Welcome to my March blog – I hope you’re all well and enjoying the lighter evenings as spring heads our way.

As many of you will be aware, a series of significant changes to the NHS were announced recently which came as a shock to lots of us. Such announcements included the abolition of NHS England, a shift towards bringing the health service back under direct DOHSC control, and a halving of ICB running cost budgets. We’ve also heard that providers will also be expected to make cost reductions.

At this stage, we are still awaiting further details on the specifics and the implications of these changes. However, reductions of this magnitude will undoubtedly impact the capacity of ICBs.

Understandably, our immediate priority has been to support our staff, who have already undergone an organisational review and restructure that reduced our running costs by 30% over the last two years. We are also busy preparing for year end and finalising our plans for 2025/26 so these last few weeks have been particularly pressured.

I’d like to offer my thoughts and compassion to everyone who may be affected these announcements – we anticipate more clarity in the coming days and weeks, and as we learn more, we will share further information with our staff and key stakeholders.

This month’s focus: Population Health Management

Last month, I spoke about prevention and the steps we can all take to improve our health while encouraging patients to do the same. This time, I want to turn our focus to Population Health Management (PHM).

PHM is sometimes confused with public health and prevention, but it is distinct. It leverages joined-up local data to better understand the health and care needs of our communities, allowing us to take proactive steps to improve wellbeing and reduce health inequalities.

This is an area I am particularly passionate about, and I am incredibly proud of the achievements we have made. For instance, we have used PHM to identify individuals at increased risk of diabetes, proactively contacting them via letter, phone, or text to ensure they understand their risk and can access proven support.

I am keen for all medical staff to understand PHM, not only so they are aware of what we are doing at a system level but so they also have the tools to utilise it within their own teams.

The first step in PHM is using data and insights to understand population needs – whether at a practice, Primary Care Network (PCN), Place, or ICB level. There are three key tools available to help access this information. Be warned: it is easy to get lost in this wealth of fascinating data!

The next step is where PHM gets particularly exciting: using the information to plan interventions that address the identified needs. Finally, it’s about taking action – targeting those most in need with specific interventions. The ICB PHM team leads various projects across Norfolk and Waveney, but equally, there are great initiatives happening within PCNs and individual GP practices to address local needs and inequalities. I encourage you to explore how you can be part of this work.

Key Tools to Support Population Health Management

Norfolk & Waveney ICS Population Health and Inequalities Dashboard

This dashboard helps users monitor population health changes over time within our Integrated Care System (ICS). It includes:

• Life course outcomes aligned with the Norfolk & Waveney Joint Forward Plan.
• PHM strategy priorities, covering smoking, severe mental illness, cardiovascular and respiratory diseases, diabetes, cancer, and children and young people.
• Healthcare inequalities, overseen by the Health Inequalities Oversight Group, including Core20 comparison indicators.
• Lifestyle factors such as smoking, physical activity, and healthy weight.
• Living and working conditions, covering employment, housing, and social resilience at the Place level.

The dashboard provides benchmarking data from a wide range of sources, displaying measures at Place level and by deprivation score for GP populations and small areas, helping users understand inequalities.

If you would like access to this dashboard, please contact the Public Health Information and Analytics team at i&a@norfolk.gov.uk.

Local Insight Tool

The Local Insight tool allows users to explore highly detailed data about the local context, focusing on the wider determinants of health, community wellbeing, and available local resources. The tool enables customisable maps at the Place, PCN, or Health and Wellbeing Partnership level.

With just a few clicks, you can uncover invaluable insights such as:

• The locations of care homes and libraries.
• The number of households without access to a car.
• Emergency admissions data by district.

Use this link to access Local Insight and explore the data available in your area.

Norfolk & Waveney Population Explorer

For those wanting a deeper dive into population data, the ICB intelligence team provides the Population Explorer Power BI tool. This tool helps us identify where inequalities persist and where action is needed.

The Population Explorer includes:

• Demographic data, including age, sex, and ethnicity.
• Health behaviours, such as smoking, alcohol consumption, and obesity.
• Long-term conditions data.
• Johns Hopkins patient segmentation model, categorising patients into one of 11 mutually exclusive need groups.
• Risk measures, including emergency admission risk and mortality risk scores.

If you’d like access to this tool, please email Nwicb.powerbi@nhs.net.

Additional PHM Resources

A range of resources to support PHM are available on the Norfolk & Waveney ICS website.

Additionally, the public health team produces Norfolk’s Joint Strategic Needs Assessment (JSNA), which provides a comprehensive picture of our county’s health and wellbeing, identifying key issues, inequalities, and service needs. The JSNA includes topic-specific briefings, needs assessments, reports, infographics, and intelligence packs covering a wide range of areas, from loneliness to the availability of community pharmacies.

Looking Ahead

At a time when NHS finance and performance pressures dominate discussions, it is vital to remember that we are making a tangible difference in the lives of our patients. There is still so much more we can do together to improve the health of our entire population.

I encourage you all to explore and utilise these PHM tools and approaches.

If you have any questions, need support for your own project, or have ideas for system-level initiatives, please do get in touch.

Best wishes,
Frankie