Blog | From sickness to prevention

With the launch of the new NHS 10-Year Plan, the message is clear: the future of healthcare lies not just in treating illness, but in preventing it altogether. Does this mark a turning point in how healthcare is approached across England? Is the NHS equipped to make this plan a reality?

Why prevention matters

The new plan is now embracing a proactive, prevention-first strategy that aims to keep people healthier for longer. This strategy strongly aligns with Optum’s mission to help people live healthier lives.

While there has been important proactive work at both public health and practice levels such as through the quality outcomes framework (QOF), our health system has often leaned toward a reactive model - stepping in primarily when people become unwell. With increasing demand, an ageing population and complex conditions on the rise, we’ve seen hospitals under strain, evidencing the existing model is no longer sustainable.

Proactive intervention

A prevention-first approach means identifying health risks early and intervening before problems escalate. A population health management cycle creates a useful framework that actively works towards prevention and enables you to evaluate the success of proactive interventions. This includes:

Identifying at-risk patients before health conditions worsen
Targeted outreach to those patients
Ensuring they receive the right care, in the right place at the right time
Evaluating the success of preventive interventions

We help integrated care systems identify different population cohorts and enable them to manage a defined cohort proactively. We supported Trent Primary Care Network (PCN) to do just this by identifying patients who frequently used emergency services. Once the high intensity users were identified, they were able to develop interventions and create care plans aligned with individual needs. By catching issues early, they reduced emergency admissions by 58% and A&E attendances were down by 41%. Shifting hospital care back into the community helped release pressure on acute services and ensured that patients got the right care, first time.

58% reduction in emergency admissions

41% reduction in A&E attendance

Tackling inequality

The NHS aims to target health inequalities by investing in underserved communities and addressing the social factors that impact health, like housing, education and employment. Health outcomes shouldn’t depend on your postcode. Addressing wider determinants of health is crucial to supporting prevention efforts and reducing disparities in access to care. NHS Cheshire and Merseyside recognised that smarter use of data could address the underlying factors shaping people's health and wellbeing. Their project focused on fuel poverty. Using PHM Pathfinder Analytics, they used linked data to define cohorts based on social factors, such as poor housing, that contributed to poor health and wellbeing. Once identified, they designed and implemented various proactive interventions.

For one intervention, out of 122 patients contacted, 100% were referred to the local affordable warmth team, 100% to the local wellbeing team and 14% to the pulmonary rehabilitation team, supporting their overall health and wellbeing.

Our work with NHS Cheshire and Merseyside demonstrates that accessing holistic data and taking action based on that data insight has a positive impact on communities. You can download the Blueprint guide Tackling Fuel Poverty in Cheshire and Merseyside: A Population health management approach and learn how to implement PHM at your organisation here.

Outcomes, not activity

As the NHS pivots to meet the demands of a changing health and care landscape, we can support that journey to transformation. Not just with PHM tools, but with the lived experience of practicing clinicians in our team. As a GP, working closely with clinical teams has given me a deep understanding of the pressures and priorities on the frontline. Through close collaboration with analytical teams, we’re able to blend clinical insight with data-driven evidence to uncover the real needs within our communities that result in value-based outcomes for people.

By combining expertise and insight, together we can:

Identify at-risk groups of people at risk of poor outcomes
Predict health deterioration and inform action earlier
Target interventions where it will have greatest impact
Collaborate, system-wide on redesigning services
Understand financial implications to support decisions
Benchmark to drive improvements

A healthier future

Embracing change and implementing proactive interventions now, we can ensure that future generations will enjoy better health and wellbeing.

Population Health Management (PHM) is pivotal in realising this vision. By leveraging data-driven planning and proactive care delivery, PHM enhances health outcomes across entire populations.

It doesn't require doing everything at once; starting with one successful project allows for scaling and adding more interventions over time. This approach to early intervention builds better outcomes, boosting the health of the populations we serve and ensuring the future sustainability of the NHS.

Disclaimer

This article was prepared by Dr Jim Forrer in a personal capacity. The views, thoughts and opinions expressed by the author of this piece belong to the author and do not purport to represent the views, thoughts and opinions of Optum. Any general health information contained in this article is for information purposes only and is not a substitute for your doctor’s care.

About the author

Dr Jim Forrer

Clinical Director

Dr Jim Forrer is a Clinical Director at Optum focused on developing services, tools and analysis that support the NHS. He is a practicing GP.