A new approach to population health planning and collaboration in health systems is required to tackle health inequalities – and data is the key vehicle for social change, says David Sharp

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The devastating impact of covid-19 on health inequalities has led to calls for greater investment in the equitable prevention of illness and introducing standards for healthy living. It also highlights the need for communities to be involved in the design and delivery of interventions to support their health and wellbeing.

Providing local health systems with a better understanding of the population health issues driving health inequalities is essential to help NHS executives decide how best to plan and manage resources in collaboration with local authorities, as well as where to focus funding on prevention. We know that a deep understanding of community health, social deprivation and the social determinants of lifespan and wellbeing are key to generating new insights into designing and planning health and care services.

Data-driven insights are within reach; collecting and analysing complex demographic and patient datasets across local authority, primary, secondary and community care begins the journey towards longitudinal data – a critical stepping stone in building more resilient communities and more targeted health interventions. To make in-roads into the national agenda towards levelling-out health inequalities, we need to get smart and agile about using deep data to plan, manage and target health services during the pandemic, and deal with its long-term consequences.

Analysing this rich data can provide an overall picture of adverse health deterioration, revealing streets, towns and boroughs where health inequalities are greatest and allowing for detailed analysis into their causes. This insight informs decisions for implementing future services – how to access the hard-to-reach; how best to use mobile clinics; how to plan outpatient services – while also providing the framework to integrate other services such as housing and councils to create an overarching community plan to tackle health inequalities.

From a resource perspective, population health management also enables us to see which cohorts of patients are accessing health and care more than others. By comparing different segments of the population in this way, we can provide a platform to start predicting and planning for the way services might need to change to improve patient experience and outcomes.

We need to get smart and agile about using deep data to plan, manage and target health services during the pandemic, and deal with its long-term consequences

On the supplier side, analytics and data companies with a desire to help eliminate health inequalities must do three things: They must eliminate structural bias in data, they have to find the missing data that hides the inequalities from sight, and they have to ensure that the analytical teams have the ability to communicate clearly where in amongst data about overall improvement in population health, people are being left behind.

As an example, take Telstra Health UK’s patient risk stratification work in primary care. The programme, created with Lambeth GP Federation, is being used to create real change at primary care level, where the GP Federation is using its data to assess the levels of risk within identified cohorts across their population, and enable GPs to predict and proactively manage these cohorts’ care needs. Telstra Health UK is also working with Lambeth to determine its burden of care and associated spend across the system.

This approach is helping GP Federations find patients with the highest risk of hospital admissions so that they can receive the most appropriate care interventions at home or in their preferred setting. It has been replicated in Bradford where the clinical commissioning group used the Dr Foster platform to identify patients who most use emergency care and who would be better treated in the community. Crucially, this work also gives primary care providers the tools that they need to ensure that no patient or citizen falls through the cracks, and that all members of the community have equitable access to care, treatment and outcomes.

Dr Foster is now Telstra Health UK, part of the Telstra family. In Australia, Telstra Health has deployed its Communicare platform, a fully integrated patient solution for community health services, to make a significant difference to the health and care of Aboriginal and Torres Strait Islander organisations who deal with complex care needs in Indigenous and remote communities. The programme has helped the South Coast Medical Service Aboriginal Corporation to streamline its processes including data collection and reporting for better planning and care provision.

Combining the expertise of Telstra Health UK and Telstra creates a powerful vehicle for social change that goes beyond health and care. Solving the challenge of eliminating health inequalities is complex and multidirectional, and population health management – rooted in data, analysis and scalable platforms – will be the key to turning ambitions into outcomes and improving the health of the whole nation.