Population health framework

The organisation works collaboratively across an integrated care system to promote, protect and improve health and support the local community.

Area	Core Principle	Components
Collaboration with partners	The organisation works collaboratively with local organisations across an integrated health and care system to improve health and plan and deliver high value services which meet the needs of the population.	The organisation works collaboratively with system partners including health, social care, public health, voluntary sector, independent sector, academic and community bodies to plan, deliver, monitor and improve services The organisation’s medium and long-term plans are included in plans for the wider integrated care system The organisation’s plans take account of information on local health needs including local joint strategic needs assessments (JSNAs) All services where there are joint/shared responsibilities are reviewed and agreements reached on their planning and delivery including aims, outcomes, resourcing and responsibilities, information sharing and monitoring.
Collaboration with patients, carers and community	The organisation works collaboratively with service users and the wider population to improve health and to plan and deliver high value services which meet the needs of the local population.	The organisation actively encourages and supports the involvement of service users and their carers and community groups in service planning and design The organisation involves service users and their carers and families, and community groups, in service evaluation and in planning the service’s response to the findings

Case studies

Collaborative working improves diagnosis of liver disease

A collaboration between hospital specialists, general practice and public health in Leeds is seeking to diagnose liver disease earlier. Public health data specialists can identify areas within the city with high prevalence of obesity or alcohol consumption where there will be a correspondingly high rate of liver disease. GPs in these areas have access to diagnostic tests to easily identify people who may have advanced disease. People with abnormal results are then reviewed in a liver clinic, run in GP practices by hospital specialists. Over the first six months over 250 people have been tested and 100 of these seen by liver specialists. Thirty cases have shown signs of significant disease and have received further tests of treatment that might not otherwise have been started.

An integrated approach to frailty

The city of Leeds has committed to delivering person-centred, proactive, and coordinated care for people living with frailty through integrated health and care services. Leeds Teaching Hospitals Trust (LTHT) is a core participant in this work. Leaders across the trust are working to align hospital service development to local system strategic priorities for people living with frailty. LTHT public health staff have supported this work by helping to strengthen relationships with partners, promoting more integrated patient pathways, recommending proactive and preventative inpatient services that recognise the multi-dimensional influences on frailty and valuing personal choice for patients. This approach aims to improve local population health and outcomes that matter to people, as well as patient flow, care quality and service sustainability at LTHT.

Case studies

Collaborative working improves diagnosis of liver disease

An integrated approach to frailty

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