Using data to understand the health of local populations

One of the early priorities identified by the PCC working group was to help local teams use the data available to them to understand particular issues in their communities. We believe this will give our Primary Care Networks a really good basis for integrated ways of working, and in time bring colleagues looking after people across general practice, pharmacy, optometry and dentistry closer together.

Over the last four months a NECS team has worked closely with the PCC to develop and implement a Population Health Management approach to support the development of this integrated neighbourhood working.

We’ve done this by working on a pilot with South Durham Federation and their PCNs, taking the data and analysis they had already done and building on this with some of our population health analytics.

We’ve developed reports such as the Community of 1000 (see illustration), to bring data to life across an Integrated Neighbourhood Team area or PCN.

The analysis was delivered in a workshop style format, and teams were able to understand and discuss the insight. Conversations highlighted population cohorts that may not have been identified previously.

As a result, South Durham are now looking at defining their ‘frequent flyers’ from a joined-up Primary / Secondary and Mental health perspective, and also doing more detailed work with NECS’ support on 111/999, Emergency Department, and In-Patient and Out-Patient activity.

The teams are now considering what they can learn from their data, and what they might be able to put in place for local people using that understanding. They are also considering how they use existing tools such as RAIDR to identify cohorts of patients that could benefit from a more joined-up model of care from a multidisciplinary team.

The PCC have asked the Analytics and Insight team to provide all PCNs across NENC with their own Community of 1000 report and these have now been distributed to Clinical Directors. They make fascinating reading! As part of our work this year we hope to support general practice to use this data to understand their local population and begin to build integrated neighbourhood working with other partners to make a real change to patients’ lives. Coming soon there will be opportunities for other PCNs and Federations to get involved and learn from the South Durham pilot.

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