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Organisation in partnership develops a model to improve patient satisfaction, providing GPs with a snapshot/ timeline view on patient cohort through the range of dashboards


    • Enhance the quadruple aim of better health of the population; improve provider satisfaction; and improve patient experience along with a reduction in health system cost
    • Extend the length of life by 1.4 years, achieve high levels of citizen satisfaction, reduce system costs by more than 7 per cent and solve recruitment and retention problems


    • Created project teams to make organisation do what was right and integrator team with expert knowledge in population health management
    • Developed a Population Health Management (PHM) model to support patients diagnosed with/at risk of type 2 diabetes mellitus (T2DM)
    • Established model enabled to re-design services using a System Integrator, establish partnerships, redesign health care services, manage population health and implement tailored solutions


    • Delivered a range of dashboards providing a snapshot/ timeline view of the patient cohort enabling GPs to interrogate the data to gain insights
    • Recognised 1,058 patients most at risk of developing T2DM
    • Resulted in a shared contract between stakeholders aligning incentives
    • Distributed a system integrator implementation guide handbook enhancing knowledge on integrated PHM


As part of the Hampshire System Integrator project NEL (in partnership with OptiMedis Cobic, Imperial College Health Partnership, Social Finance and PPL) was commissioned to develop a Population Health Management model of Fareham and Gosport patients diagnosed with, or at risk of, type 2 Diabetes. Key business questions were:

  • Would a System Integrator provide benefits to service provision and benefits realisation in Fareham and Gosport beyond business as usual operations?
  • What would the appropriate structure, resourcing and functions of an Integrator be?
  • What large scale and area-wide changes would need to be made for an Integrator to have long term success?

The project drew on lessons learnt from population health models in Gesundes Kinzigtal (GK) in Germany, one of the world’s most established, documented and effective integrated care systems, which delivers on all aspects of the Quadruple Aim: Better health of the population; improved provider satisfaction; improved patient experience; and reduction in health system cost.

The principles of this project are to demonstrate through a System Integrator how proactive and preventive care led by the font-line, can be used for developing practical front-line population health for other disease areas and population groups across whole systems, working as part of an Integrated Care System.


The ambition of the System Integrator project was to implement the lessons learnt from GK in Germany and apply it to the quadruple aim; such as extending the length of life by 1.4 years, achieved high levels of citizen satisfaction, reduced system costs by more than 7 per cent and solved recruitment and retention problems.

Three separate workstreams were established:

Commercial/Incentivisation – to create a shared contract between GPs, acute, community providers and wider stakeholders looking at the alignment of incentives across the neighbourhood. This is crucial to changing behaviours and facilitating the construction of structures that enable the sharing of risk and allowing neighbourhood teams to work together, and begin to manage the health of their population.

Data, Analytics and Clinical re-design – to identify gaps within locality and system level, to provide support on a local level to identify concrete actions for GPs, using data to identify areas of opportunities/biggest impact.

Locality development (Change academy) – to deliver programmes of support for teams of commissioners and providers (around projects defined by service, but increasingly populations) that take multidisciplinary teams on a journey of culture change (facilitated with technical support) on how to change the way they commission and deliver services.


The overall aim of the project was to progress the system towards the goals of the Quadruple Aim. This would enable the system to assess and manage population health; redesign health and care services; achieve system integration at the macro level, and address local issues; establish partnerships with individuals and families and implement tailored solutions with the involvement of all stakeholders.

The specific outcomes achieved were:

  • A range of dashboards delivered, providing both snapshot and timeline views of the patient cohort.
  • Ability for GPs to not only answer specific business questions but the flexibility to interrogate the data interactively to gain wider insights, highlighting both best and poor practice.
  • The identification of 1,058 patients most at risk of developing T2DM. This included identifying cohorts for review – e.g. 35 elderly patients with well-managed diabetes but still on multiple medications.
  • A System Integrator Implementation Guide handbook to support the CCG in scaling up to other localities and Hampshire wide.
  • A bespoke organisational development/change academy programme to support GP/commissioners in rolling out best practice.
  • A shared services contract signed by all stakeholders with agreed financial, governance and risk share arrangements.


To support learning from the project, a system integrator handbook was written for the Hampshire Health and Care economies. The handbook serves as a guide to anyone interested in integrated population health management in England. It is based on proof of concept work undertaken in Fareham and Gosport CCG localities (as part of the Hampshire Integrated Care System), lessons learned in other areas( such as Dudley and Croydon), and the adaptation of successful integrated care delivered over more than a decade in Germany.

The handbook addresses action required at two levels:

  1. The creation and support of neighbourhoods serving populations of between 30,000 and 100,000 people as the basic building blocks of integrated care and population health delivery.
  2. The system and integrator roles in enabling, scaling, spreading and supporting front-line service transformation across the whole the Integrated Care System (ICS). The heart of the handbook sets out how the system creates system building blocks of teams serving populations to deliver the quadruple aim by focusing on whole populations, evidence-based pathway and service redesign and focus on identifying and addressing waste and unwarranted variation (overuse, misuse, underuse).


The focus of the project is to deliver the quadruple aim in financial and non-financial terms. The non-financial values of the project focused on how a System Integrator would deliver this across a system that was working in silos, not thinking about whole population health but just about each organisation and the impact that the population had on the organisation.

The project team, in terms of value-added, was a neutral conductor who could act as an honest broker to make each organisation to do what was right and then shift resource to make sure no organisation was injured as a result of doing the right thing.

The integrator team were, above the NHS partner, a partnership of organisations with expert knowledge in population health management. Through the due diligence process, the team used a range of analytical and benchmarking tools (including RightCare), working with clinicians to identify targeted areas for improvement – the biggest of these being diabetes T2DM, Respiratory conditions and nursing home admissions.

Following a financial modelling exercise by Social Finance, management of patients with Type 2 Diabetes Mellitus was identified as the area of maximum value add in non-elective admission, pay person cost of the intervention and cumulative net savings over the next five years.


Workshops and individual interviews were held with patients and stakeholders from Fareham and Gosport to share concept aims and progress, as well as service mapping and co-designing future solutions.

These interviews identified uncertainty among providers on which interventions/schemes were being implemented, and to what extent, with some being completely unaware of these services. There was also limited coordination between these and other services. Key responses were:

  • Patients with long-term conditions noted managing their own care with fewer hospital appointments was most important to them.
  • Access to GPs, specialist and community care and support was desired to avoid hospital admissions.
  • Greater trust in community services when it comes to LTCs, being happy to divert care away from a GP practice and closer to home.
  • Lack of working together/across organisations, requiring help to make it happen and open the conversations.

The findings highlighted a clear need for a single coordination point for change initiatives as a key enabler. This supported the project team to re-design services using a System Integrator in establishing partnerships with individuals and families, redesigning health and care services, managing population health, achieving system integration at the macro level, and addressing local issues and implementing tailored solutions with the involvement of stakeholders.