What question did this study set out to answer?

To evaluate the implementation of Population Health Management (PHM) across Primary Care Networks in an Integrated Care System.

April 26, 2026Open Access

Implementing Population Health Management (PHM) Across an Integrated Care System in England, Using Action Learning Sets and an Embedded, Formative Process Evaluation

Key Points

To evaluate the implementation of Population Health Management (PHM) across Primary Care Networks in an Integrated Care System.
Comparative case study design over 24 months
Data collection included ethnographic methods, interviews, observations, and Action Learning Sets
Thematic analysis conducted using Excel and NVivo for data analysis
Around 200 stakeholders engaged in Action Learning Sets for collaboration
Limited innovations reached delivery stage due to operational pressures and resource constraints
Establishment of PHM infrastructure did not translate into effective delivery due to governance and integration challenges

Abstract

Introduction: Population Health Management (PHM) is a UK priority for Integrated Care Systems (ICSs), aiming to deliver proactive, preventative, person-centred care using integrated health and care datasets. However, evidence on implementation in primary care remains limited. Methods: This comparative case study used embedded researchers, ethnography, interviews, and observations to formatively evaluate a 24-month PHM programme across 31 Primary Care Networks in one ICS. Data were thematically analysed using Excel and NVivo, with findings fed back to participants to guide programme delivery. Results: Around 200 stakeholders participated in Action Learning Sets, fostering cross-sector collaboration within four localities. Few innovations, developed using integrated datasets, progressed to delivery, limiting their impact on patient health. While PHM infrastructure was established, delivery was constrained by operational pressures, data governance challenges, limited resources, lack of strategic integration and the nature of local relationships. Discussion: Effective PHM implementation requires more than infrastructure and governance. It depends on developing system-wide soft skills (facilitation, co-production), motivating stakeholders, and investing in processes that support insight generation, innovation piloting, and evidencing of impact. Conclusion: The study highlights the need for stronger strategic integration, sustained resourcing, coordination, and co-production to realise PHM’s potential at system, place and neighbourhood levels in addressing health inequalities and improving population outcomes.

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