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Population Health Management

What are our overall aims by 2028?

Population Health Management (‘PHM’) is embedded as business as usual across our system – meaning that there is a shared understanding of and commitment to PHM as “everyone’s business” across all system partners and PHM is built into strategic planning and decision-making at all levels of the system and across all partners.

We have established digital, data-sharing and leadership capability to enable PHM at all levels of our system.

We have built and developed our analytical capacity and capabilities to support PHM and deliver actionable insights at all levels of the system. 

PHM approaches are being used by our Places and PCNs to design and deliver targeted care, improve population health outcomes and reduce inequalities.

PHM approaches are embedded in contracting and resource allocation within the ICS. 

We have a body of tangible evidence to demonstrate the impact of PHM on population health outcomes and inequalities.


What’s our starting point?

Our Population Health Management Roadmap sets out our local vision for PHM to “empower everyone to live well by joined-up, proactive, data-driven health and care”. The PHM Roadmap outlines the actions that we will take to spread, scale and sustain PHM capabilities across our system, aligned to the four components of the national PHM Maturity Matrix.

We have a PHM Board which engages representation from across partner organisations and provides oversight of the delivery of the PHM Roadmap. The PHM Board reports to our Population Health, Prevention and Inequalities Board, which strategically aligns PHM, prevention, personalised care and health inequalities and wider determinants work. The PHM Board also links to our Digital Transformation Board.

We have made significant progress in implementing a local PHM platform, through which we will ultimately be able to link near-real time data from a range of sources. Key information governance documentation is in place to support PHM activity and data has been on boarded from 40 GP practices.  


What are some of the key links to other parts of the plan?

Personalised Care and Prioritising Prevention and Wider Determinants – PHM enables us to understand population needs at a local level in a holistic way, design more proactive, personalised and preventative models of care and target these to reduce health inequalities. 

Collaboration and Integration – PCNs and Place based Integrated Neighbourhood Teams will play key roles in improving population health at a local level.  Three out of four of our Places and four PCNs have already participated in national Development Programmes which include a focus on PHM.

Digital, Data and Technology – embedding PHM as business as usual is a key objective within our local Digital Transformation Strategy. 

Workforce – a workforce that values and is competent to implement PHM approaches is a key component of embedding PHM in our system. 


What will we be focusing on in the next 2 years?

PHM transformation support – continuing to work with the four PCNs that participated in the national Population Health Development Programme to progress work with their identified population cohorts, including development of targeted interventions and evaluation plans.

PHM transformation support – using linked data to work with two Places and six new PCNs to develop PHM leadership and capability, supported by local analysts.

Analytics transformation support – by September 2023 completing delivery of a series of analytics coaching sessions and action learning sets focused on the use of linked data for PHM; predictive analytics; and evaluation tools and methodologies. 

Analyst Network – launching a digital analyst networking platform to help build a collaborative community of practice within our system.

Continued delivery of PHM Platform – progressing activities across the four workstreams of our PHM Platform Delivery Plan with oversight from a dedicated PHM Platform Delivery Board.

PHM Platform – completing a review to inform, and then agreeing, our future investment and contracting approach by the end of quarter 1 2023/24. 

Development of key dashboards in our PHM platform – releasing our first dashboards on cardiovascular disease and diabetes to support clinical case finding for specific groups such as those with potentially undiagnosed conditions. 

Development of tools in our PHM platform – developing case finding tools to enable users to take a data-led approach to identify cohorts of interest in the population and develop interventions to meet their needs. 

PHM to support planning and decision making – local analysts to support our geographic Care Collaboratives to adopt and evidence how PHM is driving and shaping their programmes of work.

Decision Support Unit (integrated intelligence function) – building on local engagement undertaken to date and taking into account recently published national guidance, developing and implementing a work programme to deliver a local Decision Support Unit.

Communications and engagement – in line with our PHM Communications and Engagement Plan, progressing public and patient and stakeholder engagement activities, including creating an NHS Futures site to enable shared learning, developing a network of PHM Champions across our system, and continuing to develop our dedicated PHM website.

Workforce/Clinical Leadership – embedding PHM in organisational development approaches, core leadership responsibilities and as a core competency for all staff.  Offering coaching and support for Clinical Leads as part of the PHM transformation support offer.  Developing clinical leadership for PHM through our Clinical PHM Fellows.


Key Challenges

Finance – funding for the continued delivery of the PHM data platform requires significant system investment.   

Technical – PHM relies on linked data to understand population needs. Data is held on different systems with no interoperability between them. Linking and standardising this data requires significant resource.

Culture – a paradigm shift from the focus of illness to wellness is required to embed PHM across our health and social care system.

Information Governance  having the right IG in place is paramount as we develop PHM capability, moving from direct care use cases to the ability to use PHM data for secondary uses.

Incentives – Most current funding initiatives rely heavily on performance management financial incentive systems. PHM will require a different funding approach to support proactive care.


Key Metrics and Deliverables

Data on boarded to the PHM Platform from an additional 61 GP Practices across 12 PCNs by end of quarter 1 2023/24.

Acute hospital data on boarded to the PHM Platform from SWFT and GEH by the end of September 2023.

Three out of four Places and ten out of nineteen PCNs have completed a programme of PHM coaching and development support by the end of September 2023.

Analysts across all ICS partners will have received training and coaching on the PHM Platform to support clinical case finding by July 2023.

Initial case finding tools released by end of May 2023.

Ongoing delivery of milestones within PHM Platform Delivery Plan. 

At least one clinical PHM champion identified per Place.

A dedicated Coventry and Warwickshire PHM NHS Futures site to enable sharing of learning between partners.