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A beginner's guide to population level healthcare.

A beginner's guide to population level healthcare.


Population level healthcare is a modern approach to improving patient health at scale. Analysing health data allows service providers and commissioners to combat local health challenges. How does it work?

The IT systems at GP practices are full of detail about each patient's medical history. These are usually only referred to during individual encounters. But what if we combine thousands, hundreds of thousands or even millions of records? Now we have data that enables active healthcare analysis for an entire population. That population might belong to a single GP practice. It could be for a federation or other GP network. Or it could be for all the people living in several CCGs or an STP area.

Introducing Outcomes Manager

Outcomes Manager is the Vision solution for population level healthcare management. It offers a simple and pragmatic approach that:

  • is easy to put in place
  • collects data from all major clinical IT systems used at GP practices
  • offers reporting on up-to-date information
  • encourages consistent care across clinicians
  • allows service providers to influence change

In England, Outcomes Manager is available as a centrally funded solution on GPSoC. There is no cost to GP practices or CCGs.

Typical uses

Long term condition case finding

The UK population is ageing and as people get older it is common for them to have many long-term conditions. Case finding identifies people that are likely to have a disease but don't have a diagnosis.

Disease Management

Deep-diving into a specific clinical area lets you identify patients meeting certain criteria. Changing their individual, disease-specific care plans helps to improve health outcomes.

Prevent avoidable diseases

Take this a step further. Outcomes Manager can help you prevent avoidable diseases. It can show you how many patients are at risk of developing long-term conditions. Understanding who these people are is the fundamental first step towards prevention. It allows accurate targeting for healthcare initiatives, educational programmes and individual interventions.

Local service reporting

A very simple but effective use of Outcomes Manager is to report on local service provision. It takes the pain out of collecting and collating information from practices. It can calculate payments too, freeing up time at GP practices for looking after patients.

Influence change to improve outcomes

Having population level information is only the starting point. It is the resulting delivery of new or adjusted services that creates change.

Outcomes Manager allows CCGs and GP networks to influence change in two ways:

  1. GP practices can run matching reports on their practice data. They can identify patients, investigate medical records and make decisions with confidence. Creating care plans for specific diseases can slow down or stop further deterioration. This leads to a better quality of life for these patients. It can also create long-term cost savings for the NHS.
  2. CCGs and networks can build standard data entry and decision support templates. These integrate with the Vision, SystmOne and EMIS systems at GP practices. They encourage all clinicians to be compliant with local care policies during consultations.

Service transformation

The NHS is under increasing strain from a growing and ageing population. At the same time, primary care is under immense pressure.

Any NHS organisation that commissions or delivers healthcare services must find new ways of working. Outcomes Manager catalyses change by offering:

  • a fast and innovative approach to healthcare analytics
  • accurate decision making at scale
  • a simple way to overcome the arduous task of implementing policy changes at GP practices


How to get Outcomes Manager at zero cost

Outcomes Manager is available as a centrally funded solution on GPSoC. There is no cost to GP practices or CCGs. It includes the following templates to get you started, including:

  1. INR management
  2. DMARDs management
  3. Cancer risk
  4. Chronic kidney disease
  5. Frailty

This is how CCGs and GP networks can get Outcomes Manager at zero cost:

1. The GPSoC Tracking Database

The authorised person at the CCG must add Outcomes Manager (decision support templates and advanced data entry forms) to the Tracking Database. We will know when this is complete and can then make the templates and forms available to practices. If you're not sure who the authorised person at your CCG is, ask us using the form at the bottom of the page. We can let you know.

2. Download the templates

GP practices will need to download each template and form before they can use them. This is fast and straightforward. Find out how to download templates and forms.

3. Get started

The templates and forms all integrate with your clinical system to offer:

  • Alerts when patients need a review
  • Clinical decision support
  • Data entry templates that only show relevant information from the patient's record
  • Reports to identify particular patient cohort
Online help, user guides and eLearning tutorials are available for all templates. 

Need help?

Click below and then complete the form for more information or to ask us a question about GPSoC funding.

Ask about health improvement with Vision


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