Developing our approach to population health management

Population Health Management

1. What is Population Health Management (PHM)?

Our health and care needs are changing, people are living longer in poorer health, with conditions like asthma, diabetes, heart disease and dementia, while our behaviours are increasing our risk of preventable disease.

We want to help healthcare professionals and public services:

• understand patient needs that might have been overlooked
• design better health services
• make better use of public resources
• prevent diseases
• predict future health issues

This is ‘Population Health Management’ (PHM). 

Population Health Management uses patient information to identify local groups of people who have chronic illness or are at risk of ill-health, so that our health and care services can work together to improve the health outcomes of these groups.

 

2. How does PHM work?

Population health management brings together information from local health and care services so that we can understand the needs of our communities. This helps us to spot patterns, identify groups of people who may be at risk of becoming unwell, and design more effective services and support. This could include better medical care, or support with housing or employment, which can also affect health.

Population health management uses data to focus on:

• Understanding different groups: Sorting the population into groups based on their needs.
• Prioritising support: Identifying those who are most at risk of ill health and focusing on them first.
• Targeted actions: Using insights from the data analysis to design personalised care and interventions to prevent illness and provide ongoing support.

This approach ensures that care is proactive, tailored to the people who need it most, and health inequalities are reduced.

 

3. Who does this affect?

Anyone using the health and/or social care service in Herefordshire and Worcestershire will benefit from the PHM approach and be included in the analysis, unless they have opted out.

The main objective of PHM is to support the individual care of a specific population and enable new ways of working, with Primary Care Networks (PCNs) taking the lead in ensuring the wider health of their local population.

By taking this approach, we can manage the health needs of our local population and allocate resources designed to enable prevention of ill health, and best direct care where prevention is not possible.

 

4. What are the benefits of PHM?

The approach can help in multiple ways.

Some areas are using PHM to predict who is at risk of falls and emergency admissions to hospital. They have developed services to improve patients’ mobility and greatly reduce the risk of falls and proactively invite those at risk to attend those services.

Targeted support for communities with poorer outcomes - Reducing health inequalities means giving everyone the same opportunities to lead a healthy life, no matter where they live or who they are. Wider factors, such as poor housing, can have a significant impact on our health and life expectancy. PHM data analysis will enable the ICS to identify population groups experiencing poorer-than-average health access, experience and/or outcomes, and who would benefit from a tailored, inclusive healthcare approach.

Seeing the link between physical and mental health conditions - Many people living with Type 2 Diabetes also have other health conditions, such as depression, anxiety, and hypertension. These other conditions can make it more difficult for individuals to manage their diabetes. PHM data analysis enables health professionals in Herefordshire and Worcestershire ICS to identify the specific needs of individual patients/populations, to improve their quality and experience of care and their clinical outcomes.

Identifying and supporting people with poor housing and poor health - Housing is a key contributor to poor health. Adults and children who live in cold, damp housing may be more likely to develop respiratory problems in the future because their lungs are affected by the mould spores in their home. By jointly analysing health, social care and housing data and finding ‘at risk’ patients, enables social work professionals and wellbeing practitioners to connect with the right groups in the community to address the adverse influences on these people’s lives – offering support with completing housing application forms, helping them to find employment, offering nutritional advice and connecting them with social groups.

Managing unplanned admissions – PHM data analysis enables health professionals to proactively manage the health of their patients who are at high risk of experiencing unplanned hospital admissions. By intervening earlier and taking preventative action can avoid the development of long-term conditions and help to reduce unplanned hospital admissions.

Using data for purposes beyond individual care – Data which is anonymised (which means you can’t identify an individual) will help the ICS to plan and commission services for the people of Herefordshire and Worcestershire.

 

5. How will the PHM technical process work?

Data is collected about your care from the multiple organisations that have provided your care. This will include your GP practice, your hospital(s), ambulance, NHS 111 and out of hours services. It will also include mental health services, talking therapies, and adult social care. None of what you discuss in the privacy of your consultation is shared. Only coded, unidentifiable, non-sensitive data is shared.

The combined data is given a unique code (a pseudonym), and no identifiable information is shared. This is a two-stage process:

1. A unique code is applied to your GP record by a company called Magentus. They are a company registered with NHS England to extract data from general practice systems
2. To ensure that no one can identify who the personal data belongs to, a second stage is carried out by a very small team of staff employed by NHS England

This coded data is then shared with data analysts.

The coded data is used to select groups who may benefit from specific support, such as falls prevention or management of Diabetes etc.  This information helps the teams who organise these services to plan and manage resources.

Specific groups are only ever re-identified by the same NHS England team to the clinician responsible for their care, at the request of the clinician.

 

6. Who will see my information and why?

Your personal health information will be given a unique code, so data analysts won’t be able to identify you as they will only see coded information.

If data analysts, working under the responsibility of clinical colleagues, see that your health information indicates that you might be at a higher risk of developing a disease, they will be able to inform your GP practice who will be able to request that your information is re-identified. This will mean that your GP can then contact you and discuss what preventative steps can be taken to minimise the chance of you developing the disease in the future. 

 

7. What information will they be able to see?

Data analysts, who are working under the responsibility of health and social care professionals, will be able to see appropriate details contained in:

• coded information from your GP practice medical record
• coded information from secondary care, including hospitals
• coded information from your social care record
• coded information from mental health teams and community services
• coded information from the ambulance service, 999, NHS 111 and out of hours services

 

8. Is my information safe?

Yes - there are strict rules around how we use your information. We’ll make sure it’s managed and viewed appropriately and in line with all legal requirements, including UK data protection legislation (UK GDPR and DPA 2018). Official inspections, or audits, will check this is the case.

 

9. Which organisations are involved in the PHM programme?

• GP practices in Herefordshire and Worcestershire
• Herefordshire and Worcestershire Health and Care NHS Trust
• Wye Valley NHS Trust
• Worcestershire Acute Hospitals NHS Trust
• Worcestershire County Council – Social Care
• Herefordshire Council – Social Care
• NHS Midlands and Lancashire CSU (MLCSU)
• Herefordshire and Worcestershire ICB
• West Midlands Ambulance Service
• DHU Healthcare
• Malling Health
• Practice Plus Group
• Taurus Healthcare

 

10. What is the lawful bases for processing personal data which PHM relies on?

We take the sharing of confidential patient information extremely seriously.

There are several legislative frameworks that allow us to collect and share information and the lawful basis is detailed below:

•            Article 6(1) (e) - processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller.

•            Article 9 (2) (h) - processing is necessary for the purposes of preventive or occupational medicine, for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services.

•            DPA 2018 Provision: The processing meets the following provisions set out in Part 1, Schedule 1 (2) of the 2018 Act:

•            Health or social care purposes means the purposes of:

a)           preventive or occupational medicine

b)           medical diagnosis

c)           the provision of health care or treatment

d)           the provision of social care, or the management of healthcare systems or services or social care systems or services.

 

11. Should analysts have access to personal data concerning health?

Yes.

The obligation of professional secrecy under section 11(1) of the 2018 Data Protection Act, makes provision for analysts working under the responsibility of registered health or social work professionals to have access to health/social care data to:

•            stratify and segment data concerning health into specific population cohorts of patients, and to enable health professionals to intervene earlier by identifying and providing targeted support to patients who are at high-risk of experiencing frailty, poorer health outcomes, and long-term health conditions, such as hypertension, atrial fibrillation, high cholesterol, diabetes, asthma and COPD.

 

12. Can data that was originally collected for direct/individual care purposes be used for purposes beyond direct care when pseudonymised?

Yes.

The principles of data protection only apply to any information concerning an identified or identifiable living individual. Where personal data is pseudonymised, the principles of data protection legislation do not apply to personal data (see recital 26 of UK GDPR) which is rendered anonymous. Pseudonymised data can therefore be used for purposes beyond direct care (e.g research and planning).

 

13. What is pseudonymisation of data?

Pseudonymising data protects patients’ privacy, while allowing useful data analysis.

Pseudonymisation is a process which involves using an algorithm to replace personal information in data with a pseudonym, so that individuals cannot be directly identified.

For PHM, the NHS number is replaced with another random number, but that number is unique to the individual so that it is possible to make sense of the care provided to that individual by multiple organisations. All other identifiers, such as name, address, date of birth, are removed from the data.

Pseudonyms do not contain any information which could identify the individual, such as characters from their date of birth. The pseudonymisation keys (which allow the re-identification of an individual) are held by the NHS England team and are not accessible to anyone else.

Pseudonymised data can be restored to its original state with the addition of information which allows individuals to be re-identified. In Herefordshire and Worcestershire, this re-identification process will only be done at the request of a GP by the NHS England team that carried out the pseudonymisation in the first place.

 

14. What steps are taken to ensure the quality of the data?

All partners have effective data quality management processes in place, so that data provided from source systems is accurate and ready for processing.

Each partner organisation will:

• Take all reasonable steps to ensure the quality and accuracy of data in its system(s) (with "accuracy" meaning that the data is correct, complete and up-to-date) which it is sharing, and have in place appropriate systems to update any information if it is subsequently discovered to be inaccurate.

 

15. What happens to anything in my record that might be sensitive?

There are some pieces of information that won’t be available to view, such as visits to sexual health clinics, any fertility treatment records, and gender reassignment records.

A Data Sharing Agreement (DSA) will be in place to make sure this kind of information is not included, in line with legal and statutory requirements and concerns around sensitivity.

 

16. Who runs Population Health Management in Herefordshire and Worcestershire?

The NHS and local councils in Herefordshire and Worcestershire own and are responsible for Population Health Management.

 

17. What is risk stratification?

Risk stratification helps GPs focus interventions on patients who may need extra support.

To conduct risk stratification, national datasets are linked with GP data using the NHS number and an algorithm is applied to produce risk scores. Risk stratification uses algorithms and data analysis to evaluate patient data and identify those at higher risk for conditions, such as diabetes, heart disease, and respiratory issues.

Patient data is initially de-identified using pseudonymisation to protect privacy, but it can be re-identified by the patient’s GP practice if needed for direct care. Pseudonymising data involves replacing an NHS number, a name or an address with a unique number or code (a pseudonym), to protect the privacy of the individual patient.

You will not be personally identifiable to data analysts, nor will any staff have access to your personal or confidential data.

NHS Herefordshire and Worcestershire ensures this process complies with all legal and ethical standards, safeguarding patient confidentiality while allowing for informed clinical decision-making.

 

18. What if I don’t want my information to be shared in this way?

You have a choice about whether you want your confidential patient information to be used in this way. If you are happy with this use of information you do not need to do anything.

If you don’t want your data to be used in this way, you can opt-out by contacting your GP practice.

 

 

 

A Population Health Management pilot involving 12 GP practices across Herefordshire and Worcestershire is currently taking place. This privacy notice relates to the pilot practices.

What is Population Health Management?

Population Health Management (or PHM for short) is aimed at improving the health of an entire population.  It is being implemented across the NHS and this Practice is taking part in Herefordshire and Worcestershire.

PHM is about improving the physical and mental health outcomes and wellbeing of people and making sure that access to services is fair, timely and equal. It helps to reduce the occurrence of ill-health and looks at all the wider factors that affect health and care.

The PHM approach requires health care organisations to work together with communities and partner agencies, for example, GP practices, community service providers, hospitals and other health and social care providers.

These organisations will share and combine information with each other, in order to get a view of health and services for the population in a particular area. This information sharing is subject to robust security arrangements.

 

How will my Personal Data be used?

Information about your health care, which includes personal data, will be combined to create a picture of your health care.

Anything that can identify you will be removed and will be replaced with a unique code, so that people working on that data will only see the code and cannot see any personal data.

This means that the people working with the data will only see the code and cannot see which patient the information relates to.

If we see that an individual might benefit from some additional care or support, we will send the information back to your GP or hospital provider and they will use the code to identify you and offer you relevant services.

Examples of how the information could be used for a number of healthcare related activities, include:

• improving the quality and standards of care provided
• research into the development of new treatments
• preventing illness and diseases
• monitoring safety
• planning services

 

Who will my Personal Data be shared with?

Your GP and other care providers will send the information they hold on their systems to the Midlands and Lancashire Commissioning Support Unit (MLCSU), who are part of NHS England.

NHS Midlands and Lancashire (midlandsandlancashirecsu.nhs.uk) has more information. 

MLCSU will link all the information together. Your GP and other care providers will then review this information and make decisions about the whole population, or particular patients that might need additional support.

MLCSU is legally obliged to protect your information and maintain confidentiality in the same way that your GP or hospital provider is.

 

Is using my Personal Data in this way lawful?

Health and Social Care Providers are permitted by data protection law to use personal information where it is ‘necessary for medical purposes.’ This includes caring for you directly, as well as management of health services more generally.

Some of the work that happens at a national level with your pseudonymised personal information is enabled by other legislation. Sharing and using your information in this way helps to provide better health and care for you, your family and future generations.

Confidential patient information about your health and care is only used like this, where allowed by law, and, unless directly for your care, pseudonymised data is used so that you cannot be identified.

For more information, speak to our Data Protection Officer who will be happy to help with any queries you may have.

 

Can I object to my Personal Data being used as part of the Population Health Management project?

You have a right to object to your personal information being used in this way.  If you do choose to ‘opt out’ please contact our Data Protection Officer at the practice in the first instance.  If you are happy for your personal information to be used as part of this project, then you do not need to do anything further, although you do have the right to change your mind at any time.

You also have a number of other rights relating to how your personal information is used. See our main privacy policy for more information [insert link to practice website].

If you still have concerns, you can also contact the Information Commissioner’s Office directly.

 

Share your views on Population Health Management

Over the past few months, we have started sharing information about Population Health Management and how data is being used.

We want to understand the views of local people and provide an opportunity for feedback.

Please share your views about this new approach to improving healthcare by completing this short survey.

Population Health Management Survey