Reducing Health Inequalities is central to Public Health and Population Health. Contemporary healthcare is increasingly focused on optimising patient care and outcomes at the population level.  Public Health and individualised healthcare are essential partners rather than concepts in conflict. Public Health applies a broader and proactive view than traditional health care by extending the 1:1 individual approach to a targeted cohort of people (e.g. specific medical condition, community, age-group, etc.). It also adds the delivery of interventions such as public health, risk factor modification, health promotion and community engagement within the interaction of a patient and a healthcare professional.  

Public and Population Health considers the determinants of health that fall beyond the immediate reach of the healthcare setting such as social circumstances, environmental exposures and behaviours. Chronic medical conditions such as obesity, diabetes mellitus and cardiovascular disease are suited to a population level approach.  

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


Fellowship Programme 

South West Health Education England (HEE) agreed to support the development of Primary Care Training Hub (PCTH) Fellowships.  In the initial phase 1 development,7 Fellowships were developed 1 to each ICS/STP area in the South West. Successful applicants embark on a year-long part-time fellowship, typically 1 day a week, alongside their permanent post.   

Public Health supervision is provided by a Public Health EducationalSupervisor and line management from the training hub. 

The approach to the assessment of the learning outcomes is formative (via written reports and presentations). In addition to Public Health competences there is also a strong focus on leadership and management development. 

The aim is to enhance Primary Care’s contribution to Public Health and Population HealthAlso, to recruit Fellows with potential and help develop the contribution they can make to local place-basedsystems and improve patient and population outcomes.This should include a reduction in Health Inequalities. 

As part of the Programme each Fellow will produce a case study on the work they have undertaken as a Fellow. 

We are very delighted to present this series of case studies produced by Fellows in the first cohort of the programme and give thanks to the Public Health Supervisors and Primary Care Training Hub leads who support the programme. 

~Professor Maggie Rae, Head of School of Public Health and Transformation 

~Dr Lizzie Eley, Primary Care Dean 


Please see the case studies from Cohort 1 - please note that more will be added as Fellows complete the programme. 

Richard Tilson

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I am an NHS GP and spent 12 months doing a Population Health Management fellowship, supported by the primary care training hub and public health colleagues.  I had noticed that the uptake to the Bowel Cancer Screening Programme was significantly lower than other large scale screening programs such as cervical cancer, and one of my initial thoughts was that this may be related to the lack of primary care involvement in bowel screening (in contrast to cervical).  Looking into it further, I found that uptake is also socially graded and that men have significantly worse uptake than women, with this having the potential to worsen health inequalities. 

Together with my mentor I developed an intervention based on existing evidence on improving uptake to screening, which demonstrates that GP endorsement can boost uptake significantly.  Combining this with elements of behavioural economics/nudge theory, we designed a text message which could be timed with the receipt of the screening kits, encouraging patients to take up screening.  We segmented the target population by looking at screening history, which has been shown to be a very strong predictor of future uptake and targeting those at higher risk of non-uptake. 

Over 6 months at two different GP practices, we were able to significantly improve uptake to bowel cancer screening; compared with pre-intervention control groups, we saw uptake increase from 47% to 69% at one practice, and from 65% to 77% at the other.  I have been able to present the work in local primary care forums such as the CCG and my PCN and hope that the intervention can be rolled out to more practices in our locality and beyond.

Caroline Crentsil

I am a GP working in Bristol with a special interest role as clinical lead at The Haven, the asylum seeker and refugee primary care service. I undertook my 12-month population health fellowship under the supervision of the Bristol, North Somerset and South Gloucestershire (BNSSG) Primary Care Hub and South Gloucestershire Public Health Team.

Asylum seekers and refugees are known to face multiple barriers when trying to access healthcare, resulting in poorer health outcomes. The Haven is a specialist primary care service, which works closely together with local authority and third sector organisations to overcome these barriers but despite the presence of this dedicated service in the region, we know that asylum seekers and refugees still face health inequalities locally. During my fellowship I set out to address two issues:

1)    To measure the health inequalities experienced by asylum seekers and refugees to appropriately target and evaluate improvement interventions.

Measuring healthcare outcomes for asylum seekers and refugees is often very challenging or not possible at all, as immigration status is not consistently coded in health records. I worked with the local clinical effectiveness team with BNSSG clinical commissioning group (CCG) to develop a ‘flag’ for the system-wide dataset that would allow us to track health service use and certain health outcomes for this group. This is a complex task and was not fully achievable within the 12 months but this has been recognised as a local priority and work continues to finalise this measure.

2)    To identify the specific local barriers to accessing healthcare, and particularly primary healthcare for this population.

To assess local barriers to access I worked in collaboration with public health and University of Bristol colleagues to conduct a survey of individuals in healthcare, local authority and the third sector. Respondents reported their experiences of supporting asylum seekers and refugees to access healthcare and this identified significant issues at every stage of the NHSE patient primary care pathway as well as highlighting barriers to accessing secondary care. A number of suggestions for reducing barriers were also generated and again, work is ongoing with local primary care leaders to reduce these inequalities.

Nicholas Batten

I’m an NHS GP working in Plymouth with a special interest in Functional Illness (physical manifestations of stress and trauma).  I completed a one session per week Population Health Fellowship between 2021-2022.  Following on from some prior research into intensively supporting those patients in the highest tier of crisis regarding their health, as measured by health service usage, I aimed to look at a tier lower where less intensive measures might have greater impact on patient wellbeing.  The proposal was that by focusing on wellbeing, biometric health measures in diabetic control would improve in turn.

By correlating those patients within a primary care network (PCN) with; poorly controlled diabetes, recently suboptimal hypertension, and who were (or had) been prescribed “drugs of distress”, we were able to identify a group of patients who were all experiencing distress in their lives which they recognised as having an impact on their ability to manage their health.  Not all of these patients had a formal current or prior diagnostic code associated with stress or poor mental health, yet 100% of those recruited told stories which demonstrated that they were facing significant stressors, or were living with the effects of trauma.

Those who agreed to participate were given an outline of how our wellbeing impacts our physical health, and were offered input from a Wellbeing Hub Advisor or Social Prescriber.  Following participation, patients were interviewed regarding their experiences and the majority of them appear to have benefitted. There is also a suggestion that average HbA1c (diabetes control) measures reduced by 8mmol/mol, though it’s important to note that this was a small sample size, reduced by some patients not having attended for repeat tests at time of writing.

This work sets the groundwork for a larger study conducted across a greater number of PCNs. I would envisage those patients recruited who had shared their unmet needs, to then be discussed within an MDT of a continuity GP, Mental Health Worker, and Social Prescriber.  The Social Prescriber would then take the lead in implementing the plan agreed with the patient to meet their unmet needs, with GP and Mental Health services involvement as required.  Data including HbA1c, Blood Pressure, Person Wellbeing and Activity scores obtained at recruitment, could then be re-assessed after 1-2 years to analyse.  Ultimately the aim would be to create a common, effective framework for optimising wellbeing for those patients who would benefit from this approach.

Deborah Gompertz


Summary: This way of working is about changing prescribing practice across a system, leading to cost saving benefits, improving personalized care and reducing environmental impact of medicines.  It uses a simple screening question, “Show me your meds, please”, during routine home visits by community staff.

What was the problem?

Currently medicines account for 25% of CO2 emissions within the NHS in England each year, and £300 million pounds is wasted on medicines that are thrown away or stockpiled. 

The role of the Complex Care GP in South Somerset is to perform holistic assessments of patients’ needs within their homes.  These patients include people who have recently been discharged from hospital, had frequent admissions to hospital and/or are involved with multiple services.  During our assessments, we identified many patients not adhering to their medication as prescribed. This leads to wastage of large amounts of medication. This was only apparent from asking to see their medication; it would not have been identified otherwise.

In our first pilot we identified 40 patients not adhering to their prescribed medication regime, this accounted for 1 in 4 of people assessed.  Viewing medication is not part of the normal medication review.  However, if we perform this simple task we identify a cohort who are at increased risk from adverse events from erratically taking medication, poor optimisation of long term conditions and missed diagnosis (e.g. dementia).

What was the solution?

The solution was a simple screening question asked on routine visits by community staff:  “Show me your meds, please?”

After simply viewing patient’s medications, staff reported if they had any concerns that the medications were not being taken properly. Everyone was encouraged to report this, including the complex care team, health coaches, district nurses, community physios, adult social care etc.

The information was then fed back to primary care via regular huddles, which are Multidisciplinary team (MDT) meetings.  During the MDT it was decided which staff member was most appropriate to follow up the patient. Follow up ranged from a phone call to a comprehensive assessment aligned to patient goals. The Primary Care Network (PCN) pharmacist, pharmacy technician, complex care team (which includes GP, nurse and support worker) and primary care team have all had a role in follow up patient contact.

What were the challenges?

There needs to be a sensitivity to the psychological impact of removing or stopping medication in case people feel their medical care is being withdrawn.  There is a potential challenge of increased clinical workload, which was addressed by the enthusiastic involvement of our PCN pharmacist and pharmacy technician who have been invaluable in helping with assessments and also liaising with community pharmacists around communication and altering medication regimes.

Two potential methods of addressing the workload involved in this impactful intervention in this group are to:

  1. Fund extra pharmacy support required through financial savings (initial impact assessment has suggested this would significantly exceed the costs).
  2. Reallocation of resources away from an emphasis on routine, high volume but low impact medication reviews.

What were the results/Impact?

The first pilot over a 3-month period identified 40 patients not adhering to their medication as prescribed.

  • 1049 individual months of unused prescription items were identified.
  • Wasted medication was valued at £10866
  • It is estimated that every pound spent on pharmaceuticals generates greenhouse gas emissions of 0.1558kg CO2 per pound (£), representing avoidable CO2 emissions of 1693 Kg
  • 39 medications were stopped providing predicted cost saving over the next 12 months of £3529 and 549 Kg CO2 emissions prevented
  • Medication regimes were simplified in more than 50% of cases
  • Social prescribing was initiated in 30% of cases
  • New cognitive impairment was identified in 35% of cases

What were the learning points?

  • It is necessary to physically look at people’s medication at home to identify non-adherence for some patients.
  • This screening question can be performed on routine visits by community staff and could be extended to carers and relatives.
  • It is important to recognise that poor adherence to medication is an indicator to screen for dementia.
  • The medication review should not be considered an isolated intervention but rather one piece of the jigsaw of a holistic patient assessment.
  • This simple screening question can save resources for the NHS, has a positive impact for the environment, and can reduce risk to patients from taking medication incorrectly.
  • The success of the project has come from good communication with community teams who share the same ethos around person centred care.

Next steps

This study has demonstrated the positive impact for patients, the environment and the NHS from asking a simple screening question by community staff on routine visits.  This is a small descriptive study and scaled up this could have an enormous impact on wellbeing for patients and the environment.

Erika Andrews

I am an NHS GP with an interest in public health, adverse childhood experiences (ACEs) and children and young people’s well-being. These areas are particularly important currently due to the impact of the Covid-19 pandemic which has adversely impacted young people, increased the risks of experiencing ACEs and reduced access to support. I have worked on several different projects over the last 12 months focusing on these areas with the support of the Somerset Public Health team.  

I have been involved in a steering group working to develop a cross-sector, county-wide approach to ACEs, including a training sub-group looking at and identifying training needs for the local workforce. I have been on a trauma-informed care train the trainer course and have subsequently provided training to approximately 100 primary care staff, including all of the current GP registrars locally. 

I have also looked at the data at a county and practice level for children and young people’s mental health which highlighted a significant level or need. Additionally, from my work in primary care, I have seen how young people often struggle to access support and fall through the gaps. To try to address this need I have set up a health coaching service within my practice. Our health coach supports young people and their families and is able to signpost to resources such as organisations, websites and apps. We have subsequently also identified the need to support families with children who have additional needs, for example neurodiversity, and have been able to support families to access assessments and additional sources of support.  

Ndubuisi Egwin

I am a Portfolio GP, working in Cornwall, with a special interest in Population health and health inequalities. I spent 12 months working on a Population health management fellowship, funded by Health Education England, and supported by the primary care training hub and public health colleagues in Cornwall.

Working with colleagues in Primary care, public health, and Voluntary sector, I identified the paucity of evidence around the work of social prescribing link workers (SPLW) especially as relates to health outcomes in patients with chronic disease. Furthermore, while there was a consensus that social prescribing had good value to patients and their communities, there was a need for a common approach to document the outcomes of social prescribing schemes.

With support from, my local primary care and public health supervisor, I designed and deployed a 12-week SPLW led program, which identified patients in 7 GP surgeries, who were most at risk of hospital admission due to COPD exacerbation that could be triggered or worsened by wider determinants of health. The identified cohort (frail, housebound, COPD patients) were offered targeted intervention and appropriate referrals. Subsequently, I piloted a 12 weeks’ evaluation of the outcome of SPLW intervention in this specific patient cohort and developed an outcome framework for evaluating social prescribing programs.

Over 6 weeks, I found significant improvement in a small number of patients, post SPLW intervention, using both COPD clinical measures and wellbeing scores. This has laid a groundwork for further evaluation of SPLW outcomes across my local PCN and the wider county.

Additionally, in my role, I have been able to discuss my work in local primary care forums as well as promote population health among primary care colleagues, including a teaching session to new GPs in Cornwall. 

Charlotte Hickson


I am an NHS GP and recently completed population health fellowship, hosted by BSW primary Care Training Hub. I had been increasingly aware that as workload pressures increased as did the challenge of serving my patients who were homebound. It was headline news in 2019 when 54% of delegates at the England LMC conference voted to remove home visiting from the core GP contract due to capacity issues.  As institutional priorities such as efficiency and digitalisation are advanced homebound residents were a group vulnerable to becoming excluded. I was also interested in the holistic health needs of homebound residents and the benefits of non-medical prescribing in promoting health and wellbeing in homebound residents with minimal risk of iatrogenic harms.

Literature modelling identified two key clinical antecedents to becoming homebound, immobility or physiological instability, both closely associated with frailty markers such as multi-morbidity, medical complexity and symptom burden. However, social, economic and environmental inequalities were shown to influence which members of our society were more likely to develop the prerequisite conditions that produce home-boundedness. It is also known that despite homebound persons having amongst the highest healthcare costs, they had some of the poorest health outcomes, with home-boundedness being an independent risk factor for disease. Studies have found that even when correcting for age and health baseline characteristics, homebound people experience poorer physical and mental health outcomes, and higher annual mortality rates than their peers.

BSW health data searches were limited: the number residents coded as homebound varied widely depending on the clinical database searched, and the majority of identified residents had missing demographic and care data. That said we did find that the likelihood of being homebound increased for female residents, Irish and also black ethnic and racial groups, and those experiencing higher levels of socio-economic deprivation. Locally home-boundedness was strongly linked to multimorbidity (54% had 3-6 chronic health conditions) and older age (90% aged >60 years; 60% aged >80 years) yet 63% of homebound residents had no coded frailty care.

With the support of VirginCare and DHI, we completed a retrospective audit identifying 288 homebound residents who had accessed the social prescriber link worker (SPLW) service between Decermber 2020-2021. The clients were younger on average than the typical BSW homebound resident (mean age 62 years), the majority of these contacts were remote telephone consults (83%), and were generated by GP referral (73%). The most common reason for accessing the SPLW service in this group for mental health needs (36% of referrals). While numbers were admittedly small, 100% of those responding to Friends and Family Test  responded as “likely” or “extremely likely” to recommend the service, with 0% negative feedback received from this client group.

The scope and ambition of my initial fellowship project plan was significantly curtailed by the pandemic and service pressures. However I had many opportunities to meet with local service planners and commissioners, and also to work alongside social-prescriber and personalised care colleagues across BSW. I hope that my work, and the connections I made in my fellowship year, are the beginning of a conversation of how we better design holistic and personalised care options for homebound residents, but also how we might be able to support those at risk of becoming homebound to delay this milestone health event.

Judista Lasek

I am an NHS Psychiatry Registrar with a special interest in public health. I spent 12 months working on a Population health fellowship, funded by Health Education England, and supported by the primary care training hub and public health colleagues in Dorset.

I became increasingly aware of the fact that GP practices have a high proportion of patients presenting with mental health problems, and that a large number of these patients are frequent attenders and either don’t reach the threshold for CMHT referral or have their referrals rejected. There is a need for trying to ascertain the best way to meet this populations needs to improve mental wellbeing and to think about the social determinants of mental health that can be addressed.

I worked with a local GP who had identified that in their practice there was a large number of patients, particularly those identified as having a personality disorder/complex trauma, for whom there is a need for mental health support, particularly in the wake of Covid-19 with limited resources available to support patients, particularly those not reaching secondary care thresholds. We wanted to explore if there is a better way to approach the care of people with these types of difficulties. This involved meeting and speaking to patients who had consented to talk to us about their experience and find out what they feel had or would help going forward. I also liaised and spoke to third sector organisations who are able to offer support and think about support that is actually available that may not be widely known about.

A common theme among many of the patients was an expression of interest in setting up peer support. Other themes included access to other support with more practical aspects of life such as  legal advice, education and finding employment and about overcoming feelings of social isolation.

This has led to ongoing work in looking at speaking to this group of patients and seeing if there is a possibility to try to co-produce something that they feel would be beneficial to them going forward. Although my fellowship has ended, I am still involved in working on this.

I have learnt many things from this project to take back with me to work, including availability of some resources I have been made aware of in the community which I have had the chance to share with colleagues and patients. Also, the ability to try to think about and incorporate a population health management approach to my everyday practice.  

Brynn Bird

I am a GP Partner and PCN lead in Yate, South Gloucestershire. I have previous experience working with public health and local authority teams as Chair of the Health & Wellbeing Board and in ICPs. I lead for our practice on cardiovascular disease (CVD) and Cancer outcomes and have previously worked with the Optum team on a pilot project in South Glos. My roles and experience led me to wanted to use pooled data of physical and mental health problems to develop an alternative intervention to improve outcomes for this population, targeting the 3 highest deprivation deciles in our PCN.

Using Local Authority Business Intelligence data, I focused on the poorer CVD outcomes that were shown in the data compared to other areas in the region. From my previous experience I thought it was important to work mostly with the services that were already present and align their productivity to people who needed it the most. We targeted people with a history of depression, diabetes, hypertension, and obesity in the last 3 years with poor outcomes currently.

Using an initial cohort of 150 patients identified in the data, we proactively approached patients with an offer of coaching and taking a holistic approach to their situation to target their specific wider health determinants. I encouraged the team to discuss screening uptake and family immunisations if these were a concern. We focused on a non-medical management model, led by a new health and well-being coach in the area with the knowledge and support of mental health nurses and social prescribers. This concentrated on motivation and connections rather than medication changes.

Qualitative feedback was supportive of the intervention from both patients and primary care staff. We are looking to objectively assess health outcomes towards the end of the year to identify any quantitative change. As part of this work in the locality we are developing community preventative hubs in PCNs to offer non-medical focused support with voluntary services to cohorts with the highest need of intervention. These hubs will focus on peer support and empowerment of individuals in their management. We are starting with two pilot sites including our PCN and we are looking to develop these across the locality.

Lynne Carey

I am a Registered nurse working within Primary care and I am also a trained Health Coach and lead for the Taunton health coaching team.

Over 12 months I had a one day a week population health fellowship in which I worked on increasing the ability for individuals to have access to Blood pressure machines within the community. I tried to improve the Diagnosis of Hypertension to help prevent cardiac events and Stroke, targeting key groups. These were men aged 45-65, those who had not had their BP taken in over five years, and those in deprived areas which meant they were more likely to have health inequalities.

I approached several venues about homing a BP machine for the use of the public including tyre fitters, men’s shed and community venues. The tyre fitters although keen needed the request to go through the head office and although I tried to contact them, I had no reply. This is something Public Health may take up and ask from a more area wide approach. 

Two community sites agreed to have machines, the YMCA in Taunton, and Morland Community Hub in Highbridge. Both sites where keen to help their local community and provide this service. Both sites were in areas of high deprivation and catered for all ages groups. The Morland Hub was also situated next to the local Men’s shed. The Taunton YMCA machine was used on average 36 times per week over a 20-week period and Morland community hub 12 times per week over a 12-week period.

Both sites reported case studies of individuals who had found high blood pressure readings. A 70-year-old gentleman attended their GP and was found to have dangerously high BP and was commenced on medication immediately, he had not had his BP checked in over 30 years and was fit and active. The other was a female who attended A&E as the algorithm had advised and was found to be in renal failure.

The main issue I had was in getting the BP readings back into the surgery records. I linked in with North Sedgemoor PCN who were looking at an app to help with this but the issues around Information governance and data protection had not been solved by the end of my fellowship and the app had not gone live because of this.

Health coaches would be able to provide health and lifestyle coaching to those with slightly elevated BP. All machines had information about the health coaching service left with them. The health coaching teams noted no increase in referrals resulting from community taken BP readings and GP surgeries noted no increase in workload. This could be that individuals were not motivated to instigate changes to health and lifestyle.

Conclusions I drew from this was that the community is keen to have this facility and the venues within them are keen to provide the service, but it still needs some input to encourage people to act on the readings taken. This could be by training individuals working in the venues in what to look for and how to signpost to services or by using satellite clinics within the venues provided by NHS teams.

I am continuing to work alongside public health by sharing everything I have learnt and linking in with primary care Health Hubs so we can utilise the community venues willingness to work with the NHS. Improving the awareness of health coaches and the impact they can make on some ones health and lifestyle is my main focus moving forward.