Population Health Management

Population Health Management logo What is Population Health Management (PHM)?

Population Health Management (PHM) relies on integrated data to build healthier communities. We use data to enhance the health of our population by understanding general trends and needs and identifying individuals for improved care. We lead a system across Lewisham Health and Care, using a data platform, Oracle Population Health Management Platform, developed by Oracle Health (a global health technology company). We support various health and care initiatives, providing a horizon view of the population at the Borough level, identifying gaps in care, and zooming in on anticipated and less anticipated inequalities in access and care outcomes. Our goal is to identify early disease, co-ordinate data for those with multiple morbidities, improve care, and address ongoing inequalities while tailoring care to suit our population.

Why is our PHM platform unique?

The PHM platform brings together a multi-source data platform that includes information from primary care (EMIS), community (RIO), and acute sources (iCARE), including some SLAM data (EPJS), to facilitate data-driven initiatives. We are broadening our data depth by onboarding Greenwich datasets, expected to be live by the second quarter of 2024. In the future, social care data (liquid logic) will be included as part of our long-term data improvement plan.

What distinguishes this platform is its nearly real-time live feed. The datasets are updated daily, containing information that is at most three days old. This feature enables us to make decisions based on fully up-to-date information.

And depending on the systems on which users normally access data, the platform can be much, much faster: a search in EMIS that may take a couple of hours will take a few seconds here, and it can then be combined automatically, rather than manually, with dozens of other searches at once (e.g. to create priority groups for intervention across different long term conditions, see whether health checks or tests have been done, and add in filters for deprivation and other demographic indicators) - so that you can see everything applicable to each patient in each search quickly and easily. 


What are we doing with data?

All data is collected with consent from patients, and we exercise utmost care to maintain the confidentiality and security of all personal information, aligning with data protection regulations and best practice guidelines. We only release patient level data to those directly delivering care to them. Upon gathering data from various sources, the platform systematically organises and standardises it to ensure consistency and usability. It then links disparate pieces of data associated with each individual, enabling us to construct a comprehensive profile for that person. We leverage a variety of analytical tools to interrogate the data at different levels of granularity, ranging from individual patients to various combinations and groupings, up to the entire population.


What sort of data can we access?

We collect data generated when individuals interact with the health system, whether through a GP visit, hospital appointment, or community service utilization. This encompasses sociodemographic details, such as their name, address, gender, ethnicity, along with information regarding their health and well-being, including GP history, medications, hospital visits, and any other physical or mental illnesses or conditions. Currently, we do not gather broader data, such as housing, employment, or benefits information.  Importing and identifying this broader data for use in the platform is more complex, but we can do it!


See the drop-downs below to find out more about Population Health Management at LGT:

What we do with our PHM data

Here is a summary of some of our request scopes:


1. Supporting Individuals:

  • Proactively case-finding diagnosed cases of Hepatitis B & C post-COVID that have been lost to follow-up to prevent late presentation with liver cancer.
  • Identifying individuals eligible for health or lifestyle checks or at high risk for cancer screening in deprived areas with inequality in access to care, experiences, and health outcomes.
  • Identifying cases of type 1 diabetes in adults under 40 years to support NHSE funding business case for targeted interventions.


2. Planning Our Services:

  • Analysing the North Lewisham PCN population health and service needs assessment to inform the service redesign and capacity planning of the Waldron estate health facility for improving patient experiences.
  • Analysing the 'Vital 5' to address health inequalities, focusing on blood pressure, mental health, obesity, smoking, and alcohol misuse to provide insight into ways to actualize integrated interventions for improved patient outcomes and service coordination.
  • Conducting insight work into populations with high vs low service utilization to support service design or redesign, e.g., the expansion of Mulberry clinic and understanding specific mental health conditions.
  • Proactively case-finding those with Atrial Fibrillation who would benefit from community pharmacy anticoagulation services to facilitate population tailored community anticoagulation services.
  • Developing a hypertension predictive model for targeted preventive interventions.
  • Creating a summary platform to identify patients with overlapping comorbidities, unregistered populations, supporting the identification of those at high risk of long-term conditions and those likely living with long-term conditions but yet to be diagnosed. Co-ordinating existing projects can assist service delivery teams in investing in preventive, diagnostic, and rehabilitative services and capacity planning.


3. Waiting Lists:

  • Prioritising people on waiting lists and identifying those at particular risk for recommendation into the most appropriate pathway of management.


How to we facilitate change?

The very fact that this data is available, and that it can be understood and shared in a timely manner, is a unique attribute. With increasing evidence, specialists are increasingly able to see how their areas overlap with others, and how the intelligent use of data can help them to help their patients in a smart, connected way.

Data sharing will lead to more change the more we encourage it. In recent years, we have seen more and more instances of this.

Our PHM successes and looking to the future

How successful have we been in Population Health Management?

Population Health Management is a relatively new approach that we are currently testing in various ways. In the past, we successfully identified women with gestational diabetes, people with high blood pressure, and patients with undiagnosed chronic obstructive pulmonary disease (COPD) to facilitate targeted interventions. 

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. A glimpse into some instances of our impactful work is presented in the following case studies:

>> Download our LGT Population Health Case Studies


Looking to the future

Our initiative at Lewisham and Greenwich holds significance, offering us the chance to continuously accumulate more data, undertake additional projects, and explore various methods for examining, interpreting, and leveraging population health data.

Sharing our methodologies and outcomes will simplify the adoption of a Population Health Management approach for others, extending the benefits to individuals, local government, the NHS, and society at large.

Team Members

Population Health Associate Director
Rachael Smith

I’m the Programme Lead for the Population Health Management programme of work and Oracle data platform. My day-to-day role is very varied and can range from liaising with Oracle who provide our data platform, to overseeing the programme of work – all projects and queries that we receive and manage.  It also involves having an understanding (albeit from a non-analyst’s perspective) of the data and queries we run.  I liaise with a variety of people and organisations on a day-to-day basis on how we support the strategic aims of all Lewisham and Greenwich Partners and at any one time we might have up to 20-25 projects running.

Prior to working in the population health team, I have worked in a variety of roles in the NHS. The Strategy and Transformation Programme for SEL and the Cancer Network, also for SEL, were my last two areas of work.  Prior to that I worked in Lewisham PCT as the RiO project manager and as a transformation manager.  My first job was with Sainsburys on their graduate scheme and then working in stores and at their business centre on a number of change and programme roles.

Stephen East Chief Technical Architect
Stephen East

As the Chief Technical Architect supporting the Population Health Management Team, Stephen serves as the linchpin between health and care domains and technological solutions. With a deep-rooted understanding of software development, systems integration, and data management, he orchestrates the design, support, and development of a platform that harmonizes Primary Care, Mental Health, Acute, Community, and Adult Social Care. Acting as a trusted advisor, Stephen provides invaluable guidance to analysts, shaping data architecture decisions, system design strategies, and overall platform management. Stephen’s relentless pursuit of excellence have revolutionized healthcare technology, paving the way for enhanced patient care and improved population health outcomes.


Clinical Fellows (Population Health Inequality)
Sarah Entwistle and Kathryn Griffiths (Kathryn pictured right)

Kathryn Griffiths Our role as Clinical Fellows involves utilising population health data to formulate key questions and design customised interventions that directly target local health inequalities and challenges. By informing pivotal decision-making processes, these efforts contribute to tangible improvements in health outcomes for the population. The role encompasses providing essential support, training, and expert advice to services from diverse backgrounds, empowering them to investigate critical areas of population health.

We lead in planning, researching, and executing population health projects within the PH&C programme in Lewisham, actively advocating for health equity across the borough. Through these varied responsibilities, our aim is to create a meaningful impact on the overall health and well-being of the community. The Population Health Management Team annually recruits fellows from a range of registered specialties, including Nursing, Physiotherapy, Midwifery, and Physicians with an interest in population health and the reduction of health inequalities in our boroughs.


Strategy Manager
Matthew Hopkins

In my role as Strategy Manager for Lewisham and Greenwich NHS Trust I provide support to the Population Health Management team. I help shape projects by working with colleagues across the health and care system to understand how a population health approach can support their work to improve care and reduce inequalities. I can work with you to understand your priorities and the outcomes you are looking to achieve and then think through how a population health management approach can support you in delivering these. I am also able to support you to take projects through delivery and support you to evaluate the outcomes.


Noah Ajanaku Population Health Portfolio Manager
Noah Ajanaku

In my role as Population Health Portfolio Manager, I coordinate requests from external stakeholders seeking insights into Lewisham and Greenwich populations' health and care profiles, including hospital, community, patient cohort, and individual profiles. It requires engaging with both clinical and non-clinical stakeholders, defining requests in terms of scope, expectations, and timelines, and aligning them with the population health team's capacity for further engagement, analysis, and delivery. Work with the team to identify and manage portfolio risks, issues, and dependencies. I also deputize for the Associate Director when needed. Prior to joining the population health team, I pursued postgraduate studies in Public Health at the University of Nottingham. My previous roles include project manager within the University of Nottingham Clinical Trials Unit, as well as positions within the humanitarian and development sector, including Programme Manager with Save the Children, Deputy Head of Dept. Health & Nutrition with Action Against Hunger, and Medical Officer with Medecins Sans Frontieres. Before that, I worked as a foundational doctor and SHO in Nigeria.


May Rowe-Spencer Principal Population Health Analyst
May Rowe-Spencer 

In my role as Principal Population Health Analyst, I work closely with the with Portfolio Manager and the rest of the team to ensure we deliver the analysis and insight each stakeholder requires. I have a background in population health analytics and provide subject matter expertise and analytical oversight for the analytics team, working with them to translate complexities into insight, and ensuring we deliver quality health and care for the people we cover. 

As lead for Lewisham Population Health and Care system’s analytics function, I work with the wider population health team on its development and implementation and expanding its functionality, and on upskilling our team to take on more and more complex and impactful work. 

As part of this, I work with stakeholders from across the health and care system, from public health consultants and clinicians in local services to teams working on population health across SEL and London, to learn from everyone in exploring epidemiology through the use of the Population Health Platform and designing new models of transformative care. 

Andrea Ferrante Population Health Analyst
Andrea Ferrante

As a Population Health Data Analyst, I collaborate with a diverse range of stakeholders, including clinicians and internal project managers, to conduct data analyses targeting specific health conditions, risk factors, and disparities. Leveraging the capabilities of the Oracle Population Health Management platform, we query data from multiple data sources to conduct thorough assessments of health disparities. Through this process, I partner with clients to develop compelling visuals and presentations, empowering them with actionable insights to drive effective interventions. 

With a background in Health Economics, I also enjoy analysing cost-benefits, probabilities, and risk ratios around long-term conditions.


Lewis Batkin Population Health Analyst
Lewis Batkin

As a Population Health Analyst, I work across different projects with a range of stakeholders such as clinicians, senior managers, and decision-makers. From generating queries, complex modelling for insights and designing dashboards - I use Population Health Data to support and outline the work to tackle health inequality across the Lewisham and Greenwich area. Projects such as modelling Long-Term Conditions to provide a framework for action, visualisation of complex activity within communities and acute settings and using specialised and advanced analytics functions for prediction and stratification, showcases the variety and dynamic world of Population Health. With a background in analytics and health inequality, I always strive to incorporate disenfranchisement from the health sector into analysis to ensure that we are providing impact to those who need it the most.

Get in touch

Get in touch with us at: lg.pophealthlewisham@nhs.net

Kindly contact us to book training on:

  • Overview of Oracle Population Health Management Platform.
  • Project Demos, including specific dashboard and predictive model use.

If you have ideas or projects needing PHM data to address inequalities, fill out the Population Health Request Form to begin now.