Population health and ageing
Presented by: Iain Wilkinson, Sophie Norman
Special Guests: Phoebe Wright, Jennifer Kaye and Muir Gray
Broadcast date: 13/04/2021
Supplementary interview
Social Media
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Learning Outcomes
Knowledge
- To know the meanings of and the differences between the terms population health, population healthcare and population health management
- To understand why population health is important and relevant, particularly in the context of an ageing population.
Skills
- To be able to explain approaches to tackling population health issues and how future government policy might provide a framework in which to do this.
Attitudes
- To foster an approach to population healthcare which is value based (systems/networks/cultures being key to this)
- To foster an attitude that an understanding of, and involvement in, population health is necessary for all clinicians and health care professionals.
CPD Log
Show Notes
Definition
King’s fund’s adopted definition: An approach aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people within and across a defined local, regional or national population, while reducing health inequalities. It includes action to reduce the occurrence of ill health, action to deliver appropriate health and care services and action on the wider determinants of health. It requires working with communities and partner agencies.
https://www.kingsfund.org.uk/publications/what-does-improving-population-health-mean
King’s Fund (2019): prevent illness and improve health & wellbeing of local communities by considering more than traditional health care -e.g.
- green spaces
- social activities
- education & employment opportunities,
- healthy food
- good housing
- transport
Main Discussion
What is population health?
The phrase ‘population health’ is used to convey a way of conceiving health that is wider still [than placing an emphasis on wellbeing as well as health]. It includes the whole range of determinants of health and wellbeing – many of which, such as town planning or education, are quite separate from health services.
- Referring to ‘population health’ rather than the more traditional phrase ‘public health’…
- helps avoid any perception that this is only the responsibility of public health professionals.
- Population health is about creating a collective sense of responsibility across many organisations and individuals, in addition to public health specialists.
- Population health is slightly different from population healthcare and population health management
- ‘Population healthcare’
- An approach in clinical care/practice by which the whole population is considered – or the whole population with a particular symptom, condition or characteristic – e.g. all patients who are frail, or who are high falls risk
- ‘Population health management’
- A widely used phrase, with a specific meaning that is narrower in focus than population health.
- Population health management refers to ways of bringing together health-related data to identify a specific population that health services may then prioritise.
- Public Health England: The aim of population healthcare is to maximise value and equity by:
- focusing not on institutions, specialties or technologies, but on populations defined by a common symptom, condition or characteristic, such as frailty, breathlessness, arthritis, or multiple morbidity.
Why is it important?
- There are some questions we should be able to answer about our population’s health which, in the UK, we currently cannot – e.g.:
- Is the service for people with seizures and epilepsy in Manchester better than the service in Liverpool?
- Which service for frail elderly people in London provides the best value?
- The importance of these questions lies in how the answers could affect the distribution of resources, how a lack of the answers might lead to inequity, and how, if we have the answers to these questions, we could deliver care of high value and quality.
- Spending on care for musculoskeletal disease, for example, varies 3 fold between different areas of England.
- This is reflected directly in the number of people receiving hip replacements in these areas.
- Are these varied numbers/is this varied spending appropriate for the need of the populations? Perhaps, but we cannot know for sure without data.
- A model example of applying the principle of knowing your population to geriatric care would involve; knowing how many people in the area are in their 70s/80s/90s, knowing how many of these are being seen in healthcare, and knowing of any imbalance between areas in terms of disease and care.
- Jennifer Kaye and Phoebe Wright, in their work in South West London, have found that different boroughs measure different things relating to the population’s health – and tend to ‘lump’ the whole population into one.
- Data on physical activity may not be broken down by age, for example.
- This means it’s difficult to understand differences between different communities – where needs are, if we are meeting the needs, if we are really addressing inequalities and inequities, and if we are allocating resources in the right places and on the right things?.
- The system focuses on outcome measures, and making sure that as a system we are aiming to measure the same things across the population – which may not be the best thing for the populations in question.
We need to move towards a paradigm of value based healthcare, whilst still ensuring both quality and evidence based medicine and care are practiced. Knowledge of populations, and data on needs, inequity and inequality are key to this.
An Ageing population
We all know that we have an ageing population – in Merton the over 80s are projected to grow from 13% of the population (2020) to 19% (2040).
It might seem easier to imagine the principles of population-based healthcare being applied to single diseases/’simpler’ populations of patients, as opposed to the comp[ex, multimorbid population of people that those specialising in geriatrics look after.
However, we are all in the most complex professions possible, and there are examples of a population healthcare approach benefiting more ‘complex’ groups of patients.
For example, Phoebe has looked at those in their last year of life – reviewing preferred places of death, and actual places of death in this population, gathering data that could be used to inform care.
Jennifer has been looking at activity and encouraging healthy behaviours and ageing in the community, with interventions including;
- Technological interventions allowing for people to monitor and record physical activity and ability themselves.
- Linking the information from patients with GP summaries and documents – so that GPs can be aware of how their patients are getting on
- This also allows for significant data collection on population levels of activity.
Why do healthcare professionals need to know about population health?
The formal way we are taught as healthcare professionals encourages the approach of looking after the patient in front of you, being empathetic to them and their concerns and advocating for them as an individual.
As HCPs become more senior, the need for an understanding of, and skills in, population health becomes more apparent. However, we would argue that this should be encouraged from the beginning of training. Population health is included within the GP curriculum but not other training programmes, such as palliative care.
Preventative approaches and health promotion are a key part of physiotherapy training, but only in respect of the patients that we see. It doesn’t extend to tackling health outside the cohort of patients that are referred to our service or end up on our wards. This means that we don’t naturally think about the patients we don’t see.
Clinicians are key to the ‘revolution’ in population health and need to…
- Consider how we can reach everyone in the population
- Think about the people who are not in front of you, and not seen by traditional health care services
- Motivate people to do things themselves, away from formal healthcare settings.
What might be described as a ‘third dimension’ in relation to healthcare provision is that which focuses not on the organisation of the system, or those working in it, but on the people with the relevant conditions and in the populations for which clinicians are responsible – and clinicians have to lead on this. This will require more communication and liaison between tertiary, secondary and primary care than happens presently.
What impact has COVID had on the older population from a population health perspective?
Age UK Report (published 2020, surveyed people >60);
- 1 in 5 are feeling less steady on their feet (represents 2.4 million people!)
- 1 in 5 are finding it harder to remember things)
- >⅓ of those who found preparing food difficult pre lockdown are finding it even harder to do.
- >⅓ of those polled reported their anxiety was worse or much
worse than pre-pandemic
- Those >70 experiencing depression has more than doubled
- More than ⅓ less motivated to do things they previously enjoyed
- Many have lost confidence in ADLs and feeling like they cannot see their lives returning to ‘normal’.
- Lancet articles – 2021 is the year of reconditioning [Gray, M. (2021) 2021 – the year of reconditioning. Lancet Healthy Longev. 2(2) e62-e63 ]
http://careandsupportalliance.com/wp-content/uploads/2021/03/CSA_A_Cry_for_Hope_Survey_2021.pdf
These figures and reports reflect what most people know and have seen over the past year – deconditioning, social isolation and poor mental health have been significantly worsened/accelerated by the pandemic and related restrictions.
Health and social care services already had pressure to adapt and respond to the challenge of a rapidly growing aged population, and the COVID pandemic has made this all the more urgent.
However, COVID has also shown us that for healthcare in Britain, money is not the limiting resource – staff and time are both more limited than money.
COVID has accelerated the pace of switches to and use of digital technology in the health sector, with older people engaging with the use of technology – and this should be encouraged further.
The pandemic also highlighted social factors and wider determinants of health that are very beneficial – nature and green space access, and the benefits of music, arts, volunteering and social activities.
A paper identifying ‘blue zones’ – areas in the world with anomalous longevity – identified an area of Japan which highlighted the importance of the practice of Ikigai. This loosely translates into ‘reason for being’, and having purpose, and encourages us to consider meaningful goals for our patients.
Dan Buettner ‘Lessons from the world’s longest lived’ [Buettner, D., & Skemp, S. (2016). Blue Zones: Lessons From the World’s Longest Lived. American journal of lifestyle medicine, 10(5), 318–321. https://doi.org/10.1177/1559827616637066]
Importance of purpose & social connection (Hold-Lunstad, J., Smith T.B., Layton J.B. (2010) Social relationships and mortality risk: a meta-analytic review. PloS Med. 27(7)
How should we tackle population health?
Muir and team advocate a ‘systems/networks/culture’ based approach.
Systems
- Based on systems theory
- A system is a set of activities with a common set of objectives
- There are 4 purposes for systems in the context of healthcare in the UK:
- Improving population health & healthcare
- Tackling unequal outcomes and acces
- Enhancing productivity and value for money; and
- Helping the NHS to support broader social and economic development
Networks
- Networks as they are referred to here are connections outside of bureaucratic and NHS structures
- They do not have large budgets themselves
- The internet and technology enables the formation and working of these
- Relevant NHS and bureaucratic structures do need to be linked into the network, however
- Involved parties might be geriatric departments, charities, businesses, local groups.
Culture
- Culture change is required for improvement, innovation and development.
- This is for both professionals and the population/public
Another key intervention/method to ensure and aid good population healthcare is the ‘map on the wall’ – ie clinicians having a good idea in real time of the needs of the population and the use of services, and reflecting and reviewing this on a very regular basis.
A cultural revolution is needed to share knowledge and counteract ageism!
An example of a population health approach to ageing;
Live Longer Better
The aim of ‘live longer better’ is to shorten the period of morbidity that is often experienced in the last years and months of life.
There are 11 objectives – including;
- increasing physical activity
- Mitigating the impact of deprivation
- Facilitating ‘dying well’
The network that live longer better fosters includes Age uk, sport england, some local authorities, the NHS, business and local groups.
The key message is;
- The ageing process has some effect on ability and/or resilience to stressors.
- Luck is involved in ‘ageing well’ – related to education, socioeconomic situation, avoiding particular diseases.
But there are 3 main causes of avoidable morbidity related to ‘ageing’
- Loss of fitness.
- The ‘fitness gap’ widens year on year, with the cumulative effect of reduced physical activity as we live sedentary lives.
- This gap can be closed at any age
- Disease
- Which is often due to environmental reasons
- This accelerates the loss of fitness
- Negative thinking and ageism –
- For example, the belief that people need ‘care’ may accelerate loss of independence, and using terms such as, and ways to support/enable, may be better than how we provide and view care at present.
https://www.livelongerbetter.uk
How do we achieve this? – Our 5 top tips to population health
- Importance of language in changing culture (need a glossary: ‘citizens not patients’ &’coaches not carers’)
- Map on the wall – we need to consider all of the people in need across a population – (HCPs who have a focus on the population as a whole, for example the citizens that they are not seeing)
- Outcome measures at a population level – we need to spend time understanding the health within the population (where the need is, where we are having an impact, where we are not).
- Networks floating alongside bureaucracy
- Knowledge is the elixir of life
Supplementary accompanying discussion on the recently published Health and Social Care white paper, between Iain and Muir;
There is a new ‘triple aim’ for NHS organisations:
- better health and wellbeing for everyone,
- better quality of health services for all, and
- sustainable use of NHS resources.
