Population Health Management

People’s health is changing, and care needs are evolving. Our lifestyles are crucial to our long-term health and the health inequality gap is getting bigger. We all need to be more proactive in responding to that change.

Population Health Management (PHM) is key to making it happen sooner. It actively helps to reduce health inequalities and offers proactive, personalised, and preventative healthcare for every community.

PHM techniques will transform the way we work and the way we care for people. It’s for everyone working in integrated care, striving to improve health outcomes for all.

Evidence and knowledge are fundamental to how we make the best decisions for individuals and communities. PHM takes this to the next level by bringing together a much broader range of data. Gathering insight from health and the wider aspects that impact a person’s health, including housing, finances, employment and education, will help us to build a holistic view of people’s needs and identify risk factors that are driving poor health outcomes in different population groups. This will help us to recognise where best to focus collective resources to accelerate prevention programmes and tackle health inequalities and deliver personalised care.

Working in partnership is key to all of us working in integrated care. By connecting across health, social care, public services and the voluntary sector we can ensure people receive the right service at the right time, from the right people. PHM allows us to connect more effectively to create a more personalised offering that responds to people’s wants and needs.

PHM changes the focus from reactive care to proactive, personalised and preventative care – an approach that allows long-term health solutions to be developed. By understanding who is at risk today we can predict who might be affected in the future. Effective prevention models in hospitals and at home can help to improve the lives of people with complex social needs, who feel lonely or isolated living with conditions such as obesity, diabetes, heart disease and cancer. By supporting people to live their healthiest lives, based on what matters to them, we ensure that every contact and every tailored intervention is effective. This leads to greater job satisfaction for us all and better health outcomes for everyone. PHM is a critical component in our integrated care system and the foundation to building a healthier future together.

Visit the Population Health Academy to find out more about how it can help you or take the Intro to Population Health Management e-learning module.

PHM: proactive, targeted health care for your community
PHM: a GPs view
PHM: a voluntary sector view
PHM: a public health view

Population Health Management Strategy

Population Health Management (PHM) is a way of working, delivering care in a proactive rather than reactive way. Using local knowledge and linked-up data, we can accurately target support, care, and services to those who need it or will benefit from it the most. In this way we can focus on preventing ill-health and addressing health inequalities and make the biggest impact on improving health outcomes.

This strategy sets out our vision for PHM in Norfolk and Waveney for the next 5 years, our working principles and data-driven priorities for action and how we will deliver them, to improve health and reduce health inequalities for our residents.

Further information

Population Health Management – Protect NoW

Our aim is to work alongside healthcare services to tackle inequalities and to offer a wide range of health and wellbeing solutions, many of which lie beyond the reach of health and care services.

Learn more

PHM – Protect NoW Projects

We are passionate about the work we do, find out more about our past and current projects.

View projects