Understanding the patient population


Many conditions seen in hospital practice are preventable by interventions undertaken long before the patient presents to specialist services. However, prevention is still relevant at later stages. Disease processes may be reversible even after presentation to specialists (eg non-insulin dependent diabetes).

Therefore, prevention in secondary care is a real and important opportunity. Evidence-based prevention programmes can benefit greatly from the advice and support given by specialty physicians.

Specialists with a good understanding of the health needs of the local communities they serve can advise on unrealised opportunities for physicians practising secondary care medicine. The specialist can also judge if resources allocated are being used to maximum effect both in the hospital and community.

Whole-system population medicine requires expert input from specialty physicians in exposing issues from specialty physicians, related to unidentified need and appropriate resource allocation.

Some of the information that is valuable here should be provided by the main audience for the work: trust medical directors, managerial colleagues with links to NHS and social care commissioners, public health support staff and health and wellbeing boards.

Physicians may consider health promotion and prevention of disease (HPPD) in the following three ways: 

  • understanding the patient population
  • health promotion and prevention
  • planning effective and efficient services.

Understanding the patient population

Questions for the medical director:

  • What are the implications of the relative distribution of new (incidence) and established disease (prevalence) in a specialist service’s catchment population?
  • Does the demographic profile of patients seen by a specific specialty align with the population at most need?

Questions for the specialty:

  • Is access for patients with the most need of services appropriate and equitable?
  • What are the implications for improving access to services and reducing population inequality in the burden of disease?

Factors applicable to all specialties

For instance, this may identify that particular racial or gender groups are under-represented in your caseload. Or that the patients with COPD you are seeing don’t seem to align with the profiles of severity published elsewhere. Do NHS commissioners know that? Does that have any implications for improving access to your services and reducing population inequality in the burden of disease?

There are often inequalities in access for patients in the community to specialist services, unless efforts have been made to enhance case finding and engagement with the health services for potentially vulnerable groups. In general, people from ethnic minorities, and/or deprived communities, with severe mental illness or intellectual disability, who misuse substances, prisoners or those who are homeless or from travelling families are most adversely affected. In some specialties addressing this inequality is very important because these individuals often carry the highest burden of illness.

Health promotion and prevention of disease

All specialists have a role as expert advisers, and leaders in HPPD. There is a need to define what the healthcare service is doing to help prevent diseases commonly treated by the specialty.

Questions for the specialty:

  • What is the evidence base for (primary and secondary) prevention in patients with the condition(s) to help reduce the burden of disease?
  • Has the specialty identified the key interventions required? Does it have evidence about whether those interventions are happening in the community?
  • What does the specialty seek to provide directly and what should it be signposting to other preventive services?

For instance, are all patients at very high risk of developing diabetes getting access to evidence-based intensive weight reduction services? Does the local hepatology service have access to, and is it assured of the effectiveness of, alcohol treatment services provided for patients it sees who need intervention?

Factors applicable to all specialties

All patients in contact with specialty services are less healthy and therefore at higher risk if they smoke, have inappropriate weight profiles, have poor diets, inadequate exercise, alcohol or substance misuse, or poor mental wellbeing. How important these factors are for specialty practice varies, and the specialties have identified some of the nuances of this in their contributions.

Planning effective services

Specialists have a vital role in advising on what health services will best meet population healthcare need. Only some of those patients will receive services from the specialist, but the specialty should advise on all parts of the care pathway and ‘whole-patient care’. The specialty may already have carefully researched commissioning advice or guidance.

Questions for medical directors:

  • The specialty has a role in understanding clinical variation within its service provision and in the way patients are referred into it. Does this appropriately reflect patient variation or medical practice variability?
  • Are commissioners aware of the value of specialty input – for both health and social care planning?

Questions for the specialty:

  • Does the specialty already have published needs assessment or commissioning guidance and what are the key messages?
  • How do these compare with the local Joint Strategic Needs Assessment for your patient group?
  • How would the specialty advise on the distribution of given resources (between the different interventions) within local care pathways for patients who come under its care? For example, are there any recurring gaps in service provision that your specialty may see as a priority to champion?
  • Are you aware of other specialty services providing care through the patient journey and do you have advice about ensuring continuity of care?
  • Does your specialty already carry out peer review audits on activity or outcomes and what messages are relevant?

Does the specialty have any recurring gaps in service provision it sees as a priority to champion? Is the care pathway balanced – for instance in a neurology service, is the balance of resources between that spent on GP-requested diagnostic scans and psychological services to support patients reasonable? Does the specialty already carry out peer review audits on activity or outcomes and what messages are relevant?

Factors applicable to all specialties

In some specialties, regional or local networks or ‘senates’ bring together clinicians and planners who can take responsibility for the whole patient pathway. Specialists have a particularly important role here to ensure a strong evidence base at all stages of the pathway, including primary care and prevention. Variation in care needs to be understood and the developing Rightcare Atlas of Variation is of potential use in some specialties as are specialty specific audit programmes. Many specialty societies have well-developed commissioning guidelines.