Population Health - 'Driving Force' behind ICSs for General Practice

In Calderdale, we've already rolled out PHM techniques to surgeries in every primary care network in the system and are really starting to see the benefits for specific cohorts of people like those who are homeless, people with diabetes and those living with frailty.

After being part of the NHS England and Improvement Population Health Management Development Programme, we've started to think more keenly about our opportunities for reducing health inequalities and offer new and more personalised interventions.

It's helped us bring together health and care professionals from across the integrated care system to look at all of our data in a new way and begin to segment and assess differently.

We're still exploring how we can embed the learning across multiple sectors for different professionals but already I believe we've unearthed three important learning points which other systems starting out might use.

• Firstly, what is the level of maturity, capability and understanding in your system at the start so you can begin with the right strategy to embed PHM? Make sure you have the right organisations round the table to create the insights you need to guide design
• Secondly, taking the time to honestly reflect on what the existing relationships are like in your system? This has been so key to our success that it must be first and foremost of any plan. Again, we had quite a good starting position so expected a bit more from our partners.
• Thirdly, how do we increase true understanding of the problems? Quantitative techniques to creating meaningful insights from the data are critical here but equally important is narrative data – qualitative approaches to tap into local wisdom of patients, carers and providers.

In Calderdale we've taken a very person-centred approach to PHM. There's a danger when you've been in healthcare for a while you think you understand a situation but actually, you're only viewing it from one perspective.

Our Primary Care Networks for example have been a huge asset and their buy-in has been more important than anything.

We asked them what keeps you awake at night? Then we asked what do you want to know about a certain cohort, and we crunched the data - for example how many people with mental health problems have an increasing number of contacts in the last year?

Because this truly reveals a list of our patients at an identifiable level we feel they now know who will benefit most and we can start to wrap a plan around them. It has been important to build confidence by seeing an early impact from the work and that we continue to collect the data to demonstrate the long-lasting positive effects.

A great example is the work we've done for the homeless community. We gathered all the organisations who provide care for the homeless and shared views - many were voluntary sector. They included: St Augustine's supporting asylum seekers and refugees, the Gathering Place supporting homeless individuals, the alcohol and drugs support team, and providers of GP, A+E, outreach community, and mental health services.

We saw first-hand through this process that we needed to tighten up the validity of the data we had – the official numbers were small compared to how many we knew were homeless or leading street-based lives.

We ended up with a wide breadth of qualitative information and then moved to number crunching from colleagues from across Primary care, data analysis, voluntary sector and the local councils.

Combined with the stories people told us we soon began to understand quite deeply this cohort and are now rethinking how we can improve the routes to better care.

Covid-19 has presented us with a fantastic opportunity to refocus on the individualities of different communities and cohorts of people.

Hopefully the learning from our journey in Calderdale will inspire your system. My expectation is that population health management will continue to drive the agenda of the NHS and its partners, which will benefit the effectiveness and efficiency of the system and improve the care of patients.

This blog was originally posted on NHS England, view the original blog here.