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Population Health is ‘driving force’ behind Integrated Care Systems, says GP Davies


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The voluntary sector and population health management (PHM) are key building blocks of Integrated Care System (ICS) Design Framework, Dr Helen Davies writes in a blog on the NHS.

Davies, who is a GP clinical lead for community and population health management at Calderdale Clinical Commissioning Group, said that earlier many barriers prevented us from truly embedding PHM approaches and opportunities.

However, with the integrated care systems, the forthcoming legislation and incentives for Primary Care falling into line, there is hope for it to become the driving force behind the NHS.

She wrote: “In Calderdale – a place within West Yorkshire and Harrogate (WYH) ICS – we’ve already rolled out PHM techniques to surgeries in every primary care network in the system and are really starting to see the benefits for specific groups of people like those who are homeless, people with diabetes and those living with frailty.

“… we’ve started to think more keenly about our opportunities for reducing health inequalities and offer new and more personalised interventions for at risk groups, whilst working closely with WYH’s own improving population health programme.”

The approach has helped in bringing together health and care professionals from across the integrated care system to look at data in a new way and to identify population groups and assess needs differently.

Davies highlighted three key learning points which other systems starting out might use.

“Firstly, what is the level of maturity, capability and understanding in your system at the start so you can begin with the right strategy to embed PHM? How far have we got in joining up data, have we got a strong population health analytical platform which allows for population and risk grouping, have we got clear leadership and governance to enable PHM approaches? Making sure you have the right organisations and skills (ie analytical) round the table to create the insights you need to guide design is crucial.

“Secondly, taking the time to honestly reflect on what the existing relationships are like in your system. This has been so key to our success that it must be first and foremost of any plan. Again, we had quite a good starting position so expected a bit more from our partners.

“Thirdly, how do we increase true understanding of the problems? Quantitative techniques for creating meaningful insights from the data are critical here but equally important is narrative data – qualitative approaches to tap into local wisdom of patients, carers and providers so we can both bring their insight into where to focus but also involve key groups in care model design.”

She noted that Calderdale has adopted a very person-centred approach to PHM. To substantiate this, she shared the experience of working with the homeless community. As a first step, all the organisations that provide care for the homeless were made to share their views.

This process revealed the need of tightening up the validity of the data – the official numbers were small compared to how many we knew were homeless or leading street-based lives.

After collecting qualitative information, the next step was number crunching from colleagues from across Primary Care, data analysis, voluntary sector and the local councils.

All the data combined with the peoples’ stories helped in developing deep understanding of the cohort. The team is now thinking of ways to ensure better care driven by better data and evidence for these marginalised population groups.

She added that Covid-19 has given a fantastic opportunity to refocus on the specific needs of different communities and groups of people.

“Hopefully the learning from our journey in Calderdale will inspire your system. My expectation is that population health management will continue to drive the agenda of the NHS and its partners, which will benefit the effectiveness and efficiency of the system and improve the care of patients,” Davies wrote.

Meanwhile, commenting on the recently published interim guidance on the functions and governance of the integrated care board, Lou Patten, chief executive of NHS Clinical Commissioners and ICS Network leader at the NHS Confederation, said: “The NHS Confederation, including NHS Clinical Commissioners and NHS Employers, has been heavily involved in partnerships with NHS England and NHS Improvement and trade unions via the Social Partnership Forum to develop this new HR technical guidance.

“We are very grateful for the considerable input of members, and while mindful that central guidance addressing the needs of every system is very difficult to achieve, this has been a really good collaborative effort that seeks to bring clarity as to the way forward.

“Many senior commissioning leaders face uncertainty themselves regarding their futures, but they are committed to ensuring the effective transfer of staff, teams and functions to their new ICS based roles.”


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