Embedding PHM at the heart of the Model ICB

Hertfordshire and West Essex integrated care board (ICB) has used population health management (PHM) to transform care for people with frailty – an approach which should inform the federated data platform’s (FDP’s) capabilities, writes associate medical director Sam Williamson

NHS England’s Model ICB Blueprint marks a pivotal moment for ICBs, setting a clear direction for them to become intelligent commissioners – stewards of population outcomes, strategic purchasers of healthcare, and convenors of system improvement.

The task ahead is not structural, it’s practical, and ICBs must turn these functions into reality. This means being systematic in taking data-driven, evidence based, and clinically informed decisions across all levels.

It starts with the problems we need to solve and how the analysis enables change, rather than what data platform we use.

PHM and analytics need to be sat alongside clinical, change management and strong leadership to unlock these functions. At Hertfordshire and West Essex ICB, PHM informs system priorities, service design, and delivery.

Redesigning proactive care at scale

In summer 2024 the ICB applied PHM across all levels of the system to improve care for people with frailty. Starting with a system-wide review of health needs, we identified potentially avoidable emergency care, resulting in poor outcomes and experience for patients, and high cost to the system.

More detailed analysis of linked data demonstrated patterns of service utilisation, highlighting characteristics associated with worse outcomes. It showed underdiagnosis of frailty and palliative care needs, high rates of falls, polypharmacy, and opportunities for anticipatory care.

Combining analysis with a review of evidence and mapping current services led to the development of seven interventions.

These covered both proactive and reactive care, including: managing medication related harm; falls risk management; advance care planning; proactive care through neighbourhood teams; increasing urgent community falls response; transferring appropriate cases from ambulance to community providers; and maximising alternative community pathways through early review in the emergency department.

Forecasting and scenario modelling demonstrated the number of people who could benefit and the potential shift in care from implementing interventions at scale. This facilitated local discussions around resource shift and funding.

To support delivery, the ICB co-developed pathways and a delivery framework. An implementation guide supports our emerging integrated neighbourhood teams. It includes PHM tools identifying high risk patients, clinical pathways incorporating evidence based proactive care, and support for developing INT infrastructure.

Evaluation of both delivery and impact is embedded across the programme and transparency of information ensures change is dynamic. Feedback identifies areas of success, and where progress is needed.

By placing insights at the centre of discussions, the system adopts a culture of continuous improvement, with longer-term population health outcomes viewed alongside process and performance indicators.

This ensures that the system keeps focus on the ends and the means, providing a common goal for all parts of the system to work towards whilst maintaining sight of shorter-term deliverables.

Building the FDP’s emerging functionality around use cases like this… will ensure that systems can adopt it without lost capability

High quality data and analytical tools are critical to each stage, supported by data platforms that link information from providers across the system, including primary care.

These core tools will be needed for ICBs to deliver on strategic commissioning, many of which exist in local data platforms and will be needed in the FDP for ICBs to adopt it.

Early signs look promising. Building the FDP’s emerging PHM functionality around use cases like this will support its development and ensure that systems can adopt it without lost capability.

The impact

Setting a system priority around frail and end of life care in our Joint Forward Plan means all parts of the integrated care system are engaged in delivering change. Each provider and integrated team recognise their role in delivering improvements.

Early outcomes, six months after implementation, include:

• Double the number of people identified as needing palliative care support, with twice the number of people receiving advance care planning;
• 12.6% reduction in the proportion of people with frailty currently on polypharmacy;
• scaling up of neighbourhood health teams, focused on people with complex frailty needs;
• 40% increase in the daily number of people being transferred from a 999 ambulance dispatch to rapid community provider response teams; and
• evidence of reductions in non-elective admissions in the frail population.

Three imperatives for ICBs

To realise the Model ICB’s vision, systems must:

1. Embed PHM at the centre of decision making
   PHM must shape how priorities are set, investments made, and outcomes evaluated, across the whole system.
2. Build multidisciplinary PHM capacity
   Strong PHM combines clinical, public health, analytical, and commissioning expertise in an integrated team that supports strategy and delivery, working closely with digital.
3. Drive delivery through PHM, not just planning
   Use PHM to define expected standards, target care to those most in need, and evaluate interventions in real time, assessing impact and identify variations in outcomes.

Our experience shows that PHM offers a foundation of an intelligent, value-based system focused on delivering the triple aim of healthcare and the shifts outlined in the Darzi review. It offers the ability to address system problems in the round, across the continuum of care.

For ICBs to successfully align PHM to strategic commissioning, this needs to be adopted at scale, with learning shared through key networks such as the Chief Data and Analytics Officers Network and used to inform the capabilities of the FDP.

The Model ICB gives us a blueprint, PHM and analytics provide the means to deliver on it.

Sam Williamson is associate medical director at Hertfordshire and West Essex ICB.