Bending the curve: how data analysts, GPs, public health and hospitals are using the ‘golden thread’ of Population Health Management

As a GP my priority is to help patients stay well for longer or prevent them developing long term conditions, where possible. It can be difficult to do that on a daily basis with 10 minute appointments, heaps of paper work and mounting pressures. We often find ourselves fire-fighting with a relentless and increasing workload.

But what if we could find the time to re-consider why those patients ended up in the doctors’ chair, and how to look after them differently?

In Dorset, we’ve been lucky to do just that by piloting an exciting 20 week Population Health Management (PHM) programme to use data in new, innovative ways, find new insight into specific groups of patients and understand more about how to redesign service delivery at local level.

The challenge, for us, was in initially linking the GP data sets but the willingness of clinicians across the system within the Integrated Care System (ICS) made it much easier to get started and our excellent business intelligence units and analysts solved these issues.

Public health has done fantastic work in this area over many years and we’re now building on this using the improved relationships developed through Integrated Care Systems. These more mature local relationships with our neighbouring GP practices means in Dorset we have been able to link data from 18 GP surgeries with secondary care data – for the first time, thanks to our fantastic data analysts.

By interrogating that data local clinicians have gained new and unexpected insights about our patients including huge variation in the disease burden we see in different practices, even in the same area.

This linked data means that we can understand even more about where and how a patient has been treated and some of the reasons their condition may have become unstable.

We have done this in a number of ways, with different conditions, but let me give you one example.

Patients with Chronic Obstructive Pulmonary Disease (COPD) are a complex group with huge variation in their health and can visit the GP and/or hospital many times a year. With each ‘exacerbation’ they become more ill but by reducing these their chances of living a healthier quality of life become much greater.

We took anonymised data on this group of patients from across 6 practices and ran a carefully created algorithm search including: the severity of their disease, how many were smokers, how many admissions they had to hospital in a year, how many other illnesses they had, how many came for routine checks, how many infective exacerbations they had suffered, and their medications.

We were able to segment patients according to severity of disease, and designed new service models to look after them according to need – the “one size fits all “approach does not necessarily maximise the best use of resources.

Population health management is two-fold – it’s about looking at what we can do today for today, including looking for gaps in care, as well as what we can do today for tomorrow. It is becoming a “golden thread” connecting patient outcomes, management, quality improvement and service redesign.

First of all, we could see the patients who were clearly very ill with multiple admissions to hospital who needed more interventions to keep them healthier at home. This will give them the best quality of life and save expensive resources in the NHS in the long run through reduced unnecessary hospital admissions.

However, it doesn’t fix the long term problem of people developing COPD. What we’re truly working towards is preventing the cohort of people with  COPD from growing over the next 15-20 years – where a strong focus on prevention is needed.

And we need to find the group of patients with moderate disease with whom we can begin to bend the curve and halt deterioration with evidence-based interventions such as Smoketop and pulmonary rehabilitation.

Was it Einstein who said the definition of insanity was doing the same thing over and over again and expecting different results?

Out of the 1,000 people on my register with COPD I was looking for the cohort of patients with whom I could make the biggest difference and stop their deterioration.

For these people we know we can begin to put in place something new giving them something they don’t currently receive. For example, our new models of care are already up and running so I have options to refer in to a multi-professional team consisting of consultants, nurse practitioners, physiotherapists, mental health workers who can intensively optimise treatment in a carousel style one-stop clinic.

We are now at the stage of selecting those individuals and as those people begin to need GP and hospital appointments less often we can gradually begin to release time back to clinicians.

For those with moderate disease, we will use our practice based teams to optimise care, pooling practice nurse resource if needed, and ensuring standardised recalls and processes.

For those with very mild disease, a focus on self-care and self-management, potentially using new apps such as MyCOPD and a more remote digital approach could be used.

Not only does the algorithm for COPD work in Dorset but the learning can be easily spread from one Primary Care Network to another.

PHM is helping us in Dorset to think differently about our daily workload, to target proactively and get upstream and prevent deterioration, and co-ordinate high intensity care where needed.

By using the PHM approach the possibilities are endless to help people early, save lives and the NHS’ time and money, and build strong local teams who use the data to design the right services which is also great for workforce morale.

To register as part of our on line Population Health Management network and stay up to date with the latest information please email:

Karen Kirkham

Karen Kirkham has been a GP for over 25 years and is now senior partner in a large practice, combining this with a senior leadership role in Dorset.

She also has a national role as Senior Medical Advisor to the Primary Care Provider Transformation team.

Karen is currently focusing on the redesign, transformation and delivery of the integrated community services and primary care component of Dorset’s STP.

During 2018/19 she was a national clinical advisor for primary care with the NHSE System Transformation team.