As the government ponders the NHS 10-year plan, developing a neighbourhood-based health & care system would be strengthened by understanding some of the principles behind Value-based healthcare. The role of General Practice must be considered beyond being seen as traditional reactive service delivery. Rather than acting like other providers in the health and care system, General Practice could emerge as a central population risk manager, playing a critical role in preventing disease and managing long-term health outcomes. This shift requires a move away from transactional care models to one where General Practice operates as a proactive steward of population health, focusing on identified risks, prevention, and long-term impact. In this blog, we’ll explore why General Practice is critical to this role and how a system-wide commitment to data-driven risk management and value-based incentives can make it a reality.
General Practice as a Population Risk Manager: A Shift in Purpose and Impact
In the current system, General Practice largely operates in a reactive, episodic model, addressing immediate healthcare needs as patients present with symptoms. Much of this is due to overwhelming demand and funding changes resulting in less emphasis on the traditional ‘cradle to grave’ relationship and continuity. Although long term condition management is a key part of General Practice (including QoF), it has become formulaic and can, at times, focus on key metrics rather than holistic care. This approach, however, doesn’t leverage the full potential of General Practice to prevent illness, prevent illness progression, reduce demand on all services, be pivotal in improving outcomes and tackling health inequalities. By positioning General Practice as a population risk manager, the NHS can shift to a model where prevention and early intervention are paramount. Here’s what this could mean in practice:
Moving from Service Provider to Health Steward
As a population risk manager, General Practice should focus not only on treating illnesses but also on help identifying and managing risks before they manifest as acute health issues. This proactive role entails identifying high-risk or rising risk individuals or groups based on system-led data analytics, creating personalised, preventive care plans, monitor patients to prevent disease progression and be central to case management of those with very high risk requiring multidisciplinary input. Rather than being one of many providers in the system, General Practice holds an integral role in shaping community health outcomes. Of course, General Practice would need to review the skillset required to work in this way and the term ‘General Practice’ should not be confused with ‘The GP’.
Holistic Risk Management across Patient Populations
General Practice has a comprehensive view of patient history and health patterns, enabling it to support management of population-level risks across a broad spectrum of health and social care needs through direct, family and person-centred interventions. By using data on social determinants, chronic disease trends, and behavioural factors, it is best placed to guide targeted preventative measures that address both clinical and social risks, reducing downstream demand for higher-cost care. This risk management role aligns General Practice with the broader goal of reducing activity in all care settings and improving system-wide health outcomes.
A Strategic Partner in Health & Care System Sustainability.
General Practice, as a population risk manager, would act as a strategic partner in achieving system-wide stability. When General Practice helps identify & manage high or rising-risk individuals and implements preventative measures, patient experience and outcomes improve, whilst still benefiting overall financial sustainability. This approach requires General Practice to reclaim its position as the foundation stone in neighbourhood health & care, helping to reduce demand fluctuations through more scheduled pro-active rather than unscheduled reactive care.
Enabling General Practice to Manage Population Health Risks
For general practice to fulfil this role, it must be empowered with the right tools, incentives, and resources. Effective population risk management requires a supportive structure that includes system-led risk stratification (another blog will be dedicated to an understanding of risk), healthcare economics, and actuarial science to accurately quantify risks and support decision-making. Here’s how these elements work together to empower general practice in its expanded role:
System-Led Risk Stratification as the Foundation for Preventive Action
In a population risk management model, the health and care system identifies individuals at high or rising risk, using comprehensive data from multiple sources, including social, demographic, and clinical factors. By leading the risk stratification process, the system provides General Practice with accurate insights on the people & populations that need the most focus. General Practice can then prioritise its efforts based on these insights, ensuring preventive actions are targeted, timely, and impactful.
Actuarial and Economic Quantification of Risk to Inform Contract Values
As a population risk manager, Health & Care systems must use healthcare economics and actuarial science expertise to quantify risk and set accurate contract values. Actuarial methods allow the system to assess how specific risks, if left unmanaged, will translate into future demand for services, helping set realistic contract values that incentivise preventative care. This quantification ensures that General Practice and its partner organisations (including community and 3rd sector) are adequately resourced to target high-risk populations and address the long-term value of upstream measures.
Data-Driven Incentives Aligned with System-Wide Health Outcomes
Incentives for General Practice could be structured around measurable health outcomes, along with activity measures and engagement. By aligning incentives with the reduction of demand and improved population health metrics in a way that tracks back to a quantified, valued risk, newly resourced schemes through primary care are underpinned by a sound business case and clear benefits realisation. Incentives should encourage practices to prioritise preventative care, patient monitoring, and health promotion, making their contributions to the health system more proactive and sustainable for the long-term. How these incentives could transfer risk is also worth future consideration.
Integrated Partnerships with Third-Sector Providers to Address Holistic Needs
An interesting discussion is about resourcing community-based schemes. There will always be an important aspect of care, which is reactive. Resourcing also does not always have to be totally financial. General Practice can partner with local statutory and third-sector organisations around Primary care Networks or wider partnerships to impact the social determinants of health that often contribute to poor health. For instance, a practice could collaborate with mental health charities to support at-risk patients before they reach crisis or local authority housing to address damp. Partnerships, with appropriate resourcing, support General Practice to manage risk comprehensively and proactively, rather than waiting for conditions to worsen to the point of requiring more acute intervention. A key challenge is also engagement and 3rd sector organisations can be unbeatable partners in developing reach of proactive services.
Benefits of a Population Risk Management Approach for the NHS
Many would see a lot of this role already being implicit in the way General Practice operated, but by explicitly recognising the importance of this function in the both the sustainability of local health systems and the health and wellbeing of local populations, the NHS can ensure there is both a capability and financial focus to achieve significant benefits across the system:
Reduced Demand on all Services through Targeted Prevention
With general practice managing population risks proactively, high-risk individuals are less likely to require acute care interventions. Preventive measures tailored to high-risk populations reduce the likelihood of disease progression, freeing up resources in the acute sector and reducing hospital admissions (whether this is cash releasing or not is more complicated).
Sustainable Healthcare Delivery with a Focus on Long-Term Health
A focus on managing population health risks enables the NHS to deliver healthcare in a more sustainable way, reducing the financial burden associated with treating preventable conditions. By investing in prevention and early intervention, the NHS creates a long-term approach to healthcare that aligns with its value-based objectives. A key challenge is the funding cycles and sometimes benefits of action may even materialise in other government departments, such as the criminal justice system or welfare. The benefits realisation and associated investments may need careful consideration over a longer period than a single government.
Enhanced Patient Engagement and Health Outcomes
Patients benefit from a General Practice that actively manages their health risks, offering personalised, preventative care addressing not only immediate symptoms but long-term well-being. This approach enhances engagement, encourages self-management, and improves health outcomes across the community. It also paves the way for better use of technology, when it is seen as part of a continuous care plan.
Conclusion
The future role of General Practice in a value-based NHS should incorporate an explicit population risk manager role, rather than simply being another service provider. By taking a proactive, preventative approach to managing population health risks, General Practice could significantly reduce overall demand, enhance patient outcomes, and contribute to the long-term sustainability of the health & care systems. With system-led risk stratification, actuarial and economic insights, and aligned incentives, General Practice can reclaim its position as the cornerstone of neighbourhood care, creating a healthcare system that prioritises prevention, collaboration, and sustainability through best Value. If we need convincing about this, we just need to look at other health systems internationally, where they are effectively creating or contracting with primary medical services to deliver this function out of necessity.