Population health

Norwich PCN is developing its population health approach through a number of projects and programmes. The IMPACT team first trialled this at the start of 2021 by looking at the population health data of each neighbourhood and identifying specific cohorts of patients with long term conditions using UCLP risk stratification techniques.

The IMPACT team proactive contact patients identified as having a long term condition, but who are not currently engaging with health and care. Each patient is given the opportunity to complete a personalised care and support plan with the care coordinator. Following completion, the care coordinator make referrals to appropriate services and teams. The first cohort for each neighbourhood is expected to be completed by Q4 21/22 with a full evaluation to follow. At the time of writing, tasks sent to practices represent only 9% of total onward referrals made by the team.

To continue to develop our population health management approach, ONP has appointed a BI analyst whose role is to systematically review the at scale services ONP delivers. The data produced with these services can be overlaid with wider datasets shared by local authorities, the CCG and others, to give a fuller picture of our local population.

The PCN is now part of wave 3 of an NHS England population health programme that will deliver two projects: one at neighbourhood scale and one at ‘place’ level. This process will last approximately five months from November 2021 and will include working with system partners from the voluntary sector, community health, local authority and others to develop a comprehensive approach to population health that can be replicated and scaled up as needed by the PCN.