Norfolk and Suffolk ICB has published details of its digital weight management programme, highlighting the contribution of a population health management approach to achieving “significant” outcomes.
The report, informed by work undertaken through the population health management programme, clinical steering group, and research and innovation teams, highlights the use of the Eclipse platform in identifying eligible residents. Those identified are then proactively contacted by a virtual support team to offer referral and support into weight management services.
Over 2025/26 the programme received 4,458 referrals, reaching 187 percent of its target, reportedly making Norfolk and Waveney the highest performing ICB nationally. The ICB shares that 92 percent of practices referred patients into the programme, with referral quality reaching 94 percent.
“This example demonstrates how proactive identification and patient engagement can improve access, reduce unwarranted variation and support equitable uptake of preventative interventions,” it states. “Whilst the focus of this example has been for Norfolk and Waveney there are emerging opportunities to implement across the ICB footprint.”
The ICB is now in the process of expanding the availability of its Eclipse population health management tool to inform system efforts around similar initiatives. It also establishes its offer to providers, with the Eclipse tool offering access to linked data, cohorts, and digital pathways; support available in the development and delivery of population health management programmes; access to the ICB data hub and Atlas segmentation tool; and involvement from the virtual support team.
Reflecting on performance for population health and inequalities across the 2025/26 period, the ICB notes “particularly strong performance” in serious mental illness health checks, with coverage reaching 65 percent. “System discussions highlighted focused leadership on cardiovascular disease prevention and wider ambitions around neighbourhood health and early intervention,” the board reports.
Further improvement is required in some areas, it continues, including breast screening and learning disability annual health check delivery. Variation in place maturity and neighbourhood development has the potential to affect consistency and the pace of population health delivery across the region, it adds.
Wider trend: Population health
Central London Community Healthcare NHS Trust has published a plan of action for population health and neighbourhood infrastructure, outlining a shared outcomes framework to support collective leadership, along with four proposed neighbourhood health aims aligned with the National Neighbourhood Health Framework. Sharing an ambition to develop neighbourhood infrastructure as a strategic capability and provide the foundations for integrated working at place level, the trust looks to establish a consistent integrated neighbourhood model across all places, using population health management to reduce inequalities and improve outcomes, and optimise care pathways to be person-centred, proactive, and neighbourhood-based.
University Hospitals of Liverpool Group is seeking feedback on its five-year strategy developed using population health data – “a once in a generation opportunity to make bold changes and transform patient care for the future”. Chief executive James Sumner commented: “We need to think differently about the way we work and take a totally different approach if we want to shift the dial and make things better for our population. This is your opportunity to take a look at our proposed plan for the next five years. It outlines the challenge and what we need to do, but we need your support in starting to think about how we do it.”
The Derby & Derbyshire, Lincolnshire, and Nottingham & Nottinghamshire (DLN) ICB cluster has published a five-year strategic commissioning and population health improvement plan, detailing the role of digital in supporting system ambitions to 2031. DLN notes a “decisive shift” from traditional commissioning to a “should cost/should deliver” model with focuses on the three shifts toward prevention, care closer to home, and digital. “Strengthened data, intelligence, and digital innovation will underpin this more mature population health management approach, enabling targeted action to improve outcomes and reduce inequalities,” it states.
