When the Integrated Care System (ICS) Design Framework landed recently, it was great to see that the voluntary sector and population health management (PHM) had both been referenced as key building blocks of systems as we move towards legislation.

PHM has been a passion of mine for many years because it is an opportunity to work in partnership locally to tailor services to individuals and groups.

Many barriers have prevented us from truly embedding PHM approaches and opportunities but now, with the advent of integrated care systems and the forthcoming legislation and incentives for Primary Care falling into line, I can really see its future as the driving force behind the NHS.

In Calderdale – a place within West Yorkshire and Harrogate (WYH) ICS – 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 groups 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 for at risk groups, whilst working closely with WYH’s own improving population health programme.

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 identify population groups and assess needs differently.

We’re still exploring how we can embed the learning across all place-based partners 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? How far have we got in joining up data, have we got a strong population health analytical platform which allows for population and risk grouping, have we got clear leadership and governance to enable PHM approaches? Making sure you have the right organisations and skills (ie analytical) round the table to create the insights you need to guide design is crucial.
• 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 for 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 so we can both bring their insight into where to focus but also involve key groups in care model design.

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 group of patients, and we crunched the data – for example how many people with physical and mental health problems have had an increasing number of contacts in the last year?

Because this reveals a list of our patients at an identifiable level we can start to proactively support and 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 with the homeless community. We gathered all the organisations who provide care for the homeless and shared views – many were from the 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 driven by better data and evidence for these marginalised population groups.

COVID-19 has presented us with a fantastic opportunity to refocus on the specific needs of different communities and groups 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.