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We are supporting the development of community based population health systems 

Background

The changing needs of our population require a fundamentally different approach to the delivery of health and care, with a focus on promoting and maintaining health rather than delivering episodic care. A strong system of primary and community care is the foundation of such systems. This needs to be underpinned by appropriate contractual forms and payment mechanisms, including outcome based elements where helpful.

The NHS already benefits from a comprehensive and high quality primary care system, but funding gaps and poor coordination between all parts of the health and care system mean that patients do not always receive the best outcomes they could. There is increasing emphasis on addressing these challenges through a focus on population health, with more integrated care, additional investment, and approaches tailored to the needs of specific patient groups. Many areas are seeking to do this through creating Accountable Care Systems. 

We are working with a number of Clinical Commissioning Groups (CCGs), primary care providers and their partners in local health systems across England to support new models of primary and community care, and the development of population health systems.

Why are we doing this?

The needs of a growing and ageing population are putting unprecedented strain on our health and care systems. Too much healthcare provision is reactive, responding to crises rather than proactively managing peoples’ health. This results in poor patient experience, worse outcomes, and higher cost. There is a clear need to refocus our system towards preventative, primary and community based care, and on people as people rather than diseases to be cured.

Increasingly, providers and commissioners of health and care services are seeking to work together collaboratively to deliver the best patient care in the most appropriate setting, irrespective of traditional organisational boundaries. There are a number of exciting developments across the country starting to deliver better outcomes for patients and improve system sustainability.

These changes are complex, requiring new ways of working for health and care staff as well as new governance arrangements, contracts, and financial mechanisms. Shifting care to a community based and preventative focus requires double running of services for a period of time.

What are we doing?

We are applying our experience of developing, funding and managing community based outcomes contracts to support local areas develop population health models.

We are working both with providers and commissioners. For example, in Newcastle we are supporting a group of primary care providers seeking to expand and enhance their offer to patients, with a focus on person centred care and the social determinants of health. In London, Sussex, Sheffield and elsewhere we work with local systems to develop collaborative models and accountable care. We focus on community based care provision, and work with acute providers for specific pathways – for example on Accountable End of Life Care.

Our impact can be through advising our partners, developing social investment cases and raising investment, or a combination of both.