SCW are implementing the new Integrated Population Analytics (IPA) tool which will utilise the Johns Hopkins ACG algorithms in providing effective risk stratification and population health analytics to our customers. Our new solution will be accessed through the SCW Intelligence Point Platform enabling our customers to access all their information through a single platform.

How we can help you

SCWs in house population analytics tool provides:

• A modular, flexible Integrated Population Analytics Tool, supported by our Data Management Services

Insights 1

• As well as “off the shelf” reports at CCG or locality level, customised reports can be produced for specific services, and tailored to your requirements

Insights2 web

• By using a solution located in the SCW data warehouse, additional information governance requirements for the service are minimised
• Implementation and roll-out support, including training, is provided
• We also work with partners where this provides the best fit with customer requirements.


The main components of the IPA tool are outlined below:


Data Extraction and Validation

A specialised primary care data extraction and consolidation solution from Graphnet provides a robust, consistent feed of primary care data. Secondary care (SUS) data is fed via our DSCRO service.




Data Extraction and Validation

A specialised primary care data extraction and consolidation solution from Graphnet provides a robust, consistent feed of primary care data. Secondary care (SUS) data is fed via our DSCRO service.

Data Storage and Linkage

The SCW data warehousing platform will be used to provide secure storage of data.

Applying Risk Algorithms

The Johns Hopkins University ACG Risk Stratification solution is embedded in the modular tool, Enabling the use of multiple risk stratification solutions/algorithms. Other algorithms; e.g. the Electronic Frailty Index (EFI) will also be incorporated into the initial release.

User Interface

SCWs Intelligence Point portal will provide a simple, easy to use interface for case finding, cohort management and other activities; with scope for customised usage and integration with graphical display of information.

The tool includes:

Patient-identifiable reports/functions for clinical use:

·         Find patients according to specific criterion (e.g. DES criteria, specified level of risk, specific conditions, and combinations of criteria).

·         Find a specific patient.

·         Patient review and management

·         User defined searches which can be shared

·         Download/export patient lists and merge with patient names (de-pseudonymised)

·         Data coding/quality flags and checks.

·         Meta data


Anonymised/aggregate reports:

·         Profile of population according to specific criterion

·         Self-service aggregate reporting function

·         Standard report for practices

·         Read code listener

·         Data quality coding/accuracy

·         Metadata


Population Analytics

The new modular tool will enable us to provide a data mart with full access to the underlying data for analysis (from Release 2 of the tool)

This will enable analysts to undertake further bespoke analysis and reporting.



We have designed our tool and service to effectively engage with primary care clinicians and teams as vital stakeholders for population health:

• We have worked with primary care clinicians to design the user interface and requirements, so that the information is intuitively relevant to GPs and primary care teams, with minimal “clicks” to get to patient information, and appealing visual presentation

• Our tool includes the Electronic Frailty Index, and a mortality predictor, and we have the flexibility to add further case finding tools and algorithms

• For added benefits to practices there are a range of data quality reports

• We understand that ease of use is a priority, and we have ensured that implementing the tool is not a burden: the extraction of primary care information will be automated, and support will be provide to manage data sharing agreements and minimise workload on practices.

Our approach builds on existing data flows from secondary care, already used for planning and performance management: this ensures consistency of analysis and building on the in-depth knowledge and understanding of our analytics teams working in each area.

This also enables us to provide a cost-effective service, as we can minimise additional data management costs.

Our expert team will support you with setting up data sharing agreements across GPs and relevant partners. We provide full support for the operational side of the service, enabling our analytics teams to work with you on understanding current and future requirements, and providing the evidence you need to develop new models of care.

Information Governance for the new tool

Risk Stratification is facilitated by the Section 251 agreement secured by NHS England to support linkage of primary and secondary care data for Risk Stratification. We will continue to maintain compliance with NHS England registration process and NHS Digital data sharing agreements.

We have Privacy Impact Assessment and associated Data Sharing agreement for GP practices to authorise the extraction of primary care data for risk stratification.

We are developing a solution to support Pseudonymisation/Anonymisation of all data flows in line with the Information Commissioners Office Code of Practice for Anonymisation of Data. This is currently the only solution for this purpose which has been signed-off for implementation by NHS Digital.

Roll Out Plan

Through the summer and autumn we are working with customers for whom we currently supply the Sollis tool, to migrate their service over to the new SCW tool. Customised delivery plans are being developed for each CCG.
For more information on the new tool take a look at the recent WebEx and watch a demonstration by Chris Morris, Principal Analyst