This site is intended for health professionals only

Explained: How to prepare for population health management


By David O’Callaghan
Head of Data & Systems, NHS Arden & GEM Commissioning Support Unit
16 April 2020

Share this story:

This is the second in a three-part series about population health management for Healthcare Leader. If you missed the first part, you can find out more about what it means, how it works and the benefits here.

Patient data is one of the most valuable and protected assets we have. Patients need to be confident in our ability to keep their data secure, but we also need to make better use of it if we are to get beyond firefighting and focus more on preventing and managing health problems.

There are four key elements that will make this more achievable for Primary Care Networks (PCNs) and the wider health system.

1. Information governance
Every PCN is different and how you choose to manage your network will depend in part on your set up, existing relationships and experience of working together. But underpinning any integrated working arrangement – whether that’s at PCN, clinical commissioning group or regional health system level – there needs to be a data sharing agreement that sets out what data can be shared with whom and for what purpose. As well as meeting the stringent requirements traditionally applied to patient identifiable data, you need to factor in the additional rules introduced through GDPR.

Data sharing is undoubtedly complex, and caution is understandable. But there are examples where health systems are successfully sharing patient data, and some have published their data sharing agreements to help others get a head start. Putting work in at the outset to understand the requirements and risks, and agree how these will be managed, will pay dividends in the future.

If you don’t have the right permissions upfront, your ability to do anything meaningful with your data will be vastly reduced. This is particularly important as we look to the future of integrated Local Health and Care Records (LHCR), where we’re working with Exemplar sites such as Greater Manchester to develop robust data sharing and analysis agreements.

2. Technology

Many practices are currently grappling with the removal of support for Windows 7 and the pressure to upgrade to Windows 10. But there’s an opportunity here too.

While there’s no requirement for PCNs or localities to all work on the same systems, there is a lot of sense in doing so. Unified operating models and single integrated patient record systems across multidisciplinary sites and services help you to work optimally at a practice, network and system level.

We recently worked with the Norfolk and Waveney CCGs to migrate all their practices onto the Health and Social Care Network (HSCN), update to Windows 10, upgrade hardware and move all sites onto a single domain. While this created some challenges and disruptions in the short term, it has given the practices solid digital foundations, which will not only support collaborative working, but will make it easier to offer newer interventions such as online triage and video consultations.

3. Data quality

We all need to get better at how we record information, particularly as we start working together. Effective data analysis is reliant on the quality of the data you put in and consistency is key. For example, one person’s interpretation of epilepsy may be different to another’s, leading to different coding structures.

When processing data at scale, we can see fluctuations and inconsistencies in data which limit the potential for analysing and predicting trends. This is often put in the ‘too hard’ box when considered across the NHS, but relatively new PCNs provide an opportunity for us to improve how data is recorded in more manageable chunks.

If PCNs can adopt a consistent approach to recording information – such as always using the medical drug name rather than the common name, or recording the total daily dose rather than the breakdown, this will feed into much more consistent patient notes and clearer coding to enable you to track and manage patients across your network.

4. Culture change

However good your technology might be or how informative your data, it is people that will drive the change towards better use of Population Health Management (PHM) approaches.

The best way to exploit data to benefit your patients is to make it part of the day job and improve your team’s understanding of what it can do. Use case studies to highlight opportunities, put PHM on the agenda in your multidisciplinary team meetings and work towards PHM becoming core to identifying local priorities and supporting cases for change.

The benefits

This might sound like more pressure on an already heavy workload, but if we put the right preparations in place early on, the potential PHM offers to improve services is significant.

For example, in Leicestershire, CCGs have already used PHM to understand the impact of multiple comorbidities on hospital referrals and have directed funding accordingly. PCNs in Norfolk have used a localised segmentation model to develop a case for change to proactively target preventative care for individuals with Long Term Conditions who have not accessed mental health support but are at risk of developing co-morbid issues. The model demonstrates that improving patient’s resilience and wellbeing in the community could reduce their associated acute costs by up to 42%.

With resource pressures mounting, and further highlighted during the Covid-19 pandemic, PHM gives us the insight we need to be much more targeted with our interventions, benefiting those receiving care as well as those tasked with balancing the books.

The final blog in this series will focus on turning theory into practice, highlighting examples of how PHM is being used to redesign care pathways and support business cases for new models of care.

David O’Callaghan is Head of Data & Systems at NHS Arden & GEM Commissioning Support Unit

Want news like this straight to your inbox?

Related news


How Liverpool primary care networks are using tech-enabled collaboration to manage Covid-19
Dr Simon Bowers is a GP partner at Fulwood Green Medical Centre in Aigburth and Medical...
How virtual group meetings with the community during Covid-19 have helped reassure patients
Healthcare Leader is speaking with decision makers and those on the ground dealing with the...