What is population health management?

Each time that you use or visit an NHS or social care service they record information about your health and the care and treatment that they give you. 

Bringing data from these records together helps health and care services to understand the needs of people across Hampshire and the Isle of Wight, as well as those of specific communities or people with a similar health condition. 

Analysing and making use of this data can help to:

  • identify people who are at risk of illness (for example people with long term conditions such as high blood pressure, diabetes or who have anxiety or depression) 
  • provide these people with care and support to help them manage these conditions and prevent them becoming unwell
  • understand more about people’s health and care needs so we can target support and those who need it most 
  • design and improve services to provide people with the best possible care
  • plan the best use of health and care resources where they will have the most impact

All of these things can help people live healthier and longer lives and help reduce pressures on NHS and care services. 
This approach is called population health management (PHM). 

We can also use this information to look into the future and understand what people’s heath and care needs are likely to be over the next 20 years so that NHS and local government organisations can work together to plan services to meet these future needs and improve the health and wellbeing of people across Hampshire and the Isle of Wight. This will include looking at the wider factors that can affect people’s health, such as their lifestyles, pollution, housing conditions and the safety of their neighbourhoods.

Using health and care data, and the insight it provides, will really help our integrated care system achieve its strategic priorities and support our five areas of focus – children and young people, mental wellbeing, good health and proactive care, our people and digital and data. 

We’re introducing the PHM approach in Hampshire and the Isle of Wight over a five-year programme, which is being funded through the national NHS long-term plan.     

We’ve already started to use population health management to improve the health and wellbeing of identified groups of people in a number of pilot projects including:

  • helping a group of people living in Andover, who had been diagnosed with depression and also recognised as obese, to take more control over their physical and mental wellbeing, including referral to exercise schemes and support from local charities and community organisations.
  • supporting people in Gosport who have high blood pressure to improve their wellbeing and prevent them becoming ill, including exercise opportunities, stop smoking clinics and providing them with blood pressure monitors.
  • health and care partners in Basingstoke working together to provide new targeted support to around a thousand people who had been diagnosed with anxiety and depression, including recruiting a new group of Community Care Wardens, offering people individual support or signposting them to self-care apps or websites.

All the data used for population health management in Hampshire and the Isle of Wight is kept in a secure IT data platform. 

Information from GP records and patient records from hospital, community and mental health trusts is brought together in this safe and secure system. In the future, data from other health and care services will be added to the platform. This data can be analysed and used to understand people’s health and care needs and then make plans to improve their health and wellbeing and prevent them becoming ill, including producing lists of people for targeted help or support.

All the information used is anonymised, which means you can’t be identified from it – it’s normally made up of numbers and codes and doesn’t contain information such as your name, date of birth or postcode. The only people who can access personal information from the platform are users with special access (such as GPs) who need to contact people to offer targeted help or support.    

The population health data platform is a very secure system which follows industry security standards and is kept up to date against the latest cybersecurity threats. Legal agreements (called Data Sharing Agreements) are in place between all the organisations who share data in the platform, setting out what data can be shared, how it can be used and the principles and controls in place to keep it confidential and safe.

There are strict rules in place to protect your information. This includes rules on who can access HealtheIntent data, who must be approved by their own organisation.

To find out more

Improving population health is a national NHS strategic priority for integrated care systems across the country, with work on population health management happening in each area. You can find out more on the NHS England website.

The King’s Fund also have some useful information explaining what a population heath approach is, including this helpful video.

If you are a health or care professional in Hampshire or the Isle of Whight and would like to know more about the HIOW PHM programme, please take a look at these pages on NHS Futures.  

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