Population health management

Population Health improves people's physical and mental health and wellbeing while reducing health inequalities across an entire population by using data to drive decision-making and pro-active care.  

What is population health management?

In Surrey Heartlands, population health management means:

  • Infrastructure – we support the Surrey Health and Wellbeing Strategy with a system-wide approach to Information Governance. Through our data warehouse and Population Health Management platform, we develop ways to share data about our population in a timely, accurate and safe manner.
  • Intelligence – we link analysts from different organisations through a Community of Practice to use these tools to provide insights to help our partners understand their population's needs.
  • Interventions – these insights inform evidence-based interventions to improve population health at every system level.
  • Incentives – working to understand better how we use different resources to support the population we serve more efficiently.

Our Population Health Management Programme will continue to develop these enablers to ensure that our future services will be even better connected.

Current examples of this work include:

  • Using local data to support the Core20Plus5 approach to understand better population groups who may experience health inequalities and overlay the distribution of Long Term Conditions with the broader determinants of health, like respiratory diseases and air quality.
  • Collaborating with partners in the community and voluntary sector to build a shared understanding of people's priorities to inform our approach to prevention.
  • Using the PHM platform to identify specific cohorts who would benefit from proactive care in the community and working with Primary Care Networks to refer them to social prescribing or multidisciplinary teams.