Getting to grips with Population Health - 28th Feb 2018

Getting to grips with
Population Health
Holiday Inn, Maidenhead
Wednesday 28 February 2018
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In Browser – select
“Complimentary”

Welcome
Dr Shahed Ahmad
Medical Director
NHS England South Central

Welcome
Birmingham
Southampton
Oxford
LondonBristol
Heathrow
Gloucester

In general outcomes are good –
important work still to do
• Over 480,000 people smoke.
26,000 hospital admissions due to smoking
• Over 1.8 million people are overweight
• About half a million people have uncontrolled hypertension
• 175,000 people with diabetes. Over £400m.
Over £300m spent on complications of diabetes
• At least 50,000 more people with diabetes by 2035.
£125million additional costs. £100 million on complications
• Over 27,000 people with undiagnosed atrial fibrillation
• 140 infant deaths per year
• Over 250 suicides per year

Previous gatherings
• Genomics
• Digital
• Clinical Leadership development
• Patients and clinicians leading together
• Narrowing the life expectancy gap
• Clinical Effectiveness Group, Q initiative
• Empowering people
• Weight management in primary care
• Diabetes management
• Ebola management
• Hypertension; AF, Thrombectomy

Today
• AOs asked us to help develop thinking on
population health management
• Why us?

Public
Health
England
Local
Authority
AHSN
Academia
Innovation
Patients
& carers
Healthwatch
Provider
TrustsCommunity
Acute Mental
Health
NHS
England
Health
Education
England
Leadership
Academy
Thames
Valley
Clinical
Senate
Strategic
Programmes
AssuranceNational
Clinical
Leadership
Specialised
Commissioning
Charities
3rd sector
Sustainability &
Transformation
Partnerships
(STP)
Urgent &
Emergency
Care
Professional
Bodies
LMC
LDC
LOC
Primary
Care
Dentistry
General
Practice
Optometry
Pharmacy
Royal
Colleges
South Central
Leadership Forum
NHS England
South Central
Medical
Directorate
Our relationships

Why is population health important

Your definition of population
health management

Thanks
• To team who have organised today
• To speakers and chairs who have given up their
time
• To all delegates who have taken time out of your
busy schedules . We have a much broader group
of delegates than had originally signed up and
that should lead to us developing better
solutions.

My hopes
• I better understand the breadth of thinking about
population health management
• The information presented today and the
connections made today, help us as a system to
accelerate the development of population health
management systems.

Welcome from Session Chair
Will Hancock, Chief Executive -
South Central Ambulance
Service

Population Health –
the Public Health imperative
Julian Brookes, Deputy Chief Operating Officer –
Public Health England
Dr. Shakiba Habibula,
Consultant in Public Health -
Buckinghamshire County
Council

Population Health – The Public
Health Imperative
Julian Brookes
Deputy Chief Operating Officer at Public Health England

In general
16 Health Prevention and Specialised Services

19
Three myths about
prevention
Health Prevention and Specialised Services

20
It takes a long time
to get a pay back
Smoke-free legislation and hospitalizations for acute coronary syndrome. (2008)
Pell JP1, Haw S, Cobbe S, Newby DE, Pell AC, Fischbacher C, McConnachie A,
Pringle S, Murdoch D, Dunn F, Oldroyd K, Macintyre P, O'Rourke B, Borland W.
http://www.ncbi.nlm.nih.gov/pubmed/18669427

21
Prevention can’t save the
NHS money
It has been estimated that the main
areas listed could save over £400m net
over five years. More evidence in PHE
Menu of Interventions
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/565944/
Local_health_and_care_planning_menu_of_preventative_interventions.pdf

22
Health & wellbeing gap is
improving
In fact the gap between healthy life expectancy and life expectancy
is increasing

24
If AF registers across the South matched the
performance of the practices in Ashford CCG
(the best in the South) then 94,276 more
people would be on AF registers. If all were
then anti-coagulated, this would result in 3,771
fewer people suffering a stroke. £135
million pounds of net savings in health
and care costs every year by year 5
The potential gain in
the South: AF and stroke

25
If the rate of detection and control of
hypertension in the South of
England matched that of Canada
8,925 strokes and 3,971 heart
attacks could be prevented over
5 years. With potential costs
avoided of almost £240 million
the South: hypertension

26
An extra 49,620 people known to
primary care could achieve the 3
Treatment Targets if they matched
the rates seen in Chiltern CCG
(best CCG in the South). This
would make a significant impact
on the complications and costs
associated with diabetes. 80% of
NHS spending on diabetes goes
on managing these complications
– heart disease and stroke, kidney
failure, amputations and blindness
the South: diabetes

Morbidity in England
• Between 1990-2013, life expectancy in England increased
from 75.9 to 81.3 years (one of the biggest increases in
EU15+ countries); mainly due to falls in the death rate from
CVD, stroke, COPD and some cancers.
• So, as a population we’re living longer but spending more
years in ill-health. For several conditions, although death
rates have declined, the overall health burden is increasing.
• For example, deaths rates from diabetes fell by 56%, but illness and
disability associated with diabetes went up 75%.
• Sickness and chronic disability are now causing a much greater
proportion of the burden of disease
• Low back and neck pain is now the leading cause of overall disease
burden.
Source: Global Burden of Disease
27

Potential Contribution of Prevention
• Cancer Research UK have estimated that 42% of cancers in the UK are preventable
• 80% of NHS spending on diabetes is incurred in treating potentially avoidable
complications
• In more than 90% of cases, the risk of a first heart attack is related to at least one of
nine potentially modifiable risk factors
• Two thirds of premature deaths could be avoided through improved prevention, earlier
detection and better treatment
• It is estimated that if Atrial Fibrillation was adequately treated, around 7,000 strokes
would be prevented and 2,100 lives saved every year
• The National Audit Office suggest that 47% of type 2 diabetes cases in England can
be attributed to obesity
• Despite reductions in levels of smoking 17% of deaths in adults over 35 are
attributable to smoking
28

Delivering Prevention
A comprehensive approach to prevention should: -
• include a suite of activities at primary, secondary and tertiary levels
• follow a Life Course approach
• take a population perspective
• Maximise the prevention potential at each stage of the disease
pathway
National prevention priorities include (NHS 5YFV)
• tackling obesity, smoking and harmful drinking
• ensuring that children get the best start in life
• reducing the risk of dementia through tackling lifestyle risks
29

‘How to Guides’
Prevention Guide: Success in 2020
• Targeted advice tackling unhealthy behaviours is provided at the point of care
 Address high-risk drinkers and emergency admissions
 Screen and refer patients to stop smoking services
• A healthier environment is created by health and care providers and local employers
 Encourage a healthy diet and improve weight management services
 Support people to remain or get back in work
• Improved patient pathway, from early action to better management
 Improve detection rates and management of high blood pressure, high cholesterol, atrial
fibrillation and raised blood glucose
 Identify patients at risk of first or repeat falls and provide preventative support so they remain
healthy
Prevention elements in other Guides for example Primary Care; Learning
Disabilities; Mental Health; Cancer; Finance etc..
30

17
Are you seeking data relating to
healthcare?
Is there a health profile relating to
what you are seeking on the PHE
Fingertips platform?
Have you tried the PHE Data and
Knowledge Gateway?
Are you looking for data relating
to infectious disease rates or
vaccine coverage?
Have you checked local sources
of data such as the JSNA?
JSNAs are a rich source of local data. Many local areas also have their own observatory
sites which provide a range of health data.
Fingertips is an online platform for publishing data developed by PHE. The PHOF and an
increasing number of profiles are delivered via this platform, link.
The PHE Data and Knowledge Gateway brings together non-communicable health
profiles and data resources across PHE, some 110 in total, link.
PHE health protection resources have a dedicated portal with information on a range of
common diseases as well as on vaccine uptake, link.
NHS England collects and publishes a range of data relating to healthcare activity,
performance and outcomes, link.
This site will include key data that NHS England uses to conduct its core business, link.
Data and Intelligence Tools
Have you looked at the NHS
England Data Catalogue?
Are you interested in
understanding how local services
compare to elsewhere?
NHS Right Care publishes a range of resources designed to help commissioners and
providers understand variation in health and healthcare and aims to maximise value from
the health system, link.
Have you looked at ONS or
HSCIC?
The Health and Social Care Information Centre (HSCIC) and ONS collect, analyse and
present a range of data, including on population (births, deaths and census), the economy
and health, link.
1
2
3
4
5
6
7
8

Opportunities: Improving productivity
32
Tool Link
NHS Atlas of Variation in
Healthcare http://www.rightcare.nhs.uk/index.php/atlas/nhs-atlas-
of-variation-in-healthcare-2015/NHS Atlas of Variation 2015
Opportunities Locator
Commissioning for Value
online tool
http://ccgtools.england.nhs.uk/cfv/flash/atlas.html
Pathways on a Page packs
https://www.england.nhs.uk/resources/resources-for-
ccgs/comm-for-value/#icpIntegrated Care Pathways
pack
Spend and Outcomes Tool
(SPOT)
http://www.yhpho.org.uk/default.aspx?RID=49488

Population Health Management in
Buckinghamshire: From Theory to
Practice – The story so far
Dr Shakiba Habibula, Consultant in Public Health
Buckinghamshire County Council

34Your community, Your care : Developing Buckinghamshire together
What do we mean by Population Health Management?
A process which takes a defined population, analyses its needs in detail
and as a result develops services tailored to that specific population. It is a
journey rather than a destination and the specific services/initiatives
which result, will be unique to each population group/locality.
This aims to achieve:
 a healthier population
 better managed long term conditions and fewer unplanned and
emergency admissions
 lower cost
 Innovative combinations of existing services and the development of
new services
 an integrated health and social care service which has prevention at its
heart.

Our Vision and Objectives for PHM:
Our vision for PHM is to:
A. achieve parity of esteem for prevention,
B. improve the health and wellbeing of our residents and
C. reduce clinical and financial risks to the system.
Our specific objectives are:
• To better understand our population’s health status and needs for care
• To strengthen the focus on wellbeing and prevention and close the health
inequalities gap faster
• To ensure a systematic approach to engaging patients in managing their health
more effectively
• To ensure patients have timely access to comprehensive care and coordination
among health and social care providers
• To forge a partnership between health, social care and community and voluntary
organisations and service users for the benefit of the population’s health and
financial sustainability

Our approach:
• Population segmentation into groups of people with similar needs
• Risk stratification to determine where needs are concentrated most
We will use risk stratification for the following purposes:
• To ‘case find’ those individuals most at risk of an adverse event
• For population health planning and commissioning / design of care pathways etc
Our Priorities for 18/19:
• Multi-morbidity
• Frailty
• Supporting Primary Care transformation programmes
• Supporting Community Services transformation programmes

Supporting Programmes:
1. Integrated Healthy Lifestyle Services , Prevention@Scale, the Diabetes
Prevention Programme & NHS Health Checks, screening programmes
2. Care and Support Planning for people with LTCs
3. Primary Care Transformation Programme – GP clustering
4. Bucks Out of Hospital Care
 Locality Integrated Teams (LITs)
 Rapid Response Intermediate Care (RRIC)
 Community Care Coordinator
 Community Hubs
5. Digital Transformation Programme
6. Community Development Initiatives (Primary Care Navigators, Community Link
Officers, Community Prevention Services/Social Prescribing)
7. Adult Social Care Transformation Programme
Our Model of Care for Complex Patients:
Integrated Personal Commissioning (IPC) : Delivered through enhanced MTD
within Care Coordination Hubs in primary care bringing different specialties together.

Integrated Personal Commissioning (IPC) :
5 key changes that are required:
1. Proactive coordination of care
 Population segmentation
 Tailored information and advice & advocacy offer
2. Community Capacity and Peer Support
 Asset based approach
 Systematic use of peer support
 Strategic approach to community capacity building
3. Personalised Care and Support Planning
1. Understanding patients’ activation
2. Multidisciplinary Team (MDT)
4. Choice and Control
 Integrated budget setting
 Different personal budget options (Direct payment, 3rd Party)
5. Personalised Commissioning and Payment
 Unlocking funding from block contracts
 Individual service funds

Progress to date:
• Initial scoping work on the capabilities of population health management
• Developing links with other sites implementing PHM
• PHM Steering group established
• Priority areas for PHM agreed (Frailty and Multiple morbidity)
• 5 PHM Task and Finish Groups (TAFG) have been set up to undertake initial PHM
readiness assessments for the implementation of PHM
1. Data Systems
2. Analytical Tools
3. Dissemination Translation of data/information
4. Transformation of Services
5. Outcomes
• All TAFG have met and completed the tasks:
• An initial mapping/review of data systems and analytical capabilities
• Identified early opportunities with current systems
• An initial mapping and gap analysis of prevention and self-care services
• Identified areas for further development and investment

Next Steps:
• Priority areas for investment will need to be agreed by ICS
• Business cases will be developed and presented to the Integrated Care
System (ICS) Executive Group
• Delivery of first analytics outputs for early priority areas
• Ensure data systems and analytical capabilities are strengthened
• Identify and agree disease specific priorities for pathway analysis
• New models of care for priority groups will be developed and agreed
• Ensure PHM is aligned with the Adult Social Care Transformation
workstream
• Continue to support Primary Care Transformation
• Continue to support the development of Bucks community integrated
teams
• Move towards a gradual implementation of IPC

Healthy New Towns:
A population based approach
Dr. Rosie Rowe –
Bicester Healthy New Towns
Programme Director

Bicester Healthy New Town Programme
Promoting Population Health through Healthy Place making
Dr Rosie Rowe, Bicester HNT Programme Director

The implications of growth 2015-30
INCREASING
CHRONIC
DISEASE
INCREASING
INCREASING
BIRTHS FROM
GROWING
POPULATIONS
INCREASING
POPULATION
AGE
Oxfordshire’s population
is due to grow by
27%,
the number of people aged
85+ is due to increase by
92%.
The number of people with
long term conditions is due
to increase by 32%

NHS Healthy
New Towns
Programme

• To shape new towns, neighbourhoods and
communities to promote health and
wellbeing, prevent illness and keep people
independent;
• To radically rethink delivery of health and
care services, supporting learning about
new models of deeply integrated care
• To spread learning and good practice to
other local areas and other national
programmes
The Healthy New Towns Programme has three key objectives
Healthandwellbeing
benefits
Time (Years)
Potential
additional
impact
Current
good
practice

Growing Bicester: a place based approach
1 NW Bicester 6000
1 Elmsbrook 393 (90 homes
complete)
2 Graven Hill 1900
SW Bicester Phase 1 1742(600 homes
complete)
3 SW Bicester Phase 2 726
12 SE Bicester 1500
Rest of Bicester 30,845

Bicester Healthy New Town Programme:
Key Features:
• A population based approach to prevention
• Co-production with local people so that innovations
are based on insights into their needs
• Adding value by building on existing assets and
partnerships
• System-wide approach that breaks down silos
• No organisational restructuring
49

Healthy Place Making requires a whole systems approach

Bicester Healthy New Town Partnership

Programme Development: Objective Setting
Stage 1
Expert workshops:
What are the key health and care challenges
faced by the current and future population of
Bicester?
What is the theoretical framework for selecting
interventions?
What is the evidence base for potential
interventions?
Stage 2
Community engagement to:
• agree direction
• identify local assets that we can build on to
achieve our objectives
• Secure support for delivery

Two key priorities:
• To increase the number of children and adults
who are physically active and a healthy weight.
• To reduce the number of people who feel
socially isolated or lonely in order to improve
their mental wellbeing
Programme Objectives

1. Bicester’s built environment
- making best use of the built environment to encourage healthy living
2. Community Activation
– enabling local people to live healthier lives, with the support of local
community groups, families and schools, and employers
3. Health and care services
- delivering new models of care that are focused on prevention and care
closer to home which minimise hospital based care
Programme Work Streams

Transformation of relations between built environment and health professionals
Outcomes:
• Standards that create health promoting environments
are being developed for local planning policies
• Planners now understand new models of care
and need for an NHS estate that can provide it
• A coordinated ‘ask’ for health services from S106 funds
Built Environment – creating policy that supports healthy living

The built environment is supporting healthier lifestyles
Outcomes:
• Early provision of community assets is
supporting social connections
• Digital innovation is addressing social isolation
• The built environment is acting to nudge
residents to be active
Built Environment - creating an enabling environment

• Built environment nudge to make walking part of daily routines
• This project delivers marked routes that are safe and accessible
• Developed with community engagement
• Supported by ‘Health Walk’ programme
• There is no cost to participation
• Suitable for a wide range of ages,
at any time of the day
Neighbourhood Health Routes
‘Bicester’s Blue Line’

On the Bicester West HR, the daily average footfall prior to
installation of the Health Route was 557 people: this increased
to 708 (a 27% increase)
• The social media reach of messaging about the
installation of the routes was in excess of 50,000
people.
• The Facebook post pictured reached over 17,000
people (140 ‘likes’ in the first 8 hours, and over
60 comments.)

• Local stakeholders working together to deliver the programme in their
organisations and across business, education, and voluntary sectors
• Targeting the population to change behaviour at ‘Trigger Events’:
- retirement/moving house/starting school/nursery
Outcomes:
• Local leaders ‘own’ the programme and are willing to
commit time and resources to support behaviour change
• Community capacity and social capital are increasing as
the programme supports cross sectoral working
• Senior leadership support is
ensuring a ‘whole school’ /
whole business approach
Community Activation - delivery

New models of care enabled through use of technology are being
developed and tested with Bicester acting as a ‘demonstrator site’
Outcomes:
• Improved use of health resources: Digitally enabled, enhanced
local Long Term Condition Management
• Improved health and wellbeing: working with the third sector
and social media
• Improved access to services: Development of sustainable
and enhanced primary care fit to meet the needs
of the growing population
• Workforce Transformation: Integrated training programme
for support workers
Health care remodelling

How will we know if the HNT programme is working and what elements
should be spread?
Outcomes:
• Potential metrics are wide ranging
• Rapid cycle evaluation with feedback loops is already informing the
programme
• Aim to identify the ‘active ingredients’ that could be applied to other
populations and places
• National Guidance planned for 2019
Evaluation

• HNT is a catalyst for the NHS to connect with district authorities, schools,
businesses and the voluntary sector to promote health and wellbeing
• Proactive engagement between health care and planning
• Healthy place making approach focused on the whole
population encourages local engagement
• Change in the built environment is necessary but not sufficient to deliver
behaviour change – it needs support from community activation
• Meaningful community activation takes time but is essential
to support behaviour change.
• Residents’ insights are critical to developing effective interventions
• Technology is an enabler but is most effective when building on trusted
relationships
Learning to date: Programme Value

- Partnership beyond NHS providers: third sector/Local government
(District and County Councils) which have
• Systems for meaningful public engagement
• Responsibility for promotion of health and wellbeing
• Responsibility for community development
• Good links with the voluntary sector
• Planning lead responsibility for a healthy built environment
• Strong local accountability
• Intelligence into local residents’ needs
- Common objectives but different delivery mechanisms flexed to address
local needs
- Delivery vehicles do not require organisational restructuring
- Engagement and activation of local people
Implications for Integrated Care Systems

The Healthy New Town programme is acting as a catalyst for
addressing population health by developing Healthy Communities

Follow Healthy Bicester
rosie.rowe@cherwell-dc.gov.uk

The “Art of the Possible”
Paul Gaudin, Clinical Entrepreneur -
CareRooms.com

Coffee/Networking
Back at 15:30

Welcome from Session Chair
Lou Patten,
Joint Accountable Officer –
Buckinghamshire CCG
and
Oxfordshire CCG

Digital & System Transformation;
Making it stick
John Lisle, Accountable Officer –
East Berkshire CCGs
Mark Sellman,
Associate Director
Digital Transformation
NHS South, Central
and West Commissioning
Support Unit

Art of the possible
We are lucky enough to be at the start of the health & care
equivalent of the invention of the internet. In 10 years’ time
we will not recognise how we used to do things in 2017.
• Making it happen
• Making it stick
• A short example
• Thoughts for the future

Making it happen
• Patience… but excitement!
• Securing commitment – and spending the time to reconfirm regularly
• A clear plan
– At high, medium and detailed level
– Aligned to service transformation
• Defending the scope
– A process for holding good, but “not yet”, ideas
– Reduced contention from competing projects
• Take a whole system view
– Manages unintended consequences
– Inclusion builds engagement

Our Vision
Helping People to
Manage their Own
Health and Wellbeing
Patient Portal
New business
intelligence and
reporting tools
BI – Population
Analytics
a single view of an
individuals’ care data
to support the
delivery of high
quality, appropriate
and effective health
and social care
Shared Care Record
Supporting: New
Models of Care,
enhanced patient
participation and
innovative ways
to manage care
Apps and Wearables

Aligning digital to transformation

Making it stick
• Widest possible design involvement
• Training and building in to normal work-flow
• Simplicity – easier to use than avoid
– Context-sensitive launching
– Clear design
– Useful, accurate information
• Monitor and celebrate usage
• Gather and tell the patient stories

Making it stick II
• Put energy into feedback and review
– Data quality
– Information scope
– Usability – individual & meetings/processes
– Next steps ideas
• Work through examples to support wider
application
– Diabetes -> urgent care

System Prevalence- How big is the cohort and what
services are they using?

Focus on diabetes, renal and hypertension

What does the pathway look for a patient

Monitoring the impact of an intervention

Which practices have a high prevalence

Is the practice an outlier for any other condition

The future
• Value grows exponentially as the coverage increases, both
for individual clinicians and for system decision-making
– Put effort into skilled use by individuals
• Realise the potential in the system
– The foundation for a different way to think about the system –
optimum health gain within finite resource
• Two key challenges
– Managing Information Governance challenges proportionately
– Developing system/organisational capability – analytical
approach; health economics – alignment with Public Health

Systems Thinking for Population
Health – developing and
using linked datasets
Dr Abraham George,
Consultant in Public Health,
Kent County Council

Moving towards a JSNA ‘plus’ – framing the right questions
Complex care
evaluation - matched
controlled analyses
Modelling and
simulation for
capacity planning
Predictive modelling /
risk stratification
Population
segmentation
/ capitation
budgets

KID - The story so far
• Started 4 years ago as national pilot
• KCC Public Health works closely with local data warehouse team
that collates and link NHS and non NHS data from up to 250
health and social care organisations
• ~700 million rows of data vs 897 columns, spread across 28
exclusive data tables
• Minimal cost but IG arrangements time consuming
• > 30 analytical projects carried out supporting local health and
care commissioning including Kent & Medway STP
• Development is incremental – Adding more datasets, flags,
segmentation tools etc
• Considerable R&D potential – number of universities want to
work with us
• New supplier for CCG business intelligence – OPTUM will start
developing new KID next year

HISBI data warehouse (Trusted Third Party Data Processor)
What datasets make up the KID?
GP
>220/238
practices
signed up
as of Aug
2017
Mental
health
Out of
hours
Acute
hospital
HospiceAdult social
care
Ambulance
service
KENT INTEGRATED DATASET
Accessed securely by
Kent County Council Public Health
Community
health
Public
health
KID minimum dataset: data on activity, cost, service/treatment received, staffing, commissioning and
providing organisation, patient diagnosis, demographics and location.
Datasets linked on a common patient identifier (NHS
number) and pseudonymised derived from Patient
Master Index (Household level data is linked via
pseudonymised UPRN)
Arrangements are in progress to link to data covering other services, including:
Health and social care services: Children’s social care, child and adolescent mental health, improving access to
psychological therapies, and non-SUS-reported acute care.
Non-health and social care services: District council, HM Prisons, Fire and Rescue, Probation, and Education.

What information does the KID hold?
Demograph
ics
Segmentati
on tools
Provider
/commissioner
Diagnoses Activity/cost Service
Age IMD Practice code Morbidity profile
(Read codes)
Contact date Healthcare
Resource
Groups
(acute)
Sex CPM (Risk
Stratificatio
n tools)
Provider code Referral source Cost/price Tariff cluster
(mental
health)
Lower
Super
Output
Area
MOSAIC Commissioner
code
Point of
delivery
Care Package
(social care)
ACORN Service code
(community)
eFI (Frailty
score)
Specialty
(outpatient)
ACG
(Restricted
use)
Staff type

INTRODUCTION
AIM
Of the 26,856 KFRS subjects identified, 7,478 (28%)
were found to have attended A&E during the period
01 April 2012 to 30 September 2015.
Of these, 4859 (65%) attended once only whereas
2,619 (35%) attended on two or more occasions.
The subject to attendance ratio for this group was
1.63 attendances per person on average.
The 7,478 subjects included in the analysis were case
matched to 9,588 (128.2%) ‘control’ subjects in the
A&E attendance dataset. The subject to attendance
ratio for this group was 1.1.
HSV data from KFRS was linked with A&E Attendance data from the KID, to carry out a case -
control evaluation, matched for age, sex and deprivation, and assess any differences in
intensity in A&E use between householders who had a HSV (7,458 persons) versus those who
didn’t (9,588 persons), over the same time period.
Statistical assessment of the proportional differences showed that there was no significant
variance between either group. The absence of impact in this context (A&E) does not
necessarily imply a lack of association between HSVs and health care use. Further work is
required to explore more sensitive health care metrics as markers of impact as well as other
innovative methods for data matching.
Richard Stanford Beale Gerrard Abi Aad Abraham George
Utilizing linked data to evaluate Safe & Well Visits delivered by Kent Fire & Rescue Service
METHOD
RESULTS SUMMARY / CONCLUSION
CONTACT INFORMATION
‘Fire as an Health Asset’ is a national initiative,
supported by Public Health England and NHS England1,
where Fire Authorities are expanding the remit of
existing Home Safety Visits (HSVs) to broadly improve
health and wellbeing of local residents, renamed Safe
and Well visits2.
Whilst, the primary objective of each visit is to
enhance fire safety, opportunity is also taken to
address other issues which might improve safety or
wellbeing. This includes reducing the risk of falling,
excess winter deaths, supporting smoking cessation,
mental health, dementia, burns and scalds and general
wellbeing.
To evaluate the positive impact of Safe & Well Visits
undertaken by Kent Fire & Rescue Service on the
safety and wellbeing of people using a linked dataset.
HSV administrative data from Kent Fire & Rescue
Service was linked with A&E Attendance data from the
Kent Integrated Dataset (KID), to carry out a case -
control evaluation, matched for age, sex and
deprivation, and assess any differences in intensity in
A&E use between householders who had a HSV versus
those who didn’t, over the same time period3.
The KID uses person level data linking routinely
collected administrative activity and cost data from
almost all NHS providers across Kent and many non
NHS organisations.
Each linked person has the same NHS number
throughout the dataset so each contact with a service
is traceable.
Personal data is anonymised e.g. names removed, NHS
number encrypted, date of birth becomes age, address
becomes Lower Super Output Area.
Partnership working between the local fire & rescue
service and public health departments is seen as a
possible model in order to capitalise the use of
expertise in bringing data and information together,
optimising analyst capacity, and the use of advanced
analytics.
A number of valuable lessons have been learnt:
- Developing better data standards in terms of coding
and consistency of data collection and minimise use
of free text.
- Use of Unique Property Reference Number as
method of data linking at household level to
complement existing person level linking using
pseudonymised NHS number.
- Use of risk based criteria for better targeting of Safe
and Well Visits to high risk populations as well as
assessing individual risk of poor health and wellbeing
for each visit.
Richard Stanford-Beale
Richard.Stanford-beale@kent.fire-uk.org
01622 692121
Non parametric tests were used to assess
whether or not the proportional distribution
in A&E attendances differed between the
control and the intervention groups.
A two-way analysis of variance by ranks
revealed no significant differences between
both groups (p=.180).
REFERENCES
1. Working Together Working Together
https://www.england.nhs.uk/wp-
content/uploads/2015/10/working-together.pdf
2. Principles for a Safe and Well visit
https://www.england.nhs.uk/wp-
content/uploads/2015/09/safe-well-visit-pinciples.pdf
3. Evaluation Report
http://www.kpho.org.uk/__data/assets/pdf_file/0007
/58444/KFRS_report_Final_25052016.pdf
www.kent.fire-uk.org
www.kent.gov.uk
www.kpho.org.uk

Modelling and simulation
for forward planning
Frail
Multiple
conditions
Single
conditions
Healthy
population
At risk
population
Single
conditions
Single
conditions
Single
conditions
Deaths
rates
Deaths
rates
Progression of need
Case finding, prevention (1/2/3), effective treatment etc
Population cohorts
aged 15 and over
Single conditions include: Cardiovascular Disease, Diabetes, Respiratory, Mental Health,
Digestive, Visual Impairment and musculoskeletal
Sources include:
British Household
survey (1990+), ONS
pops/deaths, Health
survey for England,
published research
Adult cohort model

Children & Young People cohort model

The model interface
and scenario
generator
Changes in
population health
needs in response to
prevention strategies
 impact on service
utilization rates

An SD model of anticipatory care … stocks and
flows
22 June 2017 © www.thewholesystem.co.uk 121

Developing a ‘Community of Practice’
124
Core
FriendsAssociates
Wider system
The KID and other
relevant datasets
Shared Health and Care
Analytics board
STP/ACS Clinical and Strategic
leadership groups
Website and other communication approaches to keep people connected and to make
the work of the CoP accessible and user-friendly
Expertise and coaching
in SD modelling

Key challenges – broad issues
• Poor understanding in the ‘complex supply chain’ of data
management steps → fragmented resourcing → fragile end to end
solution
• Commissioner provider split in the provision of informatics
• Poor understanding at senior / exec level in the use of population
health analytics
• Lack of understanding when comparing methodological approaches
eg. actuarial (commissioner tariff) vs population health needs
• Commissioner interest largely in bottom line
• Limited skills / emphasis in question setting
• Lack of expertise in applied analytics, analytical workforce
fragmented across system
• Dysfunctional collaboration between Academia and CCGs / LAs –
lack of needs led research strategy to support systems planning

Key challenges – Information
Governance
• Labyrinth of governance of data controllers
• Varying interpretations of the data protection
• Varying risk appetite of data controllers
• Legal justification of use of person identifiers (NHS number
matching currently not routinely available for non NHS
datasets (except adult and children social care)
• Developing robust equivalent code of practice for safe
secure transfer, linking and access to data (outside NHS
Digital)
• Lack of understanding of uses of data (more emphasis on
direct care vs population health analytics
• Satisfying GDPR – pseudonymised data is personal data
(need to be more precise and strict in the design,
implementation and enforcement of our code of practice

Key challenges – Data quality
• Varying data dictionaries (or a lack of)
• Quality of coding – eg. GP data ‘wild west’
• Gaps – data on activity but no costs
• Cost vs price
• Other issues: data on drugs - prescribed vs
dispensed
• Updating registered patient lists - ?addresses up
to date

Moving forward….key messages
• Huge amount of routine administrative data generated
in health and wider public sector
• (Cloud based) warehousing of data is now more
economical than previously
• Most of them potential to be linked at person level.
Analytic uses are exponential
• UK possibly further ahead than most other countries in
terms of capability and desire link data
• Time is ripe for national policy to change to help rather
than hinder democratization of access to data
• The right question framed → right sort of analytical
approach → right sort of data / datasets → system
leadership to bring the data together

Understanding patient data –
Why do we need to talk
about patient data?
Philippa Shelton,
Policy and Communications
Wellcome Trust

National opt-out
• Recommendation by National Data Guardian for new opt-out model, accepted by
Government in 2017
• Allows patients to opt out of their personal confidential data being used beyond
individual care, for example for research or planning and delivery of NHS services
• Does not apply to:
– individual care
– where there is a legal basis (e.g. notification of infectious diseases)
– explicit consent
– anonymised data
• Timing: to be aligned with GDPR implementation (May 2018)
• Delivery: online, telephone helpline
• Single question with wording being refined now
• Previous opt-outs:
– Type 1 (data leaving GP practice) will continue until at least 2020
– Type 2 (data leaving NHs Digital) will be transferred to new opt-out

www.understandingpatientdata.org.uk
@Patient_Data
Funding

In a survey of 2,000 members of the general public,
what proportion said they knew a great deal or a fair
amount about how health data is used by:
a) the NHS and b) academic researchers?
1. a) 25% b) 25%
2. a) 33% b) 18%
3. a) 50% b) 33%
4. a) 70% b) 50%
Data from ‘The One Way Mirror’ Ipsos MORI (May 2016)

Awareness of how data is used is very low
• Only 17% of people feel
properly informed about
current data sharing plans in
the NHS (Healthwatch, 2016)
• 74% of people living with
cancer have never heard of
the cancer registry; only 6%
felt they know a great deal or
a fair amount about it
(CRUK / Macmillan, 2016)
7
5
5
12
13
11
21
25
25
29
25
27
21
31
31
16
1
1
1
Academic researchers
Commercial
organisations
NHS
% A great deal
% A fair amount
% Just a little
% Heard of,
know nothing
about
% Never heard
of
Some awareness of health data usage, but little depth of understanding
Source: Ipsos MORI/Wellcome Trust
Base: 2,017 GB adults, aged 16+
How much, if anything, would you say you know about how the following organisations
use health data for these purposes?*
33% 21%
16% 58%
*See appendices for full question wording
56%18%
(Wellcome/Ipsos MORI, 2016)

…but the more informed people are, the more
supportive they feel
I knew nothing about this
until today. At first I was
concerned, but now I’ve
heard more I’m reassured.
It’s important that data is
used in this way by the NHS.

(Wellcome/Ipsos MORI, 2016)
What drives acceptability: four key tests

Health data is sometimes viewed differently
• Many, but not all, regard health data differently
• Perceived, unquestionable benefit in sharing health data with those
providing you individual care
• Strong sense that health data is confidential, private and sensitive, and
should not be shared outside the NHS
• Concerns around misuse if in the ‘wrong hands’
• Mental health and social care data is seen as particularly personal and
sensitive
• Population health data that is anonymous is usually seen as good
• Yet still concerns around individual identification, if data should fall
into the ‘wrong hands’

Perceptions of linking health data
• Low awareness…again
• Can see some benefits when prompted, but conceptually more complex
• Linking at an individual level, people worry about being blamed or ‘told off’
• But linking on an aggregate level is viewed for the greater good of society; concerns
are around integrity/accuracy of data
• Big concerns about surveillance, and cynicism when government involved
• Targeted messaging prompts discomfort and resistance
• Public want to see data linkage to increase knowledge around health issues
• Unease around purpose, complexities, with the sense of Big Brother prevailing.
(Wellcome/CM Insight, 2013)

Findings are consistent
Public attitudes to the use and sharing of
their data (RSS/Ipsos MORI, 2014)
British consumer attitudes to sharing
personal data (ODI/YouGov, 2018)
GPs/NHS trusted with personal data above
banks, local authority and online retailers.
Healthcare organisations are most trusted
ahead of friends and family, banks, local
government and online retailers.
Support for anonymised data sharing outside
of government varies according to with whom
and why, with researchers most trusted.
Consumers are prepared to make worthy
trade-offs to share data about them if it
benefits themselves and others in society.
People want to know more about how their
data is used.
A third would feel more comfortable if an
organisation provided an explanation of how
it intended to use or share the data.
Younger people are more trusting with data
than older, but heavier users of social media
more likely to find data sharing ‘creepy’.
Young adults were generally more
comfortable sharing information about
themselves.
Lots of misunderstanding – people think data
is shared where it isn't.
One in three say nothing would make them
feel more comfortable about sharing personal
data.

Public attitudes conclusions
• Low awareness and understanding how health data can be used even within
the NHS – let alone beyond
• Difficulty relating abstract research purposes to personal health data
• Confusion about identifiable/ de-identified/ anonymised/ aggregate data
• Anything individual-level perceived as ‘my’ data
• In general, more information leads to greater acceptance if there is a clear
public benefit
• A significant minority object to commercial access under any circumstances
• Strong need to develop accessible narratives about how data can be used in
practice, including:
• Clear purpose, with public benefit
• Description of what kinds of data, including honesty about risks
• Robust ‘red lines’ – including for anonymised data
• Safeguards and protections
• Opt-out for those objecting

1. Why it is important to use patient data?
2. What happens to your data (and who sees it)?
3. What are the risks?
4. What are the safeguards?
5. Is the data identifiable?
6. What’s allowed?
7. What’s not allowed?
8. What choices do you have?
9. Why do companies need access to data?
10. How can you find out more?
“Toolkit”: what people want to know

What are the best words to use?
‘Direct care’ ‘Individual care’
• ‘Care’ works better than ‘treatment’ because it’s
broader.
‘Secondary uses’ and
‘purposes beyond direct care’
‘Improving health, care and services through research and
planning’
• Sense of ‘the greater good’ and people wanted specific
detail to help understanding.
• ‘No surprises’ for people. All of the uses, commercial
access, academic research and NHS service
improvements, were felt to fall under this umbrella term.
Don’t use ‘planning’ on its own.
People thought it alluded to
hospital closures.

If you use data, acknowledge it

• Launch: 12-23 March
• 5 stories about families on Bevan Street + overview
• Sharing your data could help save lives. Including your own.
Awareness campaign

Looking ahead in 2018
• Governance
– GDPR / Data Protection Bill
– National opt-out
– National Data Guardian Bill
• Infrastructure
– NHS Target Architecture / local health + care records
– Life Sciences Industrial Strategy: innovation hubs
– Health Data Research UK
– Cybersecurity
• New digital technologies / AI

Key messages
3. Be transparent
2. Be clear about the safeguards
1. Talk about the why

Thank you
p.shelton@understandingpatientdata.org.uk
www.understandingpatientdata.org.uk
@Patient_Data
#datasaveslives

Social networking for health
and activating self-care
Matt Jameson-Evans
Co-Founder
HealthUnlocked

What if you could enlist
your population to scale
up access to patient
support and self
management resources?

Clinicians believe social networks play a
key role in progress
New England Journal of Medicine Catalyst Insights Council Jan 2018

HCPs believe social networks will play
a key role in progress
New England Journal of Medicine Catalyst Insights Council Jan 2018

RUNDO
600
PATIENT
ORGS
740k
MEMBERS
160
CONDITIONS
3.7m
MONTHLY
USERS
HealthUnlocked is a mature
social network for health…
A safe, validated peer-support platform,
Prevention and chronic disease focused
Powered by the voluntary sector
Delivering engagement and outcomes
(AT SCALE)

RUNDO
Online peer support and self care
We help people manage their health and illness by
providing a safe place to:
Understand they are not alone✔
✔
Find support online and locally
✔
Gain knowledge, skills and
confidence to self manage
Create a better experience for
professionals and patients
✔
Generate better pop-health outcomes
✔

RUNDO
Communities supporting holistic
needs

RUNDO
Understanding based on holistic
needs

RUNDO
Building education resources from
partners

RUNDO
Pooled self care from NHS and
patient organisations

RUNDO
Integrated into NHS and patient
organisations

RUNDO
Integrated into primary care

RUNDO
Bringing our service to NHS
organisations

RUNDO
First time
peer
support
…
improved
confidence
self-
managing
…
improved
confidence
with
clinicians
68% 77% 54%
Patient Experience

RUNDOSocial Demographics
52% 66% 50%
Household income
Under £30k
Not in full time
employment
Over the age
of 60
Reaching The Hard-to-reach
*Survey 2014 n=2716

RUNDO
Patient activation in online peer
support study
Low PAM
level
At Baseline
Mean point
improvement
across low
level PAM
group
33% 5.8 31%
Net shift to
PAM high
level
*Manchester Uni Activation in Online Peer Support study 2017 (submitting for peer review)

RUNDO
Self reported reduction in A&E visits at
follow up

Why it works
Ongoing holistic support

RUNDO
Service for CCGs/LAs
INTEGRATION
INTO WORKFLOW
SERVICE
MAPPING
ADOPTION
KIT

Add key local digital programmes and assets into
key need areas so they can be signposted.
Areas of need…
• Broad chronic diseases
• Prevention
• Information & Support
• Holistic Needs
• Public Health
1. Mapping local assets

EMIS PRESCRIPTION CCG MICROSITE WEBSITE API
2. Integrate into local channels

Adoption kit
• Startup and training materials for clinicians
• Startup and training materials for non-
medical staff
• Adoption methodology for programme leads
• Branded materials
• Support from HealthUnlocked
• Reports on usage for distribution
Reports are shared with all
parties monthly, with
commentary
3. Enable adoption across channels

RUNDO
HealthUnlocked
Quality-Assured
Self Care APPS
Peer Support and Self Care Resources
PARTNERSHIP

HealthUnlocked.
UK Office: 147-149 Farringdon Road, London
US Office: 111, 5th Avenue, New York
Mobile/Cell: +44 (0)7595 068 712

Activating populations through
Health-apps
Liz Ashall-Payne,
CEO & Founder -
Orcha

Quiz
How many health and care apps are there?
How many downloads of health and care apps are
there each day?
What % of health and care professionals believe
health and care apps could improve patients’ health?
Out of every 10 children in the UK, how many own a
Mobile phone?
@OrchaUK

ARE HEALTH APPS
AND MOBILE
HEALTHCARE
THE FUTURE?
With over
326,000
health & fitness related
apps currently on
app stores &
5 MILLION
downloads per day
it is difficult to deny
the rising popularity
of the industry

Room for caution…
 Some suicide prevention apps found to provide a list of means for instant
death…
 Similar to the shortcomings of information found on the Internet, information
provided by apps is of variable quality
 50% of health apps receive LESS THAN 500 downloads… and what users say
doesn’t equate to a quality app
 Unlike pharmaceuticals & medical devices there exists a
considerable absence of information about the risks and side
effects of apps
 Most apps have a usage drop-off rate of 64% after just
one month

https://www.youtube.com/watch?v=igLjli-yl9M&t=18s

Digital Health Apps by Category 2017

Disease specific app categories

Driving Transformational Change

App Matching?
• There are many different
features available. These
include ‘education and
information’, health
tracking, alerts and
reminders, goal setting etc
• Are you an iOS or Android
user, fitbit or Garmin, Alexa
or Google Home or
integrated with EMiS v
System One, Cerner v
Meditech etc
• These can include your
Age, Gender and your
physical and mental
capabilities
• What health or care issue
are you looking for
support around
Condition or
Health Issue
Your personal
Characteristics
Features and
Functions you
require
Technical
Preferences

Driving Transformational Change via professionals

mHealth apps in the Person Journey

Where is ORCHA Working at the Moment
We were are working with:

Thank You to all our Speakers and
Attendees
Please stay for supper and
further networking opportunities

Getting to grips with Population Health - 28th Feb 2018

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