The population health management pilot programme has helped improve health outcomes for local people through personalised care interventions. Here, Dr Sakthi Karunanithi, population health and prevention lead for Lancashire and South Cumbria Integrated Care System explains how.
We often use data to create heat and argue! But after 20 weeks on the population health management (PHM) programme, we’ve been able to turn that heat into light.
I’d like to tell you how already we’ve been able to help people with mental ill health, frailty, respiratory conditions and housing problems – all by using data in a different way.
In Lancashire and South Cumbria we’re really lucky to have a fantastic relationship with our local councils and voluntary sector groups which made what I’m about to describe much easier.
When we started off on the PHM journey many were sceptical including myself, thinking this would ignore the importance of acting on wider determinants of health, like housing and social isolation.
We decided to pursue new ways to get health and social care right for people who need them the most.
So, GPs in five areas out of 41 in our patch trialled PHM; they sat down with business intelligence colleagues, GPs, CCGs, data analysts, public health, finance leads and local councils and talked about what's concerning them most and which datasets we have in order to understand those concerns better.
In Chorley and Burnley, they chose frailty as one of their core focuses because it was a major driver of local need that they felt was fuelling a high number of A&E admissions.
But the root causes were not clear from previous work and they wanted to do more to understand what was happening for these people.
In Skelmersdale, they focused on respiratory conditions, in Barrow on serious mental health issues and in Blackpool on the health and wellbeing support needed by people living in houses of multiple occupancy.
Each area team held regular meetings to develop better insights using data. However, making change happen is only partly down to the data, it’s mostly about engaging with our residents differently, and the way we work together differently.
What we discovered was fascinating - in Blackpool we found people living in houses of multiple occupancy were living with mental health issues due to a combination of social factors impacting on their wellbeing.
Through social prescribing link workers, we’ve been able to help solve some of the practical problems relating to their built environment and empower people to become more actively engaged in managing their own health and wellbeing.
By carrying out more in-depth conversations with those people, the link workers were able to identify some of the problems they were facing at home such as issues with housing, finances, isolation or depression and anxiety, then increase their confidence or put them in touch with support groups such as council housing teams or the likes of Age UK who can help.
In Skelmersdale, the team discovered that the group of people identified with respiratory conditions often had other inter-linked health conditions such as diabetes or depression and anxiety.
They used this insight to tailor more personalised care which better meets local people’s needs by looking at the whole person rather than just one condition at a time, as well as developing group consultations to provide peer, as well as clinical, support.
I’m calling this a ‘hyper-granular resolution’ because what we’ve been able to do here is discover a much more nuanced insight about local people. By going into one cohort and understanding how they had been using healthcare it was apparent that, for example, it wasn’t just their mental health that was the issue, it was that the place they were living in was in such a poor condition.
Although one could argue we already knew poor housing condition was an issue, we were now able to identify the individuals affected and supported them more effectively. In fixing those more minor issues we’ll help with much more than their mental health - their whole life and contribution to wider society.
So how did we get to this point? The programme helped us to bring the data analysts and clinicians regularly around the table to think about what our patients and residents really need and how we can find the evidence to support that instead of using individual datasets and informed guess work.
Then it was about making sure the arrangements around information governance were correct. It wasn’t an overnight mission and took a lot of hard work but once we were able to talk to each other in a common language we found common aims for our residents and patients and looked towards common goals.
From a digital perspective it helped us connect with a wider purpose and the business intelligence community feels we’re making a difference to how people are cared for.
For clinicians, it’s given them headroom for learning with other organisations at neighbourhood level which they cherished and put them steps ahead for delivering primary care networks.
It’s enthused our GPs with a sense of excitement and opportunity to have this in their toolkit. A clinical director for a PCN has got to be equipped with PHM to do their job effectively helping them build skills and knowledge to help patients to look after themselves better. It will also release clinicians’ time because they will be more linked into and able to use available community services.
This isn’t about passing people onto somebody else, it’s a recognition that many patients need something that isn’t found in the doctors’ surgery.
Contrary to common beliefs and criticisms, adopting PHM approach is actually helping us to tackle the real reasons why people end up in the doctor’s surgery and not just patch up the problems we’re faced with once they’re in the chair.
Dr Sakthi Karunanithi is population health and prevention lead for Lancashire and South Cumbria Integrated Care System. Follow him on Twitter @dr_sakthi