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Capabilities for an effective Population Health Management approach


Building Population Health Management Capabilities

Innovation Icon

System leadership requires collective actions and outcomes. The health and care system share a cohesive approach to working together to improve health and wellbeing for a population.

Intelligence Icon

System wide intelligence capability to generate actionable insight into opportunities to improve care quality, efficiency and equity.

Implementation Icon

Using intelligence to change care delivery and inform new service models based on population need.

  • Becoming a population health organisation from ground up ensuring prevention as key to the health of future generations.
  • Having dedicated system leadership to drive action-orientated, data-led decision making.
  • Using whole population data to drive planning to improve the health and wellbeing for local people now and in the future.
  • Using population health data to design workforce development across health and care - realigning and creating new roles fit for the future.
  • Anchor institutions - what can only the Health Board do; health services as well as wider determinants.
  • Linked, person-level datasets
  • Segmentation tools that compliment risk stratification to deliver information for action.
  • Alignment of multi-disciplinary analytical and improvement teams to produce actionable insights.
  • Analyses and actionable insight - to understand health and wellbeing needs of the population, opportunities to improve care, manage risk and reduce health inequalities.
  •  Advanced analytical tools, software and system wide multi-disciplinary analytical teams, supplemented by specialist skills.
  • Building capability and capacity, growing the expertise in public health, and developing PHM champions.
  • Data-led decision making and planning to drive care coordination and proactive personalised care, using the evidence base with a focus on reducing health inequalities and delivering proportionate universalism.
  • Focus on prevention and community well-being - asset based approach, social prescribing and social value projects.
  • Incentives alignment – using a value based healthcare approach to align funding and incentives to improve population health now and for future generations.

The Population Health Management Improvement Cycle

The improvement cycle provides a framework for understanding, implementing and evaluating a Population Health Management approach to drive improvement.

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