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Population Health

Over 13m citizens benefit from targeted, planned care using our population health management tools. Together with our partners, we are leading the way in data rich population health intelligence systems that provide actionable insights for the resilience, reset and recovery of health and care economies.

Our population health platform uses the integrated health and social care data held in our shared care record to produce in-depth insight at the population, cohort or individual level. The insight drives actions such as enrolling identified individuals onto a remote monitoring programme, where clinicians can drill down into the underlying shared care record and patients self-record onto their integrated personal health record. Analytical tools measure the impact of interventions and the results are fed back into the shared record, closing the loop and creating a 360 degree solution.

Key benefits:

Using our population health tools, ICS leaders, public health and care professionals can:

  • Track key aspects of health and care operational delivery and forecast the impact of changing population needs on operational demands. 

    The operational performance dashboards provide an executive overview of local service demand, capacity and resourcing to support decision making.These include real-time information for a health and care system, such as Covid-19 status, bed capacity, staff sickness and other factors that help understand existing and emerging demand and plan for the future. 

    For example, we provide the National Immunisation Management System (NIMS) dashboards for reporting and analytics which are currently used by 1,500 local professionals to manage local vaccination programmes. 

  • Use data insights to take swift, targeted action at population, community and person level. 

    We collate information from our shared record i.e. primary, secondary, community, mental health, social care and Secondary Uses Service (SUS) data, our personal health record and public data sources such as Public Health England’s ‘Fingertips’ profiles and other wider determinants data. Organisations can further enhance their analytical capability by loading in other datasets as required.

  • Identify groups of vulnerable people who would benefit most from proactive care and target limited resources to where they are needed most.

    The Enhanced Case Finding tool uses rich, comprehensive data to allow public health and care professionals to rapidly identify individuals and specific groups who could benefit from early intervention for integrated and proactive care.

  • Improve existing care pathways and establish new ones with a focus on offering more community-based care and enhancing patient outcomes.

    The data intelligence generated by the population health platform is used to drive actions. This includes planning services such as working out what is needed, predicting when and where surges in demand are likely to come from (e.g. mental health pressures post Covid) and putting appropriate provisions in place.

  • Study the impact of interventions and use this insight for research and/or to drive best practice. 

Using shared care and personal health record data intelligently, integrated care systems will be able to operate in a more agile way, adapting and scaling up new services as demands change.

Case studies:

Combined Intelligence for Population Health Action (CIPHA) programme


The NHS CIPHA programme supports health and care systems across the country develop their population’s health by providing the insights which help them target actions, measure impact and transform services.

CIPHA combines local and national feeds, including Pillar 2 community testing data and NIMS data, and makes it available in the CareCentric population health platform, with real-time analytics and dashboards presenting information to allow prompt co-ordinated actions at the local level and across ICSs.

In addition, the programme collaborates on developing and documenting use cases which can then be picked up by other health and care systems and implemented more widely. Its ambition is to accelerate the process of transformation and develop new care pathways. 

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Using population health and shared records to deliver Covid remote monitoring services to patients in their home

We have been working with Frimley Health and Care ICS to identify patients that would benefit from remote monitoring at home.

Patient groups can now be filtered interactively to identify and highlight cohorts to be monitored more closely i.e. Covid patients, those at risk from Covid, or those with other health conditions who might need flagging and monitoring through programmes such as Pulse Oximetry @Home. 

Findings from 11 Nov 2020 to 27 Feb 2021 (108 day period):

  • 42% reduction in mortality in shielded, hospitalised patients 
  • 50% reduction in mortality in hospitalised patients who are not shielded
  • 28 lives saved
  • Median lengths of hospital stay reduced from 9 days to 7 days

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Population health data system working behind the scenes on the Events Research Programme in Liverpool.

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Being development partners with Graphnet and using their population analytics platform has really enabled us to build the supporting analytics that enable our move towards developing a mature population health Intelligence system.

Mark Sellman – CIO Frimley Health and Care ICS & Connected Care

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Population health – providing actionable insights

The need for population health management systems has never been more important as we move ahead into restoring services, reducing backlogs and identifying unmet need – all while tackling inequalities in access, experience and outcomes.


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