A population health management approach to ageing

A population health management approach to ageing

Every GP rightly advises: “Don’t start with the solution, start with the problem you’re trying to fix”.

As we continue to look at ageing and society’s response to ageing, we should start by asking what exactly is the problem we’re trying to fix?  It’s not ageing itself, as that would require some rather tricky changes to the natural laws of physics or biology. It must be the effects of ageing on our minds and bodies and its impact on our daily lives we are seeking to address. So let’s work with that.

The good news is that while we currently can’t stop the physical or biological clock, there are things we can do to reduce the effects of ageing and its impact on our functioning and quality of life. We can maintain our health, fitness and resilience throughout life. We can significantly reduce the risk of diseases which are more likely to develop as we age. Lastly, once we develop diseases and disabilities during our life course, we can develop interventions which reduce the impact of those conditions on our lives and the services we use.

The trick here is recognising that while linked, these are fundamentally different problems, requiring different service responses.

In order to do this, we need a population health management approach. To read more about this, see Greg Fell’s blogs: Population health management and Revisiting segmentation.

The National Association of Primary Care (NAPC) has developed a population health management approach as part of its Primary Care Home programme – a new care model that has over 200 sites across England and covers 16% of the population. The approach is based on two dimensions:

  • Life course – children and young people; working age adults and older people.
  • Need – generally well; long term conditions (LTCs) and complex needs.

Using this matrix we can identify three distinct population groups, with different needs and different models of care required to meet those needs:

People who are generally well

This cohort will benefit from primary prevention interventions to maintain mental, physical, cognitive and social health throughout their lives, such as excellent:

  • maternity care
  • childcare
  • education
  • family support
  • physical activity
  • employment
  • housing
  • social interactions
  • diet


  • avoiding smoking and drugs
  • safe alcohol consumption.

The actual interventions and delivery mechanisms will vary to some extent by life course and other social factors.

Identifying people who are currently well but at risk of developing LTCs will enable a more focussed response. This targeted approach might be at both the individual (known individual risk factors) and population levels (known risks in certain populations and communities).This approach will prevent or delay the onset of LTCs and their functional consequences.  For further information, see Sir Muir Gray’s blog A quest for clearer thinking on ageing.

People with long term conditions:

In addition to the primary prevention interventions above, this cohort will benefit from early identification and treatment of LTCs, personalised care planning, self-management support, medicine management and secondary prevention services.

For most, this will be a Disease Management type of care model with support to improve “activation” and self-management to stop or delay progression to complexity, frailty and functional impairment/ disability.

Older people with complex needs or frailty:

In addition to the interventions above this cohort require something quite special – integrated, holistic, personalised, co-ordinated care with a high degree of continuity.

Their needs are likely to be a mixture of physical, psychological, cognitive and social and will need to be brought together in the person’s own – according to their needs, values, goals and preferences –  care and support plan.

They are likely to require a Case Management approach with both proactive and highly responsive care when they have an urgent care need.

It is likely that a Multidisciplinary (Dream) Team (MDT) will be required at locality level (e.g. 30,000 – 50,000 population) which is both multidisciplinary and multiagency and involves non-professional peer support and voluntary sector support in addition to professional and statutory health and care staff.

This MDT would need to include an expert generalist clinician such as a GP or geriatrician who would work as part of the team specifically focussed on the holistic needs of the “older people with complex needs” cohort – likely to be about 1,500 people in a community of 50,000.

But while the clinical expert generalist is an important member of the MDT they are not necessarily the lead or the most important member. The MDT needs to be co-designed with users and carers, appropriately scaled and skilled, and commissioned to deliver the highest quality care which meets all the identified needs and priorities of this cohort.

Different challenges, different solutions.

I know we are up for the challenge, but are we up for the different solutions?


Dr Steven Laitner, GP and Regional Primary Care Home Lead, National Association of Primary Care (NAPC)

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