At the end of 2018 we were selected by NHS England as one of four accelerator sites for Population Health Management, which is running from January to May 2019.

Population Health Management involves understanding our communities better and designing person centred care to support people in living longer, healthier lives. For example, our Primary Care Networks and neighbourhoods are organising personalised care for particular cohorts of people, based on local knowledge of needs and available resources.

We were selected for the accelerated programme based on data connectivity across systems, senior leadership buy in and resources being available to support a 20-week accelerator programme.

This will see us strengthening our capabilities for Population Health Management beyond the 20 weeks.

As part of the programme, we are working with Optum UK, a technology and data provider chosen by NHS England.

What we've been doing

Each of the ICPs was asked to identify one of their neighbourhoods and a cohort of their population to focus on for the programme.

The five neighbourhoods that are involved in this programme are:

• Central Lancs: Chorley Central - focus area: people age 45 to 60 years and who have had more than ten GP appointments in the past 12 months
• Fylde Coast: Blackpool Central West - focus area: mental health
• Morecambe Bay: Barrow - focus area: mental health
• Pennine Lancs: Burnley East - focus area: over 65s with a moderate frailty score (five or six on the Rockwood clinical frailty score). This includes individuals from Daneshouse, Stoneyholme and Burnley Wood 
• West Lancs: Skelmersdale - focus area: Chronic Obstructive Pulmonary Disease (COPD).

Within the neighbourhoods we will look at patient journeys and history of access to health care services to help clinical teams understand what could have been done differently to improve outcomes for patients and enable them to design new models of care. 

At an ICP level we will look at how resources are used, and for this we will look at segmenting our population.

At an integrated care system level there is an intelligence product which provides actuarial data modelling to demonstrate different scenarios for how our population could be using health and care in the future based on current patterns, risk factors and what would happen if new approaches were put in place.

The offer from Optum is to build our Business Intelligence, clinical and Executive / Leadership teams’ capabilities to embed Population Health Management approach and strengthen current systems to support this.

Currently we are hosting learning / coaching workshops to support ICPs through this programme. Our focus for the 20-week programme, is data connectively and how this can help the planning process going forward.

An exciting time for Healthier Lancashire and South Cumbria

Dr Sakthi Karunanithi, Senior Responsible Officer for Population Health for Healthier Lancashire and South Cumbria said: “The success of our Population Health Management programme resides in our ability to understand our communities better and designing person centred care to support people in living longer, healthier lives. It’s taken a huge amount of effort from colleagues working in our neighbourhoods, integrated care partnerships and the integrated care system across Lancashire and South Cumbria to get us to this stage. I would like to take this opportunity to recognise that and thank everyone for helping to further develop our Population Health Management programme. It is an exciting time for Healthier Lancashire and South Cumbria as we look to set up new ways of working and build on our learning during the 20 weeks of the accelerated programme and beyond.”

Watch our video – Population Health Management at a neighbourhood level

Collette Walsh, Interim Deputy Director of Commissioning at East Lancashire CCG on Population Health Management and what this will mean for local people at a neighbourhood level.