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Population Health Management

Our health and care needs are changing: our lifestyles are increasing our risk of preventable disease and are affecting our wellbeing, we are living longer with more multiple long-term conditions like asthma, diabetes and heart disease and the health inequality gap is increasing.

A new approach – called Population Health Management (PHM) – is helping us understand our current, and predict our future, health and care needs so we can take action in tailoring better care and support with individuals, design more joined up and sustainable health and care services, and make better use of public resources.

By studying the population make up of groups of patients we can look at problems that keep cropping up, or a particular band of people who keep needing treatment, and look at the best way of intervening early on and helping them.

For example, research has shown smoking rates are higher in Reading and Newbury than in Wokingham and more people are overweight and less active in Reading and around Newbury.

A deeper study of the data helps pinpoint things like people at risk of falls, those suffering mental health problems or others with respiratory problems, and this means health and social care professionals can then intervene to try and tackle problems earlier. This can prevent them turning into more serious, chronic illnesses like diabetes and heart disease – health problems that cost the NHS large sums of money and take up big chunks of staff time.

So, by tackling them early, it’s not only improving people’s quality of life, but also allowing the NHS to earmark vital resources to areas where they’re most needed.

NHS England has published a podcast on 'PHM from the front line' which discusses some of our work in Berkshire West. You can listen here

The film below highlights how professionals in the Berkshire West Integrated Care Partnership are using a Population Health Management approach to identify patients in need of targeted support & making a very positive difference: