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Header image for the current page Population Health Management

Population Health Management (PHM) Solutions and Services

Adopting a population health approach provides an opportunity to improve the health and wellbeing of an entire population through better planning and delivery of proactive care.

As Population Health Management (PHM) models continue to evolve and mature throughout the world, Arden & GEM is taking the emerging best practice and collaborating with health economies to help them develop a unique PHM solution that reflects their local circumstances and challenges.

Our solutions will support you to realise the aims of PHM for your health system and population.

Our approach is built on bringing together our unparalleled access to data with advanced analytical expertise, to guide your care planning and delivery, with the aim of reducing health inequalities and improving health outcomes.

We can work strategically with you to deliver an end-to-end PHM approach or on a modular basis to meet a specific need or challenge.

We have a track record of helping organisations and systems put in place the building blocks that will enable them to understand and plan for the health needs of their population.

Information Governance (IG)
Patient data is one of the most valuable and protected assets we have. Our IG approach allows us to build data around the patient and enables solutions to be developed that provide insight directly to clinicians. We are increasingly supporting emerging partnerships – at neighbourhood, place and system level – to put the right data sharing agreements, procedures and responsibilities in place.

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.

Data capture and linkage
We can help you to capture or locate the sources of data required for your PHM needs – including health, social care, education, demographic and housing data – and bring it together into one place using sophisticated online portals and cloud-based technology. We built the National Commissioning Data Repository (NCDR), on behalf of NHS England, which provides specialised services data to deliver a comprehensive view of the patient pathway.

As a Data Services for Commissioners Regional Office (DSCRO), we operate a secure and robust data environment.

Digital maturity
As PHM grows and develops, a more mature digital infrastructure will be required to make the most of its potential to improve care. We have worked across multidisciplinary sites and services, implementing unified operating models and single integrated patient record systems to enable health and care providers to work optimally, at a practice, network and system level. These solid digital foundations will support collaborative working while making it easier to offer newer interventions such as online triage and video consultations.

We have also worked with STPs across the Midlands and East of England to help them better understand the current status of the region in terms of digital leadership, strategy and architecture, with clear recommendations.

We are passionate about turning data into intelligence, providing the bespoke tools, dashboards and engagement needed for a rich and accurate understanding of your patients.

Dashboards and benchmarking
Our unique GEMIMA BI tool empowers clinicians and commissioners by providing tailored views that deliver the local intelligence required to perform their roles effectively. We have also developed a condition-specific peer selection tool, using machine learning techniques, to identify and reduce unwarranted variation.

We have developed standardised analytic and reporting solutions across a wide customer base, but as every area is unique, it is our highly skilled analysts that maximise the value of your data. By working alongside your system leaders we tailor the solution to your pathways, challenges and vision.

Population segmentation
Our advanced segmentation approach can help you to break your population down into different groups, with different behaviours and needs. Through our work with Outcomes Based Healthcare and NHS England and NHS Improvement we have produced a dashboard, based on the Bridges to Health population segmentation approach, which will be freely available to health systems across England. Using national data sources – including A&E, inpatient, outpatient, mental health and community data – the dashboard will provide the basis for targeted healthcare planning.

For those areas wanting to complement the national dashboard with their own local segmentation tools, we can combine local dataflows to develop models that identify interventions to improve the health and wellbeing of the registered population.

Risk stratification
Our risk stratification tools use advanced algorithms, based on the Johns Hopkins Adjusted Clinical Groupings system, to predict who is likely to need care and for what. One pioneering ICS, who has used our tool for over five years, has seen a reduction in unplanned emergency hospital admissions thanks to a better understanding of at-risk patients.

Using the combined segmentation and stratification tools, GPs are able to understand who is attending their practice, for what reason and whether their potential outcomes are being achieved.

System engagement
Our experienced change and transformation specialists facilitate workshops with system stakeholders to interrogate and validate data, test assumptions, map pathways and agree strategies. Establishing a shared vision and common goals is key to successful change approaches.

Our analysts are experienced in using the advanced tools and techniques needed to support decision making, enabling systems to allocate resources more effectively and personalise care.

Opportunity analysis
Identifying appropriate and realisable opportunities to improve population health requires robust data and analysis. Using a range of tools such as comparative analysis and evidence reviews, our team has supported local health economies to identify and implement change and transformation programmes.

Predictive modelling
Our advanced analytics team draws upon a range of modelling techniques – including financial, econometric, forecasting and decision-trees – to accurately predict the likely impact of change. We completed System Dynamic Modelling for Nottingham University Hospitals to support a prostate pathway redesign based on sound logic.

Business cases
By utilising data and statistical algorithms, we are able to substantiate why change is needed, helping health and care systems to build a robust case for change and value proposition. Our specialist health economists have used these techniques to support business cases for the introduction of new interventions and models of care such as social prescribing support and digital self-care tools.

Evaluation tools
Our teams support care systems to define key indicators and outcomes, as well as evaluating impact against those indicators. We worked with Sandwell and West Birmingham CCG to develop an outcomes framework, with agile metrics for defined population segments, to drive the development of new care models.

We can help you to implement effective interventions to target your priority patient groups, at all levels, whether that’s designing a new model of care or identifying and tweaking an existing evidence-based intervention.

New models of care
We have a proven track record in bringing together health and social care to design and implement new models of care which improve the health and wellbeing of populations. Our transformation programmes span multiple geographies and drive collaboration between commissioners, providers, patients and wider stakeholders to successfully co-design new care models in areas including mental health, learning disabilities, cardiology and stroke.

Digital tools
With a network of partners across the NHS, industry and government we are at the forefront of digital innovation and transformation. From developing strategy, to designing at-scale solutions, to delivering digitally-enabled care, we have a wealth of experience and expertise to support you in your digital journey. We have worked with local health economies to embed digital solutions which empower citizens to have more control over the care they receive, provide support to keep themselves well and enable better self-management of conditions.

Behaviour change
Introducing interventions aimed at preventing ill health and helping people to manage their own conditions are only possible if we can find effective ways of influencing an individual to improve his or her health. We have a strong track record in delivering behaviour change campaigns from reducing smoking rates through pregnancy, increasing screening for specific conditions and helping people to stay well through winter. We use a ‘people first’ philosophy – built on research and insight – a proven approach to campaign management and a focus on evaluation.

Workforce planning
To ensure local health economies are managing human resources collectively, strategic workforce planning, development and delivery is needed at system, place and neighbourhood levels. Our support includes intelligent stakeholder engagement, assessment of current workforce and mobilisation of functions and teams into new organisational forms.

We have a strong track record of workforce development and delivery including whole system workforce redesign support in Bedford, Luton and Milton Keynes, and realisable workforce planning for the Coventry and Warwickshire stroke service reconfiguration.

Where to start

PHM works best as a cyclical process. It starts with identifying what you want to know – which patients you are looking to target, what problem you are trying to solve and what changes or new interventions you plan to introduce. Careful thought also needs to be given at the outset to how you will evaluate the impact of any change so that you can review your approach accordingly.

If your starting point is an idea for a new intervention, data analysis can help you identify which patients would most likely benefit.

PHM can also be approached from the opposite direction, where you’ve identified a group of patients that are using a lot of resources. Risk stratification can help you identify suitable interventions which could improve patient health and/or reduce service demand.

Sometimes, it is the initial analysis of data which throws up something interesting which leads to more detailed work and ultimately a change in how you provide a particular service.

As PHM models continue to evolve and mature throughout the world, Arden & GEM is taking the emerging best practice and collaborating with health economies to help them develop a unique PHM solution that reflects their local circumstances and challenges.

We would love the opportunity to talk with you about working collaboratively to develop your PHM solution.


Arden & GEM already supports health systems to design and develop their individual PHM solution. Find out more about our work by accessing the resources below.


If you’d like to find out more about population health management, please contact us here: