important to note that in recent decades the NHS has devolved many responsibilities to the constituent regions of the UK (England, Scotland, Whales, and Northern Ireland); in other words, the centralized NHS in England has divested itself of certain responsibilities, empowering the different parts of the UK to become more in control of their day‐to‐day activities.
Because of this, groups like the King’s Fund are careful to note the differences (and, in some cases, similarities) between the approach to population health in the different regions. And the literature I’ve seen on PBSC, while referencing successful projects in other UK regions, tends to focus mainly on England. For the above reasons, this blog post will mostly cover what’s going on in England at the moment with respect to PHM.
And it should be noted that place‐based care is probably easier to operationalize in what’s still essentially a single‐payer system (albeit a more fragmented one than in decades past) like the NHS. Although entities outside the healthcare system are integrated into proactive care, and despite the fact that conflicts of interest exist between healthcare systems within the NHS, I have to imagine that on the whole, sharing resources based on geography is probably more achievable than in the relatively more fragmented, competing healthcare systems we have in the United States.
Also important to note up front: despite the major differences that exist between the NHS and the American healthcare systems, they share a few similarities. For one thing, both countries are (just like many nations throughout the world) are dealing with aging populations during a time of scarce resources. Indeed, PBSC recognizes that, even before the COVID‐19 pandemic, healthcare resources were scarce in England.
PBSC and Integrated Care
To control rising costs, in the same way the U.S. healthcare system has turned to accountable care organizations (ACOs) and other alternative payment models, the NHS has in recent years begun experimenting with Integrated Care Systems (ICS). According to NHS England’s website, ICS are “new partnerships between the organisations that meet health and care needs across an area, to coordinate services and to plan in a way that improves population health and reduces inequalities between different groups.” From what I’ve read, it seems that people interchange the terms PBSC and ICS, but there may be a shade of meaning there that’s escaped me.
Officially, ICS were designed to achieve four goals:
- Improve outcomes in population health and healthcare
- Tackle inequalities in outcomes, experience and access
- Enhance productivity and value for money
- Help the NHS support broader social and economic development
In describing ICS, NHS England asserts that healthcare services should be situated as close to people who use them as possible, the foundational argument for PBSC: “For most people their day-to-day health and care needs will be met locally in the town or district where they live or work,” says the agency. “Partnership in these ‘places’ is therefore an important building block of integration, often in line with long-established local authority boundaries.” There seems to be an emphasis on not reinventing the wheel with PBSC, since much of the infrastructure needed to run ICS efficiently is already in place and all that’s needed is a reimagining of how to share resources.
King’s Fund researchers note that a place-based approach incentivizes providers in the same geographic area to collaborate because “health care provision is essentially local and the opportunities to develop systems of care are therefore best pursued among those serving the same or similar populations.” The authors contrast this approach with the “fortress mentality” in which healthcare providers work independently to secure their own resources at the expense of surrounding health systems ‐‐ and, ultimately, to the detriment of patients in neighboring communities.
“Place” Defined
While we’re in the business of defining nebulous terms, before we go any further, we should examine what the NHS and King’s Fund mean by “place” in their PBSC framework. According to an NHS Confederation document, “The NHS has defined ‘place’ as meaning geographies comprising populations of 250,000 to 500,000…Local places also build naturally on previous efforts to integrate care and local services, such as the Better Care Fund and integrated care pioneers. Strategic leadership at the place level also supports the development of primary care networks and integrated care providers.”
Also, the authors of this paper say the following:
“New systems and models need to reflect factors such as geography, rurality and other local needs, and there is no ‘one size fits all’ solution. We believe that place-based systems should be established or amended following local discussion and considering the role of all the partners who contribute to health and care in a place, including housing, employment and training, and emergency services.”
The emphasis placed on encouraging care, even proactive care, beyond the walls of the hospital is key to PBSC, as is the understanding that organizations should have the built‐in flexibility to work across borders. While the latter would seem to fly in the face of the physical boundaries needed for PBSC to work, in fact primacy is placed on improved health outcomes of geographic populations. Therefore, if allowing patients to cross “borders” to receive care will improve their outcomes, this is permissible.
How PBSC Will Operate
I won’t delve too much into the history of how the NHS commissioned healthcare in the past, but suffice it to say that since 2012, as with the U.S healthcare system, the NHS as a whole has been shifting towards value‐based care. As part of the Health and Social Care Act of 2012, Clinical Commissioning Groups (CCGs) were established to succeed Primary Care Trusts, the latter of which used to commission (i.e. purchase) primary, community, and secondary health services from providers and, for a while, provided direct community health services.
Again, not to go into too much detail, but CCGs are groups of general practices (GPs) that decide which services are most appropriate for their patient populations. I couldn’t find evidence of this anywhere, but although healthcare providers were involved in decisions within Primary Care Trusts, I have to imagine that they play an even stronger role in CCGs and (as I’ll mention soon) in whatever healthcare delivery schemes supersede CCGs.
In keeping with this trend to think bigger when it comes to implementing PBSC, the authors of the aforementioned King’s Fund study stress that an approach to commissioning beyond the scope possible within the current CCG framework will be necessary to make PBSC work:
“Commissioning in future needs to be both strategic and integrated, based on long-term contracts tied to the delivery of defined outcomes. Scarce commissioning expertise needs to be brought together in footprints much bigger than those typically covered by clinical commissioning groups (CCGs), while retaining the local knowledge and clinical understanding of general practitioners (GPs).”
In a pared‐down version of the King’s Fund report, ten design principles are identified that will help to operationalize this approach:
- Define the population group and the system’s boundaries
- Identify the right partners and services
- Develop a shared vision and objectives
- Develop an appropriate governance structure
- Identify the right leaders and develop a new form of leadership
- Agree how conflicts will be resolved
- Develop a sustainable financing model
- Create a dedicated team
- Develop systems within systems
- Develop a single set of measures
Another interesting aspect of PBSC is the idea of establishing “population health intelligence” and analytical capabilities to better understand where gaps in care exist. This is also known as predictive analytics. As with the U.S. approach to PHM, NHS England has recognized the need for robust data sources to enable patient segmentation into manageable groups. Indeed, says NHS England, “This typically includes segmentation and modelling to understand future demand across different population groups and care settings, working with PCNs and other partners to understand their population’s bio-psychosocial risk factors, and supporting the implementation of anticipatory care models.”
New Payment Models
Speaking of implementing anticipatory care models, experts seem to agree that perhaps the most crucial step in the successful implementation and maintenance of PBSC over the long haul will be the development of sustainable financing models. If done right, these incentive structures will reward healthcare providers for efficiently sharing resources to provide quality care to patient populations while holding down costs.
I should note here that in my research I didn’t come across any concrete examples of payment models that are currently in use, so I may revisit this topic in a future blog post. At any rate, although this post isn’t meant to contrast new payment models with how the NHS has allocated healthcare funds in the past, a brief summary will help set the stage for the changes that have been accelerating over the past ten years or so.
Let’s start with what hasn’t changed: NHS funding sources. Insofar as I can tell, NHS England hasn’t changed much about how it pays for healthcare in the past decade or so. The King’s Fund says it better than I could:
“The level of NHS funding in a given year is set by central government through the Spending Review process. This process estimates how much income the NHS will receive from sources such as user charges, National Insurance and general taxation. If National Insurance or patient charges raise less funding for the NHS than originally estimated, funds from general taxation are used to ensure the NHS receives the level of funding it was originally allocated.”
But I suspect that in recent years, NHS England has admitted to itself that, going forward, allocating funds simply based on analysis of past spending habits won’t be enough on its own to keep their health system afloat. If I understand correctly, that’s why, in 2015, NHS England established organizations called “vanguards” to help reimagine care delivery that reduces waste and improves care outcomes by trialing new payment models. As a point of comparison, this program shares features with the Pioneer ACO program in the U.S.
In another publication, one of the co authors of the King’s Fund report linked to earlier states that, in order to avoid conflicts in how resources are distributed, paying for healthcare will need to change in three important ways:
- Identifying and pooling collective resources needed to achieve agreed‐upon objectives. “In practice,” the author writes, “this is likely to mean commissioners of health services and local authorities working together to pool their budgets and commission services jointly.”
- Developing new ways of contracting with providers to align incentives behind the aforementioned objectives. The author favors capitation, longevity of provider contracts, and a portion of provider payments being linked to outcomes as keys to holding down costs.
- Lastly, providers should agree on how resources are allocated, and the basis on which costs, risks, and rewards will be shared. The author states, “More important than the technical detail, this will require strong relationships between local leaders willing to work together rather than compete for resources.”
Again, these are general guidelines and not very concrete, so if I see any practical applications of these ideas in the UK, I’ll let you know.
PBSC and Healthcare Inequalities
Apart from effectively using scarce resources, a real effort has been made to try and tackle healthcare inequalities within the system. The subject of PBSC and healthcare inequalities could be a blog post of its own, but suffice it to say that NHS England has foregrounded this issue.
This coincides with efforts being made within the U.S. system to address inequities that were starkly revealed by the COVID‐19 pandemic. Actions already taken to combat this issue in the United States include everything from State Transformation Collaboratives to requiring specific language within some Medicaid Managed Care (MMC) contracts that incentivizes and promotes equality in care delivery. Some of these state‐level contracts even incorporate community-based strategies targeting Social Determinants of Health (SDOH), expanding responsibility beyond hospital walls and encouraging proactive healthcare.
Since improving access to care is a central goal of both PHM and PBSC, we can point to the Wessex Kidney Centre in the UK as a successful example of PBSC in practice. At this site, they have recognized that not all renal outpatient appointments add a tremendous amount of value since each appointment presents a burden to patients, especially considering that originally, clinical visits were set up during times that suited the clinical team. Since routine appointments, which system administrators have designated as a “low value add,” dominate outpatient care at this center, the center realized a change was needed.
This set of circumstances resulted in the team establishing a virtual clinic as a pilot project in which 100 patients participated. The virtual clinic puts patients in the driver’s seat, empowering them to undertake routine monitoring like taking their own blood pressure, keeping track of their weight, and reporting any abnormal symptoms, which they submit virtually to an app as opposed to having to physically visit the site. In addition, patients can schedule any necessary tests at a convenient place and time.
Once all of this is done, the physician reviews the data in the app, a process that takes about five minutes on average. The physician then proceeds to upload their feedback into the app and lets the patient know when the review is complete. At this point the clinician sets up the next “routine” virtual clinic check-in.
Baked into this process is the understanding that if something significant has changed with the patient’s health since their last visit, they are allowed to set up another in-person office visit. When surveyed at the conclusion of the pilot, 82% of patients said they preferred virtual visits, and 57% felt more involved in their care. This is a great example of PHM in the sense that this clinic used technology to streamline their workflow in a way that opened up access to more patients and made patients feel more invested in their own care.
In the spirit of more deeply involving patients in their own care, NHS England has taken inspiration from the Nuka System of Alaska. Administered by the Southcentral Foundation, the Nuka System of Care, which is based in Anchorage, Alaska, has been described as the “result of a customer-driven overhaul of what was previously a bureaucratic system centrally controlled by the Indian Health Service.”
Before 1999, Alaska Native people residing in Southcentral Alaska received their health care from the Indian Health Service’s Native hospital, a large, bureaucratic system controlled from Washington, DC. There was a tremendous amount of waste and dissatisfaction with this system, as patients often waited weeks to get an appointment, seeing different providers each time. In response to residents advocating for changes to the system, Congress passed a federal law that allowed for a complete redesign based on “Alaska Native values and needs.”
Ultimately, residents become “customer-owners” more in control of decision-making and administration. The approach ticks many of the same boxes that PBSC aims to cover: the Nuka System administrators have a shared mission and vision (“A Native Community that enjoys physical, mental, emotional and spiritual wellness”), the system is based on geography (covering a 108,000-square-mile service area), and healthcare providers strive to establish “trusting, accountable and long-term relationships” that allow them to “be in a better position to understand symptoms, answer questions, have meaningful conversations about risks and benefits, and work with each customer to make better health decisions.” As a result, the Nuka System has successfully improved patient outcomes and satisfaction while holding down costs, the aims of the IHI Triple Aim.
I’ll conclude by saying that PBSC is an enormous area of endeavor, and I could write a number of blog posts about it. At the end of the day, NHS had made the decision to undertake this massive reshaping of their healthcare system because they really don’t have any other choice. As with the American healthcare system, there is a substantial amount of wasted time and money that could be used to improve the care citizens of each country receive. I hope we take inspiration from the UK’s example and continue on the track toward value-based care. I will update this post if I learn of any significant changes in the UK’s approach.