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Header image for the current page Putting population health at the heart of Integrated Care Systems

Putting population health at the heart of Integrated Care Systems

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The Government’s legislative proposals for a Health and Care Bill will see the creation of statutory Integrated Care Systems (ICSs) covering the whole of England. With the right infrastructure and skills, these organisations will be ideally placed to commission and deliver care, using data to drive local priorities.

To achieve this, modern building blocks need to be in place to underpin a data-rich, preventative health system. But how can ICSs move away from traditional, activity-based commissioning towards more proactive, personalised care?

There is no ‘quick fix’ or ‘one size fits all’ solution, but as ICS leaders embark on this journey with their teams, there are three key aspects that will help these new organisations respond to the needs of their communities, tackle health inequalities and improve outcomes.

1. Board level leadership and accountability for data

The COVID-19 pandemic has clearly demonstrated how patient data supports decision-making – and the public has become familiar with the use of data to inform health decisions. Alongside this, temporary block purchasing brought in during the pandemic has freed up BI resources to devote more time and energy into population health data analysis, rather than contract management – a change which could help propel us towards the more personalised, proactive care originally envisaged in the Five Year Forward View. But ICSs will need the data expertise to lead this ongoing transformation and manage the value and risks associated with it.

Taking the opportunity to embed dedicated data expertise and accountability within the leadership team will strengthen the ability of ICSs to build the right processes, systems and skills to lead decisions around digital and data development plans, and the confidence to recalibrate analytics teams to focus more on population health.

2. Getting the business foundations right

Forming standardised business processes to look after an ICS’s data assets will enable productive, efficient integrated working across system partners. This includes robust infrastructure, data collection and analysis processes to establish and maintain a ‘single version of the truth’, as well as the skills to analyse and interpret information.

What the data says about local patient populations will help to determine the most appropriate set-up in each case. For example, some ICSs will have huge variations in patient need across its geography. As such, a ‘hub and spoke’ approach to data analytics is likely to work much more effectively than a region-wide approach, with place-based analysts at Primary Care Network (PCN) level providing the local insight needed to inform priorities. By contrast, smaller, more homogenous geographies may benefit more from disease group-led analysis.

As data controllers for their locality, ICSs will also need clear information governance in place to cover how data will be housed and how internal access will be managed.

3. Using data to improve patient outcomes

This begins with having the right tools such as dashboards and population health data to monitor and manage services. But where an ICS comes into its own is where it can use locally focused, place-based intelligence to support transformation and drive preventative interventions that improve patient care.

BI plays a pivotal role in the quality and cost efficiency of care when risk models are used to stratify patients and plan interventions, provided the right resources are available to act on the data. An ICS hub and spoke model would enable place-based analytics teams to interrogate data about patients at risk of an unplanned hospital admission, for example, and work with the relevant PCN to bring in a multidisciplinary team to intervene, putting patients on disease registers to proactively monitor their care and reduce their risk of admission.

Understandably, there is pressure to set up new ICSs quickly, but in that rush to get up and running, let’s not lose sight of an opportunity to structure our new landscape to give the NHS the best chance of tackling the issues that matter most to the people we serve or, to quote former Chief Medical Officer Sally Davies, becoming an “exporter of health”.

This article by David O’Callaghan, Chief Data Officer at NHS Arden & GEM CSU, was originally published in National Health Executive. You can view the full version here.

Picture of David O'Callaghan

Author: David O'Callaghan |

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.