As the NHS implements the Five Year forward view, and health and care systems develop to become ACSs, they will need to combine information from primary and secondary care, and group patients based on clinical need; applying statistical models to identify patients with high predicted risk of service use in the future.  

This “whole patient” view is needed in order to deliver integrated services – starting with understanding need, activity and cost across the population through to monitoring service delivery using linked data.

How we can help you

At SCW we recognise you have to be able to analyse your population to enable the current distribution of healthcare utilisation and costs to be understood. This includes identifying gaps and duplications in care, and where there are opportunities to improve outcomes and reduce unwarranted variation and wasted resources.

Patients can then be grouped into mutually exclusive population segments, as a basis for planning future service delivery models which target services to the needs of each segment of the population. Sophisticated costing of resource and modelling future utilisation also supports organisations with developing capitated budgets.

Population analytics enables the “whole patient view” by combining information from primary and secondary care, and grouping patients based on clinical need. Statistical models are then applied to identify patients with high predicted risk of service use in the future.

SCW provide a comprehensive integrated population analytics service to support population health management, from understanding health needs and identifying opportunities to improve health, through to case management, monitoring and evaluation.

Our expertise includes:

• Population segmentation and health needs analysis
• Identifying gaps and duplications in care, and unwarranted variation
• Understanding cost per patient across the whole patient population
• Predictive models to predict future service utilisation and cost
• Modelling alternative future care pathways
• Case identification and management tools
• Monitoring and evaluation of service changes

Underpinning our specialist analytics service, is a modular tool which takes advantage of our existing Business Intelligence platform, to provide fully integrated population analytics; including scope to interface with clinical interoperability solution integration where available, to develop integrated data flows and analytics outputs.

By presenting the findings in an engaging visual way, for example using maps, we can help clinicians and managers develop a shared understanding of the health needs of the population, and identify opportunities to improve care and deliver services more efficiently.


SCW provide a comprehensive service to support Integrated Population Analytics. We draw on expertise of working on population analytics using both our own solutions, and also working with partners, to maximise the value of the IPA solution, working with customers on realising benefits and to meet bespoke requirements. This support can be delivered along with systems and digital transformation services.

We have extensive expertise in analysing, presenting and interpreting population information, and have worked closely with Johns Hopkins University in adapting, validating and improving a range of predictive algorithms for use on the UK population. We have used this knowledge to develop a flexible set of population analytics which is the basis for in-depth work to support your organisation. read more about our work with Johns Hopkins and how we have used population analytics supporting CCGs to understand population needs and activity drivers

What’s worked for our customers?

Our integrated analytics support has provided vital insights in a number of service model developments:

North East Hampshire and Farnham CCG

The CCG are creating a new care programme to identify and track their at risk patients, as part of their Vanguard programme. This is a GP led project in which they are using the ACG Risk Stratification tool to identify a cohort of patients that they have pulled from their own specific criteria. These patients are then placed on a register that can be identified within the tool, the register is monitored for an increasing risk of admission and the patients are then placed on a MDT register for discussion with other services. Their risks are then monitored to track if intervention aids in the reduction of A&E admission and long term hospital stays.

Isle of Wight “My Life, A Full Life”

The multi-disciplinary team use the tools to identify patients that are not yet known to the multi-disciplinary teams and arrange for intervention for these patients to prevent a hospital admission. The CCG promote the use of the ACG tool to identify these patients, they also create reports at a CCG level and then push these out to their Practices using the tool.

Symphony Project, South Somerset

Providing integrated care packages, where the funding follows patients as they move around the system, requires all of the providers in the Symphony Project to work collaboratively. It also requires them to take joint responsibility for delivering outcomes and for financing care packages. By linking conditions, activity and costs, the dataset we built and its subsequent analysis allowed the Symphony team to focus their efforts on the patient groups that would benefit most from integrated care. The data also supports collaboration by helping providers agree appropriate financial contributions.

“Symphony Data is up there with the best, due to the linking of activity and cost data across health and social care organisations and the ability to look at the combination of conditions these patients have.” Andrew Street, Professor of Health Economics at York University


Through the Hampshire Health Record and Hampshire Health Record Analytics, we have been working with academic and clinical partners to improve care. Examples include supporting analysis of linked clinical data to improve the targeting of care for Acute Kidney Injury and patients at risk of liver disease. The use of linked patient-level data for analysis has identified the characteristics of people at risk who may benefit from more frequent testing and early intervention.

Population analytics supporting CCGs to understand population needs and activity drivers

Why work with us?

SCW is a market leader in using clinical grouping and risk stratification algorithms. Our experts in integrated population analytics, together with commercial suppliers, academic partners and end users, have led in the development of analytical models, publication of case studies and used our extensive population coverage to work with international partners, including developing and calibrating the Johns Hopkins University Associated Clinical Grouping (JHU ACG®) Risk Stratification Algorithms Solution to normalize the algorithms to the UK population. This expertise has led to SCW’s current involvement in developing new models of care for vanguards, and other leading health systems.

With the move towards population health management SCW are able to combine our integrated population analytics specialism together with national insight, and expertise in digital transformation and change management to support organisations ambitions.