The population health management (PHM) approach focuses on using data and predictive analytics to identify needs, join up services and deliver proactive personalised care for people in complex at-risk groups.

A local citizen walks along the streetThis puts the population at the heart of transformation efforts and supports integrated teams to build consensus on how best to maximise use of local resources and assets to have the biggest impact on health outcomes.

Northamptonshire’s Population Health Management Programme

In Northamptonshire we have established a Population Health Management Programme Board that meets monthly. Membership consists of key system players from Public Health, NEL CSU, Northamptonshire Clinical Commissioning Group, Northamptonshire Healthcare Foundation Trust (NHFT), Northampton General Hospital, Kettering General Hospital, and both West Northamptonshire and North Northamptonshire Councils.

The Board’s long-term intention is to integrate population health management into business as usual activity, using a collaborative system approach from April 2022. We aim to provide population health advice and insight into the needs and services across Northamptonshire, with a timely opportunity to build this into the foundation of the Integrated Care System (ICS) being formed throughout 2021.

The first population health management project in Northamptonshire

NHS England and NHS Improvement’s System Transformation Team have offered Northamptonshire support to embed this new approach within our health and care system by running a population health management pilot programme.

The programme will bring together a linked data set that represents the needs of a particular population and provides advanced analytics to help professionals understand and prioritise risk, complexity and need, with a view to commissioning or altering services to better meet those needs. Population health management supports these teams with the insights that can drive new proactive care models at scale.

The specific focus for the first programme in Northamptonshire has not yet been carved out, but further updates on the exciting progress of this new way of working will be provided closer to the start of the project in August 2021. The project team will also be keen to involve individuals across the Northamptonshire health and care system to help integrate this on a widespread scale, and will be undertaking engagement to support this process.

Further information about population health management is available online at