Population Health Management
Turning Insight into Action: Driving Better Outcomes Through Population Health Management
Our Philosophy and Approach
Improving health outcomes for everyone. Reducing pressure on services. Building a sustainable health and care system. Population Health Management (PHM) is central to achieving these goals. At Akeso, our PHM approach is built around four core capabilities – Infrastructure, Intelligence, Interventions, and Incentives – to provide end-to-end support across Systems, Places, and Neighbourhoods.
What is Population Health?
An approach that aims to improve the physical and mental health outcomes and wellbeing of citizens, whilst reducing health inequalities within and across a defined population. It includes action to reduce the occurrence of ill-health, including addressing wider determinants of health, and requires working with communities and partners.
What is Population Health Management?
An ageing population and the growing burden of long-term conditions are placing increasing pressure on health and care services. Alleviating this demand cannot be achieved through acute treatment alone. A significant proportion of the factors that influence an individual’s health – such as housing, employment, environment, and social support – lie outside the hospital setting. Addressing them requires a coordinated, system-wide approach. The NHS has made clear its ambition to adopt a population health approach, reflected in the establishment of Integrated Care Systems (ICSs) and a renewed focus on prevention over treatment and reducing health inequalities.
Why is Population Health Management Important?
An ageing population and rise in chronic health conditions are leading to a rise in demand on health care services. Alleviating these pressures requires interventions beyond treatment by acute services. So much of an individual’s determinants of health lie outside of a hospital setting and require a collaborative approach to improve them. The NHS has signalled its desire to embrace PHM through the foundation of Integrated Care Systems (ICSs), its priority to move “from treatment to prevention” and, when it set out the 4Is of population health.
Our Population Health Management Framework
With the changing NHS landscape and the formation of ICSs, the concepts of population health and PHM have rapidly gained currency within health and social care. Our PHM framework centres around four capabilities which are key to delivering an end-to-end PHM approach:
Infrastructure
We assess and build the foundations for PHM, from leadership capability reviews to digital infrastructure and data maturity assessments. We also evaluate analytical capacity to ensure systems are equipped to act.
Intelligence
We co-develop analytics, segmentation, risk stratification tools, benchmarking and impact modelling. Our proprietary PHM Segmentation Tool draws on 100+ variables to group similar areas and populations, enabling peer benchmarking and targeted proactive interventions.
Spotlight: PHM Segmentation Tool
Traditional population health analytics often rely on operational data – like GP registration or postcode – to define a system’s population. But this approach misses a critical group: people who aren’t actively using health services. These underserved populations often face greater deprivation, poorer health, and limited access to care – yet they are exactly the people PHM should reach.
To close this gap, we’ve developed a bespoke PHM Segmentation Tool. It analyses over 100 variables from a wide range of publicly available datasets, using segmentation techniques to focus on key demographic factors.
This allows us to group areas – such as ICSs, Local Authorities and Places – into clusters based on shared population characteristics. Within each cluster, we can benchmark the cost and quality of care delivery, uncovering actionable insights that help local geographies plan more equitable and effective services.
Interventions
Drawing on data-driven intelligence, we design and implement care models tailored to the unique needs of different cohorts. Our support includes care integration, workforce planning, operating model design, and benefit evaluation.
Incentives
We support the creation of proactive, preventative care models through incentive design – ranging from behavioural nudges for patients and clinicians to financial baselining, provider incentives, and payment model design.
Case Study: Virtual Wards Evaluation
Akeso conducted a comprehensive evaluation for a major Acute Trust to assess the clinical, operational, and financial impact of its Specialist Virtual Wards. By applying our PHM Segmentation tool alongside our structured evaluation framework, we analysed how effectively the current Virtual Ward model meets population needs. These insights informed the design of a future-facing, scalable Generalist Virtual Ward model – focused on equitable access and aligned with anticipated demand.We identified the key drivers of health inequality and used this intelligence to shape a model that not only supports the Trust’s digital transformation ambitions but also ensures inclusive, proactive care delivery.
This end-to-end evaluation and service redesign demonstrated the cost-effectiveness of Virtual Wards and their potential to transform clinical pathways – positioning them as a critical enabler for meeting growing population needs while embedding equity into the heart of care.
Client Testimonial
