Data-driven approach to health inequalities can help provide “provide the best possible care” during cost-of-living crisis, says leading doctor.

Data-driven decision-making could help reduce health inequalities during the cost-of-living crisis, according to a leading doctor.

It follows analysis by The King’s Fund that people living in the most deprived parts of England are twice as likely to wait more than a year for elective treatment.
“Throughout late 2022 and 2023, we have seen a significant decline in our residents’ health outcomes,” said Dr Priya Kumar, the Health Inequalities lead for Slough and Transformational Clinical Lead for Connected Care in the Frimley ICB.

According to council data, more than 57% of households in Slough are deprived in one or more aspects , compared to the 51.6% national average.

“As the cost of living rises sharply, it’s crucial that we think carefully about the impact on patients and citizens and make sure we use data-driven decision-making to provide the best possible care.”

Health inequality: a growing problem

The rising rate of health inequalities in the UK is a growing issue, backed up by a number of studies.

The Marmot Review 10 Years On – published March 2020 – highlighted the problem, which was then made worse during the COVID-19 pandemic.

Our health is influenced by factors such as where we live, where we work, how much money we have, our level of education, the discrimination and racism we may face, as well as things such as access to transport, community services and more.

Evidence from The Health Foundation shows that people from more deprived areas are more likely to have multiple health conditions, deteriorate more quickly, develop complications while they wait for treatment, and experience worse health outcomes.

For instance, Cancer Research UK found that people from deprived communities are more likely to get cancer, more likely to report barriers to seeking help, more likely to receive a late diagnosis, and more likely to die from the disease.

However, the recent analysis by the King’s Fund has revealed that – despite NHS England putting equality at the core of their recovery strategy – the organisation is struggling to implement the systemically inclusive approach needed to effectively address these disparities.

Data-driven approach can help reduce health inequalities

One of the key strategies for improving health equity is leveraging quality data and community insights to help shape more effective strategies.

It’s about doing the work that’s already being done, but in a more carefully targeted way.

“Understanding the experiences of our residents is key to improving their health outcomes and narrowing inequalities,” said Dr Kumar.

Software such as Graphnet Health’s CareCentric, a digital shared care record, can combine patient data from multiple sources, including hospitals, GP practices, local councils, community care and social care.

These types of software offer a more well-rounded patient data set that can be accessed and updated in real time by authorised people involved with the patient’s care. This speeds up communication and improves collaboration efforts across teams to provide better, more targeted healthcare.

The shared care record can also be combined with Graphnet’s own Population Health Management analytics platform to segment populations, model changes, and identify patients who are likely to experience inequalities and would benefit from prehabilitation or other care programs – an approach supported by Dr Kumar.

With the help of Graphnet’s powerful tools and data analysis, her team managed to identify and contact thousands of Slough residents in need of support to provide personalised interventions for them.

Dr Kumar explained: “We used a Core20PLUS5 dashboard on our Graphnet platform to identify more than three thousand residents in our most deprived areas who are living with multiple chronic conditions, including diabetes and hypertension.

“Those residents were then asked to take part in a questionnaire. The responses helped us pinpoint those who were most likely to benefit from a needs assessment and the support of our social-prescribing teams, as well as recognise areas of perceived burden, like payment of household bills, lack of food or clothing, mental well-being, and digital inaccessibility.”

Positive results include:

• Increased health checks for diabetics and hypertensive patients
• Increased screenings for cancer
• Improved uptake of immunisations
• Reduced A&E presentations
• Reduced NHS 111 and emergency calls
• Reduced inpatient admissions

Relevant patients were also offered fuel vouchers, food vouchers, mental health and wellbeing appointments at general practice, and invitations to a volunteer-run program to help improve digital literacy.

“They’re engaging more with primary care and less with emergency care,” said Dr Kumar, “so we’re shifting from reactive care to proactive care and providing better overall outcomes for our population.”

About Graphnet Health

Graphnet’s population health management platform is designed to pinpoint groups of people at a higher risk of experiencing health inequalities.
The shared care record then facilitates the identification and proactive engagement of these individuals. For additional information, please contact +44 (0) 3330 771 988.

About Dr Priya Kumar

Dr Priya Kumar has been a GP Partner at Kumar Medical Centre since 2013 and holds a variety of other roles. This includes being the Health Inequalities lead for Slough, the Transformational Clinical Lead for Connected Care in the Frimley ICB.
She has also recently been named the ‘Digital Innovator of the Year’ 2023 at the Digital HSJ awards.