KNOW
PHM brings together a broad range of insight and data, across everything that impacts a person’s health, including housing, finances, employment and education. It builds a holistic view of people’s needs to help identify where best to focus collective resources to accelerate prevention programmes and tackle health inequalities and deliver personalised care.
Population Health Management
Our Ambition: People Living in Suffolk & North East Essex Benefit from Population Health Management and Intelligence Led Health and Care
Population Health is an approach aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people, whilst reducing health inequalities within and across a defined population. It includes action to reduce the occurrence of ill-health, including addressing wider determinants of health, and requires working with communities and partner agencies.
Population Health Management (PHM) is about using linked data to provide new insight, and then taking linked action to improve the social, physical and mental health outcomes and wellbeing of people within and across a defined population, while reducing health inequalities. It includes segmentation, stratification and modelling to identify local ‘at risk’ cohorts – and, in turn, designing and targeting interventions to prevent ill-health and to improve care and support for people with ongoing health conditions and reducing unwarranted variations in outcomes. It actively helps to reduce health inequalities and offers proactive, targeted healthcare for every community.
What is population health management data?
Population health management (PHM) data is joined up health and care data that enables us to provide joined up healthcare. PHM data in SNEE includes records from primary care, secondary care, mental health, community, social care and other data related to health and care. Additionally, PHM data held by the Integrated Care Board (ICB) is:
- Pseudonymised meaning that personal identifiable information is removed before it is sent to the ICB.
- Linked across different datasets, enabling us to provide joined up insights and care. Datasets are linked at the person level using a unique, privacy-protecting code, derived from patient NHS Numbers.
- Securely stored in a secure data environment, where access is strictly controlled and limited to trained analytical professionals within SNEE ICS. Pseudonymised PHM data is also securely transferred to provider partners who build our PHM reporting.
How we use PHM data
Historically, data in the NHS has been used to understand services, and the performance of those services. Because PHM data is joined at the person level, it gives us the opportunity to ask new questions about people and their health needs. With this in mind, we use PHM data for both direct and indirect care purposes[1].
PHM for indirect care
Most of what we use PHM data for would be considered indirect care, in that it contributes to the overall provision of services in SNEE without directly being used for clinical activity. Examples of using PHM data for indirect care include:
- Using population segmentation to group the SNEE population into groups with similar healthcare needs. This is then used to better understand and predict current and future demand for services and to identify opportunities for prevention.
- Using descriptive and predictive analytics to identify areas that might benefit most from a given service
- Using descriptive and predictive analytics to identify groups of people that might benefit most from a given service.
- Identifying inequalities in underlying health need, and in access to services, so that these inequalities can be tackled.
PHM for direct care
In some cases, a GP or other healthcare professional may request for PHM data to be reidentified, so that they can contact individuals who may benefit most from a particular service. Consent of the practice you are registered with is obtained and approval goes through a strict governance process. Direct care applications of PHM data may include:
- A GP may use PHM data to identify patients who might benefit from a blood pressure check
- A Primary Care Network may use PHM data to identify patients experiencing poor access to services and invite them in to discuss their needs.
- An Integrated Neighbourhood Team may use PHM data to identify patients at risk of a fall, and may invite them to attend a falls prevention session.
Risk stratification
Risk stratification is the process of using data to identify patients who may be at risk of a particular healthcare outcome. Some GPs use risk stratification algorithms directly on their data to calculate, for instance, cardiovascular risk scores. ICS analysts may also use PHM data for risk stratification, to identify high risk groups for the purposes of service improvement (indirect care), or as part of a reidentification request for a GP or other clinician to identify individuals that may benefit from a given service (direct care).
Opting Out
You can choose if the data from your health records is shared for research and planning via the national data opt-out. Learn more by visiting www.nhs.uk/your-nhs-data-matters/. Opting out can mean that your data won’t inform future service planning, and, in some circumstances, you will not be identified by the programmes who find people who fall into ‘at-risk’ categories. This means you may not be offered preventative care you may benefit from.
[1] Section 10: Using health and social care information –direct care and indirect care purposes – NHS England Digital
Why PHM is important
Health needs are changing: People are living longer, but with more years in poorer health and it is increasingly common for people to have two or more long term health conditions. We know that health is determined by an interaction between individual characteristics, lifestyle and the physical, social and economic environment – the wider determinants of health.
PHM is a methodology that enables us to deliver the outcomes set out in the Suffolk and North-East Essex Integrated Care System strategy and Joint Forward Plan. The use of PHM techniques offers a deep insight into the needs of different populations and drivers of health inequalities. Using linked data across local health and care partners, and techniques like population segmentation and risk stratification, can offer deeper insight into the holistic needs of different population groups and the drivers of health inequalities.
Embedding this approach across integrated care systems is everybody’s business and will transform the way we work and the way we care for people.
How we use patient data
To support your understanding of how PHM data is used in SNEE, you can watch this short video. It explains how your data is used for PHM and risk stratification to improve joined-up health and care services in the area.
Watch This Short Video: Understanding PHM in SNEE
How PHM works
PHM is a function of integrated care systems in helping drive a data led focus on person-centred care.
PHM is a strategic tool built around three key pillars – Know, Connect, Prevent: The 3 core Principles of PHM
CONNECT
Connecting across health, social care, public services and the voluntary sector we can ensure people receive the right service at the right time, from the right people.
PREVENT
PHM changes the focus from reactive care to proactive, personalised and preventative care – an approach that allows long-term health solutions to be developed. By understanding who’s at risk today we can predict who might be affected in the future. PHM is a critical component in our integrated care system and the foundation to building a healthier future together.
We use PHM tools and data in 3 different ways:
Capabilities for Population Health Management:
Infrastructure: the basic building blocks that must be in place
Intelligence: opportunities to improve care quality, efficiency and equity
Interventions: proactive clinical and non-clinical interventions to prevent illness, reduce the risk of hospitalisation and address inequalities
- Organisational Factors – defined population, shared leadership & decision making structure
- Digitalised care providers and common longitudinal patient record
- Integrated data architecture and single version of the truth
- Information Governance that ensures data is shared safely, securely and legally
- Supporting capabilities such as advanced analytical tools and software and system wide multi-disciplinary analytical teams, supplemented by specialist skills
- Analyses – to understand health and wellbeing needs of the population, opportunities to improve care, and manage risk
- Reporting the performance of the ICS as a whole in a range of different formats
- Workforce development – up skilling teams, realigning and creating new roles
- Community well – being approaches, social prescribing and social value projects
- Assistive technologies and digital tools to empower patients and smooth care transitions
- Incentives alignment,return on investment modelling and risk sharing mechanisms
National Examples of Population Health Management (PHM)
Below are three examples from across the UK that show how Population Health Management (PHM) is being used in practice. Click on each video to learn more
For NHS and local government commissioners, greater understanding of the local population will ensure they can better predict what residents need and ensure health and care providers work together.
- Integrated Care Boards
- Public Health
- Social Care
- NHS Trusts
- Primary Care
- Health Watch
- VCSE Sector
- PHM Partner Provider
- ICS Workforce Lead
- ICS PHM Leads
- NHS England
- NHS Improvement
Case Studies
Population Health Management Capsule Sponge Project
Suffolk Primary Care Research Team, Cyted Health, NHS Suffolk and North East Essex ICB
