Why a population health management approach is key for effective PCNs

Primary care networks (PCNs) wondering how best to target their resources should use a population health management approach, argue health consultants Dr Simon Munk, Dr Steven Laitner and Toby Lambert.

PCNs need to understand their communities and focus on patient groups that could most benefit most from integrated care (Photo: George Clerk/Getty Images)
PCNs need to understand their communities and focus on patient groups that could most benefit most from integrated care (Photo: George Clerk/Getty Images)

While there are high expectations for the near 1,300 primary care networks in England, many clinical directors will be feeling quite daunted by their new roles.

As this group of clinical leaders considers how their networks might meet the requirements of the NHS long-term plan, their local commissioners and, most importantly, their local community, we would recommend taking a population health management approach.

This involves focusing on which patient groups in their communities (the combined lists of the practices within the network) could most benefit most from integrated care and support. We find the grid below a useful tool for considering the needs of different groups of people.

Using the table 

People who are general wellLong-term conditions/
People with complex needs
Low risk High risk Low risk High risk Low risk High risk
Children and young people (0-25)
Working age adults (25-65)
Older people (66+)

Source: Dr Steve Laitner and Dr Mark Davies, NAPC

People in the left two columns, who are generally well or those with one or more long-term conditions, are well managed by their GP and practice nurse, with some support from the wider practice based team and on occasion from hospital or community services.

In contrast, it is the people in the right-hand column, those with a complex mix of physical, emotional, and social care needs, sometimes with functional impairment and maybe disability who particularly require a different sort of care model. They will include children with complex needs and disability, frail older adults and adults with severe and enduring mental health, drug and alcohol and social challenges.

Evidence suggests these patients specifically require holistic, co-ordinated, joined-up, personalised care with a high degree of continuity, if their health, wellbeing and independence is to be maximised.1

This group of patients is generally small, for example frail older patients typically account for 2-3% of patients, which would be 1,000-1500 in a typical PCN. Models of 'total care' for people with complex needs, rather than disease-based models and pathways is helpful to consider here.

Seven steps 

Working at scale enables practices to access advice and active support and management from, for example, palliative care professionals, community care staff, secondary care clinicians, specialist mental health professionals, local community assets (such as voluntary sector services) and the patient and carer themselves.

It allows this support to be provided in a way which makes best use of primary care and health and care partners’ financial and staffing resources.

Taking such a population health management approach, allows you to consider which population groups would most benefit from multidisciplinary team (MDT) working. This typically involves seven steps:

1. Gain local buy in

Engage colleagues in the primary care network, wider stakeholders and the community itself in considering the value of focussing the network around the care and support needs of, and model of care required, for particular groups of people. 

2. Consider the care needs of different patient groups

Use the 3x3 grid as above to understand the needs and number/proportion of people in a network in the nine different boxes. This relies on working with data colleagues to collect the required data from your primary care system (and ideally patient-level linked data set).

3. Understand where outcomes are poor

Review the data to understand which groups of people currently have poor outcomes and where joined-up MDT working could be better for patients and for the staff working in different services. Agree with stakeholders and partners across your network which specific groups of patients to initially focus on.

4. Improve services and support

Review what support and services these patients currently receive for their range of health and care needs and consider how this could be improved. Review the evidence base for types of intervention which improve care and outcome for people with these needs. Specifically consider what support could be provided by a multi-disciplinary team working at the primary care network level.

5. Join up working

Consider what can be done to support joined-up working across professionals for these people, what 'care functions' are required. This is likely to include care co-ordination/case management, care and support planning, rapid response, joint training and support for professionals and use of trusted assessor models where any member of the MDT carries out an assessment of holistic needs on behalf of the team.

6. Address barriers

Consider the current barriers to delivering joined-up care for these people. This frequently includes a lack of trust between professionals and challenges around sharing data and accessing patient records between organisations. Consider what can be done across the network in the local context to overcome these challenges. How can the STP/ICS/CCG help support this?

7. Measure impact

Put in data collection mechanisms to measure the impact of better, joined-up care for these people. Measuring whether these patients with complex needs are more likely to achieve their priorities and have a seamless experience of care can be a great start. Being clear what outcomes are being aimed for, whether this is reducing emergency hospital admissions or reducing failed discharges is vital so that success can be measured against these. Use data and feedback to refine the model of care.

  • Dr Steve Laitner is a GP in Hertfordshire, who led NAPC work on population health management, and is a clinical associate at management consultancy Carnall Farrar. Dr Simon Munk is a consultant at CF and Toby Lambert is a partner at CF.


1. Ham C et al. Where next for the NHS reforms: the case for integrated care.London: The King’s Fund; 2011. Available from: https://www.kingsfund.org.uk/publications/articles/where-next-nhs-reforms-case-integrated-care

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins


Already registered?

Sign in

Follow Us:

Just published

£20 notes spread out

VAT trap for PCNs could strip millions of pounds from general practice

Tens of millions of pounds could be stripped from general practice because work carried...

Talking General Practice logo

Podcast: Is the BMA representing GPs effectively, why GPs face a pension tax hit, and views on the workload crisis

In our regular news review the team discusses representation of GPs, a new survey...

Man sleeping

NICE guidance on insomnia backs app to replace sleeping pills

Hundreds of thousands of people with insomnia could be offered treatment via a mobile...

Health worker prepares a dose of COVID-19 vaccine

JCVI backs autumn COVID-19 booster campaign for high-risk adults and NHS staff

Frontline health and social care staff and adults at increased risk of severe illness...

GP consultation

Government accused of 'misleading' claims on general practice workforce

GP leaders have accused the government of making misleading claims about the general...

Consulting room door

LMC calls for enhanced access to be scrapped after abuse forces practice to close reception

A Midlands LMC has backed a practice forced to close its reception desk after abuse...