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29 January 2025

That’s when good neighbourhoods become good Population Health Management

What is the ideal population size for applying effective Population Health Management (PHM)? Following the publication of a new paper from the Health Economic Unit’s collaborators at the World Health Organization, HEU Director Andi Orlowski argues that now is the time to focus on neighbourhoods.

As someone deeply immersed in the world of PHM, I couldn’t be more thrilled to see the spotlight shining brighter on this transformative approach. PHM has always been a passion of mine, and seeing this incredible paper contribute to and support its principles is both validating and inspiring.

The overlooked potential of neighbourhoods in PHM

The NHS has embraced the concept of neighbourhoods within Integrated Care Systems (ICS), focusing on populations of 30-50k people. This deliberate structuring provides an incredible opportunity to align PHM with the unique needs of these localities. It’s a practical manifestation of PHM’s promise: a tailored, data-driven, and people-centred approach to health care.

And yet, the connection between PHM and neighbourhoods isn’t being shouted from the rooftops nearly enough. We talk about local engagement, bespoke services, and the power of community-driven insights, but where’s the focused attention to bring it to life?

A framework we’ve been waiting for

The paper beautifully outlines the five-step PHM cycle—a framework I’ve championed throughout my career:

  1. Defining and Identifying Populations: This step is essential, and within the ICS context, neighbourhoods offer the perfect lens. Focused yet diverse, they allow us to home in on specific community needs.
  2. Health Assessment and Segmentation: Neighbourhoods provide a manageable scope for data collection and analysis, enabling precise segmentation and a clear understanding of health determinants.
  3. Risk Stratification and Impactability: By working at a neighbourhood level, we can identify at-risk groups more effectively and deploy resources where they will make the biggest difference.
  4. Tailored Service Delivery: This is where neighbourhoods shine. Customising care delivery to the unique needs of a community, from prevention to chronic care management, ensures interventions resonate locally.
  5. Evaluation and Improvement: A neighbourhood focus allows for iterative learning. Small-scale improvements can be rapidly implemented and scaled across other ICS areas.

Neighbourhoods: The missing link in PHM and primary care

As an advocate for PHM, I’ve always believed that its natural home is Primary Health Care (PHC). The synergy between PHM and neighbourhoods only reinforces this. Neighbourhoods offer a framework where PHC’s core attributes—accessibility, comprehensiveness, coordination, and community orientation—can thrive. But for this potential to be fully realised, we need to ensure that neighbourhood-level insights and strategies are prioritised and embedded across the system.

A call to action for ICS and beyond

What excites me most about this paper is its alignment with the NHS’s journey toward neighbourhood-based care. However, talk alone won’t drive change. We need focused efforts that recognise the importance of neighbourhood-based PHM and its potential to transform care delivery.

  • Policy Support: ICS must champion the role of neighbourhoods as essential units for delivering tailored care.
  • Data Infrastructure: High-quality, accessible data at the neighbourhood level is critical for informed decision-making.
  • Community Engagement: Engaging with neighbourhoods ensures that PHM interventions are both culturally relevant and effective.

Realising the potential of neighbourhoods

The NHS has the building blocks for a robust neighbourhood-based PHM approach. With the right focus on neighbourhood-level strategies, we can ensure that every community, no matter how small, benefits from the power of PHM. It’s about equity, sustainability, and creating thriving hubs of health and well-being across the country.

Let’s turn ideas into action, frameworks into reality, and neighbourhoods into the cornerstone of a healthier, more cohesive future. The time to act is now.

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