As part of the NHS England and Improvement Population Health Development Programme we developed pilot projects in Sutton Place and five Primary Care Networks in South West London. The pilots demonstrated that through good use of data we can identify unmet need and consider the wider determinants of health, working with our local partners and specific groups in our communities to develop targeted interventions. These pilots are models for the future working of the ICS and support the shift in behaviour and thinking that will help tackle heath inequalities.
The Sutton Place pilot used co-production with patients and local communities at a very early stage. Data analysis enabled a specific cohort (group) to be identified; these were people with a chronic musculo-skeletal condition and a diagnosis of high blood pressure or obesity or depression, living in areas of high deprivation. We gathered insight through in-depth interviews to understand patients’ experience of specific services and the barriers to accessing these. We used the information to develop and plan a new health and wellbeing intervention. This is a three stage process to guide and support an individual through changes they want to make and to feel more confident in leading a healthy lifestyle and managing their conditions. Work will continue into the implementation phase in 2022.
The East Merton PCN pilot enabled us to bring together lived patient experience, professional experience, and data analysis to identify people with Severe Mental Illness (SMI) and to work with them to increase their participation in and update of their annual SMI health check. We have started work on an emerging model for a holistic health and wellbeing hub in a community setting, and will be co-designing the health checks drop in space with patients and partners.