Population Health Management

A count of patients in Lewisham and the local areas in which they reside

What is Population Health Management?

Population Health Management means using data to improve the health of a population, by understanding general trends and needs, and identifying individuals to target for improved care.

What are we doing with data in Lewisham?

We host and lead a system across Lewisham Health and Care – using a data platform called HealtheIntent®, developed by Oracle Health (a global health technology company). It brings together data feeds from health partners across Lewisham:

  • Acute Trust data
  • Community data
  • Mental health data
  • Primary care data
  • And in the future, social care data.

All the data is gathered with consent from patients, and we are very careful to keep all personal information confidential and secure in line with all data protection regulations and best practice guidelines. But it is important for us to be able to identify individuals, so that we can contact them as part of our activity.

When we gather the data from these various sources, the platform sorts and organises it to make it consistent and usable. Then it connects the different bits of data we have for each individual, so that we can build a complete picture of that person.

We have a number of analytical tools that we can then use to interrogate the data, in a number of ways, at a level of detail ranging from the individual patient, through any variety of combinations and groupings, right up to the full population.

What sets this dataset apart from others is that it is very nearly a real-time live feed. The datasets update every day, with data that is at most three days old. This allows us to take decisions based on information that is fully up to date.

This unique dataset, which covers the whole population of Lewisham (we have data for about 320,000 people), gives us an extraordinary ability to explore the full potential of Population Health Management approaches.

What sort of data can we access?

The data we capture is whatever is created when someone comes into contact with the health system; through a GP visit or hospital appointment, for example. So it includes demographic information, such as their name, address, gender, ethnicity; as well as details of their health and wellbeing, such as GP history, medications, hospital visits, any other physical or mental illnesses or conditions, and so on.

At the moment, we do not capture broader data, such as information on housing, employment or benefits. While people are generally happy to share health data, they are less comfortable sharing other types of information. It is also much more complex to identify and import this data for use in the platform.

What do we do with the data?

We use the data in three main ways:

Supporting individuals: We have a number of different projects where we use the data to identify people who we believe are at risk of a particular illness or condition, or who appear to have a disease or condition but have not been diagnosed with it yet.

For example, we used data to identify people who appear to have a lung disease called Chronic Obstructive Pulmonary Disease (COPD), but who have not been formally diagnosed with it. We did this by looking at patterns of GP and hospital visits, and other health information. We then contacted these people, invited them in for a test, and then if they were diagnosed with COPD, made sure they started to receive the proper treatment.

Planning our services: A different type of project is to use the data to analyse the population more widely. At the moment, we are very focused on health inequalities in our borough. Health inequalities are avoidable, unfair and widespread differences in health between different groups of people.[i]

We have looked at what are known as the ‘Vital 5’; the health characteristics that have the most direct impact on people’s lives and wellbeing. They are: blood pressure, mental health, obesity, smoking and alcohol misuse. By analysing how these affect the population in Lewisham, we can make evidence-based decisions and plan which services we and our partners across the borough should focus on for our population – now and into the future.

This work also helps us see whether the Vital 5 are more common in particular groups of people, which could be people of a certain age, or ethnicity, or who live in a particular area. This gives us the opportunity to engage with local groups and communities to raise awareness and take action around particular health concerns. That could involve reaching out to specific community groups or, checking for a range of health issues when someone comes into hospital for a different reason.

Waiting lists: There are a lot of people waiting for care in Lewisham and across the UK. The data helps us to prioritise people on the waiting list, identify people who are at particular risk, or to find alternative treatments that may be of help to them.

A set of bar graphs showing improved outcomes of targeted health checks when compared to the standard approach

Image above: improved outcomes of targeted health checks when compared to the standard approach

Credit:  Oracle Cerner


What does the data tell us about overall health in Lewisham?

Lewisham is an urban borough with a mixed population, and areas of deprivation (Lewisham is the 8th most deprived borough in London). In general, the health profile of Lewisham’s population is typical of this type of borough, with a prevalence of heart disease, hypertension (high blood pressure), cancer (colorectal, breast and lung), respiratory disease, and diabetes.[ii]

But we can see some particular groups. For example, as we have a relatively large proportion of residents of African or Caribbean heritage, we do see higher levels of Sickle Cell Disease, which affects those groups, than you would find in other boroughs.

How successful have we been in Population Health Management?

Population Health Management is still quite a new approach, and we are trialling a number of ways to apply it. We have run successful projects to identify women with gestational diabetes, people with high blood pressure, and patients with undiagnosed COPD. These interventions have clearly shown the value of using data in this way, and brought very real benefits to the individuals involved.

One other example of the long-term value of this data, is a tool we have developed with data analysts from the borough council, that will create a predictive model for social care; allowing both the NHS and local government to see what the future requirements will be for social care in the borough, and also what early health interventions will help reduce them.

Driving change

Having this data, and understanding its potential, is a force for change in itself. As the evidence base grows, people working in particular specialisms are increasingly able to see how their area overlaps with other, and how the intelligent use of data can help them to help their patients in smart, connected ways.

The more data sharing we encourage, the more change will come.

We are seeing more and more examples of this happening. Our maternity service is a prime example of a team who really understand the power of data, who see health inequalities, and who understand their role in illness prevention and health promotion broadly, as well as in working directly with pregnant and birthing people.

Paediatrics is another area where the impact of health inequalities is very clear: as children are not yet generally in the categories of smoking and alcohol misuse, environmental effects on the health are much clearer to see.

Looking to the future

Our project at Lewisham is important, as we have the opportunity to continue to gather more data, run more projects and consider different ways in which we can interrogate, interpret and benefit from population health data.

By sharing our methods and results, we will make it much easier for others to adopt a Population Health Management approach, and bring the benefits to people, local government, the NHS, and society as a whole.



i. See What are health inequalities? | The King's Fund (kingsfund.org.uk)

ii. https://www.observatory.lewisham.gov.uk/wp-content/uploads/2021/12/A-Picture-of-Lewisham-Full-Document-2021-Final-pdf.pdf