Emma Adams, head of integration and partnerships at Coventry and Warwickshire ICB, speaks to senior reporter Beth Gault about how population health management (PHM) works in practice within the system
Beth Gault (BG): What does PHM look like in practice?
Emma Adams (EA): PHM looks different to different organisations. From my perspective, PHM is an enabler, it’s not a programme in itself. It should be an approach that enables us to make evidence-based decisions for the services and the people in our populations.
From a PCN perspective that might be who could benefit from an intervention that has only got a certain number of people that can be allocated to it, or a certain amount of time from a team perspective. Or from an ICB perspective, it could be what are the actual needs of our population, and who and where are they?
We’ve been a reactive service for too long in the NHS. With PHM, we’re trying to change that to be more proactive and preventative.
BG: What were the aims when you initially looked into PHM as an approach?
EA: Our journey started with the national development programme on PHM in 2021. We were in a fortunate position in that while this programme was going on, we’d already procured a PHM platform and were able to build this at the same time. My role was around the implementation of a platform and the infrastructure around PHM.
The aim was to empower our PCNs and practices to be better able to influence upwards by having an evidence base that ratifies the things that GPs can already tell you are the problems within their population.
BG: Did that start with a small number of PCNs?
EA: Absolutely. The development programme was very much based on PCNs being able to choose what areas of work interested them. Then when we procured our platform, we got the priorities of our places and we asked PCNs whether they would be interested in working with our places on those programmes of work. Coventry chose proactive care as their area of focus and Warwickshire chose diabetes.
BG: What was the implementation of those programmes like?
EA: It was done in two slightly different ways. One had an intervention and was looking for the patients, and one had the patient group but didn’t quite know what the intervention was going to be until they looked at their needs.
BG: Is PHM now across all of the PCNs in the ICB?
EA: I would say the concept of PHM is not equitable within our PCNs. There is probably still disparity in understanding what PHM is and their appetite to be involved.
What we’re now trying to do is to work more closely with our ICB primary care teams to show how using PHM data can benefit our PCNs and practices in their day-to-day work and to help them bring proactive and preventative care to the table when you’re having discussions about integrated neighbourhood teams or lead provider contracts, for example.
But I have a bugbear that not everything needs to be scaled. If we look at everything that’s done in a PCN as a pilot, then that belittles the work of our PCNs. What we can do is show examples of how PHM works in action and the approach of what we did can be scaled, but it doesn’t need to be scaled to make it a success. Those projects were successful in their own right.
In terms of our platform, we have about 90% of our GP practices who have signed data sharing agreements to onboard their data onto our PHM platform. That is massive in itself.
BG: What is your role as an ICB in PHM?
EA: The infrastructure is a big one, so we’ve supplied everyone with our PHM platform. And then the other is incentives. We’re now looking at using PHM data as a way to determine at our financial allocations as an ICB. Looking at how we can better allocate our money between our places rather than a more historical split between Coventry and Warwickshire. Instead bringing in health inequalities and demographic information to allocate our finances better.
The model hasn’t been agreed yet, but work is happening on it.
BG: And what outcomes have you seen from PHM?
EA: One of our endocrinologists said he’d never been able to see our diabetic population in a way that strengthened the case for change towards prevention before, rather than cure.
We’ve now started an initiative where a diabetes patient is paired with a buddy from across the city who is known to a charity as being isolated or lonely and has shown an interest in cooking. It sounds twee, but it’s amazing – it’s helping a family if they’re eating poorly or need educating on what healthy eating looks like – therefore preventing diabetes in the future. And you are helping people who are lonely.
From a business perspective, it’s made a massive difference to health inequalities funding. We’ve been able to pinpoint the number of people who have long term conditions in our most deprived areas, which we could infer before, but we couldn’t demonstrate through data. So, it’s given us an evidence base to secure more funding.
BG: How significant is PCN buy in for PHM?
EA: You don’t have PHM without primary care. All the noise around the federated data platform potentially being our solution to PHM in the future is fine, but if it doesn’t include primary care then you don’t have PHM in my eyes.
Most people are registered with a GP practice. They can tell you about patients’ met and unmet needs, which tells you much more about a population than any acute data source could ever tell you.
You absolutely need primary care front and centre. I never take for granted the involvement of our GP practices.
