Solving complex health issues at scale

What is population health?

Population health is about improving the health of an entire population, improving the physical and mental health outcomes (and wellbeing) of people, whilst reducing health inequalities within and across a defined population.

It includes specific action - often linked to prevention - in order to reduce the occurrence of ill-health in the first place.

This includes addressing the wider determinants of health (social, cultural, political, economic, commercial and environmental factors that affect people in how they are born and raised) ​​​​and requires close working with communities and partner agencies to find solutions to these complex health challenges.

What is population health management? 

Population health management (PHM) improves population health by data-driven planning - and delivery of care - to achieve maximum impact.

It includes complex data processes in order to support future transformation priorities.

  • Data segmentation (dividing population data into similar groups and clusters)
  • Data stratification (sorting  data, people and objects into groups) to identify ‘at risk’ cohorts of people

This enables health and care systems to design and develop more targeted treatment interventions to prevent ill-health.

PHM also improves care and support for people with enduring long-term health conditions and reduces unwarranted variations (care which is not consistent or meeting the needs/desires of the patient).

Developing a population health led system  

We are developing our ICS as a population health led system to help us deliver our key aims - to improve the health of people in communities across South Yorkshire and Bassetlaw, to reduce health inequalities and improve health outcomes.

To achieve this, we are working closely with our health and care partners to improve services. This involves looking at how to support people to manage their own health through the help of technology, such as health apps and online systems.

Above all, we want to improve the consistency of care across the system - regardless of where they live. It is essential that individuals and carers/representatives feel like they are getting the same level and access of service if they have a protected characteristic or are at a disadvantage due to factors outside of their control - employment status, housing environment or social welfare status.

If we can address these factors we stand a better chance of creating a fairer and more accessible health and care system that truly focuses on what matters most to each person. 

There is also a need to ensure that we improve health more quickly for groups with the greatest/most profound needs.

By looking at whole population needs - and not just those accessing services - we are able to utilise the power of innovation to bring about rapid and long-lasting change. Through digital technology which has worked to great effect during the COVID-19 pandemic to maintain services, we will be able to identify and understand why there are different standards of care and work to resolve these across SYB.