Scoping of models to support population-based regional health planning and management: comparison with the regional operating model in Victoria, Australia

Additional keywords: population health approach.

Healthcare systems around the world are attempting to manage various challenges related to the aging of their populations, rising chronic illnesses and multimorbidity, in addition to rising costs.^1,2 It has been recognised that systems are not well integrated, there is duplication and waste throughout the service platforms and ways are needed to reverse these trends.^3–5 This has led them to focus on better service integration and more targeted healthcare to those who most need it. Policy makers increasingly realise that if the health sector better meets the needs of the population, they may achieve better health outcomes and increase cost-effectiveness. Hence, the interest in population health planning and better-targeted commissioning of services.

In many healthcare systems there is a growing recognition that individual health and well being is determined by complex interactions between healthcare, environment and social contexts.^6,7 Governments realise that achieving healthy communities requires better integration between healthcare, the environment and social systems.^8–11 Reform of health systems and the shifts, in particular, to integrating population health approaches has been to the fore of recent policy and academic literature.^12–14 Population health as a field of study seeks to identify why some populations are healthier than others and to promote thinking about what can be done to make health outcomes more equitable.^13,15 As Keleher notes, population health ‘is about determinants of health among populations and their characteristics. Effective population health planning is grounded in a social determinants model, and puts equity outcomes central to its goals’.¹⁶

Internationally, there have been several initiatives to facilitate the development of healthcare delivery systems that meet the needs of the population they serve rather than operate purely on a service model.^17–21 Examples are the formation of Accountable Healthcare Organisations (ACOs) in the US, in which groups of providers take responsibility for improving the overall health status, efficiency of healthcare delivery and healthcare experience for a defined population,^22,23 and the Clinical Commissioning Groups (CCGs) in England, which are clinically led statutory National Health Service (NHS) bodies responsible for the planning and commissioning of healthcare services that meet the documented needs of their local area (NHS England).²⁴ Central to these developments is the need for reliable data sources, both quantitative and qualitative, that provide service planners with the information required to make decisions about which services to commission.^21,25–27

As part of a reform implemented in 2009, the Victorian Department of Health established eight regional offices to deliver an array of devolved functions and programs that include: program planning, development and implementation; performance management; service system development; and stakeholder relationship management. These regional offices were responsible for surveillance and improvement of the health and well being status of the residents of their region. During 2010, the North West Metropolitan Region (NWMR), through a series of activities, developed a framework to guide health services planning towards a more population-based approach: a regional operating model (ROM). The broad objectives of this model were to provide a basis to focus staff efforts on strategic goals, to serve as a unifier of the regional strategy, to highlight the complementarities and uniqueness of the region’s programs and to provide a basis for developing specific achievement-based goals and activities for programs, teams and individuals. Such operating models can be broadly defined as outlining the organisational structure and mechanisms adopted to produce services. In line with this definition, a key feature of the ROM was to rearrange streams of activity using an integrated perspective whereby regional planners and contract managers oversaw the entire range of funding streams for a defined local geographical area rather than their previous siloed programmatic responsibilities around a content area, such as mental health. In addition, the ROM clearly stated that allocation decisions and managerial oversight must take into account population needs and overall intersectoral activities in the management of health services.

In order to further the development of the operating model and develop a sound understanding of its potential and strengths, the NWMR funded an evaluation of the framework with regard to its validity and relevance.²⁷ The present study is concerned with one aspect of this evaluation focusing on the content validity of the ROM. This aim of the present study was to compare the ROM with other models in the field of regional population health planning and to assess its breadth and scope.

In 2012, we scoped models by conducting a search of the published literature (PubMed, CINHAL and Web of Science), website scanning and snowballing technique (using Google Scholar for academic journals and referring to publications from health agencies or departments, such as the NHS and World Health Organization (WHO)). Key words were defined by the research team to aid in identifying the most relevant data sources. International experts in the field of population health planning (n = 7) were identified using the current knowledge of the researchers and the project control group. These experts were consulted as a source to help identify further relevant models that had not been published.

An analytical grid (Table 1) was developed by the research team to assist in selecting documents for inclusion, extracting information from selected models and comparing and contrasting them with the ROM. This analytical grid was based on the literature around operating models and integrated planning framework and focused on strategic (e.g. mission, roles), tactical (e.g. target populations sector), operational (e.g. governance structure, monitoring) and contextual (e.g. engagement, communication) aspects.^21,28–33 The grid aimed to draw out the dimensions, subdimensions and categories common to each model, as well as highlighting potential strengths and gaps in the ROM.

Table 1.  Analytical grid

The present study received ethics approval from The University of Melbourne Research and Ethics Committee.

A total of 34 relevant documents published in various forms (journal articles, reports, strategic plans, summary documents and unpublished reports) were identified following the literature search and expert consultation. Many of the documents retrieved were health agencies’ strategic plans that provided no specific details on operational aspects or any detailed information on the organisation, governance or specific regional focus. Although none of the documents was specifically reporting on an operating model, 10 documents^34–43 contained reference to a model for health planning that was of direct relevance to the ROM. These included five Australian models,^34–38 four models^39–42 from the UK and one model⁴³ from Canada. These 10 models were used as the comparator models for this evaluation (Table 2).

Table 2.  Models included for comparative analysis with the regional operating model (ROM)
NHS, National Health Service

No single model contained all 16 components as listed in Table 2. Most of the models (nine of 11) included at least 10 of the 16 components, yet there were variations in coverage. The dimensions that were most likely to be included were statements about aims and objectives, description of public health services sector involvement and internal and external engagement in the planning and operating processes. ROM is among the most exhaustive models, covering 13 components, along with the Victorian Department of Health’s Prevention Community Model (PCM) and the Québec Population Health approach adopted in Quebec (PHQ), both of which covered 14 components (Table 3). The ROM differed from the Victorian PCM and Québec PHQ by not including the dimensions of monitoring and evaluation, or external stakeholder engagement mechanisms.

Table 3.  Coverage of components by models
ROM, regional operating model; NSWHG, New South Wales Area Healthcare Services Plan; NPHP, Planning Framework for Public Health Practice; PCM, Prevention Community Model; SASP, South Australia 2008 Strategic Plan; QHP, Queensland State Wide Health Services Plan 2007–2012; GMA, Manchester City Region Total Place; PHE, Public Health England’s Operating Model; LTC, Supporting People with Long-Term Conditions – The NHS and Social Care model; NHSGGC, NHS of Greater Glasgow and Clyde Corporate Plan for 2013–2016; PHQ, Population Health approach adopted in Quebec

Ten models had a focus on internal engagement strategies, such as up-skilling of staff, training and information sessions. External engagement strategies, such as consultation processes and service planning processes, were included, with varying levels of details, in nine models. The least covered component related to intersectoral actions. Only seven models incorporated a regionalised service planning and a whole-of-system integration perspective. Few models outlined a broad range of sectors to be influenced and the levers to be mobilised to influence them.

With regard to specific sectors covered by the various regional planning models included, public health services and primary care are the most commonly covered, followed by acute, aged and rehabilitation and extended care.

The ROM covers some components that are less often addressed in other models. Intersectoral actions were only described in four models, with the ROM being the only Australian model including this dimension. Furthermore, the ROM describes levers of influence, which were only covered in five other models. However, some models identified more precisely the planning tools, prioritisation criteria and steps, the allocation mechanisms, such as the Planning Framework for Public Health Practice (NPHP) and the Public Health England’s Operating Model (PHE). Others, such as the PHQ, provided a better description of the context into which the organisation evolves and the relationship that it maintains with various stakeholders and policy levels. Finally, some models identified the roles of the patients and population and positioned them at the centre of the model. This was the case of the Manchester City Region Total Place (GMA) and the NHS of Greater Glasgow and Clyde Corporate Plan (NHSGGC).

It is widely recognised that achieving healthy communities requires better integration between healthcare, the environment and social systems.^44–47 A Canadian study showed that most regional health authorities do include improving population health and health equity in their mission and vision.⁴⁸ However, when it comes to a system-wide effort with diverse partnerships to address medical and non-medical determinants of health, most organisations are struggling to operationalise these concepts.⁴⁹

The present scoping review identified a range of dimensions that have been incorporated into operating models aimed at supporting the integration of population health perspectives into system planning and contractual management at the regional level. Ten models were identified that could be compared with the ROM developed in Victoria, Australia. The models scoped came from various jurisdictions, both from Australia and other highly industrialised countries (Canada and the UK).

The fact that we only found 10 operating models in addition to the ROM despite the extensive search we conducted suggests that not many organisations explicitly state and make public the frameworks they use to guide their operations and the activities they adopt to achieve their mandate. Numerous strategic plans and priority statements can be found in the grey literature and in various websites of organisations. However, clear statements and an outline about how these organisations intend to operate to achieve their goals remain scant. This aspect alone distinguishes the Regional Operating Model (ROM) adopted in Victoria. It is among the few stated models describing not just what the strategic orientations or the intended programs of activities are, but actually how to structure services, manage organisational processes and operate in order to provide the planned services and activities.

Many elements found in Victorian ROM were also clearly prioritised in the other models included in our analysis. Stating the aims and objectives of the organisation was certainly the most common. In addition, some specific orientations embedded in the ROM approach were part of many innovative models scoped through this work. Adopting a whole-population approach, identifying a continuum of interventions ranging from healthy population to people with complex conditions, an intersectoral focus on health determinants, a needs-based approach and a coordination role to funnel the various stakeholder interventions supporting population health were all identified frequently. These aspects relate strongly to dimensions often cited in documents highlighting a population health approach to planning in health organisations.¹⁴ However, although the ROM definitely aims at integrating intersectoral action and individualised service delivery, many models do not adopt such a broad mandate. Kindig and Isham highlighted the fact that no single entity can be held accountable for achieving population health goals in light of the various factors influencing it.⁵⁰

The lack of identified levers, mechanisms, criteria and structural organisation characteristics highlights the challenges related to developing an operating model that can be concise enough to serve as a mobilisation tool and detailed enough to streamline activities in the new directions outlined in the model. This does not mean that the policy makers or authorities developing these models did not select and use such tools; it simply shows how difficult it can be to go to such a level of operational detail in a model. Nonetheless, the fact that several models identified some operational planning and management tools highlights the potential to add to ROM some more information about the tools and processes put in place to guide the organisation’s activities and processes. This could also ensure going beyond the rhetoric of the model (e.g. planning according to a population’s needs) by actually detailing the meaning in concrete terms.

To a certain extent, ROM seems to be integrating into a single model some of the distinctive elements of the other models scoped. This is also the case in the Quebec and Glasgow models,^42,43 where population health planning approaches have been in development over the past decade. ROM combines strategic, tactical and operational planning perspectives. However, ROM goes further by combining a population health approach and a system integration approach in the same framework. Few models among those retrieved in the present scoping exercise have adopted both these perspectives. In fact, the Quebec model,⁴³ representing a full integration of public health and curative care planning, is the one the closest to ROM in this regard, where elements of health promotion and prevention are integrated through the continuum of care and support services. The innovative nature of ROM lies in the fact that such an integrated view comes from an organisation that manages services and contracts at a level, the regional level, where such an integration approach is expected. Only the Glasgow and the Manchester^40,42 approaches were also at the regional level. All other models were developed at the national or state level, although some were designed to provide the locus of integrated planning at the regional, and even the local, level.

This scoping adopted a mixed-method approach to try to capture a poorly studied area of health system management. Complementing a literature search of published academic papers with a grey literature search and experts interviews enabled us to identify a subset of models addressing the issue of planning health and social services from an integrated population health perspective at the regional level. More specifically, the present study is among the first to synthesise how regional authorities can adopt a model to conduct their planning and management activities to support a more integrated approach.

However, the present scoping of models has some limitations. Although our search was extensive, we could not, with the allocated time and level of resources in this evaluation, provide a full scoping of unpublished models. Various organisations may have operating models without publishing them or making them available on their website. Only by contacting the various jurisdictions could such a scoping be done. However, given the very large number of regional-level organisations in countries comparable to the Australian context, such a full scoping would not be realistic as part of a rapid evaluation. However, we did manage to retrieve models from the various Australian states and are confident that we have covered the most salient models from this context. Thus, the various international models scoped can provide a complimentary view of things in a context of exhaustive scoping of Australian models.

Healthcare systems around the world are attempting to manage various challenges related to the aging of their populations, rising chronic illnesses and multimorbidity in addition to rising costs. The present study found that explicit frameworks to guide the operationalisation of population health plans are few and that the ROM developed in Victoria, Australia, provides an example that will be of use to others that manage services and contracts at a regional level, where such an integration approach is expected. Given the current lack of operating models found in the present mixed-method review, there would be strong benefits for organisations with population health responsibilities to articulate their policy, strategy, tactics and operational issues in a coherent manner in order to identify conflicts and tensions and to refine intersectoral action.

None declared.