Accelerating population health improvement

Define and co-design

Identify a group of people with similar needs or characteristics for whom a portfolio of interventions might improve outcomes. Start with the question, “Who is not thriving?” to identify broad populations, such as adult mental health or children and young people’s health, and then select more specific population segments to focus improvement efforts by identifying an aim and changes to test, such as reducing suicide rates in men aged 16-24 in a particular geographical area. The King’s Fund defines four interdependent pillars as the “system” of population health: individual health behaviour and choices; the places and communities that individuals live in and with; an integrated health and care system; and the wider determinants of health.16 These can be used to help define the population. A three part data review is also useful for population stratification to better understand the needs and assets of the population, which then inform the design choices to improve outcomes.17

Bold ambitions for population health improvement need to be supported by aims that specify how much, by when, for whom, and where. Start by developing a bold purpose statement such as “being the best place to grow up.”18 Next, create more specific and measurable aim statements that relate to the population rather than the service; for example, under the “best place to grow up” the vision could be “90% of all children in each community planning partnership area will have reached all of the expected developmental milestones and learning outcomes by the end of primary school) by the end of 2021.” Good aim setting will help identify opportunities to segment populations, establish relationships, and ensure that impact can be measured.

Co-design and co-production with individuals from the target population should be embraced at every step of the process. In population health improvement efforts, activating the agency of the population as well as that of those coordinating their care is fundamental. The process of working together towards the aim is as important as the aim itself and requires engaging key actors in the health economy (as described above), including citizens and service users, to design and adopt the changes needed to improve. People’s health is heavily influenced by factors outside of their care such as their social and economic environment, physical environment, and individual characteristics and behaviours.19 So individuals are protagonists in efforts to improve population health, not passive “receivers” of health. Activating people’s agency is at the heart of the Institute for Healthcare Improvement’s Psychology of Change Framework.20 The framework describes methods and approaches around five inter-related domains of practice that organisations can use to advance and sustain improvement.

The complexity of the population health system is such that health economies will almost inevitably need a portfolio of projects occurring in parallel to make progress. Our experience emphasises the value of identifying key drivers for each aim and tackling them through targeted improvement projects, ensuring the efforts are also aligned with strategic priorities of these systems. “Think big and start small” is a mantra we often use.

Partnering for equity

There is no quality without equity. Stratifying data allows for better understanding of variation and gaps in outcomes, which in turn allows for tailoring strategies that respond to the specific needs of different populations to eliminate equity gaps.21 If a differentiated approach is not adopted, the gap between people who have access to the best possible health and those who do not will widen, leading to avoidable suffering, intergenerational cycles of poor health, and high costs for health economies.22 The World Health Organization defines equity as “the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically, or by other means of stratification . . . it implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential.”23

Between 2017 and 2019, the Institute for Healthcare Improvement ran an initiative with eight health systems in the United States to improve equity in access to and quality of care, as well as health outcomes, through the practical application of improvement methods, collaboration, and shared learning.24 One key element was ensuring that health systems had the capacity to collect and stratify data to better understand which populations were benefitting and which ones were being left behind, including data about race, language, and ethnicity. This enabled health systems to create better solutions that took into consideration the specific needs and conditions of those left behind.24

Health systems should proactively partner with individuals, communities, and institutions within and beyond healthcare. There is a growing realisation that the historical approach to health and healthcare, which is largely dependent on professionally trained and qualified health and healthcare “experts,” needs to be reconsidered. The most successful population health improvement efforts involve actors that are open and willing to value each other’s assets (such as will, abilities, and resources) and understand that the whole is greater than the sum of its parts.

Integration will move forward at the speed of trust. In the earliest stages, health economies that are learning to work together will require humility to accept that the protagonist is the citizen, not any single actor, and will require designing systems that are organized around the needs of those citizens. This is hard to do and must be intentionally designed early in the process to create an environment of psychological safety, to develop a sense of community guided by a unified purpose,, and to foster trust and a set of behaviours that build trust, instil purpose, and generate energy.25 Municipal leaders from the Bridge for Better Health effort in Denmark have a performance indicator related to the quality of their relationships with partners as a way of focusing attention on humility and good collaboration.13

Measure and learn

Health systems should identify what matters most to the population of interest and develop measures to track progress. The large number of measures health systems are often required to track leads to diffusion of impact and exhaustion of staff, who find themselves collecting data for many indicators with little connection to the purpose of such efforts.26 More importantly, tracking too many measures might not directly benefit the people that health systems serve. Population health improvement efforts often struggle because health economy actors do not feel ownership of broad aims, and it is difficult to define who is responsible for achieving outcomes when data are collected. We foresee a future in which health systems will start to include other aspects in their measurement efforts: relationships between partners in the health economy and the environmental effects of the carbon footprint resulting from more home based health and care models, for example.

Avoiding planning paralysis is important. Too often, integration efforts in health economies dedicate a disproportionate amount of time and energy to establishing governance arrangements and idealised strategies and plans, without paying enough attention to how ambitions will be tested, implemented, and scaled up. Integration is frequently seen as an end in itself, when it’s clearly a means to an end—measurable outcomes for better population health. We encourage testing and learning, from the integration process to implementing specific changes to improve population health. This iterative testing and learning approach enables refinement of the strategy and “the work” of improving population health, and it is a cornerstone of the improvement methods described above.

Improving population health starts and ends with each citizen. Making improvement everyone’s business will create the opportunity to put improvement knowledge in their hands. We hope in the future that citizens will develop fluency in improvement methods and be able to design their personal health driver diagrams, to test changes in their own lives that are co-designed with members of their “life system,” and to measure progress over time. The same principle applies to all health economy actors, who yield the benefit of having a common language for implementation to progress towards better population health. The jargon filled nature of improvement literature needs to be tackled to make the content accessible to citizens, families, health professionals, and other actors of health economies.