Empowering general practice
One Care
NHS
What we do
Population health management
Overview
Our contribution to the population health management (PHM) programme is a good example of how we can use our expertise in general practice data to support our system to make effective decisions to improve the health and wellbeing of the local population.
Linked data is a key enabler for effective population health management. We process and provide data from general practice in BNSSG for linkage with patient-level data from secondary care, mental health, community services and social care. General practice data is often logistically difficult to access but our relationships and trust have enabled us to successfully engage practices in this important work.
What are the benefits?
primary care data forms an essential part of the system-wide dataset
PHM enables better understanding of how people interact with health and social care services
We can use linked data and PHM to design new models of proactive care and deliver value-based healthcare
“The focus should be on primary care data. Not just out of recognition of its pivotal importance (this is where all the patient attributes come from) but because of the information governance and logistical complexities in arranging this crucial piece of the puzzle. In the BNSSG system we were fortunate to work from the beginning with our GP Federation One Care that was able to pull together primary care data from across the patch and help frame the engagement with GPs on what was a new and unfamiliar endeavour.”
Head of Modelling and Analytics, BNSSG CCG
