Customer stories
Using population health management to move from reactive care to prevention
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Integrated Care Boards (ICBs) face a common challenge: rising demand, widening health inequalities and increasing pressure to demonstrate progress on prevention — all within constrained resources.
NHS Suffolk and North East Essex (SNEE) ICB, serving a population of more than one million people, has taken a system‑wide approach to population health management (PHM) to respond to these pressures. By embedding data, analytics and leadership accountability into everyday decision‑making, SNEE is enabling earlier intervention, more targeted action and better outcomes for local populations.
This page shares how SNEE has built and scaled PHM across its system — and how other ICBs can take a similar approach.
From ambition to impact: PHM at system scale
Population health management is often discussed, but harder to sustain beyond pilot initiatives. SNEE focused on building PHM as a core system capability — aligned to strategic priorities and embedded into how decisions are made.
The overview video brings together leaders, public health specialists and analysts to explain the ambition behind SNEE’s PHM programme, how it was delivered and the impact achieved across the system.
Leadership that makes PHM part of everyday practice
Progress at scale required strong leadership sponsorship and clear alignment to system priorities. Senior leaders across SNEE:
- positioned PHM as a strategic enabler of prevention, productivity and equity
- championed its use across places and programmes
- supported collaboration between clinical, operational, commissioning and analytical teams
This leadership focus helped shift PHM from a specialist analytical function to a shared way of working across the system.
A shared view of the population to support better decisions
To support proactive care, SNEE developed a linked dataset bringing together primary care, acute, mental health, community and social care data. This shared view of the population enables:
- population segmentation and risk stratification
- earlier identification of unmet need
- consistent insight to support commissioning, planning and delivery
More than 300 trained users now access insights through PHM Pathfinder Analytics, helping teams across the system make more confident, evidence‑based decisions.
Turning insight into action — and measurable outcomes
PHM only delivers value when insight leads to action.
Across SNEE ICB, analytics have informed the design and scaling of targeted interventions, including the deployment of 17 SiSU Health Stations. These delivered 12,094 health checks, with one in five individuals identified as having high blood pressure, enabling earlier intervention and prevention. These examples show how PHM can help systems focus effort and resources where they will have the greatest impact.
Replicating the approach in your ICB
SNEE’s progress was built on clear governance, leadership commitment and repeatable processes — not one‑off projects. If your ICB is looking to strengthen prevention and take a more proactive, data‑led approach to population health, speak to our team today.
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