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 Health Education England (HEE). 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/I 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 HEE Colleagues and the SW HEE Regional Director who have worked so hard to make the Programme such a success.

Professor Maggie Rae FFPH, FRCP (Hon), FRCP Edin, FRCPath (Hon), FFSRH (Hon), FFOM (Hon), FRSPH


Fellowship Programme

HEE 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 HEE 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.  

For me personally I feel this has been a great opportunity to think outside of the acute healthcare setting and to remind myself and others that healthcare is not just about what happens in hospitals. My ambition is for our healthcare system to be a shared partnership between all professions including medics, AHPs, nurses and scientists.  

The PMH fellowship programme aim is to develop healthcare professionals to have the skills and understanding to incorporate population health into their local work systems to improve patient outcomes. 

It’s made up of three components. Firstly, the national programme is delivered via online, teaching sessions. There is a lead facilitator throughout and guest speakers from various professional and organisational backgrounds delivering the set programme topics. This ranges from public health academics teaching on behaviour change to the deputy director of a public health system explaining the relationship between the political system and public health. I found this diversity in delivery very beneficial and helped to broaden my understanding of systems. 

An effective buddy group system pairing you with 3-4 other fellows was put in place. Opportunity was given within teaching sessions to spend time considering & questioning the teaching topic. This provides you with many different insights and points of views to develop reflective learning. This combination of learning from peers with different backgrounds has been a great opportunity to expand my thinking and learning. It has also been valuable for me to feel confident in how well placed AHPs are to take forward the PHM agenda. 

During the fellowship you are encouraged to seek out connections in your local area and profession to further your knowledge. This is something I wouldn’t have done in my normal day job and was a great opportunity to network and expand my horizons. 

The second element of the fellowship is working with your local host organisation and setting up a population health project. I was hosted by Dorset CCG and through my host organisation I have learned so much about our voluntary, local authority and social care organisations that exist and the work they do.For me the gift of that time and facility to share ideas and discuss concepts has aided my development and given me opportunity to take a broader look at health. My host organisation has also given me opportunities to get involved in PHM intervention design work at multisystem level. Experiencing PHM at 3 levels – Elective Care, Primary Care and at PLACE has developed my skills in the process of selecting a cohort of patients by considering wider determinants of health whilst connecting & learning about our wider healthcare system partners.  

My project aim was to apply a population health management approach to the post covid-19 elective care waiting lists and to identify and address health inequalities. I worked across boundaries with a diverse set of organisations. Within a project group we explored inequalities in waiting times including risk factors such as obesity, depression and deprivation. By bringing together data from across health & care into a linked data model, we got a holistic view of population health. Working as a multi system group we discussed and considered ways to tackle health inequalities in elective care and we questioned the data in real time to refine the patient cohorts we would focus on. We selected two cohorts andagreed the scope of the intervention and the outcome measures. We designed an intervention to pilot with a small number of the population, to allow adaptation, offering to help manage their health and well-being using a menu of existing local services.  

What next for me 

  • Use my sphere of influence to raise awareness of health inequality amongst secondary care colleagues/Dietitians/AHPs. To consider how we make space to think about system equality, service accessibility, personalisation and health literacy for our patients. 

  • Undertake PHM intervention design in my service-already started with IBS service redesign. 

  • Continued involvement in my local AHP public health forum. 

  • Build on my partnership working across the Dorset system in particular develop further the public health dietetic student placements that I instigated.  


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.

John McGuinness

I am a GP in Torbay and recently completed a Population Health Fellowship hosted by the Torbay Public Health Team and Devon Training Hub. My fellowship was focussed on cardiovascular disease within the Paignton & Brixham PCN.

I setup and delivered an outreach NHS Health Check pilot at three community sites in Paignton. These sites were chosen to target areas of high deprivation and residents who may not access the traditional health check. We used a point of care testing machine to allow a health check to be completed at the time and co-located with our social prescribing team as part of a holistic offer. The pilot reached 33 people and identified new cases of prediabetes, hypertension and elevated Q-risk. The learning showed the importance of relationships with community organizations and leaders in reaching people in need and how a wider eligibility criteria helped to pick up people at risk outside the traditional health check eligibility.

Within the PCN, we redesigned the hypertension pathway and used UCL Partners proactive frameworks to segment our population and focus on patients most in need. Pharmacist led clinics were setup to support moving workload away from GPs. Our hypertension registries and overall control has improved.

Working collaboratively with the Paignton Community Hub, I supported them to deliver blood pressure checks in the community for anyone already accessing the library or hub. Within 3 months they did over 130 BP checks and now offer this service daily.

A Healthy Hearts in the Community Workshop provided an opportunity for 25 people from across the NHS, VCSE, and local lived experience patient groups to come together, listen and share their learning and experience. Together we discussed ‘How can we work together to build heart healthy communities in Torbay?’. The outputs from this work contributed to the Torbay Public Health Annual Report 2023 and ideas to take forward into future heart health communities.

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.