Population Health Data to Drive Change
Obesity places a significant and growing burden on the NHS and wider economy. With over one in four adults and nearly a quarter of children aged 10–11 living with obesity in England [1], systems need a data-driven way to target support, personalise care and evaluate impact at pace.
The Government’s Obesity Pathway Innovation Programme (OPIP) is investing up to £85 million to help ICSs and providers develop innovative, community and primary-care-based pathways.
Our Solution
Graphnet’s Population Health platform brings together primary care and other linked data to identify people who would most benefit from weight management interventions.
The weight management dashboard supports both traditional referral programmes and pharmacotherapy pathways, providing end-to-end visibility of cohorts, eligibility and outcomes across care settings.
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How the Weight Management Service Works
- Unify the data: Ingest primary care and linked datasets into Graphnet’s shared record and analytics platform.
- Apply eligibility logic: Automated cohorting against NHS guidance for Mounjaro alongside criteria for traditional programmes.
- Take action: Generate curated lists for outreach, clinic scheduling, or referral; integrate with waiting lists where required.
- Monitor & learn: Use daily-refreshed measures and outcomes to manage caseloads and evaluate impact over time.
Eligibility Cohorts (aligned to NHS England guidance)
The dashboard assigns individuals into the cohorts defined by NHS England for tirzepatide (Mounjaro) eligibility, enabling phased selection:
- Cohort I: Very high BMI plus 4+ qualifying comorbidities - eligible now
- Cohort II: High BMI plus 4+ qualifying comorbidities - projected 2026
- Cohort III: Very high BMI plus 3+ qualifying comorbidities - projected 2027
- Cohort IV: High BMI; not currently eligible for Mounjaro but suitable for traditional weight management interventions (dietary advice, physical activity, lifestyle education)
Benefits
- Targeted action: Focus resources on the people most likely to benefit, improving outcomes and experience.
- Personalised care: Use population health insights to tailor interventions and support prevention.
- System efficiency: Streamline referral, monitoring and review with joined-up visibility across settings.
- Evaluation built-in: Track uptake, adherence and outcomes to evidence impact and inform future commissioning.
Why Graphnet Health's Weight Management Dashboard?
Graphnet’s population health weight management dashboard delivers the following:
- Case-finding at scale: Identify eligible patients system-wide and at practice level for both pharmacotherapy and traditional pathways.
- Rich patient context: View demographics, qualifying comorbidities, assigned cohort, and pathway status (e.g., Mounjaro initiated/concluded).
- Latest key results: Daily updated BMI, cholesterol, HbA1c and blood pressure to support ongoing monitoring and caseload management.
- Drill-throughs: Access long-term conditions, frailty and medications for safe, informed decision-making.
- Operational visibility: Track patients where treatment has been initiated and link lists to other sources (e.g., waiting lists) to coordinate with wider pathways such as elective care.
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Sources
[1] https://www.gov.uk/government/statistics/update-to-the-obesity-profile-on-fingertips/obesity-profile-short-statistical-commentary-may-2024
[2] https://www.nice.org.uk/guidance/ng246/chapter/Context
[3] https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/obesity-weight-and-cancer/how-does-obesity-cause-cancer
Did You Know?
Obesity costs the NHS £6.5bn annually [2] and is the second biggest preventable cause of cancer in the UK [3]. OPIP is providing up to £85m to stimulate pathway innovation across community and primary care.
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