The benefits of using data in population health management

Dr Simone Yule is a GP and Clinical Director for the Vale Network in Dorset

"I’m passionate about population health management as a system enabler. It’s really just about linking health and care data from different organisations in the real-time. Before COVID-19, we didn’t have access to linked data, as most organisations - such as general practice, local authorities, community trusts and hospitals - all have their own IT systems, which don’t talk to each other.

"By linking data, we can break down those IT barriers and access a holistic data-driven overview of a patient’s needs. This is really important, as only 20% of good health is about access to medical care, which means that 80% is about everything else - a person’s general wellbeing socially, culturally and emotionally.

"Linking data helps us join up the dots. By identifying populations and needs, we can map this to support in the community and design services and target interventions specific to that population. For example, during the COVID-19 lockdown, through access to data we were able to identify those people in our practice with depression who were isolated through shielding. We contacted them proactively and linked them to telephone befriending, online coffee mornings and even singing groups, which really helped them feel connected. Similarly, we identified those with long term conditions, such as asthma or diabetes, and by offering those whose conditions were well-controlled options such as online consultations and self-monitoring tools, we were able to then direct more intense resources to those with severe illness who needed a higher level of support.

"Another advantage of linking data is that it highlights inequalities across different areas and how these affect people's health. For example, people living in deprived areas of Dorset are 50% less likely to get their flu vaccination than others living in more affluent areas. Knowing this helps us develop solutions. 

"COVID-19 really highlighted the benefit of our volunteers and social prescribing team. This team is able to have personalised conversations with patients and find out what they need and what matters to them most. They can then connect them with local solutions within the community. We know through data that up to 30% of our patients attending the surgery present with non-medical needs, so linking them with social prescribers means they can access the support they need more quickly. During COVID-19, one of our patients was due to have family visiting from Canada, which was cancelled. Our social prescriber was able to access funding from a local charity to purchase an iPad for video calling, which helped improve her mood as she was able to regularly communicate with her family, which stopped her feeling isolated.

"My aspiration for sharing data between organisations is that it becomes normal practice. The voluntary sector, social prescribers, community teams, GPs, hospital doctors and those in social care need to start working and thinking differently. Linked data is an enabler; it helps us ask questions and ensures we can use data more effectively for the benefit of our population, ultimately improving outcomes for all."