OBH has become a supplier on the G-Cloud 14 framework. G-Cloud is the UK Government’s digital marketplace that helps the NHS and local authorities procure cloud-based technology and digital services.

OBH offers cutting-edge population health management data products and analytics services. OBH’s Segmentation Engine, Segmentation Dataset and associated data products provide an essential, core backbone for population health management, service planning, design and evaluation, for any local NHS organisation, and their health and care partners. 

Products available include both the National Segmentation Dataset, with options to upgrade this with local GP data through this G-Cloud framework, as well as a Local Segmentation Dataset.

The National Segmentation Dataset features a 7+ year longitudinal period of data, with monthly granularity. It is refreshed regularly with the latest data. It includes 6 core segments (including the healthy/generally well population cohort), and 59 subsegments/conditions. It takes into account population dynamics such as births and deaths in the entire period.

The National Segmentation Dataset is available to ICBs, and other NHS organisations for their GP registered populations through the Federated Data Platform (FDP). It can also be ‘upgraded’ with local data, for example data from GP practices, on local infrastructure (such as an instance of FDP).

G-Cloud 14 is live from 9 November 2024.

Find us on G-Cloud 14:

• OBH® Segmentation Engine and Data Products
• OBH® Segmentation and Outcomes Analytics Support Services
• OBH® Outcomes Platform

Data analysis using the National Bridges to Health Segmentation Dataset was published in Nature Medicine this week. This was the culmination of several years of collaborative work between an impressive team including NHS England, OBH, NHS Arden & GEM CSU, Imperial College London, University of Leicester, Royal College of Surgeons in Ireland (RCSI). 

The key questions the study sought to answer were:

• Are people with diabetes more likely to have multiple LTCs?
• Does diabetes accelerate the onset of developing MLTCs?
• How long are people living with diabetes-related MLTCs, and do these people die earlier?

A three-state Markov model was applied to the National Segmentation Dataset to calculate age of onset for combinations of LTCs with and without diabetes as well as years of life spent with MLTCs and years of life lost.

View a summary infographic showing the analysis, results and implications

Read the full Nature Medicine paper

In June, OBH’s Chief Financial Officer Juliana Bersani moderated the ‘From the drawing board to the ward: Making value-based healthcare work’ session at the HLTH conference in Amsterdam.

OBH presented and chaired discussions around value-based healthcare, exploring themes around how we define value, the role of individual need, what the key challenges are when it comes to implementation, and the impact on patients and systems.

Along with fellow speakers Ward Bijlsma (Chief Medical Officer at Equipe Zorgbedrijven) and Izhar Laufer (Director of Innovation at Leumit Health Services), Juliana discussed some real-life examples from across Europe and the US, where value-based healthcare has made it off the drawing board and been implemented in the real world.

OBH delivered an in-depth presentation on national HEALTHSPAN® in England, and how this objective population-level measure of the amount of time individuals spend in good health is derived and how the data can be used by the NHS to drive change. Catch up on the session on the FutureNHS AnalystX site here.

• HEALTHSPAN is a measure within the National Bridges to Health Segmentation Dataset and a view in the Population Health and Person Insight (PaPI) Dashboard. It has been developed using routinely collected, linked national longitudinal health and care data for all ages and can be tracked with monthly granularity. (More on PaPI on the FutureNHS PaPI website)

• HEALTHSPAN is a measure of when people develop their first significant long term condition, and the average age at which this occurs within a population. 
• HEALTHSPAN is assessed in the context of Lifespan (the age at which people die); the ratio of HEALTHSPAN to Lifespan shows the proportion of a population’s life spent in good health.

HEALTHSPAN is a vital emerging outcome for health systems implementing population health management solutions. The ability to measure HEALTHSPAN accurately is essential for the planning, payment and delivery of healthcare services around improving the amount of time individuals spend in good health.

More information about OBH’s work on national HEALTHSPAN with NHS England can be found on OBH’s HEALTHSPAN webpage.

In March, CEO Rupert attended this year’s Digital Health Rewired conference at the NEC in Birmingham, where he joined Hassan Chaudhury, commercial director at DATA-CAN, and ZhiQian Huang, AnalystX Process Mining Community Lead and Chief Impact Officer and Co-founder of Logan Tod & Co for a panel discussion titled “AnalystX Community: Building a vibrant NHS data analytics collaborative community”. The AnalystX community was created as a true collaborative with over 75 leading organisations and gained traction during the COVID-19 pandemic. It now consists of over 15,000 data professionals coming from the private, public and third sector.

This was a great opportunity to share and discuss some exciting initiatives to bring sustainable transformation in data and analytics within the NHS.

The work of OBH and NHS England’s Population and Person Insight Team (PaPI) was shared at an AnalystX huddle in February, attended by over 300 people. 

AnalystX is a collaborative network and community for data and analytical professionals working within the NHS.

The session covered how the National Segmentation Dataset is created and used to support Population Health Management, for example how the dataset can be used by analysts and future roll-out plans via the FDP, and currently available products for ICBs such as the ‘PaPI Dashboard’. 

Watch the video recording and see slides on the FutureNHS website

A new paper that OBH has contributed to as part of the NHS England Multiple Long-Term Conditions (MLTC/Multimorbidity) Analytical Workstream, ‘Prevalence of Multiple Long-Term Conditions (Multimorbidity) in England: A Whole Population Study of over 60 million people’, has been published in the Journal of the Royal Society of Medicine. 

Our study sought to determine the prevalence of multiple long-term conditions (MLTC) (defined as having two or more of 35 long-term conditions) at the whole English population level, stratifying by age, sex, socioeconomic status and ethnicity. The study uses the National ‘Bridges to Health’ Segmentation Dataset, which contains linked data for c.60 million individuals registered with a general practice in England and alive on 31st March 2020. 

We found that the overall prevalence of MLTC was 14.8% (8,878,231), varying from 0.9% (125,159) in those aged 0-19 years to 68.2% (1,905,979) in those aged 80 years and over. There were large numbers of combinations of conditions in each age group ranging from 5,936 in those 0-19 years to 205,534 in those aged 80 years and over. The prevalence of each condition in those with MLTC varied between age groups; in individuals aged 0-19 years, asthma, autism and epilepsy were dominant, while in individuals aged 20-49 years, depression and asthma were dominant and in individuals aged 50-59 years, hypertension and depression were dominant. In individuals aged 60-69 years, 70-79 years and 80+ years, cardiometabolic factors and osteoarthritis were dominant.

This study provides useful insight into the burden across the English population to assist health service delivery planning, however the heterogeneity of MLTC presents challenges for delivery optimisation.

Read more here: https://journals.sagepub.com/doi/10.1177/01410768231206033

Find out more about the underlying dataset used for this work, see here: https://outcomesbasedhealthcare.com/nhse-segmentation-dataset-reference-guide/

A new paper from a research partnership between Guy’s & St Thomas’​ Foundation, King’s College London and Outcomes Based Healthcare on ‘Identifying populations with chronic pain in primary care: developing an algorithm and logic rules applied to coded primary care diagnostic and medication data’ has been published in BMC Primary Care.

Estimates of chronic pain prevalence using coded primary care data have previously been lower than rates reported in community surveys. Our aim was to develop and test an algorithm combining medication codes with selected diagnostic codes to estimate chronic pain prevalence using coded primary care data. The resulting algorithm for chronic pain – based on four overarching criteria – was run on primary care data from 41 GP Practices in Lambeth (total population of 386,238 GP registered adults). The study found 16.6% (64,135) were identified as people with chronic pain. This definition demonstrated notably high rates in Black ethnicity females, and higher rates in the most deprived, and older population.

Our study demonstrates that it may be possible to establish more representative prevalence estimates using structured data than has been previously achieved. The use of logic rules therefore offers the potential to move systematic identification and population-based management of chronic pain into mainstream clinical practice at scale, and subsequently support improved management of symptom burden for people experiencing chronic pain.

Read the full article here: https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-023-02134-1

Dr Rupert Dunbar Rees, Co-Founder and CEO of Outcomes Based Healthcare, was invited to join a panel of experts for a Cambridge Health Network Event. The panel and CHN members spoke about how ICSs will capture the benefits of data for their populations and patients.

Some key takeaways from the discussion:

• there is considerable scope to use data to improve population health, reduce inequalities in health, and improve quality and productivity of care delivery.
• data can be used to predict future patterns of demand, to identify communities for outreach work, to tackle wider determinants of health and target resources .
• data can increasingly be used to look at clinical outcomes over a whole care pathway, linking longitudinal data sets across providers and clinical conditions. There is already work underway at NHSE to identify outcome metrics which can be used to more meaningfully identify optimal care pathways rather than focusing on individual process metrics / individual disease area metrics.

Read more

In partnership with All Together Better (ATB) Sunderland, Outcomes Based Healthcare have jointly published a case study which provides reflections on the progress of the ATB Sunderland ‘Outcomes’ programme, and shares learning from Sunderland’s Population Health Management journey to date.  

ATB Sunderland is an alliance of out of hospital providers and commissioning organisations, who partnered with OBH in 2019 to develop capabilities and draw on expertise in outcome measurement. Over the past four years ATB Sunderland and OBH, have developed a unique person-level linked longitudinal primary and secondary care segmentation dataset for the population, using the internationally recognised ‘Bridges to Health’ Segmentation Model to their population. This dataset now underpins one of the richest longitudinal records of whole population health outcomes data of its kind, measuring outcomes on a monthly basis from April 2013 to March 2022. 

ATB Sunderland and OBH also built a comprehensive Outcomes Framework which includes 27 outcomes, aligned to key strategic areas of Sunderland CCG’s transformation programme and scope of services. This includes a unique set of outcome measures called ‘HEALTHSPAN®’, which can show whether people are in good health, and for what portion of their lives. Population-level ‘HEALTHSPAN®’ developed by OBH over the last five years is an objective whole population outcome measure of the amount of time individuals spend in good health. This is used to indicate the success of health and care systems in helping keep people healthy for the greatest possible proportion of their lives. 

The outcomes data is visualised in OBH’s Outcomes Platform, an online tool accessible to ATB clinicians and those working in the ATB alliance. The Outcomes Platform is part of ATB’s growing Population Health Management (PHM) programme. Insights are used to understand the health and care needs of the local population and to proactively plan services for different groups of people within the population. 

To read the full report, click here

To read the executive summary, click here

OBH has been featured in the Department for International Trade (DIT) Digital Health Playbook ‘Beyond 100’.

The Digital Health Playbook showcases UK innovators in the fields of Data & Analytics, Systems & Transformation, Healthy Aging.OBH were selected based on our track-record of working collaboratively within Healthcare UK (DIT), our innovation in digital health, and our commitment to export and expand internationally.

Find out more and see the full Playbook here: https://bit.ly/3HnSAQw

This week the paper on ‘Inequalities in developing multimorbidity over time: A population-based cohort study from an urban, multi-ethnic borough in the United Kingdom’, which was published in The Lancet. This was a collaborative analysis between King’s College London, NIHR and OBH.

The research shows that social and material deprivation accelerate the development of multimorbidity, yet the mechanisms which drive multimorbidity pathways and trajectories remain unclear. Our research aimed to examine the association between health inequality, risk factors and accumulation or resolution of LTCs, taking disease sequences into consideration.

After exploring the relations among 32 Long Term Conditions, taking the order of disease occurrence into consideration, we found there were distinctive patterns for the development and accumulation of multimorbidity. There is an increased risk of transitioning from no conditions to multimorbidity and mortality related to ethnicity, deprivation and gender.

Read the publication

This week the ‘Easing pressures – how work, money and homes can make our cities healthier and fairer’ Impact on Urban Health Flagship report was published. The report addresses the wider determinants of health that can slow the progression from one to many long-term health conditions.

The report highlights research by King’s College London, with contributions from OBH, which analysed healthcare data from interactions between GPs and patients in Lambeth in 2020, as part of a broader study examining 15 years of data.
The key findings of the report highlight the strong link between health and work, and that the origins of multiple long-term conditions (mLTCs) are often linked to social and economic factors such as differences in income, ethnicity, first language, country of birth and neighbourhood.

Read the full report

In December, Rupert spoke at the third Community of Practice event for population health management leads across ICSs, organised by NHS England’s System Transformation Group.

The event began with updates from the group, followed by the keynote session focusing on enablers and outcomes of integrating health and social care at an international level. The afternoon sessions allowed delegates to participate in a variety of workshops, with topics including the measuring of health outcomes, the role of an integrated care record in supporting PHM, as well as segmentation and integration.

Speaking specifically on the measurement of health outcomes, Rupert discussed the particular segmentation requirements for outcome measurement. This included how OBH ‘segments’ populations using a version of the Bridges to Health model, built around the unique features of NHS health and care data. This evolved into an interesting discussion around child health and young adults, notably on how population segmentation requirements may fundamentally differ for this cohort.

In November, OBH started a new programme of work with King’s College London, on understanding multiple Long-Term Conditions in Lambeth and Southwark, funded by Guy’s and St Thomas’s Charity (GSTTc). The programme aims to explore and understand people who are at high risk of developing multiple long-term conditions, and delay their onset or prevent the development of multimorbidity.

OBH have been building models around defining, identifying and understanding people with long-term conditions as part of their work on the development of the Bridges to Health segmentation data model. They will be bringing this expertise to the programme, and expanding the evaluation and analysis to deep dive into multimorbidity. With both national and international approaches to defining a LTC and multiple-LTCs varying significantly, the initial stage of the project involves developing and collectively agreeing upon a definition. This is a crucial part of any work on multimorbidity as stated by the recent Academy of Medical Sciences report on multimorbidity. The long-term conditions that will be defined in scope of the programme will be included based on those conditions that impact people’s lives, that are highly prevalent, and that are most referenced by national and international sources.

We look forward to working with GSTT Charity and King’s College through the duration of this programme; with the ambitious vision of further understanding progression, and delaying or preventing the onset of multimorbidity.

This December saw the official launch of the OBH Clinical Associates Network!

CEO Rupert spoke to a full house as he welcomed everyone to the event, beginning with a brief overview of our work on value, outcomes and population segmentation across the NHS over the last 5 years. This was followed by presentations from our two guest speakers. Ivan Beckley (UCL Medical student, MSc Data science) firstly discussed his incredible journey so far as a medical student, including his experience as an intern at OBH, as well as his thoughts on AI and it’s role within the future of the NHS. Toby Colgate-Stone (Consultant Orthopaedic Trauma Surgeon and OBH Clinical Associate) then followed, providing a fascinating talk around his work at King’s College Foundation Trust, discussing ways in which he has seen and experienced the implementation of value on the front-line.

It was fantastic to see so many people interested in being part of the value-based community in the UK. We look forward to hosting our next Clinical Associates Network event soon!

If you are a clinician/medical student interested in joining the OBH Clinical Associates Network, visit the page on our website to find out more.