Population Health Management and Transformation

Dean Holliday, Head of Digital Programmes at Our Healthier South East London [pictured below, right], blogs on what we’re learning from initiatives designed to help health and care professionals to work together to deliver more proactive and equitable care, using data.

Towards the end of 2019, the Our Healthier South East London (OHSEL) team, along with colleagues from King’s Health Partners, applied to be part of the Wave 2 NHS England and Improvement (NHS E & I) Population Health Management Development Programme. This has been delivered by a company called Optum, which specialised in health and care consultancy and change.

The ambition was to use the programme and support to help accelerate the Integrated Care System (ICS) population health and integrated care work.

Our joint team was successful in their application and the programme had been due to start in Spring 2020 but before then there had needed to be some readiness actions. These included:

• Establishing a programme leadership team and oversight.
• Asking for volunteer Primary Care Networks (PCNs), who had the right attributes, team working, leadership and enthusiasm.
• Creating an integrated dataset to support the programme decision making.
• Designing and signing the Information Governance documents to enable data sharing and use.

There was a lot of positive interest from a range of PCNs, GP federations, and established Borough teams across the south east London ICS. This was fantastic to see but led to some difficult decisions as to who to select to participate in the programme. By January 2020, the selections had been made and it was agreed that six PCNs, one from each of our boroughs, would take the programme forward but with wider support and involvement from peers and supporting groups.

2020 – we all know how that played out. The programme had to be paused as a result of the COVID-19 pandemic, all staff had to revert back to their main professional roles or be redeployed to other areas of the system. This was a big setback for the programme, the positive momentum slowed and due to work pressures in some cases slipped away. Some key staff, professional and system leads had to support other priorities. This was necessary as we were in the midst of one of the most challenging times many of us can remember, but all the same disappointing.

Finally, during the summer of 2020, as the situation looked like it was improving, we were able to consider a possible re-start plan from September 2020 but with all meetings running virtually. This was a first for this type of programme and one which seemed a risk given the objectives around building relationships and integrated working. However, before work could really start, we all entered another wave of the COVID-19 pandemic and again the work had to be put on hold for a second time, as professionals focused on the vaccine programme.

What was interesting during this time was the silver lining that shone through the very heavy clouds; the start of ICS wide data sharing and the proactive use of the data support decision making across the system. Professionals and service leads were keen to understand who had been vaccinated and who hadn’t, also what were the factors influencing this. It also helped the ICS to start to make some decisions about how best to engage with people who perhaps were hesitant about having the vaccines.

From the depths of a very difficult time south east London started to use system wide data to affect the care of a population. The seeds of population health management were starting to be sown.

Sadly, the pandemic pressures continued to impact the programme. We lost three of the six borough Primary Care Networks and some strategic leaders and sponsors. However things re-started once again, slowly, in early 2021. People seem to have recognised the power of working together and data driven decision making as a core part of quality improvement. The system level workshops soon became a place where the various workstreams came together to share progress and learning and were well attended.

The final system workshop was on 15 June, nearly 17 months on from the start of a five month programme. Running in to this final workshop there was a lot of reflection about the journey we had been on, the disruption, the changes in leadership, the people that had started but not finished. Would it be a celebration of the learning and development it was planned to be so many months ago. 

Despite all of the ups and downs, it was a celebration. Feedback from the three remaining PCNs and Teams in Bromley, Lambeth and Lewisham was really inspiring. All had formed strong networks of support, worked together and looked at the needs of their population to identify areas for improvement and future support.

A real eye opener because the GPs were able to explore people’s social and non-health needs for the first time, and discuss that with other professionals.

- PCN Clinical Director

The dedicated time to look at the needs of our population and form a plan as to how best to support those needs was really valuable and a necessity.

- PCN Clinical Director

The time allowed us to be more person centred and holistic in the way we deliver care.

- PCN Clinical Director

There is now an emerging south east London Population Health Management programme and a review of analytical capacity and skills. The programme and the COVID-19 pandemic have also helped health and care professionals to accelerate some of the digital and data related work, as a core enabler.

Our ‘Inside Population Health’ series is designed to help staff and students understand the inequalities and inequity in south east London, and what part we can all play to address these challenges.