Steve How and Paul Midgley explore how the NHS is tackling the rising tide of disease
The NHS has historically focused on diagnosing and treating illness, however, disease prevention is becoming as important as cure in the battle to cut costs and ensure the long-term sustainability of the service.
In line with this, the NHS is embracing a concept known as ‘population health’, which aims to improve patient outcomes and reduce health inequalities for entire populations – including people who are not currently in need of NHS treatment.
The NHS hopes that this proactive approach, which involves looking at a wide variety of factors that can affect an individual’s health, will help to reduce future demand on its services in an era where the number of people living with multiple chronic conditions – many of which are preventable – is on the rise.
In this article, we explore what population health involves; how integrated care systems are working towards it and how pharma should dovetail its value proposition with this holistic whole system healthcare approach.
What influences health?
The healthy life expectancy gap between the most and least deprived areas in the UK is 19 years. Interestingly, however, just 10% of the population’s health and well-being is linked to access to healthcare. The remaining 90% is believed to be influenced by a variety of other factors ranging from diet to housing, money and resources, family, friends and communities.
In recent years, health policy has focused on funding, organising and delivering services to treat ill people, with insufficient attention being paid to population health outcomes and the factors that shape them. However, now the NHS wants to better understand these variants in order to keep healthy people well, nip illnesses in the bud and improve the management of existing conditions.
For this to happen, a number of basic building blocks must be in place regarding infrastructure. These include digitalised care providers and a common health and care record. Advanced analytical tools and software and system-wide multidisciplinary analytical teams, supplemented by specialist skills, will also be needed to gather the intelligence needed to design new care services.
Integrated care models will be key to enabling a population health approach within specific localities, particularly NHS Neighbourhoods, which cater for populations of between 30,000 to 50,000, and involve all services – police, health, housing, fire service, leisure and other local authority funded services and social care – working together more holistically within defined geographical areas.
Population health management
Population health management is the term used to describe the delivery approach that enables healthcare systems to better organise care pathways. It involves the segmentation and risk stratification of groups of patients, followed by impactability modelling to identify local ‘at risk’ cohorts. While segmentation and stratification identify people most at risk of needing future care; impactability revolves around predictive analytics and goes a step further in trying to identify people who could most benefit from particular interventions, allowing for more effective, personalised treatment plans.
For example, by using this type of analysis, patients could be divided into three broad categories – high risk, emerging risk and low risk. Services could then be tailored to meet the needs of these groups, which might vary from complex care management programmes for those in the high-risk category to proactive risk-based case finding and management; prevention programmes; social prescribing and community initiatives for those in the middle category. Low risk patients would be targeted with wellness and selfcare programmes.
In terms of progress, Sustainability and Transformation Partnerships (STPs) have a clear plan in place for population health management and they are beginning to engage with GPs and other key stakeholders. However, the 14 Integrated Care Systems (ICSs) are much further down the line and working in formalised integrated teams that include social care and the voluntary sector with easy access to secondary care.
There is functioning interoperability between providers of care in ICSs, including read/write access to records and data sharing agreements. The system can track data in real time including visibility of patient movement across the system and between the segments and obtain information on variability. New models of care are in place for most population segments including both proactive and reactive models with standardised protocols in use across the system. There is also systematic population segmentation, including risk stratification, and care plans for high- risk patients.
The prevention agenda and pharma
At the moment, pharma operates within the 10% sector of the population’s health and well-being that is linked to access to healthcare. However, it must begin to think across the whole system in order to understand how the wider determinants of health could affect where and how money is spent. For example, in the future it might be argued that improving conditions in damp housing, eg with the use of antifungal paint would be more effective for managing and preventing illness in people with respiratory problems than drugs, and critically both approaches are funded from the same budget and strategic plan.
The importance of diet for disease prevention and management is already being recognised and acted upon by the NHS in diabetes management. For example, NHS England recently announced that thousands of people would be offered a very low calorie diet (VLCD) by their GPs in the hope of reversing type II diabetes.
The 800-calories-a-day diet of soups and shakes, allied to a personal support package, has been shown to help people lose excess weight including the fatty build up around internal organs, such as the pancreas, which leads to type II diabetes.
To engage with the NHS on the prevention agenda, pharma needs to wrap its value proposition around a service that adds real value to the NHS rather than simply providing a product. Indeed, the wider system benefits that such a service could deliver may mean that it offsets the cost of a more expensive product for a particular cohort of patients.
On the issue of diet, for example, pharma could review patient care around this topic for diabetes and other conditions. This could provide valuable insights for population healthcare management programmes and lead to a quicker uptake of appropriate drugs for appropriate patients, resulting in improved outcomes.
Segmenting ‘at risk cohorts’ of patients is another key way in which pharma can support population health management. This could involve exploring the complexity of a condition such as diabetes, which can have many variables. Gathering data around different stages could be invaluable in helping to ensure that patients receive the right treatment at the right time and that costly complications are avoided.
With diabetes and other serious diseases expected to continue to rise, pharma also needs to help the NHS define how to manage healthy people and prevent them from becoming ill. Engaging with children is going to be particularly important around diabetes and this could involve supporting educational programmes in schools to promote healthy eating and regular exercise. If this activity is funded as part of the same budget as diabetes drugs, supporting the service and service outcomes could give significant added value.
The development of cost-effective tests to predict disease and associated care pathways that enable proactive action to be taken in the form of appropriate lifestyle changes or drugs is also very important. For example, one hospital trust has been piloting a pathway to investigate abnormal liver function tests and staging of Non-Alcoholic Fatty Liver Disease (NAFLD) in primary care by the use of non-invasive blood tests. Patients can then be categorised into low and high-risk categories and managed in primary or secondary care, appropriately. Helping the NHS to develop these kinds of pathways could bring considerable savings since liver problems can lead to complications such as hepatitis and liver failure, which require expensive drugs and possibly even liver transplants.
Understanding the many factors that can influence an individual’s health and using this intelligence to develop new integrated care models that help to prevent illness, reduce the risk of hospitalisation and tackle health inequalities in defined cohorts of patients is key to the future sustainability of the NHS. These new and innovative ways of working are unlikely in the short term to see a reduced reliance on drugs but will lead to an increased emphasis on more holistic ways of improving the nation’s health, such as changes in diet, exercise and living conditions.
Pharma must view these changes as an opportunity rather than a threat and ensure that disease prevention is at the heart of its business strategy. This involves going above and beyond simply selling drugs to defining whole system benefits that enable the NHS to deliver timely and appropriate treatment, where needed, and help people to stay healthy for as long as possible.
Steve How and Paul Midgley are part of Wilmington Healthcare’s Consulting Team. For information on Wilmington Healthcare, visit www.wilmingtonhealthcare.com