Supporting neighbourhood health with shared care, population health and remote monitoring
30 June 2026
At a Glance
Organisation: Northamptonshire Integrated Care Board
Solution: Graphnet Shared Care Record, Population Health Management and Remote Monitoring
Focus: Neighbourhood health, preventative care, risk stratification and long-term condition management
Key Outcomes
- Connected data from health and care organisations across the county
- Population-wide risk stratification and patient segmentation
- Neighbourhood-level dashboards and intelligence
- Identification of patients suitable for proactive intervention
- Development of remote monitoring cohorts
- Supporting a shift from reactive to preventative care
Why This Matters
As integrated care systems develop neighbourhood health models, there is increasing pressure to move beyond reactive healthcare and identify opportunities to intervene earlier Northamptonshire ICB is using shared care records, population health management and remote monitoring together to create a more proactive model of care, helping neighbourhood teams identify risk, target interventions and support patients before they reach crisis point.
The Challenge
Neighbourhood health represents a significant opportunity to improve outcomes, reduce inequalities and deliver care closer to home. However, delivering these ambitions requires more than organisational change. It depends on having the right information available to identify patients who may be at risk, understand local population needs and support preventative interventions.
Like many systems, Northamptonshire recognised that healthcare services often spend significant time responding to deterioration rather than preventing it. The organisation wanted to explore how better use of shared care data, population health intelligence and remote monitoring could support a shift towards earlier intervention and proactive care.
The challenge was to provide neighbourhood teams with meaningful intelligence that could support day-to-day decision making while helping the wider system identify opportunities to improve outcomes and reduce avoidable demand.
Building a Connected View of the Population
Northamptonshire has developed a mature digital infrastructure using Graphnet to bring together information from across the health and care system.
Data from GP practices, local authorities, acute hospitals and community services is brought together within a shared platform, creating a connected view of the population and enabling a more complete understanding of patient need.
Using Graphnet’s population health capabilities, the organisation can apply risk stratification and predictive analytics to identify cohorts of patients who may benefit from earlier intervention.
This provides neighbourhood teams with a more detailed understanding of the communities they serve and supports more informed decision making around service delivery and care planning.
Turning Data Into Action
One of the key objectives for Northamptonshire has been ensuring that population health data translates into practical action. Working closely with neighbourhood teams and primary care colleagues, the ICB has used Graphnet’s enhanced cohort finder and reporting capabilities to identify patient groups who may benefit from additional support.
This includes patients living with multiple long-term conditions, those at increased risk of deterioration, individuals who may be disengaged from healthcare services and cohorts experiencing health inequalities.
The organisation has also explored how population health intelligence can support areas such as diabetes prevention, weight management, frailty management and long-term condition monitoring.
By combining local clinical insight with population-level intelligence, neighbourhood teams are able to focus resources where they are most likely to have an impact.
We know there is value in seeing people differently, particularly those living with frailty, multiple long-term conditions or a higher risk of deterioration. The opportunity is to intervene earlier and provide more preventative support.
Matthew Hutton, Integrated Care Lead, Northamptonshire ICB
Supporting Remote Monitoring Through Population Health Intelligence
As part of its neighbourhood health programme, Northamptonshire has also been exploring how remote monitoring can support preventative care. Using Graphnet, the organisation has developed tools to identify patients who may benefit from remote monitoring interventions.
The approach includes analysing admission history, risk indicators and existing monitoring activity to identify individuals who may require additional support.
For example, the organisation has developed a remote monitoring cohort identifier capable of highlighting patients who have experienced multiple hospital admissions and may be at increased risk of future deterioration.
This allows neighbourhood teams to move beyond reactive responses and consider earlier intervention strategies that could help patients remain well at home. Rather than viewing remote monitoring as a standalone technology, Northamptonshire is integrating it within a broader neighbourhood health strategy that combines shared care records, population health management and proactive care planning.
Equipping Neighbourhood Teams With Better Intelligence
Alongside cohort identification, Northamptonshire has developed neighbourhood-level dashboards that provide visibility of local populations and service activity. These dashboards help teams understand health needs, monitor activity and identify opportunities for intervention within their communities. The ability to combine shared care information, population health intelligence and remote monitoring insights within a single environment helps clinicians access the information they need to support more joined-up decision making.
The approach also provides a foundation for evaluating neighbourhood initiatives and understanding their impact over time.
We went into our neighbourhood conversations looking at how remote monitoring, risk stratification and population health data could help us shift care left, identify risk earlier and support people before they require urgent care.
Matthew Hutton, Integrated Care Lead, Northamptonshire ICB
Supporting the Future of Neighbourhood Health
As neighbourhood health continues to evolve, Northamptonshire sees connected data as a critical enabler of more preventative and personalised care.
By bringing together shared care records, population health management and remote monitoring within a connected platform, the organisation is creating the foundations needed to support earlier intervention and more proactive care delivery.
The approach helps ensure that neighbourhood teams have access to the information required to identify risk, understand local need and support patients before conditions escalate.
Conclusion
Northamptonshire’s experience demonstrates how shared care records, population health management and remote monitoring can work together to support neighbourhood health. Rather than operating as separate initiatives, these capabilities are being used to create a connected ecosystem that enables clinicians to identify risk earlier, target interventions more effectively and support patients closer to home.
As health and care systems continue to focus on prevention and proactive care, Northamptonshire provides an example of how integrated digital capabilities can help turn neighbourhood health ambitions into operational reality.
