The holistic view provided by population health management systems will be crucial to local NHS and care services if they are to transform effectively to meet the new demands over the coming years. Brian Waters explains more 

The need for real-time health and care information at the local level has never been more pressing. Health economies with rich sources of live data are already able to analyse covid-19 infections and deaths in their area by ethnicity, underlying conditions, deprivation, population density, size of household and so on. This isn’t simply an academic epidemiological exercise, it is informing their local preparations for any future peaks, for the reintroduction of services and for the care of specific groups of patients.

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In each locality there is an extremely complex picture of service change due to covid-19 – all with a major impact on the health of local populations. As non-covid services are resumed, local commissioners, service providers and clinicians are looking to understand the full extent of unmet need, who and what to prioritise and how to sort and manage elective waiting lists. They will also want to cement redesigned and improved services (virtual consultations being an obvious example). None of this can be understood centrally. Comprehensive, local and real-time data, combined with population health tools, are required to inform this work.

Seismic changes in services require local, real-time information

Local NHS and care services already have some of the necessary information. However, the challenge is making sure that information is comprehensive, easily accessible by the people who need it, and up to date. We are seeing seismic changes in services: ED attendances are down 29 per cent from the same period in 2019, with significant reductions in patients presenting with strokes and cardiac emergencies. GP appointments fell 30 per cent in March. Events are moving too fast for anything other than real-time or near real-time data to be of any real use.

Shared record systems assemble real-time and near real-time information from across multiple sources – including OOHs, 111, ambulance, GP, acute, community, mental health, social care services and care homes. The real operational benefits of these shared record systems include large reductions in cross-provider requests for patient information, real-time flags about a patient’s covid-19 status, and quality of care enhancements leading to reduced ED attendances, emergency admissions and length of stay.

Population health management systems take this information, bring in other relevant data – wider determinants, Acorn, SUS, ethnicity, deprivation and so on, anonymise it, and provide the tools needed for local analysis and planning. Commissioners can identify areas or cohorts of patients requiring focus because they are disproportionately impacted – either directly or indirectly – by covid-19.

Building case lists for targeted, proactive care

Primary care networks can use case finding tools to compile lists of high-risk patients for assessment and proactive care when services are restored. One care community is looking at targeting severely frail patients with recent ED attendances as a manageable caseload for GPs to engage with proactively and build care plans for.

And despite the huge pressures at the personal and the system level, health and care leaders are talking in terms of a new opportunity to deliver service transformation. Positives have come out of the current situation, including a new spirit of innovation and increased co-operation. We’ve also seen the art of the possible in terms of digital projects. Health economies across the country are starting to use population health management systems to assemble and manage their data. Under accelerated covid-19 conditions, systems that used to take six to 12 months to build are now being developed in weeks.

The holistic view across a whole health economy provided by these population health management systems is going to be crucial to local NHS and care services if they are to transform services effectively to meet the new demands over the coming years.

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