Skip to main content

Population Health Management – Covid 19 response


In March 2020 at the early stages of the Covid 19 global pandemic, Durham Council partnered with NECS to adopt a Population Health Management (PHM) approach to support the Covid19 response. The challenge was to use PHM to:

• Identify patient cohorts by level of vulnerability and risk of severe Covid19 disease and complications, as well as the indirect impacts of the social distancing and lock down measures.

• Utilise insight and intelligence to target the most vulnerable with a range of care, welfare and well-being support through the local community hub.

The approach was supported by the North East & North Cumbria Integrated Care System (NENC ICS) Population Health Management steering group. The PHM approach combined medical and social vulnerability intelligence to identify patients and residents who had a greater risk of severe Covid19 disease and ensure they were provided with the right support. The support arrangements included the implementation of the Government advice on social distancing, isolation and shielding depending on level of vulnerability as well as the local development of the community hubs. Population Health Management – Covid 19 response


We delivered the work through a dedicated multi-agency and cross professional working group with the Director of Public Health as the sponsor. Through the NECS subject matter experts we were able to create solutions quickly and effectively in partnership with local customer teams. This included:

  • Project management- end to end project management
  • Public health consultant providing subject matter expertise, driving the PHM approach.
  • Head of Intelligence – to develop analytics
  • Head of Data and Digital Applications – to develop bespoke resources
  • Information governance – to overcome IG challenges and integrate data safely and
    successfully as well as in compliance with the requirements across the organisation

Working in partnership with;

  • Director of Public Health – sponsor for the programme
  • Deputy Director of Public Health – lead on development of the community hub and the translation of the insights and intelligence into action and support
  • Local authority lead for intelligence
  • CCG Support
  • Primary care – approval for access to data

Dynamic dashboards were developed in RAIDR, NECS Healthcare Intelligence Tool.
Using integrated data in RAIDR and expert opinion, algorithms were developed to stratify data to identify people who were at higher clinical risk and or social vulnerability.

To identify clinical risk and stratification (informed by Covid19 international research and subsequently by the government advice), the following factors were identified by interrogating primary care data:

  • Eligibility for a flu jab – this included age, pregnancy status and
  • Lifestyle risk factors – smoking, alcohol use, obesity

In order to identify social vulnerability the county council provided data on domestic violence victims, people receiving support for substance misuse, people in receipt of housing or welfare support, assisted bin collections, people in receipt of adults and children’s social care. The data on clinical/medical risk was integrated with social vulnerability using unique identifiers. This enabled the creation of an integrated data set.

From the integrated data set, profiles where created for each GP practice and made available through RAIDR with the ability for each practice to access their patient profile, stratified by the level of risk for severe Covid19 disease and complications, as well as factors in social vulnerability.

The integrated dataset was also shared with the local authority and enabled the county council to use the insights to design and coordinate their community hub, and to monitor the uptake of the support provided.

The insight and intelligence were used to inform the development of the county council’s community hub model and was made available for primary care teams to support patients in a targeted way.

Interventions were developed and delivered in partnership with local teams and were tailored to meet vulnerabilities and these included:

  • COVID19 specific preventative actions – arrangements to ensure key preventative messages had been received and understood especially by vulnerable patients, their families and carers.
  • Health and social care and support – prioritisation of the relevant healthcare (primary and community care) and social care tailored to meet individual health and care needs and ensure continuity of care.
  • Welfare support – arrangements were put in place for welfare support i.e. food, supplies, and ‘social connectedness’ including checks to ensure people were coping and reducing social isolation.
  • Social determinants – enabled targeting and prioritisation of financial, welfare, housing quality, social isolation needs were identified and prioritised interventions put in place.
Quote Left

Population Health Management has enabled us to undertake targeted work with our most vulnerable people and has ensured holistic interventions are in place to tackle inequalities.

Gill O’Neill

Quote Right


Using PHM, we were able to optimise the reach for our vulnerable populations and understand their needs more intelligently to tailor interventions and provide targeted support. The people the PHM approach identified were over and above the 26,207 patients who were shielded and identified through the national NHS England programme.

“The PHM approach identified a further 72,000 households (In addition to the centrally produced shielded patient list) containing residents who could be, socially or economically vulnerable.” Michael Fleming, Strategic Manager, Research and Intelligence, Durham County Council July 2020

The following data has been reported as at July 2020:

  • 100% initial contact with all people identified as ‘at risk or vulnerable’
  • 4697 people received government food parcels and 1,386 received additional local hub support
  • Over 6000 reactive calls into the hub of which over 3000 have required a more detailed holistic case management approach to resolve their needs.

Next steps:

The PHM approach has enabled the Durham Health System to explore other opportunities where integrating data and developing deeper intelligence and insights into the population can support the development and delivery of integrated interventions. These include the following:

  • Using the PHM approach and population stratification to inform reset of services as well as
    the development of the local recovery plans,
  • Modelling of the mental health impact of covid19 by applying planning scenarios to the different vulnerable populations (including recognising multiple vulnerabilities) and using this to inform the identification and delivery of targeted early intervention
  • Using PHM to understand the health and wellbeing issues for children and young people as part of the Growing Up In Durham programme
  • Exploring the use of PHM to help inform the NHS and wider health system operational reset and winter plans for the coming year
  • Using PHM to further understand the mortality profile for Covid19 and non-Covid19 deaths during the pandemic and using the information for future planning for subsequent waves of the pandemic as well as operational reset and winter plans.

Download our case study