LBH Social Services Interventions

Project Summary

The aim of the project is to link primary care and secondary care data to adult social care records on an individual level to understand the prevalence of multimorbidity and healthcare usage among those people with short and long term social care packages in order to target potential interventions such as digital CBT promoted through social services.  Linking at individual level and aggregating to larger geographies and/or population groups allows an accurate picture of health care needs of social care clients and future system pressures. One can also potentially identify areas or groups at risk of needing more intensive health and social care input in the future with the aim of putting in preventative measures (eg digital CBT or other social prescribing). The data may also identify areas where high levels of need lead to patient pathways that result in high levels of utilisation and adverse outcomes or where there is a mismatch between utilisation and need.

Project population

All patients currently registered, left or died on 1st April 2017 registered at a GP in Newham, Tower Hamlets, Waltham Forest and City & Hackney localities within North East London ICB, and Homerton and Barts Health Hospital trusts, with a matched NHS number from MOSAIC social care database who are resident in Hackney and the City of London (defined by LSOA2011).

Project cohort

All patients

Project criteria

• Generic primary care data:
  • Pseudonymised ID
  • PracticeCode
  • Registration start date
  • Gender
  • Age at index date (1/4/2017)
  • Year of death
  • Lower super output layer LSOA2011
  • Ethnicity code term Census (2001 or 2011)
  • Interpreter needed
  • Main Language Spoken
  • Housebound
  • Carehome status
  • Lives alone
  • Homeless
• Current Smoker
• Alcohol consumption
• FULL AUDIT Score
• AUDIT C Score
• Substance misuse
• Body Mass Index
• Serum Cholesterol
• Registered blind
• Deaf affected
• Frailty
• Long term conditions:
  • Asthma [QOF]
  • Atrial fibrillation [QOF]
  • Cancer [QOF]
  • Coronary Heart Disease [QOF]
  • Chronic kidney disease [QOF]
  • Chronic obstructive Pulmonary Disease [QOF]
  • Dementia [QOF]
  • Depression [QOF]
  • Diabetes (Type 1 & 2) [QOF]
  • Epilepsy [QOF]
  • Heart failure [QOF]
  • Hypertension [QOF]
  • Learning Disabilities [QOF]
  • Mental Health (SMI) [QOF]
  • Obesity (QOF)
  • Osteporosis [QOF]
  • Palliative care [QOF]
  • Peripheral arterial disease [QOF]
  • Rheumatoid arthritis [QOF]
  • Stroke/TIA [QOF]
  • Glaucoma
  • HIV
  • Hepatitis B
  • Hepatitis C
  • Inflammatory bowel disease
  • Liver disease
  • Motor neurone disease
  • Multiple sclerosis
  • Muscular dystrophy
  • Parkinson's disease
  • Chronic back pain
  • Gout
  • Sickle cell disease
  • Thyroid disorders
  • Total count of long term conditions
• Healthcase use:
  • Count of consultations in the GP surgery by a GP
  • Count of telephone consultations by a GP
  • Count of home visits by a GP
  • Count of emergency department attendances
  • Count of unplanned emergency admissions (spells)

Data state

Pseudonymised linked data set using NHS number - single line per person/patient

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