The development and future ambitions of the Population Health Management programme across Humber, Coast and Vale

Humber Coast and Vale Health and Care Partnership has successfully concluded the second wave of the National Population Health Management (PHM) Development Programme, funded by NHS England, after embarking on the programme in 2020.

The PHM programme has linked closely with the seven Primary Care Networks (PCNs) in the region, connecting data between primary, secondary and community care. The main objective for the Programme has been to support integrated and collaborative working to improve health outcomes for selected local population cohorts through the application of advanced analytics and intelligence-led care design. Together the programme team has worked with a wide range of partners to develop solutions to overcome the most difficult challenges facing healthcare services to improve population health, reduce inequalities and improve value.

The current climate has reinforced the drive and need for integration between health and social care. A key enabler is the ability for stakeholders to access linked data that can inform evidence-based decisions. This need, along with the commitment of all involved, has accelerated and amplified the application of PHM for Humber, Coast and Vale and has realised higher than anticipated momentum, engagement and results.

With wave two of the programme coming to an end in April, and we are now looking to progress to the roll out of PHM at scale across Humber, Coast and Vale. We have developed a roadmap, structured around the core PHM capabilities of Infrastructure, Intelligence and Interventions, to build on our learning, with objectives for the future.

The aims of the roadmap are to make PHM analytics easily available to support care planning and delivery, support the use of analytics at PCN, place and system level, improve our system wide linked dataset, create a central PHM office and ensure PHM becomes everyone’s business.

In the future PHM will enable local leaders to make decisions based on need and not organisational boundaries, so that every strategic decision is based on population health intelligence.

The seven PCNs carried out data segmentation, looking at system profiles for the different neighbourhoods for example, patients with or at risk of frailty, multiple long term conditions, dementia, cancer, heart disease and alcohol/smoking related illnesses. The PHM programme team supported the PCNs then looked for the best solutions to meet patients’ needs – not just medically but also socially – including the wider issues determining people’s health.

Looking at the example of Selby PCN, the aim was to improve the health people in the 50-64 age group who were identified as having mild/moderate hypertension. The data sets were analysed as a collaborative group with representatives across sectors including the district council, GP practices, social care, and volunteer organisations.

The team narrowed down the data involved to identify priority groups and discovered a trend of patients with mild/moderate frailty crossing over into severe frailty, with significant cost impact. Once identified, this group was narrowed down again to those with mild/moderate hypertension, with an aim to put in place early interventions that might prevent a further decline in the health for these individuals.

The team worked collaboratively to reach out to these patients via telephone questionnaires, with the patients then becoming themselves co-designers of the service. Because of the diverse representation of colleagues across the health and social care sectors, the interventions were not limited to medical interventions but were truly holistic.

Conversations with patients highlighted the need for more social structures and interventions – commonly in reaction to loneliness and isolation – rather than medical interventions, which allowed the GP practices to think about health and wellbeing, not just illness. The team developed a wealth of information leading to the re-evaluation of services in the community.

As the roll out begins, expanded collaboration across teams will bring further impactful interventions. The programme is ambitions to deliver highly targeted, and therefore highly effective, responses to the diverse needs of our local communities.

NB: Stephen Pintus has now retired 

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