What we do

Population health management


Our contribution to the 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 about the health of our local population.

Linked data is the key enabler to effective Population Health Management. We process and provide the data from BNSSG general practice to the system-wide dataset which links patient-level data from primary care, secondary care, mental health and community services. General practice data is often logistically difficult to access but our relationships and trust have enabled us to engage practices in this piece of work.

What are the benefits?

Primary care data provides essential information for the system-wide dataset
PHM enables better understanding of how people interact with health and social care services
The programme uses data to improve healthcare services
We can use primary care data to design new models of proactive care and deliver value-based healthcare
PHM brings together personal attributes and activity for our one million residents
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 Anayltics, BNSSG CCG