Overview

Our population health analyst team uses data to improve understanding of the health needs of the BNSSG patient population. We can help practices and PCNs identify specific patient groups who would benefit from proactive, targeted care, and develop strategies for the health needs of all their patients. 

The team has already completed some vital work looking at: 

• health inequalities 
• chronic disease management 
• condition prevalence  
• vaccination uptake 

We work closely with the BNSSG ICB population health management team, ensuring a consistent approach across the region.  

Each PCN has a dedicated analyst who works closely with their practice teams. The analysts provide expert, knowledgeable support, helping practices to make informed decisions that improve outcomes for their patients and reduce the risks of serious conditions developing. 

 Case study 1 – targeted care for patients with multiple conditions 

One of our analysts worked closely with a PCN in south Bristol to identify patients who would benefit most from personalised support.  

Through analysis of health and social factors data, and discussions with practice clinicians, they identified patients who had a combination of mental health issues, obesity, and diabetes who were at high risk of further ill health. This enabled the PCN’s practices to contact this group of patients to offer targeted, evidence-based support. This helped the practice to use time and resources effectively, by ensuring proactive preventative care was delivered where it is most needed. 

Case study 2 - health inequalities investigation 

Last year, the team used its expertise to help an inner-city Bristol PCN work on increasing vaccination rates among patients with drug and alcohol dependence over the winter period.

The team’s work gave the PCN an overview of the target patients and allowed them to track vaccination rates among them. The project also meant the PCN’s practices could identify a subset of the group, who they proactively approached to encourage vaccination uptake.

The project was successful in helping to increase the number of flu vaccinations given to the hard-to-reach target group. Of the 188 patients, 70 (37%) received a flu vaccination, improving care for those patients while reducing potential future demand from them on a range of health care providers.