NHS Reset: A running start – using population health management to rapidly respond to the challenge of COVID-19 | Dr Dan Alton

Dan Alton

NHS Reset is a new NHS Confederation campaign to contribute to the public debate on what the health and care system should look like in the aftermath of the COVID-19 pandemic.

In this blog, part of a series of comment pieces from NHS Confederation members and partners, Dr Dan Alton, a GP in Wargrave, Berkshire, explains how his clinical commissioning group has used population health management (PHM) tools to help address the challenges of COVID-19. He also considers the opportunities it could present to redesign systems in the aftermath of the pandemic. 

Human interactions are one of the lynchpins of any PHM approach. When we want to make any cultural change or improvement, it’s 10 per cent about data and 90 per cent about change management. It is about talking to people – your colleagues, your patients –  and identifying ways to make positive change happen. 

Before COVID-19, Berkshire West Clinical Commissioning Group was an NHS England and NHS Improvement development programme site for PHM, participating in wave one of the organisation's PHM development programme in 2018/2019. This meant that when faced with the immense challenges created by the pandemic, we already had a strong whole-system data infrastructure and analytical support in place that we could draw on. Most importantly, we had a strong network of partnerships and working relationships in place across the medical system, social care, councils, community services and the voluntary sector. 

We already know the impact that wider determinants of health can have, with potentially 80 per cent of our population’s health outcomes determined by their social and economic situation, home environment and other key inequalities. The pressures created by COVID-19 have brought all of this into sharp focus, magnifying the health, social and economic disadvantages suffered by many people.  

Focusing on responsiveness not perfection


Within hours of lockdown, we began reaching out to our networks across the Wokingham locality to plan our approach. We knew that we needed to act quickly to identify our most vulnerable groups and find out what support and care they required. This, of course, included those shielded patients, but we also worked with our analyst huddles, using key data such as residents needing assisted bin collections, sheltered housing, care needs or food and medical supplies, and identified around 2,500 residents in this first wave. 

Within days, they received phone calls from our health and social care teams to ask them what they needed. One of the biggest concerns raised was the fear of loneliness, and thanks to our voluntary and social sector members, we were able to rapidly put into place befriending services and checking calls. 

One of the things we said from the start was that we would not let ‘perfection be the enemy of good’. We identified where we were able to make an immediate impact, rather than needing to perfect our cohort of identified patients first. We used a rapid implementation model, using PDSA cycles (Plan. Do. Study. Act) to learn and make improvements, and having a PHM framework already gave us permission to think outside of our individual silos, and to act rapidly as a single team with a shared purpose. This fleet-footed approach has helped us to quickly identify and offer support to other high-risk cohorts, including those particularly struggling to cope with the impact of lockdown. 

For example, using very simple datasets we were able to identify and reach out to families with newborn babies. Most new parents had lost their support network as a result of the pandemic – they had no family around them, there were fewer new parent support groups, and health visitor calls were all online. We rang them and asked them about their mood and how they were coping. It was a simple search-and-respond approach to finding a cohort where we could manageably do something, and then doing it. On a number of occasions, this has also enabled us to actively intervene when urgent support was required.  

We are now working with other available data, such as joining up more council held data, to further segment our population according to risk. We are doing this with support from the commissioning support unit and using the integrated population analytics (IPA) tools, particularly as more information on risk factors for the infection become available. 

The huge range of resources from the NHS England PHM Academy has been immensely helpful, both in terms of information and connectivity to the other 2,300 members. We continue to need to understand who is vulnerable and to what. Not just the older person living alone, but perhaps a younger person, a single parent, a carer or someone with a mental health background. And of course new challenges are now developing. For example, from people who have not been seeing their GP or other healthcare professional as regularly or rapidly as they should have during this period. We now urgently need to find ways to identify this specific group of patients and offer the proactive care that they need. 

Recognising and adapting to the changing landscape

We also need to think about what we do next, now that the first groundswell of infections is beginning to pass and health systems can start to focus on other health priorities. If this time has taught us anything it is that we can think differently, and this is our opportunity to redesign our systems. 

For example, how can we deal with our backlog of patients most effectively? And most importantly, how can we make sure that we are seeing patients based on need and not on demand? Can we use the tools of PHM much more widely during this reset, enabling us to move towards a prevention agenda? Can we actively address the exposed health inequalities and overcome the educational, cultural and confidence barriers experienced by many of our residents? Can we act on what different segments of our population really need and take the interventions and solutions to them, rather than just expecting them to come to us?

I really believe that we can – this is our chance to redefine how we ‘do healthcare.’ 

Dr Dan Alton is a GP at the Wargrave Surgery Berkshire, and Berkshire West CCG chief clinical information officer and population health management clinical lead. Follow him on Twitter @DrDanAlton

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