Digital population health platform hits 150,000+ health and care users, bolstering preventative care for millions of patients.

More than 150,000 health and social care professionals are using a groundbreaking digital population health management platform to adopt a proactive, preventative approach to patient care – an increase of 60% over 12 months. The platform is being used to identify and support more than 17 million patients per year, before they reach crisis point.

The aim of the platform is to help the NHS achieve a left shift, moving from treating to preventing illness. This is a sentiment echoed in Lord Darzi’s NHS report, published today, and Sir Keir Starmer’s three proposed areas of reform: the transition to a digital NHS, moving more care from hospitals to communities, and focusing efforts on prevention over sickness.

The platform, created by Graphnet Health, uses analytics to identify groups of patients that would benefit from support, including those with long-term conditions, such as heart disease and diabetes, as well as those likely to suffer negative health outcomes from factors such as fuel poverty, smoking and obesity. Clinicians can monitor progress and outcomes via the platform, allowing for continuous improvement in health and care strategies.

Growth of the population health platform comes as Integrated Care Systems (ICSs) such as Greater Manchester, Frimley, Surrey Heartlands, Kent, and Cheshire & Merseyside, respond to the call for more sophisticated use of health data to improve care. They are accelerating the use of population health technology, putting it at the centre of their transformation programmes.

Recent outcomes have included Frimley using data to identify patients suitable for remote monitoring. This includes 11,000 complex need primary care patients and 900 care home residents that are now being looked after in the comfort of their own homes. This has led to a 40% reduction in hospital admissions for high need patients and 34% for care home residents.

In Greater Manchester, population health has been used to identify almost 20,000 at-risk patients eligible for receiving novel therapies to reduce their cholesterol.

Cheshire & Merseyside is using population health analytics to identify and help more than 1,300 people who are at risk of developing serious health issues due to fuel poverty. This includes those with severe COPD and preschool children with a wheeze. Individuals receive early support in the community, avoiding unnecessary hospital admissions.

And Surrey Heartlands Health and Care Partnership have used population health to look at the smoking status of patients. They noticed that smoking had a much higher prevalence in one particular area with a high level of deprivation, and were able to organise targeted interventions and programmes, such as pop-up sessions at a local community centres. Over the past year, they have seen smoking prevalence decline by 11%.

Graphnet Health Director, Markus Bolton said:

“We are delighted to see this upsurge in use. Population health, the shift from see and treat to predict and prevent, and the use of shared care records are key to the future of the NHS and the levels of usage that we are now seeing are evidence that the NHS is responding to that challenge.”

Many of the population health users are clinicians and social care professionals using the CIPHA (Combined Intelligence for Population Health Action) population health platform, which was built on the Graphnet platform. It is used by 11 Integrated Care Systems (ICSs) and covers 17m patients. It excludes patients accessing their own records.

Mersey Care CEO, Professor Joe Rafferty said:

“In Cheshire and Merseyside, we are now benefiting from a wide range of applications including remote monitoring of heavy service users, waiting list management and fuel poverty. The enhanced case finding tool has become a key tool for identifying candidates for interventions (telehealth and integrated care teams for example) and diabetic and frailty use cases are becoming embedded.

“The flow of data for analyst use is a key ingredient in providing analysts with a rich data set to create bespoke analysis and is at the heart of our Data into Action programme.”

Fiona Edwards, CEO of Frimley ICB and Chair of the Thames Valley and Surrey (TVS) Partnership Board, which manages the care record and population health system, covers over 4m citizens across NHS Frimley ICB, Buckinghamshire, Oxfordshire and Berkshire West ICS and Surrey Heartlands ICS said:

“We spent over five years building our data and population health platforms and they are fully embedded in many of our care pathways. We are seeing substantial patient and organisational benefits from data driven initiatives and they are at the heart of our transformation programmes.”

Gordon Flack, CFO of Kent Community Health NHS Foundation Trust and SRO for the Kent CIPHA programme, The Kent and Medway Care Record said:

“We have invested heavily over many years in building our data platform with extensive patient records for 2m Kent citizens and we now have over 10,000 clinicians using the record. The system is used for a wide range of uses including improved management of waiting lists, shared record access and remote patient monitoring. We have real momentum now and it is important that we continue building from what we have.”

Graphnet’s population health system is unique as it brings together analytics, shared care record, remote monitoring, PHR, research, and workflow/data capture tools to provide proactive care. Used as one integrated system, it enables health and care providers to adopt a left shift approach, identifying patients in need at an earlier stage, enabling earlier interventions and keeping hospital stays to a minimum. Proactive plans and decisions can be made with tangible, trackable results.