What it means for people living in Hampshire and the Isle of Wight

“Letting me do what I want to do when I go into work every day, which is to do the best for the people in front of me. Population health management starts us on that journey.” (Local GP) 

Our health and care needs are changing. We are living longer with long-term conditions, for example, like asthma, diabetes and heart disease, which are all affected by how and where we live.

An approach called Population Health Management (PHM) can help us understand what factors we need to take into consideration when looking at our future health and care needs (known as the determinants of health).

PHM involves all organisations who deliver care and support – and not just those who provide direct health care. We work in partnership to make better use of our collective resources through what is known as an Integrated Care System (ICS). This includes the NHS, councils, social services, schools, the voluntary and charity sector, housing associations, fire service and police.

PHM is how we use data to produce insight and make informed decisions which improve health and wellbeing. This could be by stopping people becoming unwell or, where this isn’t possible, improving the way the health and care system supports them.

PHM also looks at the wider factors that affect people’s health and wellbeing – for example housing conditions and their local environment. Working with partners from outside the health care sector to use PHM to identify changes to services or communities, such as tackling air pollution, improving homes or creating safer neighbourhoods will have a really positive impact on people’s lives and health, The need for this approach has accelerated further during the pandemic. In common with the rest of the country, ICS partners in Hampshire and the Isle of Wight continue to work together to enhance the way we use all information available. This includes looking at clinical data and how and when people use our services. Over time, this information will include social care, housing and environmental data.

Using the insights built from this combined data means we can be proactive and preventative; it will help local health and care professionals and our partners to identify people (those who are known to us and those who are not) who may need extra support and change how we provide services – to you and your community – both now and in 20 years’ time.

It supports our aim of helping everyone to live a longer and healthier life.

Here’s Dr Rory Honney to explain more about what we’re doing in Hampshire and Isle of Wight and why:

Population health management – an example 

The Covid vaccination programme is an example of how we’re using population health management information in a proactive way. It is helping us to understand who has and hasn’t been vaccinated across our communities so we can support those most at risk. This could be by running additional clinics, carrying out home visits or using a mobile vaccination centre for rural areas. 

Sharing data for Population Health Management

All health and care organisations who are providing their data for use in Population Health Management in Hampshire and the Isle of Wight have signed a data sharing agreement, which sets out:

  • what data will be shared

  • how the data will be used
  • the principles and controls that are in place to ensure that the confidentiality of individuals is maintained whilst the data is being used for PHM purposes.

You can see a list of the partner organisations who have signed the data sharing agreement here.

You can also see the Fair Processing notices for health and care in Hampshire, the Isle of Wight and Southampton and Portsmouth. These provide information for people on how their personal data will be used for Population Health Management purposes. 

Information for health care professionals

If you are a health and care professional in Hampshire or the Isle of Wight, you can find more information on Population Health Management and register to use the new data platform and analytics.

Resources

The King’s Fund is a useful resource if you’d like to find out more about population health management, particularly this animation.

Frequently Asked Questions 

Health, social care, community, police and fire and charity and voluntary services across Hampshire and the Isle of Wight are coming together to explore the data for this area.

We are now looking at specific groups of people that can benefit from us working together with this combined knowledge. Work is underway in North and Mid Hampshire, Portsmouth and South East Hampshire and the Isle of Wight with further work planned for Southampton and South West Hampshire.

We are now building a single analytics tool so everyone involved in your care can begin to use the combined data.

The PHM Programme is a long term (five year) strategic piece of work. We intend to get some early results quickly by working in local areas to identity a group of people that would benefit from a new approach to their care and then put this approach (called an intervention) in place.

The programme budget is provided as part of the NHS’ Long Term Plan (where PHM is highlighted as a priority) and as part of the Integrated Care System transformation work via our partnership with all health and care organisations. 

This means we can all deliver better joined up care and support, tailored to you and for the people who live nearby and / or have a similar health condition or need. 

It can deliver: 

  • Better, proactive care, tailored to you (before you become ill or to manage your condition) to help you live healthier for longer. 
  • Community services designed and budgeted around your population. 
  • An improved experience of health and care. 
  • Support for local health and care organisations around you  
  • PHM information can also transform our communities and reduce inequalities as we can use insight to see which areas need extra support and change how we provide local services.  

The way to think about population health management is to see your information as helping your health and the health of those around you, for example, your family, friends, neighbours and communities, as well as people who may have a similar condition to you. 

We all recognise that health and care services, while under considerable pressure, remain more committed than ever to your care and support.  

If we take primary care (GPs) as an example, PHM means we can support colleagues and patients to move from a reactive to a proactive approach. For example, it can help GPs to: 

  • Enable care to be person centred and help people to co-manage their own care (where possible)  
  • Identify and support people who are not known to us but need to be   
  • Join up our workforces to deliver improved health and wellbeing and reduce duplication  
  • Improve health outcomes and make best use of our money 

Any information used for our population health management analytics tool is taken from your existing information and used to help improve your direct care. We can do this in two ways; either by being proactive and understanding your situation before you become (too) ill, or by analysing data for a group of individuals who live in an area and / or have a similar condition to see what services and support are needed.  

We analyse information using anonymised data, which is stored in a secure and non-commercial database. Local doctors, GP practices, hospitals and community service teams are involved in this work alongside public health and social care teams to ensure they can use this insight and intervene quickly to make any changes to benefit your care. 

In the future, there might be projects or services that would benefit from using your data for wider planning, e.g., for research into diseases. We must consult with you if we intend to use it for this purpose. 

This work includes looking at the wider determinants of health such as where we live – housing and environment – and other social factors such as education and work.  

We are beginning with analysing GP practice data, local hospitals, and mental health and community services. Over time we intend to add more data from other partners including charities, police and fire services, the voluntary sector and housing.  

All partners are committed to this way of working as part of our role as an Integrated Care System (ICS), which is the future of health and care in England.  

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