Section titled module-2
Chronic pain pilot evaluation
Chronic pain is one of the most common and impactful health problems within our population, yet it is poorly understood and best practice in treatment is not established. A pilot scheme was run to compare a pain management programme against the provision of paid education.
24 patients attended a 1-hour pain education session (PES) followed by an 8-week pain management programme (PMP) and 91 patients attended just the PES followed by signposting to a range of services. We were then able to compare their NHS and medication use using linked population health management data. The PMP group showed significant reductions in medication use, GP appointments, and overall costs compared to the PES group.
Read a public published paper on chronic pain burden in Bristol, North Somerset and South GloucestershireFor more information email bnssg.phm@nhs.net.
Section titled module-3
Dementia deep dive
Dementia is an impactful condition, with a high prevalence (3.2%) in Bristol, North Somerset and South Gloucestershire. We linked data across a range of primary and secondary settings, and described the cohort’s demographics, including age, sex, deprivation, ethnicity, language spoken and geographical spread. We also looked at health conditions and social situations experienced.
Standardised rates showed that Weston Worle & Villages and South Bristol Localities have significantly high rates of dementia. Socioeconomic deprivation is associated with a higher risk of dementia and this disparity increases with age. The Black ethnic group has a significantly high prevalence.
There are very high levels of hypertension, anxiety and depression, and painful conditions in the dementia cohort. Given both the impact of Dementia and the complexity of other conditions our analysis revealed the cohort’s cost to the healthcare system was high (£85.2M over the 3-year period). In addition, people with diagnosed dementia made up 55.3% of people aged 80+ on a complex discharge from hospital, and 19.7% of all mental health sections for those aged 60+. This work has been used to suggest improvements to the way Bristol, North Somerset and South Gloucestershire commissions and delivers care for those with Dementia.
For more information email bnssg.phm@nhs.net
Section titled module-4
Piloting an integrated digital care pathway for patients living with COPD
The patient cohort was targeted using PHM approaches to those with high levels of co-morbidities (average 4, median 6 LTCs) and highest utilisation of healthcare services across Bristol, North Somerset and South Gloucestershire, including high volumes of non-elective admissions and emergency attendances. The cohort is associated with higher levels of deprivation (16% are IMD decile 1 and 25% fall into the ONS population segment of “hard pressed communities”), are relatively older (average age is 74) and have high smoking rates.
- There were three groups of intervention:
- Tier 1 and 2 – provided with access to the Mymhealth suite of apps
- Tier 3 – received support and monitoring by Doccla, alongside access to the Mymhealth suite of apps
- Tier 4 – received support from Sirona, as well as monitoring by Doccla, and access to the Mymhealth suite of apps
During the trial period, the Tier 3 and 4 patient cohort saw notably lower ED attendance and ambulance conveyances than the comparison group. The Tier 3 and 4 patient group saw a slightly greater decrease in number of GP appointments than the comparison group, but a far higher increase in the number of relevant prescriptions (indicating additional work for GPs and pharmacists).
Taken altogether, this suggests that intensive community-based monitoring in the way it has been administered here is too expensive to return a reasonable ROI in terms of system benefit, at a minimum during this time period, if not at all.
Section titled module-5
The Impact of Drug and Alcohol Related Harm on Bristol, North Somerset and South Gloucestershire
The purpose of this report was to examine the harm and impact of drug and alcohol dependency on the Bristol, North Somerset and South Gloucestershire population.
The data shows that individuals with drug/alcohol dependency use healthcare services more frequently than the non-dependent population and when they are admitted to hospital the stay tends to be more costly on average. The average cost per year of non-elective admissions for individuals with drug/alcohol dependency is £1431, compared with £188 in the non-dependent cohort. And drug/alcohol harm is higher in areas of greater deprivation.
Drug/alcohol dependent patients may access their GP 3 times more than the non-dependent population, A&E 6 times more often, and use 999 services 16 times more often.
As well as being more likely to suffer from the many medical conditions caused by harmful drug/alcohol use, dependent individuals may need to access healthcare for management of injuries or complications caused by their substance use. The analysis also revealed it can be more difficult for drug/alcohol dependent individuals to attend routine appointments due to the often-inflexible nature of healthcare appointments. And that although mental health conditions were common in the population, only a small proportion (1.57%) are in AWP treatment service.
While these findings are not necessarily a surprise, they provide a powerful way to quantify the impact of a lack of joined up work. This work has been used to make the case for greater investment in co-ordinated and flexible activity in the community to provide the support these people need, and also reduce overall healthcare utilisation.
Section titled module-6
Self-harm in Bristol, North Somerset and South Gloucestershire
A report by the Office for Health Improvement and Disparities found that the South West has the second highest rate of emergency admissions for intentional self-harm in England, as well as the highest rate of repeat emergency admissions for this issue nationally.
This population health management (PHM) project was led by Public Health and developed in collaboration with the Integrated Care Board (ICB), Bristol Health Partners, clinical and academic researchers, and experts in self-harm across Bristol, North Somerset, and South Gloucestershire.
The project produced a data profile that outlines key characteristics and various risk factors among children and young people aged 10 to 24 across Bristol, North Somerset and South Gloucestershire who presented to Emergency Departments or were admitted due to self-harm over a four-year period. This information aimed to help system partners understand this issue in greater detail and enable targeted interventions and actions to address self-harm effectively.
This work has contributed to North Somerset’s Mental Health Strategy, supported the work of the Self-harm Matters Health Integration Team at Bristol Health partners and was shared at a regional conference on self-harm by the Office for Health Improvement and Disparities. This work also resulted in the inclusion of North Somerset in the NIHR 4S study to develop self-harm and suicide postvention initiatives in education and school settings.
Section titled module-7
Population Health Management (PHM) to identify and characterise ongoing health need for high-risk individuals shielded from Covid-19
This project sought to understand the key personal attributes that characterise the ‘high risk’ patients requiring Covid-19 shielding. Six distinct segments of individuals were found to constitute this population.
Lead: Dr Charlie Kenward
A comparison of population segmentation methods
This project involved an objective side-by-side comparison of analytical methods that can be used to segment a population. This has enabled a deeper understanding of variation in health needs and the different ways in which individuals interact with healthcare services.
Read A Comparison of Population Segmentation
Lead: Dr Richard Wood
Population Health Management (PHM) Initial Insights
This project provided a first glance into the range of descriptive information and insights that could be derived from the Bristol, North Somerset and South Gloucestershire System-wide Dataset.
Lead: Dr Adrian Pratt