This week's in my view comes from... Cathy Winfield, Berkshire West Clinical Commissioning Group Chief Officer

I spend many hours studying health statistics, data, facts and figures as part of my work. And one figure that’s really hit home is the 3.7 million consultations with local GPs in Berkshire West last year.

Whilst it’s great to see that our GPs are such a trusted option, we have to bear in mind the other important factors which help people lead healthy lives. Research shows things like education, having a job, living in good quality housing, strong communities, accessible transport and contact with family and friends are all extremely important to keep us healthy and well.

And it’s this bigger picture we’ve been studying to build a new style, responsive, caring and modern health service based around what really matters to our patients as individuals. A system that is more proactive than reactive; looks at the many and varied issues linked to health; quickly pinpoints population groups and people needing the most support and gets that support system to people as swiftly as possible.

This piece of work is called Population Health Management (PHM) and it’s being pioneered in a handful of places around the country, including here in Berkshire West.

Using a data-driven approach, backed up by the local knowledge of our front line staff, we can study our GP registers, pinpoint recurring health problems, identify groups with similar needs, understand patterns of demand and activity, discover gaps in services and then plan and deliver more personalised, targeted, holistic and proactive health and social care.

Our initial work has seen us put PHM into action in communities where people seem to be more at risk of falls, others where GP surgeries deal with a lot of patients suffering mental health problems, neighbourhoods where respiratory problems are a challenge and places where there’s a high proportion of people with diabetes.

Using our PHM data, we can work with partners across the local council, voluntary sector, charities and community groups to try and break these cycles of poor health by intervening earlier and preventing them turning into more serious, chronic illnesses like heart disease – illnesses which can really reduce quality of life, cost the NHS large sums of money and take up a lot of specialist clinical time.

Our work on PHM in South Reading showed a group of people with multiple long-term conditions attending A&E more often than expected. Now, through working with colleagues in health, social and voluntary sectors, we can holistically address these patients’ needs earlier on, before they reach the ‘emergency’ stage needing A&E.

This means we’re not only improving people’s quality of life, but also allowing the NHS to earmark vital resources to areas where they’re most needed.