Structural vs Individual Interventions for Population Health

What are the differences between Structural and Individual interventions and how do the outside influences on our work in Population Health influence change?

These concepts describe how governments, health systems, clinicians, and normal everyday people, control their health and wellbeing. How do we, operate within these paradigms, and how should we talk to our system leaders about the power of connected data, and what it allows organisations to be able to do; from system to person, and person to system; Infrastructure, Intelligence, Intervention.

We do not operate in a world of unlimited resources. Sometimes limitations placed upon resource are decisions made to purposely limit the consumption of a resources despite its actual or potential availability.

How does any level of governance or government control the consumption of what it may, ultimately, not want to be consumed?

This can be true of fossil fuels, where the control is the physical limited of the amount of it there is to be consumed, where the implication of over consumption is increasing price, so people are able to afford less of it and they buy less of it, therefore controlling it.

In Health care the control is the cost, or in countries where its free to use, the amount of budget a government allocates to commissioners to buy from providers.

Theoretically there can be more health resources, whilst difficult to recruit and retain staff; theoretically we could train more, pay them more.

Unlike Oil; to which there is only a certain amount under the ground; because previously there was only a defined number of dinosaurs from which its made. We could train more doctors and nurses, we cant make more oil. 

We can define that healthcare, as a concept, is a resource that is controlled by cost rather than by limited availability over the long term. Either by the budgets of a government, as a political decision, i.e. they decide that a country needs x amount to reach y consumption, or in other models, by the people, through insurance mostly, controlling the quantity of consumption by the cost of premiums. 

For the next number of years, there will always be maximum consumption of healthcare, regardless of realistic budget increases, we need to consider how to maximise outcomes against the budget rather than just by more consumption. Currently the need for healthcare is out stripping the available supply, and budgets do increase, but not by enough.  

And it is here we come to the conflict, who is responsible of a populations, health, and ill health, in a world where the resource is limited? The person or the state? given the allowed consumption of resource, the need, and the availability of supply.  

Am I responsible for my obesity, or is the state because they allowed fast food chain planning permission to build an outlet.

Questions become more difficult as they are explored; who is responsible for my child's cancer, why am I having a heart attack? Is it all the pies I eat?    

And who should help save ourselves? The state or the individual?

Most countries in will have had these discussions and opinion varies; there is no black and white answers to these difficult questions. Governments want a healthy, working, prosperous population, but they need a balance between a ‘nanny-state’ and individual responsibility.

Where can we have the greatest impact?

Structural interventions are those that alter the context within which health services operate.

This is normally in the form in the changes in legislation at a national level.

But, there are opportunities for local systems to change their context by commissioning services differently within the framework that they operate, it depends on how much freedom they are given national government. In the US individual states have more flexibility than regional or local governments in most European countries.

Some examples of structural interventions are childhood immunisations, the Sugar Tax, and the smoking ban.

Each of these has changed the context in which health operates. The sugar tax forces food to be reformulated to, ultimately, reduce obesity. There are arguments for and against this approach, but the UK, Mexico, and some US states have a sugar tax. At a level, they have concluded that the individual is unable to control their consumption of these foods, and the state has to intervene to ‘save’ the population, and its own finances, through prevention. Prevention is better than Cure, but it also saves a country a lot of money.

This isn’t the only food example, fortified flour has added vitamins, and fluoridation of tap water improves oral health.

Structural changes change the context that something operates.

In 1854, London was in an epidemic. An area of Soho, currently behind Hamleys toy shop, had a very significant increase of deaths from vomiting and diarrhoea. Unable to identify what was causing the deaths, a local surgeon, John Snow, marked all the houses he had visited to map the spread of the disease.

His map showed little spread beyond a small neighbourhood, and concentrated around the local water pump. Examination of the water from the pump first identified Cholera as a water bourne disease, and he discovered all those who we ill had drank from the pump. The removal the handle from the pump, making it unusable, stopped the spread of the disease.

John Snow, by removing the handle, had changed the context in which the disease operated, and saved more people from dying. The structural change to the environment altered outcomes in health.

Childhood immunisations are a more modern example of a structural intervention.

Parents must have their children immunised against a list of recommended WHO diseases.

It is the local governments responsibility to ensure there is herd immunity, that is 95% immunisation coverage across the population.

The UK recently dropped out of herd immunity and lost its measles free status.

The world health organisation recently said:  

“Expanding access to immunisation is vital for achieving the Sustainable Development Goals, poverty reduction and universal health coverage. Routine immunisation provides a point of contact for health care at the beginning of life and offers every child the chance at a healthy life.

Immunisation is a fundamental strategy in achieving other health priorities, from controlling viral hepatitis, to curbing antimicrobial resistance.”

It is the state’s responsibility to ensure these immunisations are administered, although we will be aware that there is a patient choice element to this programme too.

The NHS Health checks programme is the largest CVD prevention programme in the world.

In legislation 15.7 million people are eligible to receive a standardised risk assessment and behaviour change health coaching. The output, or the choice to act on the assessment, is an individual intervention, but the programme, defined in law, changes the context to how the NHS and partners treat those at risk of life limiting disease from, in many cases, lifestyle choices.

Health checks must be available to reduce the burden of CVD in later life, it aims to change the curve on disease progression through mid and later life. It changes how local government perceives risk.  

The smoking ban is one of the most successful structural interventions of modern times.

The UK Health Act, 2006, prohibited smoking in certain places, mainly indoors, in pubs, clubs and restaurants. The legislation has been updated to become stricter over the years, but the graph on the right shows the immediate impact after the implementation of the law.

The blue line shows the number of myocardial infractions, heart attacks, immediately after the ban in Liverpool. This is a real correlation. Immediately after the ban, heart attack admissions fell, and have continued to fall.

Stopping smoking, stops heat attacks.

Structural interventions work, on mass, and quickly. They offer positive returns on investment for a country. But there is a balance between the initial investment, political choice to intervene, the ‘nanny state’, and a person’s freedom to choose.

Governments choose wisely when to invest in structural interventions as they can be unpopular.

Winning policies usually focus on harm reduction for those who don’t or cant choose; non-smokers breathing second hand smoke, or children and seat belts.

Contrasting Structural interventions, are individual interventions.

These are the lifestyle decisions I may choose.

I choose a healthy lifestyle, I choose not to smoke, and I choose to exercise.

Some individual interventions are supported by the state, but they don’t change the context in which health is delivered.

Behaviour change tactics, nudge theory and health advice are examples of how the state can support individual interventions.

Evidence shows people are willing to discuss lifestyle factors with health and care professionals, and they are seen as non-threatening.

The audit-C questionnaire is an example to highlight to the person their own levels of alcohol consumption.

“Are you interested in learning more about how your alcohol affects your health?” “What do you know about the benefits of sticking to moderate levels of drinking?”

…

“What do you feel would happen if you do not change your drinking patterns?”

…

I’m nudging you towards your own decisions and own actions to reduce your drinking. I can help by recommending an app to support you, or a local group of people who share your interests; this can be the role of social prescribing.

You may tell me, politely, you don’t to talk about your alcohol consumption.

But if you go to A&E next, or your GP, or pharmacist and everyone asks “Do you mind if we spend a few minutes talking about…?”

The evidence shows eventually people engage in these conversations. They are not confrontational, they’re conversational. 

It does not have to be about alcohol, it can be anything, weight, smoking, loneliness, high blood pressure.

“Did you know people are four times more likely to quit smoking using behavioural and pharmacological support than going it alone, would you like to talk someone about quitting?”

Individual interventions don’t need to be state sponsored; many people have fitbits and alike, and live and exercise to live a healthy lifestyle.

And when we start to investigate the reasons why everyone doesn’t live like this we are able to explore the reasoning behind Patient Activation Measures, the use of Patient Reported Outcome Measures to inspire people post intervention to live a healthier life.

And moving deeper into social economic reasoning, assessing the levels of health literacy within a population, and tailoring a systems response to how their population; not only interacts with a health and care system, but to help them understand the why?

Why do they need to change? And what are the benefits to them, their family, and their public services.

Whats any of this got to do with Population Health and changes to health and care commissioning and delivery?

Population Health has been defined as "the health outcomes of a group of individuals, including the distribution of outcomes within the group". It is an approach to health that aims to improve the health of an entire human population”

Structural interventions give you the biggest bang for your buck, significant return on investment. It is dictated to the population.

Individual interventions change the person, great for that one person, but they need to be systemic and be influential within the context that the structure defines.

Population health is a mixture of both. We focus a lot on the ability to connect data across the system, and we have value where that connected data helps individuals improve their care, but it can also be used to influence system leadership to change approach and change the context in which health is delivered.

Without big transformation change to the way many health and care systems are organised and implemented around the world, population health will not be able to deliver the improvements in outcomes to an entire population, regardless of how we segment and stratify them.

When we engage we need to be able to share a vision for population health that covers both paradigms. The NHS and local government are unique position of having some of the most comprehensive data sets in the world.

We are able to scale from the person to the system, and from the system to the person.

We can focus on outcomes, not activity, presenting the evidence based arguments for greater investment in services and changes to delivery models presenting the value to the system and to the care givers interacting at the person level.

We are able to surface the needs of the individual to focus on specific aspects where intervention is needed.

We are able to ‘zoom out’ from the person to the practice and the system.

As the leader of an ACO, state, or country, and I’m presented with evidence of gaps in care, how can I change the context of the system to focus on the maximum gains?

I see from the evidence base, and trials, and systematic reviews, that pulmonary rehab is the most successful intervention for those suffering from COPD. Therefore I am going to invest in this service, but my resources are limited so there needs to be a dis-investment in another area.

After a successful succession of years focusing on x (here we can use any service), analytical modelling is telling me we can move the pump priming funding away from a new service to fund this.

And there will be an impact, but that impact in the quality scoring is measurable and the risk is acceptable for the greater gains in COPD.

As that CEO I see the changes to funding of other services has been mitigated; those previous services have transitioned to a new model of delivery, and as we have been focused on outcomes and not activity, this disrupted the market, pushing care out of the expensive acute space and into the community. Empowering the population to look after themselves, through greater investment in health coaching and lifestyle services. 

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The next step in maturity is to see the person as a whole, and identify that multi-morbidity cannot be treated separately within the same person.

To organise your services across the life course approach as North Central London.

This is how you can improve outcomes and health of an entire population.

The reality of this approach is the need for connected datasets and strong analytics to treat the person regardless of the setting, across the health and care system. 

This approach shows our own maturity within population health, achieving these outcomes requires some new thinking as population health moves more away from clinical pathway optimisation to tackle the social-economic reasons behind, homelessness, for example.

The key to achieving population health success is understanding system and population priority.

This is why primary care networks are key, they bridge the gap between the person and the system.

You have to understand what are their drivers, and for to design and deliver things which facilitate their change, to meet the needs of their population and deliver sustainability through transformation.

Individual interventions improve the lives of the people, structural changes deliver sustainability to allow improvements for the next generations.

We should not dismiss big change, as too difficult, or too distant, it has to be in conjunction to our core of delivering better, more seamless care.

Health and care organisations cannot usually deliver structural change alone and partner with local government. They can look strategically across 5-10 years, rather than today and the immediate tomorrow.

We are very good at finding value at the individual level, we also need to focus on the structure for long term gains in life, and healthy, life expectancy.