We use cookies.

To make your experience the best it can be, we use cookies and similar technologies on our site. We need your permission to allow these technologies, which will maximise browsing experience. For more information on how we use cookies and how to change your cookie settings, please see our cookies and privacy policy.



Please complete this short form to get in touch with a member of our team and we will get back to you as soon as we can.



Sign up to our newsletter by completing the form below.

Header image for the current page Implementing a Population Health Management methodology across Lincolnshire Integrated Care System

Implementing a Population Health Management methodology across Lincolnshire Integrated Care System

Share this page

In 2022, Lincolnshire Integrated Care System (ICS) embarked on a three-year Population Health Management (PHM) programme to implement a whole system approach to intelligence-led decision making.

Arden & GEM’s clinical support team provided expertise and experience in project management, business management and clinical engagement to help the programme achieve its vision and goals. As well providing direct support to ICS partners, including Primary Care Networks (PCNs), Arden & GEM also established policies, processes and resources to help PHM become embedded as business as usual within Lincolnshire.

The challenge

PHM approaches provide an opportunity to improve the health and wellbeing of an entire population through better planning and delivery of proactive care.

Building upon the NHS England national PHM Development Programme, Lincolnshire ICB established a dedicated three-year PHM programme in June 2022 to unite system partners in generating and using insights to enhance population health and tackle inequalities. The programme brought together leads from the ICB with acute and community providers, the local authority, primary care teams and expertise from Optum.

Three months into the programme, the team sought additional project and clinical support to help bring its vision to reality. As the ICB’s current provider of a range of support services – including business intelligence, IT, contracting and IFR – Arden & GEM was well placed to utilise existing knowledge and relationships to meet the PHM programme’s evolving needs efficiently and effectively.

Our approach

Two members of Arden & GEM’s clinical support team were assigned to the programme bringing experience and expertise in project management, business management, clinical engagement and managing patients with long term conditions. This blend of clinical and business capability helped to implement a PHM methodology across the ICS including the rollout of access – for both analysts and non-analysts – to the Joined Intelligence Data Set (a reporting suite provided by the programme’s strategic partner, Optum).

Reporting suite access
Providing access to the reporting suite for all organisations within the ICS required a robust and structured approach to IG and user management. The CSU’s IG team had already been supporting the ICS’s population health management ambitions for a year prior to this programme, developing a Data Protection Impact Assessment (DPIA) to enable the linkage and pseudonymisation of data sets.

The next step was to create a combined Data Sharing/ Processing Agreement, signed by all GP practices. By communicating with all practices, meeting with the Lincolnshire LMC and producing comprehensive FAQs, a 100% sign up rate was achieved – the first ICS in the country to do so.

Working closely with the CSU’s IG consultant, organisational Caldicott Guardians and the ICB’s policy approval group, the team also put in place:

Following an initial phase to provide access to users in trusts and the local council, an extended policy was developed for GP access by using PCN Data Sharing Agreements.

Programme information
The programme needed to create easy to find, easy to access and regularly updated information for system stakeholders. Working with the ICB’s Communications team, Arden & GEM established an online area with information about the programme, its goals, the team and current progress. Practical resources including analyst training materials and useful links are also available. For those working directly within the programme, a SharePoint site was set up to house engagement and training resources, audit trails, process maps and any other useful project documentation.

Supporting PCNs
One of the programme’s objectives was to transfer knowledge and approaches from Optum into the NHS. By shadowing workshop delivery for primary care, the Arden & GEM team was able to adopt the role of ‘clinical facilitator’. A number of PCNs were supported through a process of understanding PHM which included looking at intelligence for their area, selecting a cohort for intervention, implementing the initiative and evaluating impact.

"We thoroughly enjoyed working with the project team, they are all very knowledgeable and understanding of the pressures. I sincerely hope our paths cross again."

Ann Rostron, PCN Facilitator at Meridian Medical PCN, Lincolnshire

One of the PCNs selected a learning disability cohort with a plan to increase annual health checks and improve patient/carer experience through undertaking health checks at day centres.

Using the PHM methodology
At an ICS level, support has been provided to several specific projects, including:


Over the past two years, the programme support provided by Arden & GEM has enabled system partners in Lincolnshire to gain access to and make best use of a PHM reporting suite. Not only does the ICS now have the appropriate policies, processes and information in place but the clinical facilitation and quality improvement frameworks provided have helped the ICB develop the internal resources and capability needed to implement PHM as business as usual.

Feedback from programme partners and project case studies across primary care are demonstrating the value of PHM approaches in better serving the health and wellbeing needs of the Lincolnshire population.

As the programme enters its third year – in June 2024 – delivery partners will step back further. However, Arden & GEM will continue to support the programme through a dedicated project support officer, ongoing business intelligence capability and IG expertise.

Find out more about our PHM analytics and decision support here.