A story of resilience and collaboration during a global health crisis
The creation of ICSs and the commitment to integrate services through a population health approach require a much more holistic understanding of the health and wellbeing of a local population, as well as the social and environmental determinants that impact and shape outcomes. Capturing, analysing and modelling data will help local systems to identify what support is needed by which individuals and communities. Use of this insight will help to shape and coordinate the collective action of the ICS to address key areas of priority, reduce inequalities and improve overall health outcomes.
The development of population health management (PHM) will require new knowledge, skills and data analytics. This offers opportunities for partnership with organisations that can bring experience and expertise to accelerate the learning of senior leadership teams and assist in shaping population health management strategies and plans. This case study explores the experience of North London Partners (NLP) and Cerner on their journey to developing population health management in the North Central London ICS.
Following the publication of the NHS Long Term Plan in January 2019, NLP’s mission has been to drive the integration of health and social care, enabling PHM across all the health and care providers within the five boroughs and 1.68m people of North Central London. Cerner were selected as the partner to assist NLP achieve the goal of moving away from the traditional focus on reactive care to a proactive model of care. One focused on addressing the ongoing challenge of health inequalities and helping to identify cohorts of individuals most in need and whose outcomes are most impactable.
NLP are using Cerner’s suite of population health management tools to help bring together and normalise data from multiple systems across the ICS to create an integrated, longitudinal health and care record for each of NLP’s patients. This data is being used to develop new case-finding tools, analytics and PHM registries to identify unwarranted variation and drive gold-standard care.
These tools surface insights to frontline health and care professionals and care teams at all levels of the system, which is then used for effective targeting of interventions for individuals and populations.
At time of publication, over 1,800 health and care professionals from across North London have been set up as users, and more than 500 are actively using the analytics tool available within the platform. The COVID-19 vaccination dashboard, for instance, was viewed 1,000 times over a three-day period in late January 2021. These figures are rapidly growing as the programme continues to expand.
The planning, collaboration, and relationships already in place in support of the PHM partnership had the benefit of enabling a more rapid and agile response once the COVID-19 pandemic hit. Whilst the wider national effort in meeting the COVID-19 challenge focused on reaction and response to treating the infected with critical care capacity, NLP also sought to establish a proactive community-based scheme.
In planning for this, NLP defined their PHM priorities approach as:
Working together on these priorities, and together with teams from across the system, six analytical dashboards were produced. These were viewed over 6,000 times by 355 users over a 10-week period from the end of March 2020. These dashboards included:
At a system level, making system-wide data available to the care teams saved time in waiting or chasing for information, such as contact details or updates on whether people had already been admitted to hospital, discharged already or had passed away. The partnership between NLP and Cerner demonstrated the value of PHM as a catalyst for greater system integration and a culture of collaboration through helping to understand how to assign resources to best meet the needs of their communities in a timely manner.
This level of patient information was augmented by the OneLondon shared care record programme where Cerner’s Health Information Exchange (HIE) technology was implemented to connect HIEs across London, including North Central London’s exchange. This programme provides real-time data access across multiple systems, patient-matched and presented as a single and comprehensive snapshot of each individual’s journey through the system.
Beyond the COVID-19 initial response, work has commenced on the flu and COVID vaccination programme – as well as the onboarding of data across NLP – to enable care teams to focus on key population health priorities for their individual patients and clients and the wider communities they care for in the aftermath of the pandemic. This includes the development of flu and COVID vaccination analytics using HealtheIntent to proactively support GP practices, PCNs, boroughs and the wider system in driving vaccination uptake, particularly among the most at-risk groups within the eligible cohorts, with a focus on equity across different communities. Targeted public communication and engagement interventions to increase uptake have been guided in part through vaccination analytics identifying population needs by ethnicity, deprivation, religion and first language spoken. Additional whole-life registries that have been designed and implemented include health checks for adults with serious mental illness; care quality for those living with and beyond cancer; and learning disabilities, dementia and early years. This will facilitate further collaboration and new working practices between organisations within the NCL health economy to support population health improvements.
Population health management will be at the heart of ICS and regional population health systems working in the future. The ability to gain clearer insights into how people live, work and play within a place or neighbourhood, how this shapes health and wellbeing and what can be done to improve outcomes will be core to the success of ICSs. It is this insight that helps to shape the services and support of the future. As more data arrives through greater digitalisation and use of technology, the richer the picture that will be revealed and the greater the opportunity to enhance the health and wellbeing of individuals, communities and the country.
NLP’s experience shows that PHM programmes can be a catalyst for new transformative system working. Tools and information can facilitate closer collaboration, but it is visionary leadership and behaviour change that drives true system integration.