Challenges faced

The health and social care system in Kent and Medway (K&M) cares for 1.8m people and comprises 18 distinct public sector organisations. Across the system, people have poorer life outcomes than they should; vulnerable people go to hospital more often than they should and stay in hospital longer than they need to; ultimately receiving much poorer quality of care than they should. Low numbers of GPs in K&M mean people find it difficult to access primary care services. Over 1,000 people are in hospital who do not need hospital based medical care and could be helped elsewhere if services were available. K&M have a forecast health and social care deficit of £486m by 2020/21 out of a total system spend of £3bn. The team was tasked with developing a population health management strategy to help support people stay out of hospital when they don’t need to be there, and get people out of hospital as soon as they could be cared for better in a different environment.


The team’s approach to implementing population health management was underpinned with advanced analytics. Initially population segmentation analysis was completed to understanding the local population. To do this the Kent Integrated Dataset was leveraged, a patient level linked dataset covering 1.8 million lives. The population wassegmented by both conditions and age, to understand the size of the cohort, and the service specific and total health and social care spend in each segment. Multivariate regression analysis allowed us to determine the drivers of spend in a given geography from which the segmentation grid was designed. From this we were able to prioritise the segments of the population to design new care models around, and our initial focus was adults and older people with complex needs. Through detailed activity and bed analysis, we quantified avoided admission and reduced length of stay opportunities for this segment. To ensure local ownership, we supported 15 workshops, involving over 40 leaders and front-line professionals from across health and care, to review best practice and develop a care model, consisting of 8 targeted interventions to avoid hospital admission and reduce length of stay.

Additionally, to support local areas we developed an interactive dashboard that allowed stakeholders to view their local segmentation at the practice, locality (30-50k) and CCG level. They have the ability to look at specific cohorts and see what is driving the spend, as well as looking at the ‘top 100’ most costly patients.


As a result, the system leaders across K&M are aligned and have signed up to an investment case of £192m over 4 years to fund the transformation in local care, with expected savings of savings of £490m over the same time period.  All local areas have drafted shared implementation plans across all organisations. The most developed locality is already seeing an admission avoidance. The evidence that the model works is spurring on efforts across the rest of K&M to implement, with the establishment of the Local Care Implementation Board, chaired and co-chaired by LA leaders, to guide and steer the delivery of the plans.