Helping vulnerable people with the Population Health Management programme

The Digital Lead for Lancashire and South Cumbria ICS looks at how data analysis is helping to transform care:

Five months ago I was a self-confessed cynic, sceptical about whether frontline staff had the time or inclination to embark on a new project over the busy winter period.

But 20 weeks on I find myself ready to extol the virtues of the Population Health Management programme because I’ve seen how local neighbourhood teams have used data to proactively address their communities’ needs.

In Chorley, for example we’ve proactively gone out and helped 140 vulnerable people – let me explain how we got there.

In Lancashire and South Cumbria we became a wave 1 site for PHM on the NHS England Development Programme.

The result has been that now GPs, data analysts, finance directors as well as colleagues from local authorities and the voluntary sector sit together and discuss the potential for the stratification and segmentation of data to inform the way we shape care.

We haven’t cracked it yet but what we’ve done is help groups of vulnerable people and also culturally shift frontline staff and system leaders to realise what might be possible if we continue this PHM journey.

Firstly, we quite quickly organised a local data agreement which allowed hospitals, GPs and councils to work together more effectively.

We were already risk stratifying data but when we listened to the experts delivering the programme, we started to realise there were gaps in what we were doing.

Lancashire and South Cumbria is home to 1.7m people. But looking at that level of data can only show you generally well-known hotspots.

However, by linking data insights from different organisations and delving deeper into a place – 30,000 to 50,000 people – it starts to reveal much more for clinicians within Primary Care Networks (PCNs).

Our GPs know their populations well, but with these new insights they really can start to explore the personal circumstances that may be fuelling someone’s ill-health or their use of NHS services and how we can best help them.

As a health and care system we are split into five areas, each selected a PCN – Barrow, Blackpool Central West, Burnley East, Chorley Central and Skelmersdale – who chose a specialism such as mental health, long term conditions, frailty and respiratory.

By bringing together social care and mental health data, we could see patterns in the data we hadn’t seen before. We ran analysis ‘a mile wide and an inch deep’ and could offer up possibilities to local clinicians for their reflection and expertise on the reasons for the patterns we had identified.

At neighbourhood level this worked phenomenally well – in Chorley, for example, data showed us there was a cohort of patients who attended their GP surgery far more frequently than others. However, there was nothing in the data to explain why.

Further analysis showed a different picture and we were able to pinpoint 140 people in the neighbourhood who clearly needed more care.

Based on the insight, the neighbourhood team identified that the best way to support the group was to link them up with a social prescriber and community support services provided by Chorley Council.

One particular lady’s story in this group has stuck with me; she was offered direct support for her family, with a combination of new social and educational opportunities including receiving help on healthy eating and opportunities with local community networks; these interventions gave her a sense of hope for the future.

Many of the others will be contacted and supported in similar ways. For me, this demonstrates what PHM is all about.

One of the unintended benefits of the programme has been bringing together data scientists, business intelligence analysts and public health specialists from across the System.

For whatever reason, this had not happened before and although the experts knew each other they had not really worked together – now they have formed a new Data Intelligence Network.

We will be able to support PCNs by freeing up data analysts to spend more time focussing on neighbourhoods rather than routine performance reporting.

As far as Population Health Management is concerned, the genie is out of the box.  There’s no going back, just a collective desire to push forward.

What’s the magic that’s happened in the last 20 weeks? Its drawing on the collective wisdom of our diverse workforce, sharing learning and harnessing the full potential of a neighbourhood.

We’ve acknowledged that having robust shared records, which track patient treatments over time, alone won’t make a difference.

However, when built and placed into the hands of a fully engaged PCN, these will be a powerful tool to help address demand and unmet need within their communities.

Declan Hadley

Declan Hadley is the Digital Lead for the Lancashire and South Cumbria Integrated Care System.

Healthier Lancashire and South Cumbria is the name for the partnership of NHS, local councils, public sector, voluntary sector and community organisations working together to improve health and care services and help the 1.7 million people in Lancashire and South Cumbria live longer, healthier lives.

Declan leads the Digital Health team, who have worked with colleagues across the local health and care system to co-create a shared digital health strategy for Lancashire and South Cumbria, ‘Our Digital Future’.

He has been a core member of the leadership team behind the development of a Population Health Management approach locally, with Lancashire and South Cumbria taking part in an NHS England sponsored accelerated development programme for Population Health Management in 2019. He is also joint Senior Responsible Officer for the Share 2 Care programme, a joint initiative between Healthier Lancashire and South Cumbria and the Cheshire and Merseyside Health and Care Partnership looking at extending shared local health and care records across Lancashire, South Cumbria, Cheshire and Merseyside.

Declan has worked in the NHS for more than thirty years. He started his NHS career as a Psychiatric Nurse, moving quickly into Information Management in the 1990s where he worked in a number of different roles across the North West.

Between 2001 and 2014, heworked as Health Informatics Director at Lancashire Care NHS Foundation Trust, where he oversaw the development of innovative mobile solutions, new clinical applications and technology to support an agile workforce. Declan has been leading the Digital agenda on a health and care system wide level across Lancashire and South Cumbria since 2014.

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  1. Syeda says:

    Insightful reading on the power of data analytics who can show evidence based approach to learning, however working with complex need clients requires a longer payback period to see results (ROI) so no quick wins or linear as commissioners expect as it’s more than transactional relationship. I lead on a social prescription model (3rd sector) in Birmingham for last 3 years and was faced with resistance from GP’s and Practice Managers who didn’t quite grasp the concept beyond medical model & were oblivious to risk stratification but through exerted efforts managed to get buy-in through on-going dialogue, feedback and data on +ve impact to clients and wider H&SC system from our end. Important lessons learnt along the way and pivotal to get those GP’s and health practitioners who can see the difference it makes to thier patients to act as champions early on as it’s not all about medicines & lifestyle changes but to look at the root cause issues from holistic perspective with MDT input.

  2. Anonymous says:

    I am tired of hearing about joined up services. It was happening 10 years ago with Closer to Home. When is it going to be finished???