In this article, we consider the essential role of using Population Health Management (PHM) methodologies in the design and delivery of effective neighbourhood health services in order to provide communities with care that meets local need and that deliver on the priorities outlined in the NHS Ten-Year Plan.
The Ten-Year Plan speaks with ambition and clarity: prioritise prevention, deliver neighbourhood health, and meet people where they are; often, quite literally, on the high street. These are more than policy slogans; they are imperatives rooted in both economic necessity and social justice. Yet to move from rhetorical commitment to systemic transformation, we must deploy PHM methodologies in ways that truly reflect the diverse needs of local communities.
At Akeso, deployment of our PHM methodology is an essential early stage of every healthcare engagement. This provides deep insight into the specific and unique needs of the relevant patient cohorts, allowing us to develop truly focused service models that meet local community needs and to ‘right-size’ services based on real demand.
PHM as a Bridge Between Data and Daily Life
Population Health Management is not a data dashboard. It is a methodology: one that enables systems to segment populations, predict need, stratify risk and design joined-up interventions. PHM done properly is not an abstract exercise; it is deeply rooted in place. In fact, it only works when informed by granular insight into local demographics, living conditions, and the social determinants of health.
Take our recent work with Barnsley, for example. Through the ‘Health on the High Street’ initiative, local partners are reframing what public health access looks like by placing services directly within the community. By integrating wellness hubs, mental health drop-ins, and support for long-term conditions into the town centre, the borough is responding to need not in theory but in practice, too. These initiatives have been informed by PHM analytics; local deprivation indexes, usage patterns and predictive modelling. They are made possible by partnerships that span public, voluntary and private sectors.
This is the direction of travel the Ten-Year Plan envisions. But such transformations require more than vision; they demand methodology, infrastructure and courage.
Prevention Begins in the Postcode
A core principle of PHM is that people’s health is determined far more by their postcode than almost any other factor. If we are to succeed in shifting from reactive treatment to proactive care, we must turn toward prevention as place-based design.
Akeso’s PHM tool has demonstrated this in practice. By linking data across NHS Digital, the Office for National Statistics and local sources, it enables ICSs to see not just what is happening in their system, but why. In one Midlands region, PHM insights highlighted that high-cost admissions were clustering in specific deprived wards with limited access to primary care. The response was a hyper-local neighbourhood model that involves primary care, social prescribing, housing officers and community volunteers, all coordinated through a hub-and-spoke structure. The result: fewer hospital admissions, improved wellbeing metrics, and substantial financial return on investment.
But these results were hard-won. Progress was slowed by institutional procurement hurdles, fragmented governance, and limited integration between NHS and local authority systems. Despite the enthusiasm for community-centred care, the system remains built for institutional delivery. Until this changes, success stories like Barnsley’s will remain outliers, not norms.
National Strategy, Local Implementation
The NHS Ten-Year Plan provides a strong policy framework. It rightly emphasises prevention, equity, and digital enablement. But we should resist the temptation to interpret ‘national strategy’ as ‘centralised control.’ PHM thrives when placed in local hands, with national bodies acting as enablers, not the gatekeepers, of change.
That is why Akeso is calling for bold national reform to unlock the full potential of PHM. This includes:
- Population Health Budgets at Place Level: Let funding flow to neighbourhood footprints with the flexibility to commission cross-sector teams. Only then can local leaders shape services around real need, not organisational silos.
- Digital Infrastructure that Crosses Boundaries: Regionally funded, locally governed digital platforms must support shared intelligence, not duplicate insights in separate dashboards.
- Reformed Procurement for Inclusion and Innovation: The current system favours incumbents and scale. We need agile procurement routes that support innovation, outcome-based partnerships, and the inclusion of smaller, local providers.
- Leadership Beyond the NHS: We must build governance models that reflect the reality of health creation where housing officers, community organisers and carers are often more important than clinicians in determining outcomes.
Health on the High Street: A Model for the Future?
Barnsley is not alone. Across England, there is a growing movement to relocate health services into everyday spaces, including libraries, shopping centres and community hubs. This is not just a matter of convenience; it is about legitimacy. When people see health as part of their community, not something done to them in hospitals, they are more likely to engage early, consistently, and meaningfully.
PHM provides the insight to make these models effective. For example, segmenting populations by need rather than service eligibility reveals overlapping issues from loneliness and diabetes to insecure housing, that cannot be addressed in isolation. A drop-in centre on the high street might host a pharmacist, a benefits advisor and a mental health nurse, not because that is what is available, but because that is what local PHM data suggests will make the most difference to the local population.
This is population health made real. But it will not scale unless national systems back the shift, not just rhetorically but structurally.
Building the Architecture of Prevention
To truly embed PHM into the health system, we must move from pilots to permanence. That requires:
- New Contracting Models: Multisector contracts that reward prevention rather than activity. This includes place-based contracts that can flex across primary care, social care, VCSEs and digital providers.
- A Dedicated Population Health Function at DHSC: An empowered national function to align policy, funding and accountability across the NHS, local government and community sectors.
- Predictive, Real-Time Tools as Standard: Systems need tools that support action, not just insight. These should be mandated and funded centrally but operated locally.
- PHM Maturity Frameworks: Co-developed standards and tools to guide ICSs in embedding PHM at scale, covering leadership, analytics, service design and community engagement.
Conclusion: From Vision to System
PHM offers a roadmap to realise the Ten-Year Plan’s vision of integrated, equitable and preventive care, but we must act decisively to align governance, funding, and infrastructure around that vision. Otherwise, we risk institutionalising a model we are structurally incapable of delivering. Barnsley and other local pioneers have shown us what is possible. Now the challenge is to make it probable and eventually, universal.
At Akeso, we stand ready to work with ICSs, DHSC, NHS England and local leaders to scale this change. Together, we can make PHM not just a framework for analysis, but a catalyst for transformation.
