To continue providing high quality, affordable health and care for the whole population, there is an urgent need to reduce demand and pressure on frontline services. Yet there is increasing recognition that traditional care models don't sufficiently support people to lead healthier lifestyles and avoid periods of ill health.

Keeping people well and providing great care

Population health management is about supporting people to stay healthy for as long as possible and, when they do need care, making sure it's easy to access, well coordinated, and helps them return home as soon as possible.

While every person will have their own unique requirements and circumstances, when working at scale across a whole population, groups with similar needs and characteristics can be identified. By understanding these groups, care providers can plan and deliver services in the most appropriate way and in the most convenient locations for their population.

SCW supports population health management by:

  • helping people stay well and take an active role in their own care

  • helping care providers understand what their population needs are

  • helping organisations share information securely.

Empowering people

We have teams that specialise in health education, patient empowerment and behaviour change, who help individuals think differently about their health and wellbeing and make better lifestyle choices. They can support you with evidence-based prevention programmes and social marketing campaigns which can be delivered at-scale, also targeted lifestyle interventions across whole populations, communities or specific ‘high-risk’ groups, and personalised care planning.

Shared decision making

When people do become ill, evidence shows that involving them in decisions about their care has real benefits for the individual and for care providers. If they are well informed about all the medical and non-medical options available to them, people will often make different choices about their treatment. When care providers understand what really matters to an individual, they can support them to access the services or treatments they really need.

Getting this dialogue right can result in better health outcomes and better use of resources. So we work with the world’s leading authorities on shared decision-making to help care systems create an environment in which:

  • every individual can take shared decisions at every point in their care journey;

  • staff are trained and supported to use shared decision-making techniques;

  • the necessary infrastructure, systems and processes are in place.

Understanding what people need

To continue providing high quality services in a financially sustainable way, health and care systems must clearly understand patterns of demand, activity and cost. Why and how do people with similar needs access and use health and care resources? How does the cost of care vary between different population groups (or individuals within those groups)? How could services be improved and more closely aligned with people’s needs?

We employ hundreds of analysts to answer these questions and give system leaders insight into population needs, system performance, health outcomes, resource utilisation and costs – and how they change over time. We use advanced segmentation and statistical analysis techniques to:

  • pinpoint gaps, unwarranted variations in care, inefficiency and waste

  • identify and prioritise areas for improvement

  • identify groups of patients who may benefit from targeted interventions and support

  • benchmark and assess alternative care pathways and new models of care

  • evaluate the impact of change


To provide you with this depth of information we analyse whole populations, using data from primary care, secondary care, community care, mental health and other data sets, such as social care and local integrated care records. Our teams regularly analyse data for six million people and can build integrated datasets for any population.

Helping people share information securely

Population health management relies on having integrated health and care records that all care delivery partners can access securely, allowing them to improve care co-ordination, enhance patient safety, and empower individuals to manage their own care and adopt healthier lifestyles.

Creating shared care records can be challenging. There may be competing organisational priorities, new working relationships, and different levels of digital maturity to consider.

We can share the experience we have gained from the development and deployment of five of the country’s leading integrated care record and interoperability programmes covering a population of more than 5 million people. These are:

  • Connected Care (Berkshire/Frimley)

  • The Care and Health Information Exchange (formerly the Hampshire Health Record)

  • Joining up Your Information (Gloucestershire)

  • The Oxfordshire Care Summary

  • Connecting Care (Bristol, North Somerset and South Gloucestershire)


We understand the issues and complexities and have a tried and tested methodology for guiding participating organisations through the engagement, design and deployment process.

Case studies

Delivering change