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Patient Population Report One-Pager

Track a patient group's outcomes over a year. Health partnerships use it to plan care.

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What’s on It

  • Picture chartThirteen in Twenty Are Now in Control
  • Change between two pointsWhat Twelve Months Changed (%)
  • Breakdown of a totalSix in Ten Live in the Two Poorest Fifths
  • RecommendationsWhere the Next $244k Goes

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Population Health: Diabetes Cohort
Wrenfield Health Partnership · 8,420 adults on the register · Twelve-month review
Thirteen in Twenty Are Now in Control
13 of 20
5,473 of the 8,420 adults on the register hold HbA1c under 58 mmol/mol. Twelve months ago it was fewer than ten in twenty.
What Twelve Months Changed (%)
At referralAt 12 monthsIn control 4765On 4+ medicines 3428No annual review 229
Six in Ten Live in the Two Poorest Fifths
Most deprived fifth34%
Second fifth26%
Third fifth19%
Fourth and fifth21%
Where the Next $244k Goes
High priorityA nurse-led clinic in the three most deprived practices
5,052 people on the register live in the two poorest fifths, and they hold most of the missed reviews. A clinic on their doorstep costs less than the admissions it prevents.
Cost: $180k a yearReaches: 5,052 peopleOwner: Community services
Medium priorityFold the annual review into one appointment
758 people have not been reviewed in a year. Bloods, feet and eyes currently mean three separate visits, and the people who miss one miss all three.
Cost: $64kLive by: AprilOwner: Primary care network
Funding requested
$244k
Board decision
9 October
Status
Recommended

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