Sarah Rogers, Population Health Management (PHM) Nurse Champion within the Cheltenham locality explains what her role involves and why she is so passionate about helping communities to identify what changes can be made to improve their health and wellbeing.

What does your work generally involve?

I am attached to the Cheltenham locality: 3 Primary Care Networks (PCN) and 15 surgeries. I’m tasked with looking at what Population Health Management (PHM) work is going on within the neighbourhoods, and championing that. Everything we do is very data driven, we have a lot of business intelligence through our Integrated Care Board (NHS Gloucestershire).

My role is really about linking people together, for example voluntary sector with social prescribers. I look at how we can involve the housing sector, the local council, physios, occupational therapists, carers, Age UK, Dementia UK, Parkinsons UK and more – bringing them all together in meetings to find out what they can do to help us help people out there. It’s really important to remember that I’m not working alone, there are lots of people working together on these projects. I also try to help people not become too medically focused in their thought processes, remembering that the problem is only medical 20 percent of the time.

What have you achieved so far?

My journey with PHM really began around two years ago when I did the care programme run by the National Association of Primary Care. As a part of that we were encouraged to do some Population Health Management projects and it really captured my imagination. I decided to do several!

I dipped my toe in the water with some small-scale projects within my own surgery. I recognised that we had a long list of  women who didn’t reply to the call for cervical screening, so together with admin staff I looked at how we could get them in through phoning, as often letters get forgotten about. We gave nurses time to phone and chat to these women rather than admin staff as they can have the difficult conversations about any barriers or worries. Our uptake doubled. In the first month, 15 of the 20 women we called came in, and we’ve continued this by now making time for nurses to make a few calls every month.

Another project was improving appointment attendance in people with learning disabilities. When we engaged with the cohort to find out why they weren’t coming into the surgery, we realised that they were afraid to because of the risk of catching COVID. We appointed one of our nurses as a learning disabilities champion, and now we have a range of options for seeing people, including video calls, home visits, and specialised clinics. We also have a link to a learning disability specialist nurse external to the surgery and social prescribers. Attendance has gone from 52 to 98 percent.

After that, I noticed that the NHS were advertising for PHM Champions, and I am the first nurse they have appointed to the role.

With my new role I’m looking at how to use Population Health Management across Cheltenham. The linked data told us that one of our PCNs had a high level of frailty and social isolation so I’m working on a project to look at how we can improve outcomes for those who are mildly frail, understanding that by helping downstream we prevent problems upstream. We’ve started by asset mapping the groups we already have that work with people who are mildly frail to help prevent them from becoming moderately frail.

A really interesting project I am working on is in an area of very high deprivation in our locality. We asked this community what’s not working for them, what’s good, what they like about their community, and what can we do to help. It’s not always about what we can provide, it’s about them: just because we think we should change something it doesn’t mean that we should, and we need to ask them what they want to change.

We sent out some questionnaires and were astounded to get 70 back in the first week alone. Responses highlighted the need for a bus service, some people aren’t close to a bus service and so can’t get to GP surgery, or can’t get to where our older people live. These are things we don’t necessarily think about as frontline healthcare professionals.

What do you enjoy about it?

Starting to make a difference to people’s lives. When I came into nursing my goal was to make people better by changing things from the bottom up, and this is what PHM does. PHM looks at the whole problem, holistically, not just as a medical problem. That’s what I love about it.

What are the challenges?

The main challenge is that you can’t do it overnight and there’s never enough time to do everything you want. Getting people together in one place, at one time is difficult. There’s also still a lot people need to learn about PHM and there is resistance to not medicalising the problems.

Would you recommend working in PHM to others in the NHS, local authority and VCSE sectors?

Yes! We can’t do PHM without getting all these partners involved. We get such a plethora of ideas, expertise, and different funding streams through working with PHM approaches in all these sectors. In Gloucestershire, we have some very enthusiastic people within councils and VCSE organisations who are keen to be involved in the projects and without them our projects wouldn’t flourish.

It’s vital that we work together, we all want to help the same people and to get our communities involved as well.

How does PHM feel relevant to nursing?

As nurses we undertake PHM on a daily basis without realising it, and as nurses we are great innovators of practice. I’d like to get the message out that nurses can do PHM. Not only that but they’re really well placed to do it because nurses know their communities, and the needs within those communities, so well.