26 May 2022

Guest blog: Why multi-agency data is a fundamental requirement for Population Health Management

Guest blog by Tom Davies, COO at Xantura

It is widely accepted that siloed working is ineffective and inefficient and that better coordinated  and targeted responses to the needs of citizens will improve outcomes and lower demand for higher intensity and higher cost services.  Population health management has emerged as a response to this need and is predicated on delivering this through better use of multi-agency data.

What is population health management?

The term ‘population health management’ is being used rather than the more traditional term of ‘public health’ to remove the perception that addressing these challenges is solely the response of public health professionals.  Population health management is about creating a collective sense of responsibility across many organisations and individuals in addition to public health specialists.

What are the personal & locality system challenges that population health is trying to address?

Our health and wellbeing is shaped by a range of factors, as shown in the diagram below. It is hard to be precise about how much each of these factors contributes to our health, but the evidence is convincing that the wider determinants of health (in the outer ring) have the most impact, followed by our lifestyles and health behaviours, and then the health and care system. There is also now greater recognition of the importance of the communities we live and work in, and the social networks we belong to in determining our overall health.


The Dahlgren-Whitehead model of health determinants

What are the challenges to implementation?

There are several challenges that stand in the way of delivering an effective population health management system.  Some of these are being addressed through integrated health solutions, however in order to drive truly systemic change there is a requirement for a wide range of organisations to effectively collaborate.  We believe the key barriers to change are;

  • Navigating multiple organisational boundaries – the wider determinants of health sit across many areas including public health, social care, financial inclusion, education, housing and community support – bringing all of these parties together to drive change is extremely complex
  • Creating the capacity to implement – resources and funding are already scarce, however delivering an effective multi-agency response requires initial capacity to set-up and embed which means taking a long term, strategic call
  • Addressing misaligned drivers across the system – most public sector areas currently work in siloes with their own goals and targets which are often misaligned.  As an example, councils escalating debt collection for vulnerable people (for relatively small amounts) can generate significant costs across social care, health and domestic violence.  A wider system approach to this problem alone could generate better outcomes and significant cost reductions.

What role does data need to play in this context?

Data has a huge role to play in underpinning effective population health management. Adopting an effective & operational data-led approach enables decisions to be made at a strategic level and at an individual level which drive the best outcomes for the wider system.  There are several critical elements that need to be in place to support these outcomes;

  • Leadership – Strong, collaborative, aligned leadership across all organisations and citizens is critical to embedding innovative and effective service transformation at a system level
  • Whole System Design – The ability to identifying populations and target cohorts of individuals with multiple risks and needs to enable focused, preventative measures
  • Information Governance – Legal compliance and Information Governance need to be embedded into systems and processes from the start and need to be proportionate, transparent and flexible to accommodate changes in regulation over time
  • Data Infrastructure – Data from multiple sources needs to be linked and matched at an individual level with embedded information governance, appropriate data sharing protocols and carefully constructed access to ensure strategic decisions can be made and targeted cohorts supported

How can these challenges be overcome?

The challenge of implementing a successful population health management approach should not be taken lightly.  As identified above there are several challenges that need to be overcome and stakeholders that need to be aligned to enable system-level change.

In our experience, the best way to build out a mature population health management system is to take a value-case led approach.  This involves identifying a key problem area with a clear legal basis and underlying societal benefit and then bringing together the necessary stakeholders to agree a joined-up approach.  The efficacy of each value case needs to be effectively monitored and iterated over time but each new value case delivery further enhances the underlying data maturity and partnership working of the wider system.

At Xantura, we have designed our OneView platform & methodology over the last 10 years to support the delivery of targeted population health management value cases, with each new successful value case broadening the range of data and number of partners collaborating effectively.  We have already delivered successful value cases in homelessness prevention, contextual safeguarding, supporting families, financial inclusion and falls prevention and are continuing to evolve and deliver new value cases all the time with our clients which can easily delivered to new clients through our infrastructure.

Initiating a holistic population health management approach can seem extremely daunting with such an almost unending series of challenges to overcome, however we believe that starting small and targeting key value cases delivers rapid value and creates buy-in from across the system to expand and grow into system wide change.

Tom Davies, COO at Xantura – [email protected]

 Local Public Services Innovation: Creating a catalyst for change



techUK, in collaboration with its Local Public Services Committee, has published a new report making the case for enhanced digital innovation adoption across the UK’s local public services to improve citizens’ lives. The report, ‘Local Public Services Innovation: Creating a catalyst for change



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