12,000 extra people shielded in Norfolk using population health management

Case study summary

More than 12,000 people were added to the shielding list during the COVID-19 pandemic using population health management techniques in Norfolk and Waveney.

Initially, 30,000 people were identified on the national list but the Norfolk COVID Protect scheme used primary, secondary, ambulance and social care data to identify 12,000 more susceptible to serious illness and hospitalisation.

Text messages and letters for this group led to 23,000 people being actively engaged and regularly contacted by a virtual care team which prioritised and escalated their individual clinical and non-clinical needs.


Norfolk and Waveney Integrated Care System

Network: population size: 1.1 million

What was the aim?

Norfolk and Waveney Integrated Care System wanted to ensure everyone who needed to shield was contacted at the beginning of the pandemic to identify, monitor and respond to their specific needs.

PHM approaches were then used to increase vaccination in areas/populations of low uptake and high infection/transmission rates, aiming to provide equal access for all and address any health inequalities which might have been created through lack of access to information or hesitancy for cultural or additional reasons.

What was the solution

A collaboration of diverse organisations from across Norfolk and Waveney, in partnership with data technology specialists Prescribing Services Ltd, instigated a COVID Protect approach.

They worked with more than 20 key partners across health and social care and the voluntary sector, including Norfolk County Council, Voluntary Norfolk, Every Mind Matters, Norfolk Community Health and Care and children and young people’s health services.

The approach used linked data across primary, secondary, ambulance and social care to identify those most susceptible to serious illness and hospitalisation, including many who now found themselves cut off from traditional routes into health and care services.

Remote monitoring of health conditions, ongoing contact with those most at risk of harm and the provision of early care and support interventions enabled people to stay safe and well at home. The teams worked collaboratively as a whole to proactively reduce demand on ambulance and A&E services and avoid further increases in hospital admissions during the early months of the pandemic.

As the project progressed the team also linked datasets to the national Index of multiple deprivation and a risk stratification tool to prioritise the particularly high-risk living in deprived areas.

Once the vaccination programme began, they identified specific hotspots of low vaccine uptake such as food processing or production factories with significant migrant workforce population. 31 sites were identified in priority order based on location and previous outbreaks.

They visited a wide range of key locations including:

  • homeless shelters, schools and community centres in outer estates and areas of significant deprivation (Great Yarmouth, North Lynn, South Lynn, Thetford, Mile Cross, Earlham)
  • University of East Anglia campus in central Norwich (oversees students, staff and public vaccinations)
  • Latitude festival in partnership with Suffolk and North East Essex Clinical Commissioning Group.

What were the challenges

Working iteratively in rapid cycles meant that decisions needed to be made at multiple levels of the hierarchy and quickly, particularly in the early days. Once the project commenced, leaders and project members were empowered to problem-solve, and to take decisions and ‘make the approach work’. A sense of urgency compelled the team to move quickly, putting aside common barriers that slow decisions.

A consequence of different organisations working together at pace meant there was some fragmentation and duplication. This was particularly highlighted by difficulties in data sharing. Given that local authorities operate on a different IT system than NHS colleagues, all referrals to local authorities relied on manual data transfer which was time consuming.

What were the results

12,000 extra people were shielded. Patients selected for the shielding list were invited to fill in a questionnaire on a regular basis. Anyone requiring clinical, social or prescribing support was then assessed by the Virtual Support team, the Social Care team or the central Paramedic team for COVID-19 related issues.

30,000 people who could still have the vaccine were supported with the ‘worry bus’ offer. The ‘worry bus’ sees the roving vaccination team hit the road offering a special service to those with concerns or anxieties about needles, vaccines, crowded spaces, clinical settings, pregnancy, fertility or anything at all that is holding them back. People were given a chance to discuss any concerns and ask questions with a specialist, multi-disciplinary team and supported to have the vaccine in a manner and environment appropriate for them. Publicising Emma’s story about overcoming extreme needle anxiety and agoraphobia to get a vaccine helped opened the door for many more people with similar issues. The subsequent online promotion of the ‘worry bus’ reached more than 14,000 people on social media in two hours.

Dr Jeanine Smirl, GP at St Stephen’s Gate Medical Practice in Norwich said: “Partnership working across NHS, primary care, social care and voluntary support services meant the health and care system was able to gather information and mobilise its response more quickly and efficiently.

“COVID Protect provided a safety net for our most vulnerable patients whose needs may otherwise have been invisible because they were shielding at home”.

What were the learning points?

Having the right data infrastructure was key and the risk stratification tool made this work possible. It is continuously updated with machine learning and enables the team to have a targeted approach at speed.

The team’s top tips are to:

  • Identify those patients, often non-engaged people, with the greatest reversible risk opportunity using a risk stratification tool.
  • Identify the service(s) (usually existing and sometimes under capacity) that could benefit them.
  • Proactively engage with that population through digital, print and the non-clinical Virtual Support team to facilitate a link to those services.

Dr Julian Brown GP Partner at Litcham Health Centre and Fleggburgh Surgery said: “Identifying our most vulnerable and at-risk patients using local GP practice data – in combination with the Council Data ​- was essential in expanding the care and support offered beyond the initial cohort of shielding patients.

“We received more than 250,000 contact responses from patients enabling us to focus our clinical resources on those most at-risks. Using real-time data to inform clinical decision-making and care planning is fundamental in effective healthcare”.