Knowledge hub
Contents
- Knowledge hub
- System outcomes framework
- Population Health Intelligence
- Population Health Management
- Research, evidence and evaluation
Contents
Population Health Management (PHM) is the way we work together to understand and improve the health of people and communities using joined-up health and social care records.
A core objective for our Integrated Care System is improving population health. By this we mean improving health outcomes, promoting wellbeing, and reducing inequalities across our entire population. Population health management is one of the key enablers for achieving this.
We bring together records from General Practice, hospitals, mental health providers, community services, social care, and other sources. This helps us build a better understanding of people’s health, the circumstances in which they live, their needs, and the type of care they receive.
We use this data, alongside other valuable sources of information such as from our citizens through surveys and focus groups or research evidence, to develop ’actionable insights’ – i.e. something we can use to make a positive change.
The Bristol, North Somerset and South Gloucestershire system-wide dataset is a patient-level dataset that links together information across Primary Care, Secondary Care, Mental Health and Community Services for everyone in our region (who have not opted out).
The dataset consists of two tables – attributes and activity. The first table contains information regarding patient characteristics, such as demographic information (age and sex), clinical information (long term conditions), socio-economic information (deprivation index) as well as other data like smoking status and social status. The second table contains information regarding patient contacts such as point of delivery (e.g. secondary care, inpatient, elective), specialty (e.g. dermatology), provider, dates, times and cost.
This dataset is a key enabler to furthering insight-driven and value-based healthcare across Bristol, North Somerset, and South Gloucestershire.
By linking data we can understand more about how people with different needs interact with the various healthcare services, and identify opportunities to improve and better co-ordinate the delivery of healthcare across our region.
Current Projects using the Bristol, North Somerset and South Gloucestershire Dataset Completed projects using the Bristol, North Somerset and South Gloucestershire system-wide dataset System-wide dataset guideFor more information about the Bristol, North Somerset and South Gloucestershire system-wide dataset contact bnssg.analytics@nhs.net.
To read more on this topic from Dr Richard Wood, head of Modelling and Analytics, NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board (ICB), please see Richard’s most recent blog post.
Here are some examples of how we have been using Population Health Management to improve the health and wellbeing of our population.
Linett was part of a group of 100 people living in Bristol Inner City who were identified as being at risk of heart failure. Linett and the group were offered a range of support options. This included attending a Healthy Hearts group, where people met with specialists and peers to discuss health issues and find personalised solutions. Through this group, support from a nurse, a dietician, a physio, and a social prescriber was provided.
More information about this case study can be found on the NHS England website.
Dr Charlie Kenward explains how population health management was used during the Covid-19 pandemic.