Presentation (CTI)

OBJECTIVES: Population health management (PHM) using patient-level segmentation is increasingly deployed to improve outcomes and optimise resource use in chronic disease. This study evaluates the impact of a segmentation-driven PHM intervention, delivered through primary care networks in NHS Tower Hamlets, a deprived borough in England, with low primary care access and poor long-term-condition outcomes, on clinical outcomes and non-elective utilisation within a high-need diabetes population.
METHODS: A population segmentation approach was applied to this deprived London borough using linked GP, community, acute and pharmacy data to stratify patients by clinical need and complexity. Segment-specific best-practice care packages and protocols, defined by clinical working groups and tested with patient representatives, were delivered through established primary care networks. GP practices were organised into hubs providing diagnostics, outpatient, urgent and out-of-hours care, with care plans managed primarily by primary care nurses alongside GPs, secondary care clinicians and multidisciplinary teams. Investment in primary care was increased from 9% to 14% of spend. Outcomes were evaluated using routine data following implementation.
RESULTS: Non-elective acute spend decreased by an estimated 12-14%. Disease control improved across all key indicators: an 11% increase in patients achieving blood-pressure targets (<140/80 mmHg), a 10% increase in those with controlled cholesterol (<4.58 mmol/L) and an 8% increase in patients attaining HbA1c targets (<7.5%). The proportion of patients with documented diabetes care plans increased sixfold (600%), accompanied by enhanced care coordination and greater uptake of structured management within primary care networks.
CONCLUSIONS: Population segmentation combined with targeted, network-based care delivery can deliver meaningful improvements in clinical outcomes and reductions in acute utilisation in diabetes populations. The Tower Hamlets model provides a scalable template for shifting from reactive to proactive, segment-driven management of long-term conditions, and laid the foundations for national adoption of the primary care network model across the NHS.