Population Health Management

Population Health Management (PHM) is the way we work together to understand and improve the health of people and communities using joined-up health and social care records.

A core objective for our Integrated Care System is improving population health. By this we mean improving health outcomes, promoting wellbeing, and reducing inequalities across our entire population. Population health management is one of the key enablers for achieving this.

How does it work?

We bring together records from General Practice, hospitals, mental health providers, community services, social care, and other sources. This helps us build a better understanding of people’s health, the circumstances in which they live, their needs, and the type of care they receive.

We use this data, alongside other valuable sources of information such as from our citizens through surveys and focus groups or research evidence, to develop ’actionable insights’ – i.e. something we can use to make a positive change.

Putting PHM into practice

Here are some examples of how we have been using Population Health Management to improve the health and wellbeing of our population.

Case study: Healthy Hearts group

Linett was part of a group of 100 people living in Bristol Inner City who were identified as being at risk of heart failure. Linett and the group were offered a range of support options. This included attending a Healthy Hearts group, where people met with specialists and peers to discuss health issues and find personalised solutions. Through this group, support from a nurse, a dietician, a physio, and a social prescriber was provided.

More information about this case study can be found on the NHS England website.

Case study: Covid-19 pandemic

Dr Charlie Kenward explains how population health management was used to during the Covid-19 pandemic.

Population Health Improvement Academy

The Academy exists to help colleagues across Bristol, North Somerset and South Gloucestershire learn how to turn linked health and care data into improvements to how we deliver services. Our goal is to enable more people to be healthier and happier for longer.

Find out more about the Academy by reading the PHM Academy Charter.

Starting a Population Health Management project

Could Population Health Management help with an issue or project you are working on? Through the Academy, we can provide access to linked data, with support and advice where needed.

Key things to consider

• What is the problem you are trying to improve?
• What is our population of interest?
• What intervention or preventative activity are you hoping to implement with this population?
• How does this align with the Integrated Care System priorities?
• What data do you want access to, in order to allow us to think about this problem?
• What do you hope will be different, or what additional insight will you gain, as a result of using linked data?

Make a request

To request access to linked data and support from the Academy, please complete the form below. We will then get in touch to discuss further.

Contact Us - PHM
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