Header image for the current page How to prepare for population health management

How to prepare for population health management

Patient data is one of the most valuable and protected assets we have. Patients need to be confident in our ability to keep their data secure, but we also need to make better use of it if we are to get beyond firefighting and focus more on preventing and managing health problems.

There are four key elements that will make this more achievable for Primary Care Networks (PCNs) and the wider health system.

  1. Information Governance: Every PCN is different and how you choose to manage your network will depend in part on your set up, existing relationships and experience of working together. But underpinning any integrated working arrangement – whether that’s at PCN, clinical commissioning group or regional health system level – there needs to be a data sharing agreement that sets out what data can be shared with whom and for what purpose. Data sharing is undoubtedly complex, and caution is understandable.  Putting work in at the outset to understand the requirements and risks, and agree how these will be managed, will pay dividends in the future. If you don’t have the right permissions upfront, your ability to do anything meaningful with your data will be vastly reduced. This is particularly important as we look to the future of integrated Local Health and Care Records (LHCR), where we’re working with Exemplar sites such as Greater Manchester to develop robust data sharing and analysis agreements.

  2. Technology: Many practices are currently grappling with the removal of support for Windows 7 and the pressure to upgrade to Windows 10. But there’s an opportunity here too. While there’s no requirement for PCNs or localities to all work on the same systems, there is a lot of sense in doing so. Unified operating models and single integrated patient record systems across multidisciplinary sites and services help you to work optimally at a practice, network and system level. We recently worked with the Norfolk and Waveney CCGs to migrate all their practices onto the Health and Social Care Network (HSCN), update to Windows 10, upgrade hardware and move all sites onto a single domain. While this created some challenges and disruptions in the short term, it has given the practices solid digital foundations which will not only support collaborative working, but will make it easier to offer newer interventions such as online triage and video consultations.

  3. Data quality: We all need to get better at how we record information, particularly as we start working together. Effective data analysis is reliant on the quality of the data you put in and consistency is key. For example, one person’s interpretation of epilepsy may be different to another’s, leading to different coding structures. When processing data at scale, we can see fluctuations and inconsistencies in data which limit the potential for analysing and predicting trends. This is often put in the ‘too hard’ box when considered across the NHS, but relatively new PCNs provide an opportunity for us to improve how data is recorded in more manageable chunks. If PCNs can adopt a consistent approach to recording information – such as always using the medical drug name rather than the common name - this will feed into much more consistent patient notes and clearer coding to enable you to track and manage patients across your network.

  4. Culture change: However good your technology might be or how informative your data, it is people that will drive the change towards better use of Population Health Management (PHM) approaches. The best way to exploit data to benefit your patients is to make it part of the day job and improve your team’s understanding of what it can do. Use case studies to highlight opportunities, put PHM on the agenda in your multidisciplinary team meetings and work towards PHM becoming core to identifying local priorities and supporting cases for change.

This might sound like more pressure on an already heavy workload, but if we put the right preparations in place early on, the potential PHM offers to improve services is significant. For example, in Leicestershire, CCGs have already used PHM to understand the impact of multiple comorbidities on hospital referrals and have directed funding accordingly. PCNs in Norfolk have used a localised segmentation model to develop a case for change to proactively target preventative care for individuals with Long Term Conditions who have not accessed mental health support but are at risk of developing co-morbid issues. The model demonstrates that improving patient’s resilience and wellbeing in the community could reduce their associated acute costs by up to 42%.

With resource pressures mounting, and further highlighted during the COVID-19 pandemic, PHM gives us the insight we need to be much more targeted with our interventions, benefiting those receiving care as well as those tasked with balancing the books.

This blog was originally written for Healthcare Leader. To full the view version, visit their website.

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Author: David O'Callaghan | Linked in URL


David is responsible for delivering Arden & GEM’s data and systems services – including DCSRO – for local, regional and national clients. Since joining the NHS in 2005, David has worked predominantly in the North West; creating, delivering and maintaining agile and robust data systems. A nationally recognised expert in data governance, dataflows and data management, David utilises this expertise and his wider business intelligence experience to ensure consistently high levels of service delivery.