It's exciting times in Kent and Medway at the start of 2020 as we look to progress our use of Population Health Management (PHM), especially from the point of view of an acute trust.
Up until now, a lot of the focus of the national PHM programme has been on supporting Primary Care Networks (PCNs) to align their datasets with other parts of the NHS and social care and rethink possible proactive interventions in GP surgeries and the community to prepare them for the PCN contract specifications.
But hospital trusts have just as much responsibility to support the drive to more proactive anticipatory care to ensure the patients coming through the door are treated appropriately.
That's why I've been really keen to establish our trust as one of the first to get population health onto the radar of our analysts and frontline services and re-establish the way we support and provide insight for primary and community care partners.
Hospital trusts have just as much responsibility to support the drive to more proactive anticipatory care to ensure the patients coming through the door are treated appropriately.
Chief Analytical Officer
Already, we've set up a virtual team of analysts, linking them across the integrated care system so they can begin to work better together. We’ve begun the path to ensuring our information governance and security are in place to support the work and we’re starting to think through some of the incredible impacts we can have on individuals' lives.
For example, if a teenage girl is having a baby, the hospital's initial incentive is to ensure the baby is delivered alive and well and goes home. But there is an exciting opportunity to make an even bigger impact, for example helping mum to stop smoking, consider breastfeeding, thinking about her diet and ensure she's healthy and connected to the right local support groups.
Hospitals see hundreds of people at A&E every day and have the physical problem they attended with treated with. Loneliness, mental health problems, coldness, domestic violence and homelessness are just some of the issues that greater cross-working across the system could address.
Hospital trusts have just as much responsibility to support the drive to more proactive anticipatory care to ensure the patients coming through the door are treated appropriately.
Chief Analytical Officer
In Kent and Medway STP we’ve already published our analytic strategy for the region preparing analytics for a future of working towards population health as a goal for the next five years. We’re also excited about getting access during 2020 to the NHSE/I PHM development programme and see how that will galvanise all professionals and parts in the system to get involved and start to think differently.
Tailored care
By working with our local PCNs we can start building into our hospital systems much more tailored care options for individuals. Take for example a man in his 70s with cirrhosis of the liver who has been drinking heavily for 50 years compared to a young woman in her 30s suddenly drinking too much wine to cope with stress.
They might both be seen by the same doctor and given the same leaflet with information about a support group at 2pm on a Wednesday - but they are totally different individuals and need different types of communication and levels of support. We rely too heavily on a one size fits all approach, which actually may be missing the mark with too many people.
We need to be able to process all the information we have about that person - from social care to the GP to the hospital - and know the best option for their care at the touch of a button. We could do this, for example, using an IT system which automatically flags the best-personalised approach based on their history and the linked dataset.
By designing a typology of people we can perfectly tailor what that patient will need, whether that’s a support group in the afternoon for the man who might also be lonely, or an evening group for the young woman who works during the day and needs an evening class. This is just one example, but if it helps that person cope with their problem and avoid additional ill-health and medical needs in the future it simply has to be the right thing to do.
By providing our PCNs and GPs with a live dataset showing which patients are now in the hospital and which don’t need to be there we can work together much more closely to find the right solutions.
Hospital trusts have just as much responsibility to support the drive to more proactive anticipatory care to ensure the patients coming through the door are treated appropriately.
Chief Analytical Officer
And this can be expanded through our wider links. We’ve already begun to join with police and fire services to think creatively and start tackling some of the wider social determinants of ill-health.
A good example is domestic abuse.
By linking police, mental health and hospital data, we could start to build a picture of the severity of situations, previous history and the wider environmental context and explore how to intervene early with the right support and action to avoid any escalation in future.
While not so long ago acute trusts might have been incentivised to see as many patients as possible through payment by results, the advent of ICS’ means we’re far more collaborative now with our neighbouring organisations.
Conversations
Conversations are about the best way to care out of the hospital, not about who gets paid what. Working in this much more flexible space means we can be more confident the patient in the hospital waiting room absolutely must be there – and there are so many more ways to be effective if we all work better together.
The examples above are just the tip of the iceberg, but the potential for increasing our ability to care holistically for patients instead of putting on another sticking plaster and sending them back out into the world is within reach.
It all starts with data sharing and analysis which, when done correctly and safely, will yield us the best outcomes.
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