Tackling health inequalities is a core requirement from Primary Care Networks (PCNs). But to do this effectively, accurate and up-to-date data is required.

Herefordshire and Worcestershire is taking the lead in developing a population health management tool that enables PCNs and practices to drill down into highly specific aspects of data. For example, it can be used to identify the cost of GP contacts and to break down emergency hospital admissions by different age groups, genders, ethnicities and more. It can also display common themes, for example which conditions are most prevalent within certain brackets.

Prior to this, health leaders only tended to know their own organisations, with no wider picture available in terms of what was going on in the population as a whole. The National Contract Direct Enhanced Service (DES), which sets out core requirements and entitlements for PCNs and provides funding and investment, has a particular specification on inequalities. Yet data analysts did not have sufficient flexibility within the information available to them to report accurately and decisions were made on the basis of data that was 12 months out of date or relied upon 2011 census information.

These factors provided the motivation to use data more cleverly and collaboratively across the 15 PCNs in Herefordshire and Worcestershire. 

Conor Price, Chief Analyst for Herefordshire and Worcestershire PCNs, says:

“We didn’t have in-depth information available on inequalities and the wider determinants of wellbeing. However, we realised that if we took data from across general practice we could build it in such a way that it could be used to test hypotheses. For example, to see whether certain health conditions, for example diabetes, were more prevalent in some areas."

The first iteration of the PHM tool, called Priority Finder, required the data team to input data to identify cohorts of patients with particular health conditions who could potentially benefit from additional support. However, it was soon realised that it would be much more useful if teams could play with the tool themselves to get the data they wanted. So, time was spent with each of the 15 PCNs to understand the inequalities they were trying to address, to show them how they could identify the relevant patient cohorts, and then demonstrate how the data could be harvested.

Conor explains:

“Let’s say PCNs wanted to look at patients who had high blood pressure, no GP contact, no recent health check and lived in a deprived area. We were able to show them how to extract the data, the number of patients fitting that criteria and who they are. This meant that they could make contact with these patients to offer support, as appropriate.”

The PHM tool is now interactive and allows users to easily drill down into specific aspects of the 817,000 people who live in Herefordshire and Worcestershire. For example, at a glance, users can see the cost of GP contacts and hospital admissions for different deciles, age groups, genders, ethnicities and more. And within those groups it will also show the average GP contacts and the average medication courses taken. It will also display common themes, for instance which conditions are most prevalent within certain brackets. The data can be repeatedly refined, by adding in additional factors to identify groups that can be targeted with interventions.

One real life example of how the tool has been used can be seen in the South and West Herefordshire PCN. Here the PCN Analyst wanted to look for patients with high BMI, anxiety and depression and no Covid vaccinations. With the help of Primary Care Information Lead, Deborah Humphries, they were able to do this. Identified patients were then contacted with an offer of group sessions to encourage engagement with general practice and to get vaccinated.

In another PCN, the Population Health Management tool was used to identify cohorts of patients who had high levels of contact with GPs. The data was further analysed to focus on patients who have fibromyalgia and a BMI greater than 30. Patients identified via the analysis were contacted and offered a series of education sessions with dietitians, social prescribers, expert patients and Active Herefordshire and Worcestershire. So far, the feedback has been extremely positive with patients reporting that they feel more confident, more active and hence seeking less help from their GP, with obvious cost-saving benefits to their surgeries.

The Herefordshire and Worcestershire Primary Care Analytics Team, led by Conor Price (Chief Analyst), is truly innovative and already attracting the attention of national media. In the past, data that was being used for decision making could be at least 12 months out of date. Now, thanks to the Population Health Management tool, PCNs can access the most up-to-date information to make the best decisions to target specific health inequalities.

The tool will continue to grow and its value increasingly recognised as usage grows. Conor says:

“PCNs are starting to use the tool to find out where they can make an impact. They are looking at inequalities in their area and asking us to build a search around that. The more they use it, the more PCNs are seeing how valuable data is to target specific cohorts, including tackling inequalities.”

 To contact the team, please email: hwpcn.analytics@nhs.net.