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Abstract

AbstractIntroduction: Population Health Management (PHM) is a UK priority for Integrated Care Systems (ICSs), aiming to deliver proactive, preventative, person-centred care using integrated health and care datasets. However, evidence on implementation in primary care remains limited.Methods: This comparative case study used embedded researchers, ethnography, interviews, and observations to formatively evaluate a 24-month PHM programme across 31 Primary Care Networks in one ICS. Data were thematically analysed using Excel and NVivo, with findings fed back to participants to guide programme delivery.Results: Around 200 stakeholders participated in Action Learning Sets, fostering cross-sector collaboration within four localities. Few innovations, developed using integrated datasets, progressed to delivery, limiting their impact on patient health. While PHM infrastructure was established, delivery was constrained by operational pressures, data governance challenges, limited resources, lack of strategic integration and the nature of local relationships.Discussion: Effective PHM implementation requires more than infrastructure and governance. It depends on developing system-wide soft skills (facilitation, co-production), motivating stakeholders, and investing in processes that support insight generation, innovation piloting, and evidencing of impact.Conclusion: The study highlights the need for stronger strategic integration, sustained resourcing, coordination, and co-production to realise PHM’s potential at system, place and neighbourhood levels in addressing health inequalities and improving population outcomes.

Publication Date

2026-04-24

Publication Title

International Journal of Integrated Care.

Volume

26

Issue

2

Acceptance Date

2026-04-03

Deposit Date

2026-08-11

Funding

This report is independent research supported by the National Institute for Health and Care Research Applied Research Collaboration South West. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care. This research study was funded by a Southwest NHS ICS and received Health Research Authority (HRA) ethical approval on 09.11.2022 (REC reference: 22/SC/0449; IRAS project number: 318324) through ‘proportionate review’ as it excluded patients (they were not involved in the PHM programme). There was no budget for patient involvement in the programme nor the evaluation, which is discussed in the limitations section.

Keywords

population health management, primary care, integrated care, embedded research, linked datasets, health inequalities

Creative Commons License

Creative Commons Attribution 4.0 International License
This work is licensed under a Creative Commons Attribution 4.0 International License.

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Last Page

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