Population Approach


Integrated care can be developed to benefit those citizens who are not thriving under existing systems of care, in order to help them manage their health and care needs in a better way, and to avoid emergency calls and hospital admissions and reduce hospital stays. This is a practical response to meeting today’s demands. Population health goes beyond this, and uses methods to understand where future health risk (and so, demand) will come from. It offers ways to act ahead of time, to predict and anticipate, so that citizens can maintain their health for longer and be less dependent on care services as they age.

  • Understanding and anticipating demand; meeting needs better.
  • Improving the resilience of care systems by using existing data on public health, health risks, and service utilisation.
  • Taking steps to divert citizens into more appropriate and convenient care pathways based on user preferences.
  • Predicting future demand and taking steps to reduce health risks though technology-enabled public health interventions.

Indicators of maturity:

Use of risk stratification models; a range of care pathways available for different groups of citizens; strong public health and prevention programmes; feedback available about effectiveness of new pathways and interventions.


  1. No consideration of population health in service provision
  2. A population focus of risk stratification but no risk stratification tools
  3. Individual risk stratification for the most frequent service users
  4. Group risk stratification for those who are at risk of becoming frequent service users
  5. Population-wide risk stratification started but not fully acted on
  6. Whole population stratification deployed and fully implemented.
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