Covid has given us the data blueprint for ‘programming’ population health

Progressive health & care systems will evolve around data. The latest strategy document from the Department of Health and Social Care Data saves lives: reshaping health and social care with data published in June 2021, makes it very clear the role trustworthy data-sharing will play in the transformation challenge ahead.

For Integrated Care Systems (ICS), shared information and combined intelligence will be central to understanding where to target resources and interventions to maximise value for patients and populations. Data and analytics will provide the timely insights ICS Partnerships and NHS Boards need if they are to take action and meet the new triple aim - improve outcomes, tackle inequalities and enhance productivity.

The theory is increasingly well-understood, but in practice, it is still early days. It has been clear for some time that different lenses (clinical; commissioning; quality management; public health; research) on shared data are best combined to improve care (see the Combing Health Data Uses to Ignite Health System Learning paper). For patients, those systems furthest along the intelligence-led integration path are shifting focus from optimising the episodes or ‘pitstops’ of care to building smarter pathways for better ‘journeys’ of care. For populations, the ICS focus also needs to shift from describing inequalities to programming equity.

Cheshire & Merseyside is taking this intelligence-led approach. The UK’s largest mental and community health trust, Mersey Care and the University of Liverpool’s Institute for Population Health partnered with Graphnet to produce CIPHA: Combined Intelligence for Population Health Action. The programme was initiated and then fast-tracked in the pandemic when emergency response teams reported a lack of timely, standardised linked health data to support system-wide actions. Liverpool City Region had previously committed to the underpinning data-sharing as a Civic Data Cooperative, and a ‘national grid’ of these had been explored in policy research (such as at an All Party Parliamentary Advisory Group on Healthy Longevity, held in February 2020)

The pandemic also accelerated Cheshire & Merseyside’s networking of analysts. As traditional ways of working and heavy governance fell away, the single unmoveable requirement was the need for promptly combined intelligence. CIPHA provided new system-wide insights, supporting care delivery across settings and enabling much more joined-up population health management.

Cheshire & Merseyside now has some of the world’s most integrated analytics across NHS, local government (including social care) and public health data sources. Other ICS (sub)regions, some with long-standing integrated care record systems, have joined the CIPHA expansion programme, which now covers around 17 million of England’s population. This network is now benefiting from rapidly shared intelligence tools for responding to emerging situations and driving better care decision-making and service planning.

Initially, with around 500 stakeholders, the cloud based CIPHA system in Cheshire & Merseyside was deployed in 90 days, linking health and care information on 2.6m residents using data from 15 acute trusts, 359 GP practices, 8 community trusts, 3 mental health trusts, 9 local authorities, emergency services and national agencies. The linked data fed dashboards and reports for coordinating Covid-19 responses. The priority actions determined the timing of dataflows. For example, to run a national pilot of rapid antigen ‘mass’ testing for people without Covid-19 symptoms, CIPHA took a flow of NHS Test & Trace Pillar 2 data every 30 minutes, supplementing a daily download of Public Health England’s Second Generation Surveillance System (SGSS) records on local residents. Similarly, CIPHA integrated vaccination data from national systems for more detailed, context-aware analysis of uptake and outcomes. With near-real-time dataflows, and the ability to steer care workflows with live analytic results, CIPHA can trigger prompt actions. This rapid feedback is also expected to improve data quality. The three main intelligence foci have been capacity and demand, epidemiology and population stratification. For Covid-19 responses alone, nearly 100 reports were provided to over 1,000 users across the system – preventing and controlling outbreaks while tackling the care consequences.

In November 2020, CIPHA enabled the world’s first insights into voluntary testing for people without symptoms of Covid-19 – so called ‘mass testing’. The 30-minute updating of testing information allowed a coordinated response resulting in case detection rising by a fifth and case rates falling by 20% (see Liverpool University's Liverpool Covid-SMART pilot evaluation). This agile work clarified evidence that was hotly debated internationally (see the 'Clarifying the evidence on SARS-CoV-2 antigen rapid tests in public health responses to COVID-19' paper).

The CIPHA team developed a unique set of reports to link vaccination data, testing data and health and care activity data, updated 3 times a day, seven days a week, with analysis focusing on test and case counts, geographical analysis by ward and test site, and population characteristics such as age, sex, deprivation, ethnicity and test reason – guiding deployment of testing centres and communications to change testing with different restrictions, variations and epidemic phases.

The speed of design and implementation of the pilot was challenging, but drew upon, and further strengthened, the local networks and collaborations delivering Liverpool’s COVID-19 responses. After the first month of the pilot, Liverpool was the only major city to reopen into a lower Tier of restrictions, and it has been able to move quickly in response to changing circumstances since then.

In February 2021, when the country was still in strict lockdown, CIPHA enabled Liverpool to prepare a national pilot for re-opening mass events – the Events Research Programme (ERP). Over May Bank Holiday 2021, Liverpool linked testing and ticketing via CIPHA to reopen the first live music events in the Northern Hemisphere (see the Events Research Programme: Phase I findings policy paper).

Beyond the public health effects, these national pilots paved the way for reopening economies with intelligence-led Covid risk-mitigations within Cheshire & Merseyside, nationally and internationally.

The success of CIPHA is the result of a strategic collaboration between clinical teams, academia, health & commercial partners developing products and technology, however the CIPHA architects are very clear that it's not just the technology and infrastructure that’s brought positive results within Cheshire & Merseyside. Being data driven is not a challenge of technology, it’s a challenge of culture, direction and organisational leadership and the willingness and ambition of partners to innovate. Operationally, Cheshire & Merseyside partners were quick to recognise and respond to the need to share information at all levels for health and care system planning, while strategically and in a governance context partners understood that the real value of the data is the policy implications that could be gleaned from the results of analysis.

The CIPHA designers have undoubtedly leveraged data and informatics capabilities in an unprecedented way, helping to understand and unlock the value that health data science can deliver to the NHS, patients and industry. They have also recognised how the development of such intelligence - including more sophisticated analysis; artificial intelligence; and predictive modelling - in a post-COVID world will be the starting point for all decision making at all levels of health and care system planning. In practical terms, CIPHA provides a blueprint for how multimodal data integration can act as a driver in achieving the goals and ambitions for the fledgling ICS, while advancing health science.

As Cheshire & Merseyside ICS moves to a formal decision on the adoption of its population health platform its decision will be driven by the proposition of multi-disciplinary intelligence networks, made up of analysts from the NHS, local authorities and universities. These will be supported by shared data and artificial intelligence – creating a critical mass of analytical capability that does not exist at individual organisational level, and encourages user-involved delivery of care services and collaborative working on the key population health management challenges for Cheshire & Merseyside. CIPHA has provided an opportunity to programme equity using an intelligence led approach (a theme that we will return to in a future article). It’s the whole systems approach to addressing multiagency, multisector challenges that could be used to fundamentally redesign the NHS and care services in line with population health need.

In collaboration with the University of Liverpool, Mersey Care’s ‘Connected Mental Health’ approach is continuing to build on CIPHA and capitalise on analytic and research networks to harness data for discovery, develop an array of advanced technologies to develop risk prediction forecasting, connect crisis mental health data, modelling and using AI to predict future relevant health issues, for example the impact of covid in the future, long covid and to support the achievement of Mersey Care’s nationally recognised goal of “zero suicide”.

There is a time limited opportunity with the formal designation of the ICS and post COVID drivers to sustain system wide working. CIPHA has already demonstrated what combining expertise from industry, academia, clinical and commercial partners can achieve, and while other health care systems are joining the CIPHA platform, the architects, as part of our ICS leadership drive are continuing to relentlessly pursue their goal to understand and unlock the value that health data (science) can deliver to both patients and the NHS.

With these leaders and the willingness and ambitions of the partners within it, Cheshire & Merseyside’s health care system is not following the intelligence-led integration path, they are forging it.

Please note, this is the full version of a shorter article that was published by the HSJ in October 2021, which can be viewed here.

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