One Care has launched a population health analyst support service, which aims to help primary care networks (PCNs) in Bristol, North Somerset, and South Gloucestershire (BNSSG) gain better insights into the health needs of their populations and the inequalities experienced by different patient groups.
The team provide intelligent insight to support PCNs to design and deliver appropriate services and interventions to address the identified needs.
The population health analysts at One Care also work with the wider healthcare system in making effective decisions to support general practice and the health and wellbeing of the local population.
The analysts are working on several projects, including:
- Dashboards to support locality ageing well programmes, showing the distribution, relationships and inequalities of various priority health areas across an area (including COPD, diabetes, heart failure). The dashboards visualise overall prevalence of conditions at each practice in the locality, while also breaking them down by age, deprivation and geography to show the most affected areas
- Sharing priority patients lists for practices across BNSSG, based on clinical risk and amenability to benefit from targeted sets of appropriate interventions, for example: vaccinations; chronic disease reviews; advanced care plans; and cancer screening.
- Reports on cardiovascular disease, its relationship with other long-term conditions, prescribing patterns, and patient activity within the practice, with a focus on prevention and identifying gaps in existing care
- PCN reports and priority lists of patients suffering from a combination of long-term mental and physical health challenges, to support a personalised approach to care and continuity
Rhys Lewis, head of digital at One Care, said: “General practice has a unique role in understanding the underlying causes of ill health and supporting communities to address them and drive improvement. We encourage all PCNs to get in touch with One Care’s team to collaborate on turning data into meaningful intelligence to address population health and begin to tackle inequalities.”
Each PCN in BNSSG has a dedicated One Care analyst, who can be asked to investigate specific topics or areas where clinicians feel targeted work is needed. The team is available to meet with PCNs or practices that would like to know more or make use of the service. It can be contacted via email at firstname.lastname@example.org.