Scaling up a population health management approach using digital technology

Investing in population health management and proactive care is the most efficient way of creating the most value from every pound we spend on health.

In Warrington, through the Warrington Innovation Network Primary Care Network, we had the ambition to proactively manage our hypertensive patients while better equipping them to make meaningful and impactful lifestyle changes.

Our hypothesis was that investing in solving ‘simple’ health problems today would avoid much more costly, and often catastrophic health problems tomorrow.

Swathes of research describe the significant efficiencies to be gained for the whole system by investing in proactive primary care. The NHS Confederation quote around a £14 return on £1 investment, which is astonishing but entirely justified. In Warrington alone, a cohort of 880 patients are estimated to cost over £2 million a year.

So last year, we launched a primary prevention service using the HealthyYou app. Using the UCL partners risk stratification search we identified 2,603 people in these categories:

  • GP record – blood pressure above 180/140 at last reading.
  • Last record was high yet has not been optimised.
  • Medication not optimised to treatment target.

Around 1,000 people were recruited onto the app, a remote monitoring technology developed by Etc.Health (part of British Telecom). HealthyYou enables patients to submit their blood pressure readings and supports them to create an average home blood pressure, flagging patients who are ready for review to the clinicians.The clinical team is made up of health care assistants and advanced nurse practitioners and uses remote consultations to manage patients who have a blood pressure out of target, ensuring they attain improved control.From the 1,000 patient cohort, we’ve treated over 500 patients’ blood pressure to target meaning their risk of heart attack and stroke is significantly reduced. At the time of writing, we have another 200 patients going through clinical review and on the journey to better health with good blood pressure control.

We’ve reduced the average systolic blood pressure in the cohort by around 12mmHg and have reduced the average ‘Q-Risk3 lifetime’ by around 3% (QRisk3 estimates your risk of getting cardiovascular disease over your lifetime). A 3% risk reduction means 30 less cardiovascular events in our first cohort of 1000 over the next 3 years, with an expected saving of over £400,000 to the wider health and social care economy.

Many population health management approaches start at neighbourhood level, but to realise the benefits across a much larger area is the goal and we wanted to scale the programme up to maximise the benefits. But making a case for funding for prevention activities, as opposed to the immediate demands we face, can be tricky.

Having a supportive Place team and a supportive Integrated Care System team has been a key element of our success and securing that level of support was a critical step to securing buy-in.

For the Warrington Innovation Network Primary Care Network project we started small, and grew out from a single surgery, to a primary care network and ultimately with the support of the integrated care board, we are now set to roll-out across the whole of Warrington from April 2024 fully funded from Cheshire and Merseyside Integrated Care System.

Securing the funding and buy-in wasn’t easy but by developing a compelling business case, backed up by robust data and analytics, we were able to win hearts and minds throughout system and clinical leadership.

Cost avoidance is unlikely realised in year 1, but there is a clear pay off within years 2 and 3. To help mitigate this risk, we started out by proactively managing our patients with chronic obstructive pulmonary disease to prevent hospital admissions, improve patient experience, but unashamedly to support system cost saving ‘in year’.

This made our business case more compelling, as we weren’t simply asking for money now with a return in 5 years’ time. The ultimate plan is to ‘invest’ any savings back into the proactive care project, which will become cost neutral and more likely a cost benefit.

In our experience, a successful business case included:

  • evidence of success in other areas, or at least supported by theory
  • the required level of investment and realistic efficiency saving
  • improved quality of care for the patient
  • is bespoke and speaks to local challenges
  • support available from neighbouring primary care networks, the NHS Confederation or the Population Health Academy (log in required).

Ultimately, we know well that investing in population health management and proactive care is the most efficient way of creating the most value from every pound we spend on health.

Resources within health and social care are limited and we must continue investing today for a healthier tomorrow.  There is increasing interest in proactive care, and the ability to manage our patients remotely. Starting small is much better than not starting at all, so it’s worth trying something at practice level and seeing how this will scale to primary care network and beyond.

We’ve had real success from this route and have a clear opportunity to evidence the impact of proactive care.

Photgraph of GP Dr Dan Bunstone

Dr Dan Bunstone is Clinical Director of Warrington Innovation Network in Warrington, Cheshire and lead GP at a new and expanding surgery in Chapelford.

He has an interest in innovative models of care delivery and digital healthcare.

Dan is Chair of an NHS Confederation design group exploring data and digital in primary care.