Our population profiling and risk stratification work is being used to inform a range of activity across the Leicester, Leicestershire and Rutland Sustainability and Transformation Partnership area.

Background
MLCSU’s Business Intelligence (BI) Team is involved in several exciting developments across the Leicester, Leicestershire and Rutland (LLR) STP area, known locally as ‘Better Care Together.’

LLR is one of the first areas in the country to have received approval from the Independent Group Advising on the Release of Data (IGARD) to link key datasets across the health and care system, including Secondary Uses Service (SUS), adult social care, emergency services and community health services.

We are driving forward work on population profiling and risk stratification. Alongside this, we are warehousing data as part of LLR’s data integration project.

Action
Using the Johns Hopkins ACG Risk Stratification tool, we are identifying cohorts of people for targeted intervention. We have produced analysis which demonstrates how service use and cost is driven by a small proportion of the population, reveals the prevalence of multi-morbidity across different areas and demonstrates how multi-morbidity, rather than ageing, drives costs.

We are carrying out data warehousing, working in close partnership with Leicestershire County Council to develop appropriate analytic products for all partner organisations. A phased approach will see SUS data linked to adult social care data initially using an open pseudonymiser to test feasibility and scoping for the rest of the project.

Impact
The population profiling and risk stratification work is being used to inform a range of activity across the STP, from public health planning, to identification of cohorts for integrated locality teams.

The data integration project will enable partners to track individual activity through the health and social care system and robustly evaluate different approaches to providing personalised care effectively and efficiently.

Our population profiling and segmentation work with MLCSU is the foundation for a number of strategic and operational developments.  It is the basis for a number of our GP incentivisation schemes.  It has driven our recent development of educational resources to improve clinical coding.  It is the basis for allocation of some of our discretionary GP funding.  It will be used by our emerging Primary Care Networks to engage with partners in identifying priorities for local population health management programmes.

Mark Pierce, Senior Strategy and Implementation Manager, Leicester City Clinical Commissioning Group