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Population Health: How data is driving change

26 September 2023

The health inequalities and poverty challenges exposed by the Covid-19 pandemic highlight a growing need for proactive intervention and long-term planning in health and care services.

In a report from 2021, The Health Foundation found that people younger than 65 living in the poorest 10% of areas in England were almost four times more likely to die from Covid-19 than those in the wealthiest areas. The King’s Fund also found that the pandemic widened the gap between waiting lists for elective care, with waiting lists in the most deprived areas growing by 55%, compared to 36% in the least deprived areas.

Data like this is essential to understanding the bigger picture of how health inequalities are affecting services in the UK. To truly address the problems faced by specific cohorts, however, clinicians also need to be able to analyse and cross-reference data at a local level.

Population Health Management tools offer an effective way for healthcare providers to examine data intelligence in their communities – producing accurate insights that can be used to identify and support high-risk groups, develop practical plans for the future, reduce health inequalities, and improve health outcomes for the population as a whole.

Contact us today to discuss our Population Health Management software


What is population health management?


Population health management is a strategic approach in healthcare that uses data to help identify, target and improve the health outcomes of a specific community.

Data is drawn from diverse sources – such as GPs, hospitals, social workers, local councils, and community care providers – and then combined, segmented and cross-referenced for analysis. 

Using this segmented data intelligence, healthcare providers can begin to recognise patterns, identify high-risk individuals, and proactively address the health needs of populations.

Common cohort segments might include:

  • Demographic – age, sex, ethnicity, geography
  • Health information – diabetes, asthma, pregnancy, hypertension
  • Wider determinants – household size, fuel poverty, mass deprivation score


Why is population health management important?


Population health management helps us understand how well health and care systems are meeting the needs of the population. By tracking and improving outcomes for specific population segments, we can continue moving towards a more equitable and effective healthcare system for all.

Access to comprehensive, integrated and up-to-date data allows clinicians to identify population health patterns and trends; recognise gaps in service delivery; and effectively plan for the future.

For example, population health management tools that combine health data from the NHS and residential Energy Performance Certificate (EPC) ratings from a local council will allow clinicians to identify all patients in the area who have respiratory problems, live in poorly insulated housing, and have a high number of A&E attendances.

These patients can then be targeted for proactive care and early intervention, ensuring care planning is in place to manage their conditions before winter arrives and they become further at risk.


What does population health management software do?

Technology plays a crucial role in managing population health. Tools like Graphnet’s Population Health Management program offer authorised access to electronic shared care records that combine extensive patient data from multiple sources, such as GPs, hospitals, local councils, social care, and more.

The population health management software empowers ICSs to develop their own analytical eco-systems, supplying healthcare teams with a configurable platform that can be used to drive actions such as include:

  • Integrating data records

Population health management tools facilitate the integration of data from multiple and varied sources. This enables healthcare providers to make better informed decisions and develop better personalised care strategies.

  • Coordinating care plans

With access to a unified patient record, healthcare professionals across different organisations and care settings can collaborate and coordinate care effectively to help improve health outcomes. This communication can also reduce admin time, reduce duplication of services, and improve patient relationships.

  • Identifying high-risk populations

Detailed analysis of historical and real-time data allows healthcare providers to pinpoint demographics within a region who may be more susceptible to certain conditions or have higher healthcare utilisation rates.

  • Adopting early intervention and preventive care methods

Once identified, healthcare providers can take a proactive approach, intervening sooner to helps prevent disease progression, reduces hospitalisations, and improve overall health outcomes.

  • Monitoring performance to improve service quality

Real-time monitoring of KPIs and quality metrics allows organisations to identify areas for improvement, implement evidence-based practices, and measure the effectiveness of interventions. This data-driven approach supports continuous quality improvement of health services and enhances the delivery of care.


Case Studies: Population Health Management Tools in Action

Graphnet is a leading supplier of integrated health and care management tools. Our Population Health Management analytics software helps healthcare providers optimise their resources, improve inter-disciplinary collaboration, upgrade their operational efficiency, and deliver an improved service to their patients.

By seamlessly integrating data from multiple sources, including primary care, hospitals, social care and community services, our Shared Care Record provides a comprehensive view of patients' health information. This enables system leaders to proactively track and improve outcomes for key population segments over time. 

Here are some tangible ways our population health management tools have helped ICSs across the UK:


Reduced waiting lists

  • Challenge: Increasing pressures on the NHS has resulted in longer waits and rapidly increasing waiting lists for many patients. However, poor data quality and visibility means clinicians must spend time addressing errors – taking time and focus away from the patients who need it.
  • Solution: Graphnet’s Elective Waiting List module helps clinical, operational and administrative teams cleanse their waiting list by identifying duplicate entries, cancelled appointments, people who have already been treated, people who no longer require treatment, people who can be moved to a different pathway, and people who are deceased. 
  • Impact: Initial stats from one ICS showed that they had reduced their patient wait list by more than a third – from 333,457 to 218,602 – by identifying and removing multiple entries, cancelled and DNA patients, deceased people, and those who had not been in contact in 12 months.


Reduced A&E attendances

  • Challenge: A&E departments are under immense pressure. Reports from the British Journal of General Practice, however, found that up to 40% of A&E attendances across the UK are unnecessary and could be redirected to other services.
  • Solution: Real-time monitoring and remote assessment tools allow GPs to identify patients who are inpatient at hospital or currently attending A&E and remotely assess whether they could be seen in primary care instead.
  • Impact: The Frimley Health & Integrated Care System (ICS) rolled out a proactive approach to remote monitoring service using population health analytics to 4,000 complex need primary care  patients and 800 care home residents. As a result, local communities are seeing positive outcomes. Early evaluation signals indicate that the initiative is:
  • Reducing hospital admissions by 40% for high need patients and 34% for care home residents.
  • Reducing A&E attendance by 31% for high need patients and 40% for care home residents.
  • Reducing GP contacts by 19% for high need patients and 20% for Care Homes
  • Reducing volume of medications prescribed by 11% for both high need patients and care home residents.


Improved hypertension care and stroke prevention

  • Challenge: £4.5 billion is spent annually on social care for people who have had a stroke. Regular blood pressure monitoring of patients with hypertension helps provide early indicators for those with an increasing risk of stroke. However, due to the pandemic, blood pressure health checks for hypertension patients fell from 75% in March 2020 to 50% in December 2020.
  • Solution: Population health management tools developed under CIPHA allowed clinicians to identify the highest-risk individuals in this cohort and run targeted interventions to get blood pressure readings taken or enrol patients in a remote monitoring programme.
  • Impact:
    • The practice leading this initiative went from the lowest performing on blood pressure recordings to third best in the region.
    • Increased coverage of blood pressure readings enabled early detection and intervention, reducing heart attacks and strokes in the long-term.
    • Reduced health inequalities as the most deprived populations saw the greatest improvement in proportion of blood pressure recordings.


Enhanced remote monitoring

  • Challenge: Remote monitoring helps reduce the amount of in-person patient consultations, easing the pressure on GP appointments, A&E attendances, and bed days. However, identification and selection of the patients most in need of remote patient monitoring is a highly complex task.
  • Solution: Population health management tools allow clinicians to identify, select and refer patients suitable for remote monitoring. The CIPHA remote monitoring service then combines data from the patient and shared care record to alerts clinicians when monitored readings are off. Finally, population health analytics can analyse patient cohorts to improve the patient selection algorithms and evaluate service outcomes of remotely monitored patients.
  • Impact:
    • Patients likely to be hospitalised with COVID for inclusion pulse oximetry programmed increased from 36% (NHSD list) to 86%.
    • Mortality improved from 30% to 11%.
    • Length of stay reduced by 4 days.


Improved elective recovery care

  • Challenge: Long wait times for procedures mean a patient’s condition often deteriorates so that they are unfit for surgery. This can result in cancellations, poor patient experiences, and worse health outcomes.
  • Solution: Population health management tools help clinicians identify patients on the waiting list who could benefit from early intervention to optimise them for surgery. The tool also helps healthcare providers to maximise efficient by identifying the most appropriate pre-op pathway for patients.
  • Impact: Initial findings from one ICS include:
    • 47% patients identified as lower risk and suitable for a more streamlined pre-op pathway.
    • Reduced booking team patient review time (from 15 minutes per patient to less than 2 minutes per patient).
    • Reduced calls to GP for information.


Ask us about our Population Health Management software