Understanding local population needs is fundamental when taking a population health approach to planning and delivery of services. Data driven and Evidence informed decision making at every level of the primary and community care system will support redistribution of resources towards prevention and early intervention, reducing inequalities and meeting population needs.
A number of approaches have been developed to support health and care colleagues understand population need and to prioritise activities. All of which use a data and evidence informed approach, but vary by the focus they take, they include:
Prevention Base Health and Care
Public Health Wales (PHW) have developed the Prevention-Based Health and Care (PBHC) Framework, which identifies fundamental components needed to shift the health and care system towards a prevention-based approach.
The Framework brings together a number of approaches and is intended to be aligned to work across the system, including on inequalities, population health management, healthcare public health, health care pathways and work across sectors and national programmes to embed health in all policies.
Through creating a shared understanding of a systematic and coordinated prevention-based approach, the PBHC Framework helps to identify:
Population Health Management
Population Health Management (PHM) is an approach that improves population health by data-informed planning and delivery of proactive care to achieve maximum impact for the health and wellbeing of the population. Linked datasets are used to segment, stratify, and model the local “at risk” and “rising risk” cohorts that in turn are used to design, target, and personalise interventions to deliver proactive care and proportionate universalism to reduce health inequalities.
PHM can be applied across the health and social care system to identify individuals at greatest need; those who would benefit the most from a particular intervention; and those at rising or future need.
PHM is anticipated to realise a triple aim:
Enhance quality and experience of delivering and receiving care.
Reducing Inequalities through Primary and Community Care
Primary care works in and with communities and is the right place for personalised prevention, early intervention, and treatment. As a first point of contact for patient’s primary and community care acts as a hub, connecting people to other services and resources. By focusing on health inequalities, primary and community care doesn't just treat individuals—it creates lasting, positive change for society.
The Primary Care Division, Public Health Wales, is currently in the process of co-developing an action framework with key partners to address health inequalities through primary and community care. The Reducing health inequalities through primary care webpages contain further information and resources relevant to health inequalities.
Value in Health
Value in health means delivering the best possible outcomes for patients at the lowest possible cost. It focuses on providing care that is effective, efficient, and person centred. Value-Based Healthcare for Wales - Value in Health
Population healthcare – Under Development
Asset- Based approaches for integrated care
Asset-based approaches to integrated care leverage existing resources within a community to address challenges and aspirations, emphasizing co-production between formal services and informal networks. These methods, which align with strengths-based practice, shift the focus from deficits to solutions, fostering collaborative and respectful engagement in health and social care.
Various asset-based strategies are utilised in health, social care, and housing in the UK. These include local area co-ordination, asset-based community development, community led support, social prescribing, shared lives, and family group conferencing. Whilst each has distinct feature, their common elements are what matters to the individual or community, recognising the assets that they already hold, creating solutions through collaboration, and engaging people with respect and equality. These approaches are relevant to primary and community care as they foster trust, enhances community engagement, and promotes sustainable health outcomes by aligning care delivery with the community’s inherent strengths and values.
Social Care Institute for Excellence (Scie) offers various resources including guidance, practice examples, evaluation of such programmes that might be relevant for primary and community care planning and delivery.
The Knowledge base section of the Co-Production Network for Wales also include relevant resources, courses, evidence, and examples of good practice particularly on co production and also on other asset-based approaches.