Introduction

Population Health is an approach aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people, while reducing health inequalities within and across a defined population. It includes action to reduce the occurrence of ill-health, including addressing wider determinants of health, and requires working with communities and partner agencies.  

The population health and prevention approach is a key element in the NHS Long Term Plan and embedding population health capacity and capability in the workforce is a key deliverable for NHS England. This is even more relevant in the period of recovery from COVID-19.  There is a lot of stakeholder interest in the fellowship programme and it complements work on population health management undertaken by NHSE through the Population Health Academy.  The relevance/centrality of frontline healthcare practitioners having population health and prevention skills has been recognised increasingly during the current pandemic. 

It has been a privilege to work with SW Population Fellows, their commitment to improving population health outcomes and reducing health inequalities has been outstanding.  I would also like to thank our Public Health Educational Supervisors, the SW Training Programme Team, National NHSE Colleagues and the SW NHSE Regional Director who have worked so hard to make the Programme such a success.

Professor Maggie Rae CBE

FFPH, FRCP (Hon), FRCP Edin, FRCPath (Hon), FFSRH (Hon), FFOM (Hon), FRSPH, FFPM (Hon)

 

Fellowship Programme

NHSE launched the first national multi-professional Population Health Fellowship (PHF) programme for NHS clinical staff in England in 2020. The programme aims to develop and grow a workforce of professionals who will incorporate population health into their everyday jobs and will encourage and support the development of population health strategies and approaches within the NHS and wider community.  It is available across NHSE regions. 

It is a year-long part-time fellowship at 2 days per week and the time is divided between formal learning and undertaking a population health project in their communities.

The fellowship is open to healthcare professionals from a broad range of clinical backgrounds.

The expansion of the Population Health Fellowship Programme will enable the growth of a network of like-minded clinicians who will be able to utilise their acquired competencies to incorporate population health approaches into their local work systems to improve patient outcomes.  

 

Sara Harford

I am a NHS Special Care Dentist and I recently completed my 12-month national population health fellowship with the Bristol, North Somerset and South Gloucestershire (BNSSG) Public Health Team, funded by Health Education England. I am passionate about providing inclusive, holistic care with a strong focus on prevention and I have developed an interest in tackling health inequalities and improving the health of vulnerable groups in our society.

In the first few weeks of my fellowship I spent time getting to know the system and contributing to a project to develop the Integrated Care System’s (ICS) ‘Outcome Framework’. This is a strategic framework underpinned by indictors and data which outlines the ambitions and measurable goals that the system can use to drive improvement in population health and reduce inequalities. I learned about the principles of population health and management and how to access and use relevant data.

As well as engaging with the national fellowship curriculum and contact days, I also developed and led a population health project that aligns with my area of clinical interest. Nationally, care home residents experience worse oral health than the general adult population and appear to have a poorer oral health related quality of life (data source: Public Health England). The aims of my project were to identify what mouth care training and support is currently in place for care home teams across the ICS.  

Through context and stakeholder mapping and qualitative data gathering, I developed and presented a report for the ICS outlining what the gaps and unmet needs are and recommendations of how to address them. I raised awareness of this issue and connected relevant key partners from the health, social care and residential care sector that are working towards improving oral health training and support for care home teams. 

This learning can be used by the ICS to establish what additional resource may be needed to improve mouth care training and support for care home teams, to facilitate implementation of national guidance and ultimately to improve the oral health and related quality of life of the care home population of BNSSG. 

My fellowship gave me opportunities for leadership and collaboration and I hope to continue building on and embed the population health knowledge and skills I have gained to influence positive change and to address our local population health challenges.

Solomon Lebese

I am a GP registrar and very fortunate to have been one of the National HEE Population Health Fellows based in the Southwest. I was hosted by Somerset County Council. I have interests in leadership, people-centred primary care, and public health policy. I believe this triad provides that synergistic point of influence where one can have the most impact on the holistic health of individuals, communities and entire populations.

I applied for the fellowship in order to:  

1. Gain a greater understanding of population health and the wider strategic view of health optimisation
2. Learn how to gather and interpret public health data
3. Learn how to implement and evaluate population health interventions
4. Gain a better understanding of the Somerset Integrated Care System (ICS) and the Population Health Management (PHM) agenda
5. Network and learn from others who have population health and leadership interests.

Under the mentorship and the tutelage of my supervisor I was able to work on several projects. Our projects centred around cardiovascular disease prevention, and in particular hypertension. Our projects recognised the impact of cardiovascular disease on health outcomes, health inequalities and poorer COVID outcomes. Local and national data demonstrated that surveillance and detection of hypertension had decreased during the pandemic. The projects used asset and value-based approaches to develop opportunities to innovate, collaborate and address the unmet needs of hypertension.

We aimed to:

1. Improve hypertension cases detection to 80% from the current levels of 60% and to reduce the health disparities.
2. Reduce the burden of case detection on primary care by boosting the capacity of community screening
3. Empower individuals and communities to know and manage their blood pressure (BP) as part of a healthy lifestyle
4. Pilot new ways of working in primary care to optimise hypertension management

Historically libraries have been vital to communities, more so now with the reinvention and regeneration of Somerset libraries into well-being hubs. Libraries also cater to a wide demographic population and in particular those who may have limited access to digital facilities. We chose Taunton library because it is the largest in the county, it had pre-pandemic footfall of nearly 750 people per day, and we wanted to work with the health coaches at Taunton Library. The health coaches represent 12 GP practices within the Taunton area.

Project 1: We installed the Keito M8 Integrated Health Monitor in the Taunton library for members of the public to collect biometric data, receive lifestyle information, and interact with health coaches.

Project 2: We distributed 212 BP monitors with atrial fibrillation detection to 32 libraries across Somerset where library users could participate in a library loan scheme to facilitate taking a series of home blood pressures readings to diagnose and determine BP concordance.

Project 3: From anecdotal data we knew that GP Practices within the county didn’t have enough BP monitors to loan out to their patients.  We distributed 459 BP monitors to 34 of 65 practices within the county to aid case detection. We prioritised practices with higher deprivation.

Project 4: This project aimed to pilot of a new way of working within primary care to risk stratify patients, increase BP case detection, improve concordance, and improve Quality Outcomes Framework targets. This project is still ongoing.

It has been a rewarding year and I have been privileged to be part of this programme. I am excited and look forward to contributing to population health in the Somerset ICS, in the region and in national initiatives. I am even more committed to being a population health ambassador and champion.

Amy Carmichael

I am a GP trainee with a longstanding interest in public health. Recently I took two years out of training to complete a Masters in Global Health followed by the Health Education England National Population Health Fellowship. The Fellowship was a fantastic experience that has already changed my approach to clinical work by broadening my perspective on health.

My Fellowship was based in Bath and North East Somerset, Swindon and Wiltshire Integrated Care System (ICS). I was supervised by Kate Blackburn, the Director of Public Health for Wiltshire, whose enthusiasm and positivity in leading the public health team was an inspiration.

I completed two main pieces of work during my Fellowship. The first was a report on population health and health inequalities in the ICS. Writing the report allowed me to familiarise myself with the key health issues in the area as well as major sources of data in public health. The report was subsequently quoted in several meetings and strategies, which I hope means it had an impact in the system.

For my second project, I looked into inequalities in access to the ICS Long Covid services. This project aimed to identify specific groups with unmet need for Long Covid services. My data revealed low referral rates for Long Covid in men, people over 70, and people with learning disabilities. I developed a multi-component intervention to improve access for those groups. Components included awareness-raising in male-dominated occupational groups, identification of Long Covid during assessments for assistance aids, and adding a question about Long Covid into the annual health check for people with learning disabilities.

My Fellowship has demystified the world of public health, allowing me to develop an understanding of how health inequalities can be addressed using a systematic approach. I have encountered many of the barriers and challenges common in public health work, and I have practised trying to overcome them. I have learnt about the complexity of public health problems, particularly how variable and nuanced they can be at a local level. I have realised, as a clinician in my community, I have a unique insight into what causes health inequalities locally – and that I should appreciate this insight.

Looking to the future, I hope that my Fellowship experience will give me the confidence to (at least make a start at) addressing some of the health inequalities that I see in my daily clinical practice.

Rebecca Shuttleworth

I am a GP trainee in Exeter. I completed the HEE fellowship with Devon County Council Public Health team. I have worked clinically across Devon and Cornwall, seeing diverse backgrounds including those with multiple conditions living in rural and seaside communities, where access to healthcare can be a major determinant of health. In my clinic role I see how health inequalities and the wider determinants of health play a massive role in outcomes for patients. My experiences thus far have cultivated an interest in population health and health inequalities.

Through the fellowship programme, engaging in HEE contact days and opportunities within the ICS, I had the opportunity to develop my understanding of population health. I have worked to make a difference to patient outcomes in a sustainable way, as well as creating a network of like-minded individuals working in healthcare. I will take my experiences from the fellowship forward in my career as a GP to promoting healthy living and preventative healthcare.

I had opportunity through the fellowship programme to develop skills in leadership and project management. I lead on two main projects

Equitable Access to services – The Long COVID service

Long Covid is a new condition not yet fully understood. Symptoms are varied and can be debilitating for patients. A mainstay of current treatment is rehabilitation through the Long Covid service. Tackling health inequalities is a national priority. In this project I looked at routine data to understand risk factors and health inequalities for Long Covid in Devon along the patient journey from presentation, diagnosis, and referral to the service.

Key findings included lower referral rates to predicted community prevalence particularly in male sex, over 70’s and the most deprived quintile. I worked with key stakeholders to develop recommendations and learning for the ICS including sharing of a methodology to be applied to other priority pathways. Through this project I developed skills in understanding data and its applications in public health.

Making Every Contact Count (MECC) – Vaccine Uptake

MECC was identified by the Devon System Seasonal Vaccination Programme (Flu and Covid) Health Inequalities Cell as a priority area. I led this workstream for the cell. Responsibilities including chairing meetings with attendees across the ICS and making links between key stakeholders across the ICS. I facilitated discussions between training leads and MECC leads to develop a programme which incorporated MECC into business as usual for the mass vaccination programme.

In this project I developed practical leadership skills in project management from chairing meetings and developing the project plan as well as engaging stakeholders and embedding the project into the organisational structure.

Rachael Barratt

 

I am a Dietitian with an MSc Nutrition for Global Health, and I recently completed a 1-year Population Health Fellowship funded by Health Education England.

I have long been interested in population health both in the UK and developing countries, particularly in relation to nutrition. My clinical experience has been largely community-based, along with some projects overseas, which has led me to consider the wider determinants of health and how we can reduce health inequalities. I was keen to learn more about this so thrilled to be offered one of the fellowship positions in the south-west. My fellowship was hosted by NHS Gloucestershire CCG, in partnership with Gloucestershire County Council, as part of the Healthy Individuals and Communities (Prevention) Team. My lead supervisor Jo Underwood (Transformation Programme Director) has been an inspiration to me throughout, and I have gained both personally and professionally as a result of her unfailing support throughout the year.

My main project focussed on the population health issue of obesity. With nearly two-thirds of adults in England identified as overweight or obese, the challenge of obesity management is a major public health concern. Obesity rates are not spread equally across society and inequalities exist in relation to deprivation, ethnicity, gender, geography and mental illness. Differences in obesity rates translate to worse health outcomes for people in more deprived areas and contribute to health inequalities. Guidelines to reduce obesity include routine monitoring of body mass index (BMI) in primary care, with referral to weight management services as appropriate. My project involved primarily desktop analysis of the county’s adult primary care data relating to recording of BMI and weight management interventions, evaluated against risk factors such as deprivation and ethnicity to explore potential inequalities.

The main findings from this project were that over the course of 3-years, three-quarters of patients had a GP appointment, and half had a weight or BMI recorded during that time. Only 7.6% of those identified as obese (BMI 30+) and 0.8% of those overweight (BMI 25-29.9) were recorded as being offered a referral to weight management services, despite the wide range of options available in the region. Some potential inequalities were observed but further analysis is needed, particularly consideration of those with missing BMI data and what this means, and qualitative research to understand more about why. This has implications for population health as obesity disproportionately affects people who are already at a disadvantage and it will widen inequalities if they are not being screened, diagnosed, or referred for the support that is available.

The outcomes of this project will be shared with the Gloucestershire Integrated Care System’s Weight Management Steering Group which includes the county leads for the healthy lifestyles priority in the local Health and Wellbeing Strategy, which focuses on obesity reduction. I also completed a poster summarising this work and was honoured to receive recognition for this at the Health Inequalities conference in London, when I won a prize. This poster will be used by Gloucestershire ICB to summarise this work alongside a more detailed report I produced, and for further promotion of the population health fellowship.

Overall, this fellowship experience has given me valuable insight into working in population health. I have welcomed both the practical element of my project and the more theoretical national training days, as well as networking opportunities. I look forward to building on everything I have learned over the past year and incorporating some of the principles of a population health approach within clinical dietetics.

Grainne Ford

 

I am a registered dietitian and work in acute care managing a team of dietitians at the newly merged University Hospitals Dorset. I was delighted to be successful in the HEE PHM fellowship and have learnt so much in the last twelve months. As an operational manager I can see services in the acute sector are constantly under pressure and I wanted to explore how we might develop more effective models of care across the system to optimise the health and well-being of our Dorset residents. In my everyday operational role, I constantly ask myself if we are effective and reaching those people who need us the most. As a dietitian, I’m aware, that if we can develop a strong prevention agenda, we can move from reactive to proactive healthcare services for our populations. I am passionate about the skills and opportunities that, not only Dietitians, but that all AHPs can bring to the population heath agenda.  

 

Kemi Gibson

 

I recently completed a transformative 12-month national population health fellowship with Bath and Northeast Somerset Council, a period that has been both enlightening and rewarding. Under the guidance of Annette Luker, a remarkable Consultant in Public Health, I was not only supported but also inspired by her exceptional leadership and unwavering enthusiasm for my project. It's undeniable that her mentorship played a pivotal role in shaping my experience.

This fellowship was made possible through the funding provided by NHS England, which allowed me to explore my passion for delivering inclusive care with a robust emphasis on providing equitable healthcare for all. Notably, I've developed a keen interest in using data to find health inequalities amongst a patients care pathway and driving positive changes for marginalized groups within our society through the completion of my project.

 Throughout the fellowship, my participation in our online educational sessions and networking opportunities with fellow public health professionals during conferences has been invaluable. These experiences have significantly enhanced my understanding of health inequalities and the myriad strategies available for addressing them effectively – a piece a knowledge that I has been invaluable and has further gone on to influence my day-to-day role as a medicine optimisation pharmacist, where I have now consistently challenged myself to view projects related to pharmacy through a health inequalities lens.

Rob Henneberry

 

I am a GP registrar in the Exeter training programme. I recently completed the Population Health Fellowship. My placement was with the Devon County Council Public Health team. I worked within the Health Intelligence team. I was supervised by Simon Chant, consultant in Public Health. I had a previous interest in Public Health and specifically The Social Determinants of Health, Homelessness and Housing as well as Welfare policy. I had completed a masters of Population Health at University College London. 

My project was a service evaluation of Social Prescribing in Devon. I utilised a new cross-Devon database, the One Devon Dataset, to perform my evaluation. This is a powerful database that contains longitudinal data from over 700,000 individuals with combined information from primary care, secondary care, mental health trusts, social services and policing. I used a statistical technique called Propensity Score Matching to construct a control group with very similar characteristics to the group who had received social prescribing. This allowed the comparison of patterns of Health service usage in 16,200 socially prescribed individuals with an equal number of very similar controls over time. I also analysed patterns of referral to social prescription to better understand who tends to be referred to the service. 

We found that health service usage increased more over time following the prescription in the socially prescribed group than the control. This is not what we had expected to find. This has stimulated discussion within the Public Health Department, and the project is ongoing with further data being gathered and reported over time. From our scoping and literature review we postulated that the changes seen were best explained by the fact that someone receiving a social prescription is often ‘in crisis’ and that the prescription can be seen as a surrogate for this. I feel that this means that even with very good matching of measured characteristics between treatment and control, those in the treatment group probably are more likely to be in crisis (not an easily measurable or reportable characteristic) and thus access healthcare more. Therefore one should not draw the conclusion that Social Prescribing ‘doesn’t work’, rather that those in receipt of a prescription are likely to need more support from other services, that Social Prescribing should not be used as a substitute for these services, and that Social Prescribing should where possible be targeted further upstream in the journey to ill health. 

I took a lot away from the fellowship. I built on data handling and analysis skills and am now, having used it once before in my masters, very adept in Propensity Score matching, which is quite a niche skill! I also learned to use the statistical programme R during the fellowship. I performed a literature review as part of the project, which is also a first. I also developed softer skills in scoping of the project with various stakeholders and in presenting, interpreting and discussing results within the department. The Public Health environment is very different to the NHS so it was amazing to see how everything worked and also have the time and space to network and influence within the teams I worked in. 

I am close to completing my GP training now. My long term goal is to have a portfolio career that contains work within specialist Primary Care Homelessness services and Population Health Management or research within this field. The network of contacts I have developed during this time will be very useful in achieving this goal.

 A particularly noteworthy aspect of my journey was the undertaking of a project focused on understanding the relationship between an individual's socio-economic and demographic background and their wait times and outpatient referrals for elective surgery across Bath, Swindon, and Wiltshire (BSW). The overarching objective was to improve access to care for all, through analysis of local population data, engagement with key influential stakeholders, showcase examples of good practice, and recommend a series of next steps to follow. I collaborated well with our Business Intelligence Manager to help collect and visualise data metrics that described the flow of patients through the referral-to-treatment (RTT) pathway. Using this piece of information I was able to present at a series of meeting with members representing the three largest hospital trusts that span across BSW, and the public health team. During these sessions, I highlighted potential disparities in access to elective care at various points in the pathway, leveraging the opportunity to gain system operational insights behind the data. The meetings proved eye-opening, sparking further inquiries to grasp the issues at hand. In the end, I felt proud that I was able to outline potential points within a patients journey towards elective care, where they are most likely to face inequities.

 This project was an intricate blend of challenges and excitement, constantly pushing me beyond my comfort zone. This fellowship taught me the crucial skill of storytelling with data, crafting a compelling narrative with the intent of fostering positive change for the most vulnerable in our society. As I reflect on my fellowship journey, I am filled with a sense of accomplishment, knowing that my contributions have acted as a catalyst for further investigation in this area for BSW. The learning, growth, and connections established during this period will undoubtedly serve as an enduring foundation as I continue my pursuit of equitable healthcare and innovative solutions to address health disparities in our society.

 

Dannielle Rees

I am a Service Improvement Manager working for Gloucestershire Local Maternity and Neonatal System within the ICB. I undertook my fellowship from September 2022 to September 2023, with Gloucestershire County Council as my host organisation. I found the fellowship really interesting; I learned a lot through the teaching sessions, and applied what I had learned from these to my fellowship project.

The project was a great way to meet colleagues both in the County Council and in the NHS, many of whom I had not met in my role as Service Improvement Manager. My project itself was to look into what we know about babies in care and their mothers, in Gloucestershire. This involved a lot of data analysis which I discovered I really enjoyed and is something I would like to be more involved in in the future. I chaired a multi-agency project group as part of my project and was able to share the feedback from this group with other services working to support women who have had – or are at risking of having – babies taken into care.

Since completing my project I have presented my report to service leads at the County Council and shared it with a wide number of other colleagues across the health and social care system. I have received feedback from a number of people who are interested in using my project findings to make improvements to services, so I am keen to see what happens next.

 

Jane Clarke

I am a Clinical Specialist Physiotherapist who until July 2024 led the Bath and Northeast Somerset, Swindon and Wiltshire Health and Care Long Covid service. The population health fellowship has been the best learning experience I have ever undertaken in my 25 years of Physiotherapy. I applied for the fellowship as felt I was an emerging leader who wanted to better understand population health, health inequalities, inclusion and diversity and apply this knowledge, skills and experiences to my current and future NHS roles. I wanted this experience to help me to shape services that are inclusive and where possible more prevention focused.

The fellowship has taught me about population health specifically reviewing data sets to better understand our local populations and their differing needs. It has helped me to understand how our wider systems work and interact especially in relation to funding streams, and whilst that may sound dry in fact it was one of my favourite learning moments, the pieces of a jigsaw slotted into place for me. This has helped me to frame ideas and projects in a way that better matches different stakeholder agendas. It has crucially shaped my leadership skills, given me to time to reflect on the leader and/or influencer I want to be and given me opportunities to try out new approaches.

I have worked on projects increasing uptake of Covid and Flu vaccination rates in a PCN in Swindon using a Make Every Contact Count style of telephone conversation and I have led a feasibility project proactively case finding people with long term conditions and offering a self-management enhancing service. These were very different projects providing opportunities to use population health project management tools and work directly with local authorities, charities, PCN colleagues, Public Health Consultants and the ICB. Alongside this I had invaluable mentorship from Lucy Heath, Bath and Northeast Somerset, Swindon and Wiltshire Health and Care ICB Health and Care Director, and a qualified Public Health Consultant, she helped me to broaden my vision, warmly critiqued projects and nurtured my growth of skills and knowledge.

This fellowship has achieved the goal of shaping me to be a motivated and energetic leader who is a positive disruptor committed to improving population health. I am determined to advocate and shape services to meet the needs of our patients. I have started a new role as Head of Service Redesign within Wiltshire Health and Care, this fellowship was key to my securing this post.

 

Amelia Page

 

 

 

I am a Paediatric registrar completing specialist training in Community Child Health in the Severn Deanery. I have always been interested in the wider determinants of health, and my recently completed NHSE Population Health Fellowship was the perfect opportunity to develop my skills and experience in this area. For the placement part of the Fellowship, I worked in the Devon County Council Public Heath Team, supervised by Dr Emily Youngman, Consultant in Public Health and lead for the Children, Young People’s and Families team.

The fellowship felt like a completely immersive learning experience. I loved the taught programme, which was rich and varied, and led by some truly inspiring speakers. The chance to become part of a community of learners and support each as other as group of fellows along our fellowship journey was invaluable. I met a group of like-minded individuals, many of whom I will keep in contact with as we go back into our NHS work as population health champions! The fellowship also allowed me to take a wider view, with time and opportunity for a broad range of educational and networking opportunities that would not have been possible in my usual role. It was especially interesting to experience the different world of a Local Authority, having worked within the NHS for so many years. I now understand better how the Public Health team, the ICB and ICS operate and interact, so that I can better liaise with and influence them as a Population Health minded clinician. I have enjoyed deepening my understanding of both the theory and practice of Population Health and look forwards to applying this experience to my NHS role as a Community Paediatrician; an area of medicine where I see the impact of health inequalities on a daily basis. I know the skills gained will help me better serve the community in which I work and improve outcomes for the children and the young people I care for.

Project: Exploring inequalities in school readiness in Devon using linked Education, Health and Social Care data

Aim: To explore inequalities in the school readiness of children in Devon in 2023 using linked Education, Health and Social Care data.

Background: School readiness is a key measure in population health; as both a marker of a good start in life and a predictor of health and educational outcomes. However there are significant inequalities in school readiness, largely related to socio-economic factors. Linked data may help understand local inequalities on an issue that spans the early years sector.

Methodology: Data sharing agreements were in place and a Data Protection Impact Assessment was completed. Devon County Council Education, Public Health Nursing and Social Care data were matched to create a linked dataset in PowerBI. The primary outcome was the Early Years Foundation Stage ‘Good Level of Development’ (GLD) school readiness measure. Associations with child, family, service and area factors were explored using descriptive statistics, Odds Ratios (OR) and 95% Confidence intervals (CI).

Results: 7471 children in Devon in 2023 had school readiness data. Key factors associated with not being school ready included being a boy (OR 1.79, 95% CI 1.63-1.98), English as additional language (1.85, 1.53-2.24), Summer-born (1.82, 1.64-2.01), developmental problems at 2 years (4.69, 3.82-5.76), Special Educational Needs (SEN) or an Education, Health and Care Plan (11.17, 9.34-13.35), eligibility for free school meals (2.73, 2.39-3.13), family having an Early Help Assessment (4.43, 3.77-5.21), not attending Early Years education (2.44, 1.71-3.50), Devon District (GLD range 62.5-74.8%) and area-level deprivation (GLD 58.2% in most deprived quintile to 78.4% in least deprived).

Conclusions: The findings support existing evidence on wider determinants of school readiness and highlight these patterns in Devon. Implications for policy and practice include addressing child poverty and adversity, and mitigating impacts on child development with better early, integrated support. The project generated learning for data management systems and data linkage to explore cross-sectoral issues.

 

Pabalelo Pule

I am cardiovascular research nurse at University Hospitals Dorset (UHD) specialising in cardiology, stroke, diabetes and endocrine. I had an incredibly rewarding opportunity to be part of the September 2023/2024 population health fellowship cohort funded by NHS England.  My fellowship host was Population Health Management (PHM) Dorset, where I got the opportunity to work with a wider PHM team, which also equipped me with a broad understanding of PHM.

As part of the fellowship, I went through robust educational sessions facilitated by HEE for the first half of the programme. This part of the programme equipped me with an in-depth understanding of wider determinants of health, health promotion, prevention, protection, improvement, epidemiology and learning how to navigate through various datasets and interrogate data, just to mention a few.

I worked with the wider PHM team on a cardiovascular disease (CVD) prevent project where we had identified three priority cohorts i.e., (i) diverse ethnic communities (DEC)- black ethnicity, (ii) lower socioeconomic groups- deprivation and (iii) elderly- 80 years+. Evidence suggests significant health inequalities linked to CVDs, and those from identified backgrounds have more risk factors, hence these three cohorts were a priority. Furthermore, since hypertension is a fundamental adaptable risk factor for cardiovascular diseases: the leading cause of death in the UK, this suggests that optimising blood pressure would reduce morbidity and mortality rate hence the need for this project.

During my fellowship journey, I had the opportunity to interrogate data, explore scientific literature review to understand barriers to health-care service access by the three identified cohorts and understand how to engage with people in these communities to tailor services according to their needs. Findings from this piece of work was shared with Primary Care Networks as recommendations towards supporting and providing tailored health care services to unrepresented communities aiming to tackle health inequalities, working towards preventing CVD events.

Overall, this programme has provided good opportunities like attending population health conferences, presenting my work at university and research events, building strong connections with other fellows, public health consultants, academics and enabling collaborative work in population health.

Moreover, this programme has empowered me to work collaboratively with multi-professionals on taking initiatives towards facilitating population health projects aiming at delivering the best care possible to our communities and work with executive and non-executive health inequalities board of directors. I decided to give back to my organisation and decided to continue working on this project by conducting a survey at my organisation to gain insight from staff members from DEC. This insight enabled me to introduce the CVD prevent project at my organisation, utilising my organisation as an anchor institution by offering NHS health checks services within the organisation, in collaboration with internal health and wellbeing department, staff networks (Diverse Ethnicity Network) and Live Well Dorset. With engagement and support of UHD staff from DEC, this project has been introduced to the wider community in Dorset like community events, religious communities, and various nationality communities.

 

Simon Strange

 

 

 

Alcohol Detoxification in Somerset. A Service Evaluation

Aim

To improve the provision of inpatient alcohol detoxification in Somerset.

Background and Literature Review

There has been a shift in demand from specialist to non-specialist alcohol admissions due to policy changes in England in 2012. This may be explained by a reduction in funding and increasing complexity and clinical needs of the service users (Phillips, Huang et al. 2020).

Non-specialist admissions for alcohol withdrawal are briefer than recommended (NICE CG115, 2011) which means that many will still experience symptoms after discharge, they are less likely to engage in follow-up and more likely to relapse and be readmitted to hospital (Neighbors, Yerneni et al. 2018).

The Nature and Size of the problem

Alcohol misuse is the biggest risk factor for death, ill-health, and disability among 15–49-year-olds in the UK.

In Somerset in 2021/22 there were 3,428 hospital admissions for alcohol specific conditions, and 260 deaths from alcohol related causes.

Providing timely access to high a local, high-quality alcohol detoxification programme within the NHS, supported by the drug and alcohol service, will help to address this unmet need.

Results

From speaking with staff and service users from different organisations, I discovered the following themes that have a negative impact on planned alcohol detoxification admissions.

It is difficult to find a facility who can meet the needs of complex cases. This include those people who are not self-caring, the homeless, those with poor mobility, severe neurological disability, and those with a mental illness.

Waiting times can be up to 3 months from point of referral to starting a placement. Reasons for delays include incomplete referral information, obtaining blood tests from GP within specific timeframe, obtaining reports from other healthcare providers and access to healthcare records. Delayed, rescheduled, or cancelled placements can lead to service user disillusionment, relapse and disengagement with services.

Out of area placements can be expensive and inconvenient. Factors include the availability and cost of public or private transport to get to and from the facility, including chaperones, time away from employment or caring roles during assessment and treatment and the remoteness from home support.

I analysed local hospital data on acute admissions in alcohol withdrawal, to provide a baseline to measure against changes in service provision and regional variations in practice.

Conclusion

A joint working group was established with the community drug and alcohol team and the NHS acute hospital alcohol care teams. The teams agreed to better working relationships and to co-design a pathway for managing medically complex group of alcohol dependent patients. This would include assessment by multi-agency team, preparation and follow-up care in the community, medically assisted alcohol withdrawal in an NHS facility, and facilitated discharge. A pilot project would be initially funded for a year, and include an economic evaluation and clinically relevant outcome measures, such as changes in acute admissions to NHS hospitals for alcohol related harm.

 

Rob Maybin

 

 

 

'I am a clinical fellow in Perioperative medicine working in Cornwall. I undertook this fellowship in addition to my clinical work to further pursue a longstanding interest in healthcare data analytics, critical care and public health intelligence work.  

 

The HEE National Population Health fellowship was a great opportunity to learn from several highly capable and motivated individuals within population health faculty to understand greater how the wider determinants could be specifically intervened on to improve healthcare outcomes.

 

During my fellowship, I performed a health equity audit examining the effect of the Deprivation on outcomes in colorectal cancer patients who underwent surgery. This involved scoping and building working clinical relationships between Public Health and Critical Care in Cornwall, a literature review to examine current evidence, service evaluation, data collection, statistical analysis and write-up. I have written this project up as multiple posters, presented at several meetings and the report outcomes will aid the development of the newly developing pre-habilitation service in Cornwall aiding their data collection protocol.

 

My fellowship was based at the Royal Cornwall Hospital and I was mentored by Dr Eunan O’Neil, Public Health Cornwall Council and Centre Director Cornwall Health Determinants Research Collaboration. I have learnt a great deal working alongside a Public Health Consultant and am extremely grateful for guidance he has given me over the course of this fellowship. My experience of this faculty and the fellowship is of a group of people who are interested in a broad range of issues and wish to develop and lend a hand to help us out as trainees. Eunan and the South West faculty were an outstanding example of this, and I’d encourage clinicians of any background and stage of training to explore this opportunity, as I’ve learnt a great deal. 

 

My fellowship has been an insight into a novel way of looking at challenges and approaching the cause of a problem through appraising the whole of a process. Taking this long view and examining how resources are allocated and misallocated has altered my perspective of how services can, and perhaps should, be delivered in order to benefit as much of society as possible. Without doubt, all specialities could develop their service through Population health’s insights.

 

This fellowship has demonstrated to me that there in an increasing need for an interplay between medical disciplines to aid communication, with data often being a common but challenging language. This fellowship has immediately led to my role as a Clinical Project Manager for development of AI driven risk predictive tools in diabetic patients and high BMI patients awaiting an operation. In the future, I wish to bring together my interest in Pre-hospital Critical Care/ Search and Rescue together with healthcare intelligence, modelling and analytics to predict and better resource acute service demands'

 

Emily Phillips

 

I am a GP registrar with a keen interest in public and population health, which I developed during my Diploma in Tropical Medicine and Hygiene. As a resident doctor in patient-facing services, I was driven to learn about the functioning of integrated care systems and their role in delivering optimal care for populations. This passion was further strengthened during my time at a deprived GP practice, where I witnessed the impact of inequalities in access to the wider determinants of health on community wellbeing.

The National Population Health Fellowship has provided me with an invaluable opportunity to work within an integrated care system, enhancing my understanding of organisational communication and healthcare provision. During this fellowship, I collaborated with the Public Health team at Bristol City Council and the Population Health team across the Bristol, North Somerset, and South Gloucestershire (BNSSG) Integrated Care Board (ICB), under the supervision of Dr Viv Harrison, Consultant in Public Health. Working with the Population Health team was a highlight of the fellowship, as it was inspiring to engage with dedicated individuals advocating for communities affected by health inequalities.

The teaching programme organised by the fellowship team was outstanding. Some of my key highlights included gaining insights into the structure of the NHS, understanding funding flows within the system, and participating in discussions on leadership. Reflection was a central aspect of this fellowship, which I found immensely beneficial, as it allowed me to step back and assess my achievements.

In the project titled "Patient Perspectives of Cardiovascular Multimorbidity and Healthcare Services in the BNSSG with Recommendations for Improving Patient Outcomes," I built upon work previously undertaken by the Population Health Management Team, which segmented the BNSSG population based on the number of health conditions (Cambridge Multimorbidity Score) and levels of healthcare expenditure. This project focused on patients in segment 5, who represent approximately 3% of the BNSSG population and experience multiple health conditions alongside high healthcare spending.

Patients in segment 5 were grouped according to their medical conditions, revealing that around one quarter (26%) have multiple cardiac comorbidities. This group was designated as ‘Cluster 6’, and I performed quantitative data analysis to better understand the demographics of this cohort. Following this analysis, I conducted 11 interviews to gather patient perspectives on various aspects of the healthcare they had received. Their experiences of primary care, secondary care, and any additional care were examined, highlighting both effective elements and barriers encountered.

Recommendations for improving healthcare for this population were developed for consideration at various levels of the system, including primary care, secondary care, and system-wide initiatives.

This project, combined with formal teaching, has significantly enhanced my understanding of population health management, quantitative and qualitative research methods, and the challenges faced by healthcare systems. The fellowship has inspired me to seek roles that further develop my leadership skills, and I am currently a fellow in the Faculty of Medical Leadership and Management's National Medical Directors Clinical Fellow Scheme. The Population Health Fellowship was instrumental in helping me secure this role, and I will leverage the skills and knowledge I acquired to address health inequalities on a broader scale.

This page was last updated January 6th 2025 (26 days ago)