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Header image for the current page Combining clinical and data expertise to deliver meaningful population health management

Combining clinical and data expertise to deliver meaningful population health management

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Many integrated care boards (ICBs) charged with delivering the Triple Aim see population health management (PHM) as a vital tool in helping to address health inequalities and provide more proactive care. But PHM also risks being seen as yet another task for busy GP practices and Primary Care Networks (PCNs) to tackle. Despite the potential benefits, there are often barriers to overcome such as workload, staff changes, data sharing, as well as the risk of overwhelm – the options can just feel too broad or too complex to galvanise action. So, what’s the answer?

Effective engagement with primary care is key, both in building a consistent understanding of PHM and in designing achievable interventions which benefit patients, practices and PCNs. Working with Lincolnshire Integrated Care System on a system-wide population health management programme, in partnership with the programme host Lincolnshire ICB and strategic delivery partner Optum, we found this engagement is best achieved through collaborative workshops which combine clinical facilitation and analytical insight. This helps to develop a more holistic understanding of PHM, secure buy-in from PCNs and enable knowledge transfer to primary care so that PHM can become ‘business as usual’ over time.

Understanding the data

PHM brings together multiple data sets from primary and secondary care, local government and others, to provide a much more rounded view of individuals and their wider determinants of health through joined intelligence. Segmenting that data enables PCNs to really understand their patients and identify which interventions are likely to support those most at risk and those who would benefit significantly from early intervention.

Key considerations include where the biggest workload is coming from, what targets are driving activity and where can interventions deliver decisive impact. Small, targeted initiatives, for example, can be just as beneficial as larger, more complex programmes and may deliver outcomes more quickly.

A key principle of PHM is to interrogate the data to ask more and better questions, rather than taking information at face value. This means developing a truly collaborative approach between PCN clinicians and analysts and being prepared to look at data from different perspectives to inform decision-making. Crucially, PHM should be a cyclical process, with evaluation baked into every initiative. Agreeing what success looks like at the outset enables PCNs to iterate interventions and, if appropriate, their success criteria, based on what the data and patients are doing and saying.

Clinical engagement and facilitation

Using facilitators with a clinical background helps to bridge the gap between analysts and PCN clinicians, combining a strong understanding of frontline pressures and practicalities with PHM expertise. By taking time to understand each PCN’s area, such as the size and make up of their patient populations, mix of rural and urban areas and principal pressures, facilitators can build relationships and encourage GPs and PCNs to consider more creative solutions to the problems they face.

Clinical facilitators understand what it feels like to provide patient care and complete associated admin tasks in a busy environment. But this isn’t just about empathy – it’s essential for accuracy too. By talking the same clinical language, clinical facilitators are equipped to question, for example, whether information has been coded correctly to feed into the data platform or whether more accurate use or consistent application of coding is needed to support evaluation. By collaborating with analysts, clinical facilitators can also make data more visually engaging for clinicians and relatable to patient care. This could mean using maps, bubble matrices or patient theographs which plot contact with different services over time. The aim is to provide clear, impactful information to encourage action and ignite interest in future uses of PHM.

Practical interventions

PHM can work extremely effectively to support new initiatives and existing programmes, at both small and larger scale, as well as informing future workforce needs. One PCN in Lincolnshire is using PHM to increase uptake of annual health checks among people with learning disabilities. By combining the data with frontline expertise, the PCN is running additional health checks at local day centres, led by care coordinators, to provide a more convenient and familiar setting for patients and carers.

Another PCN is using PHM to support the existing falls prevention programme, rather than starting something new. The PCN identified a cohort of older people who might benefit from a lifestyle programme to reduce the risk of falls, using resources already available locally, including medicines optimisation, emotional wellbeing advice, blood pressure monitoring, nutrition and hydration, and strength and balance exercises. At one session, it became apparent that 20% of participants had already experienced a fall but had not reported it as they hadn’t sustained an injury.

Other examples include using PHM to identify and address the needs of the most frequent users of A&E as part of the NHS England High Intensity Use programme. This programme provides quality individualised support to understand and treat the underlying issues prompting frequent A&E use, helping patients with often complex physical and/or mental health needs.

Key learnings

Effective clinical engagement, robust information governance, strong analytical skills, and supportive project management all contribute to PCNs being empowered to deliver targeted interventions. However, it’s also important to recognise and plan for blockages to keep initiatives on track. For example, building resilience into teams driving PHM initiatives can help ensure projects are not derailed if key staff members leave. Similarly, planning ahead for practical implementation, such as ensuring the right processes are in place for reidentifying pseudonymised data to enable PCN staff to review records, contact patients and confirm cohort suitability, can reduce the risk of programmes losing momentum.

Understanding of PHM is growing rapidly, but when resources are so stretched, it can be challenging to secure consistent buy-in. Considerable work is often needed to establish the information governance processes which underpin the approach, and outcomes can take time to evidence. However, as Lincolnshire is demonstrating with its system-wide approach, combining specialist PHM expertise with effective clinical engagement is helping PCNs identify ways to tackle existing pressures and implement early interventions which improve quality of life for their patient population and reduce long term healthcare demand.

This blog was originally published by Healthcare Leader.

Picture of Katie Mullard

Author: Katie Mullard |

Katie has over 15 years’ clinical experience in the NHS as a registered nurse in critical care, clinical trials and research, specialised commissioning services and endocrinology. As a Clinical Lead Nurse at NHS Arden & GEM, she has worked on a wide range of projects including an independent review of maternity services, running clinical speciality workshops for the NHS England Essential Medicines List, digitalising professional competency frameworks, and supporting Primary Care Networks in using joined intelligence data sets to make service improvements and undertake health prevention initiatives using a Population Health Management approach. Throughout her career, Katie has been committed to delivering high quality care and improving clinical outcomes.