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Population Health Management

Population Health Management

Our Ambition: People Living in Suffolk & North East Essex Benefit from Population Health Management and Intelligence Led Health and Care

Capabilities for Population Health Management

Infrastructure: the basic building blocks that must be in place

Intelligence: opportunities to improve care quality, efficiency and equity

Interventions: proactive clinical and non-clinical interventions to prevent illness, reduce the risk of hospitalisation and address inequalities

Organisational Factors – defined population, shared leadership & decision making structure
Digitalised care providers and common longitudinal patient record
Integrated data architecture and single version of the truth
Information Governance that ensures data is shared safely, securely and legally

Supporting capabilities such as advanced analytical tools and software and system wide multi-disciplinary analytical teams, supplemented by specialist skills
Analyses – to understand health and wellbeing needs of the population, opportunities to improve care, and manage risk
Reporting the performance of the ICS as a whole in a range of different formats

Workforce development – up skilling teams, realigning and creating new roles
Community well – being approaches, social prescribing and social value projects
Assistive technologies and digital tools to empower patients and smooth care transitions
Incentives alignment,return on investment modelling and risk sharing mechanisms

National Population Health Management Development Programme

In 2019 Suffolk and North East Essex became part of the national PHM Development Programme coordinated by NHS England and NHS Improvement. The programme will support us as a system to improve health outcomes for selected local population cohorts through the real-time application of advanced analytics and intelligence-led care design. Our ambition is that through the programme we build collective capability across our whole system – commissioners, providers, PCNs and community partners – to make informed data-driven decisions that enable teams to act together (across the NHS, local authorities, public services, VCSE, communities, and local people) to make best use of collective resource to achieve practical and tangible improvements in the health and wellbeing of our local communities.

Many People need support with issues that affect their physical and mental health

Solutions are often already available through, or better designed with, local people, the local council or a voluntary organisation. Better partnership working using PHM to join up the right person with the right care solution will help improve outcomes, reduce duplication and use our resources more effectively.

- For frontline staff the PHM approach enables care and support to be designed and delivered to meet individual needs, it means less duplication and a reduction in workload pressures as it ensures the right care is given at the right time by the right person.
- For NHS and local government commissioners, greater understanding of the local population will ensure they can better predict what residents need and ensure health and care providers work together.