Development and adoption of PHM

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The challenge

Suffolk and North East Essex (SNEE) Integrated Care System (ICS) sought a partner to support the development of, and to accelerate the adoption of, Population Health Management (PHM) across their localities.

Our response

NECS analysts initially facilitated Information Governance (IG) arrangements to enable key local and national data to be shared and linked at patient level, including Primary, Community, Secondary and Tertiary care information. This allowed a patient’s ‘journey’ through the healthcare system to be tracked at an individual level and then advanced PHM analytics applied.

The following techniques and tools were applied at ICS, Alliance and PCN level:

  • Risk stratification
  • Impactability modelling
  • Predictive modelling
Tablet computer with graphs on screen


The project was very successful in supporting PCNs across the ICS footprint in identifying population health interventions which would have the highest impact on local outcomes.

It’s been an eye-opening exercise, looking at the numbers across the systems spent in my PCN. NECS has been very supportive throughout the project, always challenging appropriately and respectfully, especially when we were discussing our short, medium and long-term goals which was the main driver in bringing us together and reaching the targets successfully, as we agreed in a group. 

Dr Ayesha Tu Zahra GP

IESCCG Clinical Executive Lead for Maternity