Can Do Health & Care Thinking Differently - November 2020

1 | Suffolk and North East Essex Integrated Care System Together, we want to ensure that every one of the one million people in Suffolk and North East Essex has the best possible health and wellbeing. To achieve this aim, our system is committed to ensuring our decisions and actions are based on a solid evidence base, supported by data collected by our partner organisations, and what our citizens say matters most to them. Population Health Management (PHM) is an emerging technique that uses data to design new models of proactive care and deliver improvements in health and wellbeing which make best use of collective resources. It can help us understand our current, and predict our future, health and care needs so we can take action in tailoring better care and support with individuals, design more joined up and sustainable health and care services, and make better use of public resources. It is how we use historical and current data to understand what factors are driving poor outcomes in different population groups. It is how we then design new proactive models of care which will improve health and wellbeing today as well as in 20 years’ time. This could be by stopping people becoming unwell in the first place, or, where this isn’t possible, improving the way the system works together to support them. Our ICS has completed a 20-week National Population Health Management Programme to support our system to improve health outcomes for selected local population cohorts through the real time application of advanced analytics and intelligence-led care design. We aimed to build collective capability across commissioners, providers, Primary Care Networks (PCNs) and community partners, to make informed data driven decisions that enabled teams to act together to make best use of collective resource to achieve practical and tangible improvements in the health and wellbeing of our local communities. We worked with NHS England, Optum and NECS to link pseudonymised primary care and secondary care data at PCN level and then support a change management process with those PCNs to enable change to direct patient care. The programme started in January 2020, and in six PCNs, three in Ipswich and East Suffolk Alliance, and three in North East Essex. The target populations comprised different levels of deprivation, population density, gender and age groups. We also developed a system level actuarial model, including a ‘base case’ forecast of activity and spend over future years, and a ‘mitigated case’ forecast based on the opportunities identified by the PCNs. Our event brought together over 115 stakeholders from across the ICS to celebrate our achievements, and to: • hear experiences first-hand and learn what has been achieved • explore where we think we are now and consider where we need to go • influence how we can make PHM in Suffolk and North East Essex a continuing success The event was chaired by Dr Pam Donnelly, Strategic Director of Customer and Relationships at Colchester Borough Council, Vice Chair of North East Essex CCG and Chair of One Colchester. The discussions were facilitated by Dr Martin McShane, Chief Medical Officer, Clinical Delivery, Optum UK, and Susannah Howard, Programme Director, Suffolk and North east Essex ICS. Suffolk and North East Essex Integrated Care System (ICS) 1. Introduction Online Event Thursday 19 November 2020 ‘Thinking Differently Together’ about… The impact that Population Health Management approaches can have to our ambition around integrated, intelligence-led health and care models in Suffolk and North East Essex Dr Pam Donnelly Dr Martin McShane Susannah Howard