Population Health Fellows
Case Studies – Cohort 5
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 NHS England Colleagues and the SW NHS England 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) FRSM
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.
Cat Medley
I am a Regional Manager for Alzheimer’s Society in the South West of England, with responsibility for the delivery of services to people affected by dementia and their carer’s in Gloucestershire, BANES, Swindon, Wiltshire and Dorset. I have an interest in health inequalities, but had no prior knowledge of Population Health Management before the opportunity dropped into my inbox. The disparity in access to a dementia diagnosis and support is stark across areas of deprivation, and locally we weren’t utilising data to improve outcomes at a population level. I applied (after checking that I was eligible as a participant from the VCSE) and was thrilled when I was successful.
The Fellowship kicked off with a face to face session to lay the groundworks of expectations over the year, and an introduction to Public Health and Population Health Management theory. There followed monthly taught sessions and self-directed learning around a variety of subjects. My particular interest was upskilling in my understanding and interpretation of data to support population insight, as well as solidifying my understanding of health inequalities and the wider determinants of health.
My main project was within BSW ICB and Public Health Swindon, as part of their hypertension business case to improve case-finding, treating patients to target and improving community understanding of the modifiable risk factors of hypertension. I was allocated responsibility of a Community Development Grant of £10,000 to engage local communities in the Core20PLUS5 populations of Swindon and enable them to develop a route to engage their communities to better understand hypertension risk and modifiable risk factors. Having looked at population data and spent time understanding the Core20PLUS5 population of Swindon, I undertook engagement with communities, utilising established networks (for example, Swindon’s Community Connections Network) as well as reaching out to communities from my experience in the VCSE.
Communities were encouraged to develop routes to engagement that would be suit the needs of their members. There was some nervousness from communities as, for some, this was the first time they had received funding from a statutory organisation. To build their confidence in delivering to their communities, I was able to act as conduit to connect them with Swindon’s Live Well team, as well as the ICB Inequalities team to support them. The grant recipients each identified different routes of engagement for their communities; this included access to a gym and personal trainer for people in recovery from substance abuse, a co-designed information session for autistic people, an oral health and blood pressure health event focussing on people from the Middle East and South Asian populations, and a social media driven campaign to increase physical activity and healthy eating.
Working with a variety of communities gave me insight into the specific health inequalities that they face and also gave me a unique opportunity to join up different aspects of the public health team to utilise contact opportunities with residents.
The fellowship has been a transformative experience for me; I’ve learnt so much and have been able to apply that in my substantive role – really elevating how I think about populations and health inequalities when designing and implementing services. It has reignited my love of learning, lead to an opportunity to do an MSC in Public Health, and given me a completely different perspective on Public Health – a discipline I knew very little about beforehand.
Vicki Court
I am a Patient Safety Specialist in Bristol and undertook this Fellowship with North Somerset Council hosting. It has been a fantastic experience, I have no prior experience of population health projects or smoking cessation, and I have loved every moment of this Fellowship programme. I am amazed at what can be achieved in 2 days per week over 12 months.
Bristol, North Somerset, South Gloucestershire Integrated Care System (BNSSG ICS) have the ambition that less than 5% of our population will smoke tobacco by 2030. BNSSG Smokefree Alliance is a strategic group including system partner representatives and coordinates efforts towards the vision of a Smokefree BNSSG. The impact of smoking disproportionately affects people living in areas of deprivation, and people living with two or more medical conditions at the same time, including those living with serious mental ill health. Smoking remains the number one preventable cause of early disease and death for our population.
My learning objectives were to:
1) Implement Smokefree Representatives – critical friends to Smokefree Alliance strategic group who have lived experience of smoking tobacco and quit attempts
2) Create a Smokefree Peer Support Programme using a Voluntary Community Social Enterprise (VCSE) Brokerage Framework
3) Have fun!
Smokefree Representatives
I lead on the promotion and placement of volunteers into the Smokefree Representative role. I recognised accessibility was important for our population who smokes and ensured that information and materials used to promote this role were in an accessible format for appropriate reading abilities. The role advert was shared on social media platforms as well as Local Authority text messaging service for people who had used Local Authority smoking cessation services. From this process I led on the placement of two Smokefree Representatives who have lived experience of smoking and sit on our strategic group the Smokefree Alliance, holding colleagues to account to make sure system wide smoking cessation support is accessible and relevant to our population.
Smokefree Peer Support Programme
In my Fellowship I led on the commissioning of the Smokefree Peer Support Programme. The Smokefree Peer Support Programme is a community-based, peer led, network of support, which is flexible to respond to the needs and desires of local communities. This programme works alongside Local Authority and NHS smoking cessation services. The Smokefree Alliance is not aware of any Smoking related Peer Support Programme, and we acknowledge VCSE organisations have a wealth of experience in engaging with their communities, specifically priority population groups. I worked on behalf of the Alliance following a VCSE brokerage framework and using grant funding to secure a VCSE organisation to drive this Programme forward. The new organisation should be in post by November 2025 and commencing the peer support in January 2026 taking advantage of New Year’s resolutions!
The Fellowship programme has been a blend of challenges and excitement. It has been incredible to be part of something that is innovative, using new processes, working with a wide variety of system colleagues, to reduce health inequalities for the people we serve. I have learnt a lot personally throughout this Fellowship, and even though my Fellowship has come to an end it is only the beginning of the Smokefree Peer Support Programme. An infrastructure has been created to support this Smokefree Peer Support Programme in the future, with system colleagues invested in its success. I am astonished by what I have achieved in 12 months and can honestly say everyone I have met has been so kind, patient, knowledgeable and incredibly helpful.
Sarah Dalrymple
Over the past 12 months, I have undertaken a Population Health Fellowship and have been hosted by the Complex Lives Public Health Team at Devon County Council, under the supervision of Public Health Consultant Lex Gainsbury. As a GP Registrar working in Cornwall, this fellowship offered a unique opportunity to step outside of the clinical environment I am so accustomed to and immerse myself in a local authority.
Project: Improving equity of access to general practice for inclusion health populations in Devon.
The focus of my fellowship was on improving equity of access to mainstream general practice for inclusion health populations across Devon. Inclusion health populations are among the most marginalised in society and experience disproportionately poor health outcomes compared to the rest of the population. They include people experiencing homelessness (PEH), vulnerable migrants and refugees, Gypsy, Roma and Traveller communities (GRTC), sex workers, and individuals affected by alcohol and substance dependence.
Transitioning from the NHS to working in a local authority was a steep learning curve and required a shift in mindset and working style. During the first few months of the fellowship, I focused on scoping the primary care landscape for inclusion health populations across Devon. This involved engaging with a broad range of stakeholders, including voluntary sector organisations, clinicians with a special interest in health inequalities and people with lived experience of homelessness. These discussions were instrumental in networking and building collaborative relationships across sectors, skills that are not typically emphasised in clinical training. Importantly, this phase also developed my understanding of the Integrated Care System (ICS), helping me to appreciate how the NHS operates as just one part of a wider, interconnected system.
A review of the evidence demonstrated that inclusion health populations face multiple barriers accessing primary care. In urban areas of Devon such as Exeter and Plymouth, several dedicated primary care services for people experiencing homelessness exist and mitigate some of these access barriers. However, in rural and coastal areas on Devon inclusion health populations rely on mainstream primary care services. Most of the research looking at barriers to primary care for inclusion health populations has been conducted in urban settings. To address this gap, I initiated a pilot study in Torridge, North Devon, in collaboration with local voluntary organisations. The pilot culminated in a report that provided valuable insights into the lived experiences of homelessness accessing primary care in Torridge, and was shared with the local GP practices.
My literature review uncovered several tools and frameworks designed to improve access to general practice for inclusion health groups. However, I found that these were not widely implemented across Devon. To understand why, I conducted interviews with key stakeholders in general practice, which revealed multiple barriers to implementation. Following these discussions, I refined the recommendations into a more pragmatic set tailored to the realities of general practice. This work was written up in a second report.
One Devon Dataset
In parallel, I collaborated with the Public Health Intelligence Team at Devon County Council to develop an inclusion health segment within the One Devon Dataset - a linked dataset integrating primary, secondary, and social care data. I documented the methodology and critically appraised the dataset, identifying both its strengths and limitations. This work is ongoing and represents a significant step toward data-driven population health management for inclusion health groups.
Personal and Professional Growth
The Population Health Fellowship has been a pivotal experience in my career and has inspired me to pursue a career in general practice with a special interest in reducing health inequalities for inclusion health populations. I am committed to continuing this work in my clinical role. I have begun to apply the skills I have learnt during the fellowship to identify and support vulnerable individuals within my patient population. I am undertaking a quality improvement project in Cornwall, focusing on patients who frequently miss appointments and have been shown to have increased all cause morbidity and mortality.
Being embedded in a public health team has taught me the value of interdisciplinary collaboration, and how important it is to leverage the expertise of others, particularly the VCSE sector. I’m grateful for the connections I’ve made throughout the fellowship and have built a strong network of professionals whose expertise I know I can draw upon in the future.
Christelle Kelley
I am an Advanced Nurse Practitioner specializing in multiple long-term conditions, with a passion for clinical strategy and service improvement.
I had the pleasure of completing my Population Health Fellowship with the Cornwall and Isles of Scilly ICB, funded by Health Education England. The experience has been transformational.
My fellowship focused on improving the way we care for patients with Cardiovascular-renal-metabolic disease (CVRM). This cluster of diseases frequently occur together – as complications of each other and in precedent of each other. They commonly require multiple and frequent consultations and interventions with siloed disciplines, with increased complications and poorer patient outcomes. Multiple long-term conditions disproportionately affect patients in poorer socioeconomic demographics.
Throughout this fellowship my project and learning was supported and enriched by the fellowship curriculum, bringing together taught lectures, conferences and shared group working to increase and cement my knowledge of public health processes, behavioural science, change management and government structures.
Initially I worked with the ICB to understand their goals and working processes, and how and where a collective project could fit in. We agreed that we wanted to develop a multimorbidity approach to caring for patients with CVRM disease, within place level care. Reducing appointments, personalizing care and improving outcomes were priorities. We realized we would initially need a standard operating procedure to allow an agreed consensus on the clinical approaches.
I spent a good deal of time conducting a literature review to fully understand the gaps, needs and required structure for this operating procedure. Many months were then spent synthesizing the clinical guidelines, national guidelines, quality outcomes framework, place level referral processes, MDT processes and social prescribing requirements in to a 15 step procedure for reviewing CVRM patients in primary care.
I was able to work with the Health Innovation Network for the South West who helped me to understand how this process could work as an innovation, how to interpret and seek relevant data and understand the digital potential surrounding this project. I continue to work with the HIN to map the potential efficiencies of this project. I learned how valuable the work of the HIN is.
I have been extremely well supported by the ICB and have presented this project to clinical reference groups. We hope in the future to be able to work together further to develop and test this intervention.
I feel that this fellowship has enabled me to grow in many ways. Most exciting is that because of this, my career has found a new direction that I can’t wait to follow further. Thank you to all the fellowship teams for delivering this program.
Laura Gilbert
I’m a GP trainee and sexual health SAS doctor with a strong interest in health equity and prevention. I recently completed the Population Health Fellowship, hosted by Somerset Council, which ran alongside my clinical work. This fellowship has been a rewarding and eye-opening experience, giving me the chance to explore public health in depth and understand how change happens at a population level.
Working in sexual health, I see daily how social determinants impact health outcomes. I applied for the fellowship to better understand population health systems, develop practical skills in data analysis and intervention design, and learn how to influence change beyond the consultation room.
My project
Smoking is the leading cause of preventable illness and death in the UK and contributes to around 50% of health inequalities. In Somerset, our Smokefree service has a high quit rate, but engagement is low, especially among disadvantaged groups. My project aimed to increase referrals from primary care to Somerset’s Smokefree service, focusing on Core40 populations.
Using population health management tools, I identified priority PCNs and developed tailored intervention plans. These included staff training, distribution of Smokefree resources, quit text messaging, and setting up practitioner-led clinics. Engagement was sometimes difficult due to workforce pressures and competing priorities, but through consistent outreach and collaborative working, we were able to build relationships and deliver interventions. Referral data showed a steady increase across all participating PCNs compared to historical averages.
Learning and reflections
Throughout the year, I’ve gained a much deeper understanding of how public health operates, both in theory and in practice. I learned to interpret and critique datasets, use tools like Fingertips and PowerBI, and apply behavioural science frameworks such as COM-B and APEASE to intervention design. I developed my communication and leadership skills by working with a wide range of stakeholders, adapting my approach to suit different audiences, and navigating the realities of partnership working. I also gained insight into how structures like ICBs, PCNs, and local authorities interact, and how national ambitions like Smokefree 2030 influence local strategy.
A particular highlight was completing a health protection course, which was offered as an additional opportunity. It deepened my understanding of infectious disease control and added a valuable dimension to my learning. Alongside this, attending outbreak meetings and conferences helped broaden my perspective on the scope and variety of public health careers.
One of the most important lessons I’ll take forward is how my clinical experience can complement population health approaches. The fellowship has given me a toolkit to think beyond individual patients and consider how systems, data, and partnerships can drive change. It’s also helped me reflect on the ethical complexities of public health—particularly around resource allocation and equity. Working with primary care teams under pressure raised important questions about fairness and prioritisation, especially when trying to reach disadvantaged populations.
As I continue my GP training and work in sexual health, I’m committed to embedding population health principles into my practice. I’ll advocate for equity-focused approaches, use data to inform care, and seek opportunities to influence system-level change. The fellowship has strengthened my resolve to be a public health ambassador within clinical medicine, and I’m excited to carry these insights forward into the next stage of my career.
Pav Menon (née Premkumar)
As Transformation Lead for Mid Dorset Primary Care Network (PCN), I oversee quality improvement initiatives that enhance patient outcomes and support clinicians in adopting best practice. Health literacy (HL) was identified as a priority because of its strong influence on patient engagement and outcomes, particularly among older adults and those with long-term conditions.
Setting & Problem
In partnership with NHS Dorset and Public Health Dorset, the project focused on improving HL across practices serving Dorset’s ageing population. Many patients live with complex health needs and varying HL levels, affecting their ability to manage their care. Low HL contributes to poorer outcomes and wider health inequalities, so raising clinician awareness and providing practical communication tools was key.
Methods
We developed short, practical HL training modules with reflective exercises, collected clinician feedback, and monitored patient HL and activation levels. Over 5,000 patients were coded using SILS2 to identify low-HL populations, enabling more targeted support. Commissioners and clinical leaders were engaged to embed HL objectives across Dorset PCNs, including incentivised HL targets.
Impact
Multiple HL sessions were delivered with positive clinician feedback, and coding data revealed “hot spots” for targeted intervention. Clinicians reported greater confidence in tailoring communication, and HL principles are now being integrated into wider population health strategies across the system.
Skills & Learning
Over this period, I’ve really focused on strengthening relationships and building trust across different teams and sectors. I’ve found that genuine collaboration makes it much easier to keep everyone aligned and moving in the same direction. I’ve also learned how important it is to connect local improvement efforts with broader system goals, so that the work we do at a practice or PCN level contributes to something bigger. Using data has been a key part of this, helping me understand impact, tell the story behind the numbers, and guide where to act next. One of the most rewarding parts has been supporting teams to embed sustainable behaviour change into everyday clinical practice, so improvements feel natural and lasting rather than project driven.
Next Steps
Looking ahead, I want to keep the momentum going by expanding the HL resource library and making it easier for teams across PCNs to share ideas and learning. I plan to use HL coding data more proactively to target interventions where they’ll make the biggest difference and to measure outcomes in a meaningful way. Sustaining clinician engagement will also be a priority, and I’m exploring how incentives, regular feedback, and ongoing training can help with that. Finally, I’d like to continue showing how effective communication between clinicians and patients can directly improve population health, helping make the case for continued investment in health literacy and communication skills.