The case for Population Health Management
Population health management is a crucial approach to improving overall health outcomes and addressing health inequalities. This approach recognises that a person's wellbeing is influenced by a wide range of factors beyond just medical care, including social, economic, and environmental conditions.
The conditions in which people are born, grow, work, and live significantly impact their health outcomes. Understanding these broader determinants of health is essential for developing effective interventions that can prevent illness and promote wellbeing across populations.
Research conducted by the World Health Organisation has shown that social determinants account for 30-55% of health outcomes, highlighting their critical role in shaping public health. By addressing these factors, we can tackle the root causes of health inequalities and develop more targeted, effective interventions.
Population health management enables the development of preventative, personalised, and predictive health and care interventions. This approach aims to:
- Improve overall health outcomes for citizens and service users,
- Ensure more efficient use of resources in local health and care systems,
- Address health inequalities by targeting interventions where they're most needed, and
- Promote collaboration across different sectors to address complex health challenges.
By embracing population health management, health systems can move towards a more proactive, data-driven approach to improving public health and reducing health disparities.
Mission background
The Somerset Health & Care Strategy reflects the system’s ambition to enhance the lives of the population through joined up care and collaboration – working collectively to improve physical and mental wellbeing and tackle the prevalence of health inequalities.
To do this both effectively and proactively, data and intelligence is central to identifying who requires care, and personalising advice, guidance and interventions to meet those needs. Data-driven insights provide the system with an objective source of information to track and monitor health and care outcomes and manage the health of the Somerset population.
Goal
Develop a data platform centred around population health management so that the system will be equipped with data and intelligence capabilities to prevent ill-health, reduce health and care inequalities, and drive integrated and joined-up thinking.
Objectives
- Enable the identification of data trends and population health intelligence to support system collaboration on the development and execution of preventative measures.
- Provide the ability to segment the population by a range of key health and care attributes to inform the identification and reduction of inequalities across the population.
- Connect and integrate relevant data from across the system to showcase where factors across health, community and VCFSEs inform or influence population health.
What is a Population Health Data Platform?
Although the term platform is often used broadly, for this purpose we will use it specifically to indicate products, services, or tools that enable us as ICS organisations, residents, and academic partners to collectively create value around our population health objectives.
A platform is multi-sided; it controls and orchestrates interactions between different elements, allowing for significantly reduced risk around data protection and ensuring a constant focus on breaking data out of siloed systems.
The diagram above shows an example of population health platform component architecture. It looks complicated but it is just exposing at a high level elements under the hood of most population health solutions available on the market.
Our obligations as data owners
Like any asset, data must be protected and managed to be fit for purpose, used lawfully and treated ethically.
Under the government’s new data ownership framework we as an ICS hold full accountability for the suite of data activities across any common platform.
We can’t outsource this responsibility so it is critically important we ensure we have the resources, insight and knowledge to manage and oversee all elements of the platform in the long-term.
The approach we are taking tests the assumption that the most amount of risk lies in the ingestion layer. This assumption is based off the technical complexity that will exist within this layer, but also in terms of the level of exposure it will have to cyber vulnerabilities and IG risk. If we seek to understand it in detail, we can decide whether to retain the responsibility for it long-term, because our assumption is proven correct, or whether we are happy for it to be part- or fully-owned by an approved 3rd party because our concerns are unwarranted.
Phase 1
Discovery - Testing the AssumptionsFAQs
How does this fit with other data platforms across the ICS and the region?
We are actively promoting partners to build on and maintain their own data platforms. Somerset council currently has Transform a system to join up data around vulnerable children and is progressing with a larger scale data platform for all resident services over the coming years. Somerset Foundation Trust have been focused on bringing to together data for multiple records systems in advance of the migration to an Electronic Patient Record. And the voluntary sector (through Spark Somerset) has commissioned an Insights platform to map and expose voluntary sector activity at a locality level so that commissioners know the opportunities available to them. All of these activities help enormously and reduce the pressure and risk of matching and cleansing data at a system level.
Finally at a regional level we are part of the South West Secure Data Environment programme. We’re hoping the work we in Somerset do to give a cleansed and segmented view of our population will speed up the time to value for research opportunities.
How does this fit with NHS England’s Federated Data Platform?
We are actively engaged with the team delivering the Federated Data Platform and whilst we see the value of NHS national benchmarking it’s current offer won’t meet the majority of our ICS needs from a population health standpoint. We will continue to work with the team and assess opportunities for where it can add value in the future.