Improving population health – sticking plasters for people on the wrong side of the inequality divide?

Covid-19 isn’t the only epidemic we’re facing. For more than a decade, the World Health Organisation’s been pointing out that,

“Social injustice is killing people on a grand scale”

Final Report of the Commission on Social Determinants of Health, 2008

So what are we doing about the epidemic of social injustice?

This blog post looks at the West Yorkshire and Harrogate Improving Population Health Progamme 2020-25, to see what the answers might be.

The West Yorkshire and Harrogate Integrated Care System’s Five Year Plan 2020-25 says it aims to improve population health.

When ‘Improving Population Health – Strategic Direction’ came up on the agenda of the West Yorkshire and Harrogate ICS Board meeting on 3rd March this year, it seemed like time to ask a few questions.

Improving Population Health – Public Health, but not as we know it

Public Health seems to be about carrying out measures across society to eliminate the causes of illness. Epidemiology – the science of how and where diseases originate and spread – is central, along with its key tool, contact tracing.

Public health’s founding moment was about eliminating cholera. Dr John Snow basically invented the science of epidemiology when he studied the London cholera epidemic of 1849–1854. He developed a hypothesis that the outbreaks were caused by germ-contaminated water, and studied death rates in districts served by two water companies that supplied untreated water from the River Thames to the public.

He also looked closely at the water supply in Soho during a cholera outbreak there in 1854. In the process he invented contact tracing – a key public health tool – by talking with local residents. This led him to identify a pump as the source of the Soho cholera outbreak. It was then a simple matter to take away the handle so people couldn’t continue to use the pump and become infected with this deadly illness. His epidemiological study of cholera in London also led to the construction of the London sewage system.

A more recent public health measure was the law banning smoking in public places.

Improving Population Health – a neoliberal response to neoliberal epidemics

In contrast, Improving Population Health seems to be based on attempts to change the behaviour of individuals who are ill from so-called modern epidemics – such as loneliness, diabetes, obesity, stress, respiratory and cardiovascular diseases. These epidemics are the results of specific political and policy decisions – which is why they’re also known as neo-liberal epidemics.

For example, the obesity epidemic is at least in part the product of policies that have allowed the food industry to generate huge profits from cheap junk food saturated with fat, sugar, salt and other additives, at a time when real wages have been driven down by the closure of industries, with their jobs exported to overseas low wage countries.

Improving Population Health’s “solution” to modern – or neoliberal – epidemics is to make it the responsiblity of those who suffer from them. (Critics call this the “lifestyle drift” in public health.) Individuals’ behaviour change is encouraged through lifestyle coaching and through social prescribing that directs people to social, sporting and cultural activities provided by voluntary organisations – also known as community assets.

There’s no recognition that the poorest 10% of families would have to spend 80% of their entire income on food to be able to eat a diet that was in line with government healthy eating recommendations. The House of Lords Select Committee’s report “Hungry for Change: fixing the failures in food” concluded,

“Evidence shows that poverty-driven food insecurity drives people to adopt cheaper and less healthy diets, often with high levels of highly processed foods, resulting in health inequalities that manifest in obesity (particularly in children) and non-communicable diseases.”

What’s the point of lifestyle coaching and community assets in such circumstances?

The “asset-based approach” to improving the population’s health

The “asset-based approach” to public health originated in the USA as asset-based community development, in response to the recession of the late 1970s and the ascent of the New Right through the Reagan Administration.

A 2014 article in the Journal of Community Practice records that the American New Right defunded and marginalised community organizations that supported social action to challenge structural injustices. They were replaced by consensus-based partnership initiatives, which unite public, private, and community-based actors – which Asset-Based Community Development (ABCD) is an example of.

“In this ideological context, we argue that ABCD represents a capitulation and compliance with the prevailing neoliberal reforms of the American welfare state under the Reagan Administration. Rather than seeking to organize against the elimination, reduction, and/or privatization of public services, ABCD, in theory and practice, seeks accommodation with this dominant ideological position.”

Similarly, since the bankers crashed the economy in 2008, the asset-based approach to community development in the UK has been central to successive governments’ dismantling of the welfare state.

Cutting the cost to the NHS of modern epidemics

This “asset-based approach” appears to be related to the phony claim that the UK could no longer afford costly public services.

In place of public services provided by trained, qualified professionals, with the aim of helping people to stay healthy – such as recreational adult education classes, sports and leisure facilities and day care centres – the “asset-based approach” has substituted cut-price, often precarious, voluntary sector services. These are mainly aimed at people suffering from the “neoliberal epidemics”.

A stated aim is to cut the costs to the NHS of these epidemics.

Where is the key public health tool of epidemiology in all this?

It’s as if during the cholera epidemic, instead of identifying and disabling the pump that was the source of the outbreak, Dr John Snow had employed lifestyle coaches to empower cholera sufferers and prescribed positive social activities to improve their resilience.

As it is, Improving Population Health attributes responsibility for eliminating epidemics to the individuals who are suffering from them and relies on ill paid and precarious voluntary organisations and their volunteer “army” to deliver the message and support individuals in their efforts to beat the epidemic.

In contrast, as far as I can make out, traditional public health provides professionally-run public services that are designed to improve everyone’s standard of health, backs legislation to remove harms to public health from society and crucially, uses the science of epidemiology to eliminate epidemics.

The heavy hand of American ‘health system support’ companies – population health management

To identify the populations whose health needs improving and managing in this (largely pointless and counterproductive) way, Integrated Care Systems have to spend a lot of money buying both advice and software from profiteering American health systems support companies like Optum and Cerner.

For example, the West Yorks and Harrogate Integrated Care System Board Terms of Reference para (3.1.vii) shows the heavy hand of Optum – a former employer of the NHS England boss, Simon Stevens.

That paragraph commits the Integrated Care System Board to making sure that its member NHS, social care and public health organisations operate what is clearly – if not explicitly – the Optum system of population health management in primary and community health services.

Questions and answers about Improving Population Health

Just for the record, here’s what I asked the West Yorkshire and Harrogate Integrated Care System Board meeting in March, after thinking about all that.

I really might as well not have bothered. As you can see from the responses.

All is for the best in the best of all Improving Population Health Programme worlds.

This has been in the works for years. In April 2014, NHS England announced a new, one year Enhanced Scheme to pay participating GPs a maximum of an extra £2.87/patient to introduce the use of risk stratification, putting at least 2 percent of their patients on a  case management register of patients identified as being at risk of an unplanned hospital admission without proactive case management.

A GP poll the previous January found that only 51% of GPs were planning to sign up for the new Direct Enhanced System because of fears that it would consume huge amounts of practice time.

As this 2017 report by accountancy company Deloitte points out, population health is all about data analytics, financial risk and cutting costs – with the introduction of financial risk driving the move to bigger populations per provider.

This why 999 Call for the NHS took NHS England and NHS Improvement to court in 2018/19. The #Justice4NHS campaign aimed to try and stop the introduction of contracts aimed at pushing population health management onto the NHS.

Updated 26.7.2020 with info about the House of Lords Select Committee’s report “Hungry for Change: fixing the failures in food“, published 6 July 2020

Update 25.9.2020 – Ahah! Turns out the editor of The Lancet is also worried about the double pandemic of Covid-19 and social inequalities – and has a nifty name for it: a syndemic.


  1. Excellent article, thank you. I do worry sometimes about campaigners demanding more ‘Consultation’ about services, because, having being involved in a few, they are primarily are about creating consensus. It would not be waste of time, to catalogue the current ‘asset-based’ operations in one’s locality, although they in some instances, are very coy about revealing who they are. I’ve found this out by attempting it. I’m sure the gradual mission creep in PCNs will begin to reveal less and less provision by ‘qualified professionals’.

    Liked by 2 people

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