Our approach to population health

A population health approach aims to improve the health of an entire population, in a defined area, whilst reducing health inequalities. In addition to delivering appropriate and high-quality health and care services, it also includes actions to reduce the occurrence of ill health and seeks to influence the wider determinants of health. This requires partners to work closely with individuals, communities, and wider partner agencies.

Our approach to population health in Cheshire West is based on the King's Fund four pillars of population health:

  • Pillar 1: The wider determinants of health
  • Pillar 2: The places and communities we live in
  • Pillar 3: Our health behaviours and lifestyles
  • Pillar 4: An integrated health and care system
A healthy and happy Cheshire West: The wider determinants of health; The places and communities we live in; Our health behaviours and lifestyles; An integrated health and care system.
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A healthy and happy Cheshire West: The wider determinants of health; The places and communities we live in; Our health behaviours and lifestyles; An integrated health and care system.

Our approach to population health is supported by population health management, bringing together health, care and wider data, intelligence, and analytics to identify groups within the population to prioritise for support. This helps partners providing health, social care, and wider support to share knowledge, learn from it and then work together to provide care more effectively.

Locally, in Cheshire West, we are using data to identify people who are at higher risk of their health deteriorating, so that local services can better support individuals. For example, we compare and investigate correlations between acute activity and wider determinants on a geographical basis. This is then mapped against a broad range of nationally published indicators and compared to latest acute activity data to produce data packs at a Care Community level (see Pillar 4 for a description of our Care Communities).

The areas with a high prevalence of particular conditions are then identified not only at a Care Community level, but across the whole of Cheshire West. One such condition is cardiovascular disease.

Prevalence of cardiovascular conditions in Cheshire West is relatively high at around 18 per cent of the population. This relates to members of the population who are recorded as having at least one of the following cardiovascular conditions: Atrial Fibrillation (AF), Angina, Congenital Heart Disease (CHD), heart failure or hypertension.

Total patients with cardiovascular conditions

67,598

(18.5 per cent of Cheshire West population)

The numbers of people that smoke, have high cholesterol and high BMI remain relatively static, however, there has been an increase in the proportion identified as having a high blood pressure reading in recent months.

  • 44 per cent blood pressure
  • 76 per cent BMI
  • 8 per cent smoking
  • 76 per cent cholesterol

The population health and population health management approaches enable us to work more closely with partners beyond the health and care system, identifying how to work together to strengthen ill-health prevention; simplify how people can access services; and attempt to solve the interlinked wider social problems that prevent health outcomes improvement.