• The population of Lancashire and South Cumbria includes many diverse and different communities and often we need to separate out clearly defined groups who need support. 
• This includes not only the people registered with GP practices (the resident population) but also the homeless and people visiting the area for work or holidays.
• Sometimes a population is defined by where they live, but often we look through different lenses such as deprivation, ethnicity, religious beliefs, sexuality, employment type, existing medical diagnosis etc.

• Once we have defined the population on which we need to focus, we may then seek to understand what variation exists within this group, in comparison to other parts of the local and national population.  This includes variation such as:
  • High level health outcomes such as premature mortality and healthy years
  • Condition specific outcomes, for example long term condition prevalence, recovery rates
  • How services are used, experience, the differing barriers and challenges people face.
  • The different health determinants and factors identified through the course of our work.
  • And much more.
• Understanding variation at an ICB levels tells where we have the greatest inequities and challenges as an ICB and helps the ICB galvanise effort across all of its different teams and departments.

• Understanding our populations and the variation that exists at scale is important,  but even more critical at a local level.  The term ‘place’ describes the local geographic footprints on which we work. 
• Working closely with communities, we seek to understand the variation at place.  This can mean asking information analysts to explore the data at a District, INT, PCN, GP Practice, Electoral Ward, or street level.
• It also means working with locally partners, the population and VCFSE to cross reference and check our understanding of the issues and priroities.  A health priroity defined by the NHS is often very different to what community wants and needs.

• Understanding populations by characteristics and geography etc. is important but change needs to happen for the individual.  To deliver population health actions upstream we need to understand the context of that person’s current circumstances. 
• This includes their health status, clinical history, pattern of service access etc.  We also need to understand key economic, social, and cultural markers that have an impact.
• Often, many of the people we want to support are unaware of the services available, or struggle to access them due to barriers such as digital literacy, access to broadband or transport.  Enabling staff at the front line to understand individual context means we can personalise care and help people navigate and better manage their health.

• To make Population health ‘everyone’s business’ we must integrate our tools and information into the workflows and practices of all our patient and public facing stakeholders. 
• A busy clinician or voluntary sector worker will not have time to log into and reference multiple systems.  Our ability to act in a timely and meaningful way depends on credible data being available at the point decisions are made, both with the individual concerned and when strategically and tactically planning.
• Data must also be accessible for at scale planning, both through an intuitive web interface but also direct to business intelligence analysts and researchers.  If we are to “turn the dial” on key health outcomes ten we need to be able to demonstrate the impact and return on investment for our actions and investments.

Ambition:

• A single validated, high-quality source of data for Population Health insight
• Trusted source of data for ICB and ICP partners
• IG compliant management and sharing of data from multiple agencies across the ICB / ICP

Ambition:

• Provision of strategic, tactical, and operational data through a range of digital reporting tools
• Patient level insights for public facing staff so that we can support and target our actions
• Rich, flexible, and intuitive tools that empower staff and colleagues to deliver

Ambition:

• Front line staff trained on how to access, interpret, and use PHM data
• Training on PHM tools, data availability and methodologies
• The development of super users and champions within ICB wide teams
• Embedding a culture of data driven, population health centred decision making

Ambition:

• BI skills, capacity and intelligence at system, place, neighbourhood level
• PHM analytical capacity, knowledge and skills at a system and place level
• Application of best practice analytical, statistical and data science methodology
• Alignment of expertise between partners inc. Public Health, NHS, Council, Social Care etc.
• Managed processes for receiving, prioritising, and delivering information and analysis requests
• Workforce development plan to grow our PHM BI capacity and skills across the ICB

Ambition:

• An ICB approach to machine learning in PHM that ensures we understand non-linear relationships
• Increased capacity for predictive analytics
• Develop our actuarial modelling and Impactability modelling, better understanding not only those at risk but those that will benefit from interventions and potential impact

Ambition:

• Evidence and learning on PHM collated and shared within the ICB
• Creation of an ICB wide knowledge base for capturing learning, evidence, best practice, and the development of strategy