Population health management (PHM) is as approach aimed at improving the health of a defined population while reducing health inequalities. Improving outcomes in population health is one of the strategic objectives of every ICS, and a key part of NW London’s Research and Innovation Mission to Optimise care of long-term conditions. In primary care, PHM activities include triaging and streaming patients to the right care at the right time, and using data effectively to support identification and proactive treatment of patients.
North West London’s primary care, health equity, and business intelligence teams commissioned ICHP to help answer the challenge of how the sector can best invest in the digital tools and infrastructure required to enable primary care to carry out key population health management functions.
The key project output was an options appraisal for how the NW London system could best proceed with enabling system-wide population health management in primary care.
For primary care staff in North West London, and elsewhere, key enablers for the delivery of population health activities include access to the right intelligence and data at the right time, and the appropriate tools and capabilities to facilitate easy use of that intelligence and data. Despite a wealth of integrated patient data available through Whole Systems Integrated Care, there still exist challenges to getting the data in the hands of frontline primary care staff in a way that’s easy to use – which in many cases means embedded within the electronic patient record (“EPR”) systems they use day to day.
In addition to the several different EPR systems used across primary care practices in NW London, a variety of other digital tools on top of that are commissioned by individual PCNs and Federations to suit their needs – resulting in a complex landscape of digital tools and data.
The key activities ICHP undertook to answer this question were:
Refining the ask: establishing and engaging with a Steering Group of key stakeholders across multiple disciplines (primary care, digital, population health management, business intelligence, and strategy) to build consensus regarding the core needs and objectives; conducting site visits to practices and same-day access hubs in NW London to understand the perspectives of primary care end-users and observe the key processes in focus for the project; interviewing local stakeholders to understand the wider data landscape and related needs of other parts of the system.
Early market engagement: conducting an independent market assessment with our healthcare market intelligence partner HLTH Community; liaising with local procurement teams to liaise on best practice for early engagement with the market; running a supplier showcase to give system stakeholders a feel for what kind of innovative products and functionalities are in the market that could help primary care with its PHM objectives.
Options development: developing a strategic options appraisal structure utilising the learnings gained from the above activities; a value chain laying out the activities relevant for digital systems to support users with; a set of priority use cases suitable for system-wide digital investment; and a set of final recommendations and next steps in partnership with the project Steering Group.
Ways of working
Partnership working: ICHP worked in partnership with key system stakeholders throughout the course of the 4-month project, setting up a fortnightly Task and Finish group to guide delivery, sense-check and challenge proposed plans, and unblock progress. The Task and Finish group was key to connecting the ICHP project team with GPs and practice managers across NW London that would be able to help host site visits.
ICHP also brought in a sense of what SMEs, larger industry providers, and even other internal NHS teams nationally, were working on in this space that could bring value to NW London.
User-centred design principles: The ICHP team drew upon user-centred design methods and principles in designing site visits to observe how frontline staff used digital systems in their natural environments. For example, we asked GPs and care navigators to walk us through an example of how they utilise digital systems to support the process of triaging incoming care requests to the right place, how they utilise the data they have to identify patients at risk and needing proactive intervention, and what opportunities they see for digital tools to make these processes easier. Throughout the length of the project, the entire Steering Group highlighted the importance of being user-centred in our mindset and approach to considering system-wide investment in digital tools where widespread uptake would be critical to success.
The project gave the sector key insights into the current market landscape of digital PHM tools for primary care – which at present includes a range of providers offering innovative solutions, but few that fully integrate with both of the EHRs used daily by primary care staff in NW London, and few all-in-one solutions that can support all of the activities users need to carry out.
The work also surfaced a draft set of key use cases where there is opportunity for sector-wide digital tools to support primary care – for example, solutions to enable use of rich local integrated datasets and predictive modelling capabilities to direct preventative care outreach in primary care in a scalable way.
The Steering Group agreed on a recommendation at the conclusion of the project to consider a blend of options forward that would take into account the needs of distinct user groups, capabilities of existing tools and infrastructure within the system as well as externally, and build future investment around defined use cases and needs.
This short project was a step towards ongoing wider efforts that the NW London system is taking forth to help enable the vision of data-driven, proactive, efficient, high quality patient care at an individual and population level within primary care in line with the report set out by Dr Claire Fuller and with the objectives of Integrated Care Systems – ultimately helping to improve health outcomes and reduce inequalities amongst NW London’s more than 2.4 million residents.
We extend particular thanks to the frontline staff at Hillcrest Surgery; Shakespeare Health Centre; Park Royal Medical Practice; and Healthcare Central London, for welcoming our project colleagues on site and allowing us to gain invaluable insight to inform our project recommendations.
Thanks to the team at HLTH Community for partnering with us to deliver market intelligence and give us a structured understanding of the landscape of tools available to support reactive and proactive care.
We are also grateful for the time and effort of the innovators working in this space for demonstrating their products to our clinicians and system leaders in order to inspire ideas, understand the art of the possible, and help shape our next steps.