GPs use new health data sources to identify patients at risk of disease, leading to earlier diagnoses

GPs in Bedfordshire, Luton and Milton Keynes are taking proactive steps to prevent disease, thanks to new ways of working which can help clinicians identify people who are at risk of developing prostate cancer and cardiovascular disease – preventing untimely deaths and helping people to live longer lives in good health.

Working with the new Population Health Information Unit led by Bedford Borough Council, GPs are able to identify patients on their lists who may be at greater risk of disease and invite them in for assessment and improved management.

The method – known as population health management – uses a data-led approach to look at cohorts of patients, bringing together health-related data to identify specific populations which health and care systems can prioritise for particular services.

It has long been established that a person’s income, education, housing and transport status are among the factors affecting their health and wellbeing.  Our local environment influences our health behaviours, and there is strong evidence of the impact of social relationships and community networks on both physical and mental health.

This approach is being used by all GP practices in Bedford, in collaboration with public health and Bedford Borough Council.

Dr Jane Kocen, clinical director for Caritas Medical Primary Care Network and a clinical lead for health inequalities in Bedford said:

“As GPs, it’s our job to treat patients when they develop long-term conditions like diabetes and cardiovascular disease – but in an ideal world, we’d want to reduce the risk of developing conditions and stop people from getting sick in the first place.  That’s why the population health management approach is exciting.

“We can use data to understand and identify the patients on our list who have the greatest risk of developing disease, and we can intervene earlier to limit the impact it can have on someone, or stop it happening altogether. 

“We started to use this approach last year, understanding which communities were more at risk from complications of diabetes, and that’s started to deliver results.  This year we plan to focus on cardiovascular disease, so we’re using population health data to find those who are more at risk by focusing on patients with hypertension to reduce the likelihood of a stroke or heart attack.

“The information available to us suggests that by improving the blood pressure control in 4,000 patients we can prevent at least 24 heart attacks, 36 strokes and 19 deaths over the course of three years.”

This is also an approach that’s being rolled out in Luton with significant success.  In November last year, doctors from five Primary Care Networks in Luton use a population health approach to identify those at risk of prostate cancer.  Evidence suggests that Black men have a one-in-four chance of developing prostate cancer during their lifetime, twice the likelihood of white men.  So far 2,400 Black men have been invited for PSA counselling and then a test if they wish to proceed.  The pilot has so far led to a prostate cancer diagnosis for 30 men, who have all received early intervention and treatment – leading to a positive outcome and prognosis.

Kathy Nelson, head of the BLMK Cancer Network, said:

“Without the risk identification work we’ve been undertaking, it’s possible that some or all of the 30 men with prostate cancer in this group wouldn’t yet have been diagnosed.  “We carried out a study which showed that Luton experiences some of England’s worst cancer outcomes, with 25% of deaths in Luton attributed to cancer, this is something we’ve wanted to do for a long time.  The new data tools we have, and the intelligence provided by the Population Health Information Unit, give us new opportunities to target our approach to diagnosing cancer sooner, and improve the prognosis for our patients.”