Suffolk & North East Essex Integrated Care System

Population Health Management

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.

All sectors have a role to play in addressing the interdependent issues that affect people’s health and wellbeing. It should mean that health and care services are more proactive in helping people to manage their health and wellbeing, provide more personalised care when it’s needed and that local services are working together to offer a wider range of support closer to people’s homes.

Population Health Management will enable our Primary Care Networks (PCNs) to work with their local partners to deliver true personalised care as close to home as possible. PHM enables systems and local teams to understand and look for the best solutions to people’s needs – not just medically but also socially – including the wider determinants of people’s health.

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

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.

PHM Image 2 v2

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.

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.

  • Public Health
  • Social Care
  • CCGs
  • NHS Trusts
  • Primary Care
  • Health Watch
  • VCSE Sector
  • PHM Partner Provider
  • ICS Workforce Lead
  • ICS PHM Leads
  • NHS England
  • NHS Improvement
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