19 Suffolk and North East Essex ICS | ‘Our Journey Together’ Population Health Management (PHM) that uses linked data across local health and care partners, and techniques like population segmentation and risk stratification, helps identify the holistic needs of different population groups and the drivers of health inequalities. By linking the data on individual characteristics, lifestyle and the physical, social and economic environment the system has a greater understanding of who is at risk today so it could predict who might be affected in the future. Time and space were needed to create the commitment and trust between system partners to work together and share data, to adopt and use these methodologies successfully. Suffolk and North East Essex has been regarded as one of the most digitally advanced ICSs in England, with a strong system-wide focus on shared care records, interoperability, cybersecurity, and patient-centred data use. The ICS has built a more unified digital ecosystem across health, social care, and voluntary partners. Delivering wider benefits as local anchor institutions Anchor institutions are large organisations that are ‘anchored’ in place, having a significant impact in that place and through the use of their assets and resources can help maximise social, economic, and environmental benefits, improve health outcomes and tackle health inequalities. Suffolk and North East Essex ICS has been recognised nationally for creating a system-wide approach to anchor impact measurement, developed since 2019 and aligned with the UCL Anchor Frameworkxxvi. An ICS Anchor Charter set out the ways in which partners in the ICS, particularly local NHS Trusts, could have a positive impact on their local communities through their role as local employers, purchasers, land and asset owners and in the way that they impact the environment and work with their local community. The ICS Anchors Programme Board drove activity and encouraged learning and reporting; an Anchors Dashboard provided a snapshot of the progress being made at system level and for organisations at their own Board level as a tool to help facilitate this; and a series of Impact Reportsxxvii showcased the breadth of good practice to enable shared learning, both locally and nationally. Further examples of local case studies relevant to this action area include: Sharing Data: Capsule sponge test -work in partnership using Population Health Management data to offer the test to those most ‘at risk’ of developing Barrett’s oesophagus or oesophageal cancer CAN DO Health & Care - Awards 2025 Sharing Data - SiSU CVD Project: utilising a population health management approach to locate ‘health stations’ for early identification of hypertension in groups most at risk. CAN DO Health & Care - Awards 2025 Anchor Institutions: Unity Centre Whitton - redesigning empty spaces in NHS buildings allowing community organisations to provide services from one health centre. SNEE NHS Impact Report Estate and Sustainability North East Essex Acute Respiratory Infection (ARI) Hub: uses PHM data to support patients at highest risk of acute respiratory conditions to be treated promptly in the community. CAN DO Health & Care - Awards 2025 My Care Choices Register: allows people to record their preferences for their future care and is accessible is to all local GP practices, hospital acute and community services, mental health services, several care homes, the ambulance clinical hub, out of hours primary care services and St Helena Hospice. My-Care-ChoicesRegister-St.-Helena-CaseStudy.pdf Find out more about these and other case studies at www.sneeics.org.uk/learningandlegacy
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