Population Health Management

What is Population Health Management (PHM)?

We want to ensure we are delivering services around our populations, and that all patients can access the same offer of care irrespective of which practice they are registered with.  Improving Health are providing a number of services through practices and within central hubs which are outlined below.  Some of these services aim to identify potential health issues e.g. high blood pressure, earlier on so they can be proactively managed and prevent avoidable health conditions.  Others aim to support patients with long-term conditions or more complex needs through comprehensively assessing their needs and providing on-going support.

  • High blood pressure checks to diagnose hypertension (Ambulatory Blood Pressure Monitoring)
  • NHS Health Checks – heart and circulation checks for those aged between 40 and 74 years
  • Assessments for our frail, elderly population to manage their medical, emotional and practical needs (holistic assessments)
  • Patients with complex health and social care needs will receive tailored support from an integrated case manager who will work with the different organisations and co-ordinate their needs (case management)
  • Help to stop smoking

PHM also focuses on improving the management of long term conditions and patient experience.

What does each practice in South Southwark do to provide PHM?

Each GP practice must:

  • provide PHM services by seeing patients at the practice or by referring patients to central services
  • meet the targets set for providing these services to patients
  • ensure that there is a high quality of service at the practice
  • have clinical and administrative staff to manage and organise the delivery of PHM services