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Population Health Fellowship

Our national Population Health Fellowship for NHS clinical staff in England aims to develop and grow a workforce of professionals who will incorporate population health into their everyday jobs. 

For a flavour of the work undertaken in 2020 by our first cohort, read our fellows' project summaries. You can also access case studies: Regional Health Equity Improvement Manager Dr Yeyenta Osasu, Physiotherapist Kelly HolehouseOrthotist Carolyn Royse, and GP and Specialty Trainee in Rehabilitation Medicine Ahmad Saif.  

Our second cohort of 26 Population Health Fellows joined us in autumn 2021 across our regions. A blog by Johnson Yan Ning Neo, describes a perspective of population health through a clinician’s eyes and an interview with Anna Moore  showcases her experiences of the fellowship so far.  If you would like to find out more about the projects our fellows are working on this year, please click on their individual profiles further down this page.

The application process for places on the third cohort of this programme will be led by our regions commencing in February 2022.  See the Rough Guide for more details.  

If you are interested in applying, please contact the relevant region:

Midlands and East


North West


South West




North East and Yorkshire


South East


East of England


Population Health Fellowship

Second cohort

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. (Source: PHE Multi-agency Stakeholder Forum 2019)

Fellows have been recruited from a wide range of backgrounds including nursing, pharmacy, medicine, speech and language therapy, dietetics, orthotics and physiotherapy. They are seconded part-time (for two days per week) to the fellowship, alongside their permanent post, and will experience a mixture of blended and experiential learning. The aim is to encourage and support the development of population health strategies and approaches within the NHS and wider community. For more information email: populationhealthfellows@hee.nhs.uk

Our work on Population Health and Prevention

Celebrating our 2021 fellows.

About Harriet

I am a paediatric registrar working in the North East of England. Since graduating from Newcastle University Medical School in 2015, I have dedicated the initial years of my medical career to offering compassionate and effective clinical care to my patients and their families. I completed my foundation years in West Yorkshire before returning North to embark on specialty training.  

Whilst completing a Masters of Research as an intercalated degree, I worked at the sharp end of research contributing to disease specific advances in medicine. However, in my daily clinical work I have been struck by the constant effect that health inequalities have on a large proportion of patients that I see. I feel frustrated to witness the early divergence of our children and young people’s wellbeing, and it is the potential to help improve their lives on a larger scale, that has drawn me towards an interest in population health.

This Fellowship is an important first step towards shaping a career focused on the prevention of ill health from an early age and clinical public health engagement to empower individuals and organisations make the most efficient use of our health service going forward. 

Project summary

Using a Population Health Management Approach To Assess the Presentation of Children with Respiratory Conditions in County Durham and Darlington Foundation Trust from 2018 to 2021. 

The trend for children presenting to accident and emergency with acute respiratory conditions has been increasing nationally over a number of years. Following a dip in this in 2020, secondary to the covid-19 pandemic which saw children relatively less acutely unwell than adults, a surge in respiratory illness was predicted in children in the winter of 2021, exceeding previous numbers of cases and causing increasing pressures on already stretched acute services.

The aim of this project is to understand the patterns of paediatric attendances to accident and emergency with respiratory complaints in County Durham and Darlington Foundation Trust in order to understand the acuity of presentations and the factors leading to this as an avenue of health seeking behaviour. Through understanding these patterns and how inequalities effect attendances I aim to identify immediate, medium- and long-term interventions which can improve service provision and reduce the effects of the wider social determinants of health on the younger sections of our society. Through developing this broader approach to the assessment of children’s services I aim to demonstrate a concept of approach which will encourage a population health management approach to clinical provision challenges going forward. 

About Vinesh

I studied medicine with an intercalated BSc in Neurosciences and Mental Health at Imperial College London, graduating in 2012.

I did my clinical training in London, Brighton and Leeds. In my foundation years I was awarded a Scholarship for Teaching and Educational Experience and continue to enjoy teaching and educating junior colleagues.

In 2018, I completed a Public Health MSc at The London School of Hygiene and Tropical Medicine, during which I researched developments in malaria resistance. I am currently a Microbiology Registrar at Leeds General Infirmary.

During this fellowship, I aim to gain experience of generating valuable change within the NHS as it undergoes significant change in the face of shifting pressures. In particular I am interested in how to decrease antimicrobial resistant infections and reducing health inequalities.

Project summary

I am a microbiology registrar working in West Yorkshire. As part of the need to take action to combat rising antimicrobial resistance, the UK 5 year AMR action plan 2019-2024 aims to lower the burden of infection by minimising infection (ambition 3), and engaging the public on AMR (ambition 9). It also aims to optimise use of antimicrobials in humans by demonstrating appropriate use of antimicrobials (ambition 8). I have set about contributing to these ambitions through my population health project Reducing AMR - Educational videos and a comparison of regional laboratory processes.

The aim of the project is to produce up to 5 videos on Antimicrobial resistance, hydration to prevent urinary tract infections, urinary continence management to prevent urinary tract infections and primary care diagnostic stewardship for urinary tract infections. Alongside this it will also involve a comparative process of reviewing the 5 laboratories in West Yorkshire regarding how they process urine sample standard microscopy, culture and sensitivity particularly looking at how we screen for Carbapenemase producing organisms and how comparable data is between the laboratories. The aim of this is to provide a lasting video resource to reduce the burden of AMR infections and also to provide a report looking at best practice, through comparison, in urine laboratory processing in West Yorkshire.

About Kate

I am a respiratory physiotherapist; my clinical role is as Clinical Lead Therapist delivering Pulmonary Rehabilitation in Sheffield. I am passionate about health promotion, tackling health inequalities and embracing the teachable moments in a patient’s journey. I believe we have an opportunity post-covid to design and shape services with the populations they serve at the forefront. I believe as AHPs we make a unique contribution to the population health agenda, and I want AHPs to recognise and celebrate this. 

 During my fellowship year I will be based within the Healthy Lives Team at Barnsley Hospital. The aim of my project is for the healthy lives team to be recognised as a stand-alone speciality. This will include raising profile, building awareness, and shaping function. I am also looking forward to establishing a local network of population health passionate AHPs within the South Yorkshire and Bassetlaw region. 

Project summary

My project is based within the Healthy Lives Team at Barnsley Hospital. The aim of the project is to develop a more comprehensive physical activity offering to be delivered by our healthy lives facilitators. We will be basing our approach on the evidence based Active Hospitals initiative as outlined by Moving Medicine and will be working with various stakeholders to ensure the message is safe and consistent across services.

We are also looking to coproduce a resource alongside the leisure sector within the local authority outlining physical activity guidelines that can be used across healthcare sectors. I am also establishing a local network of population health passionate AHPs, who will be working together to facilitate implementation of the Tackling Health Inequalities Framework across the ICS. This network will provide education, and work in an advisory capacity to explore at operational pressures and solutions.

About Catherine

I have worked for North West Ambulance Service for the past 12 years. I am a registered Paramedic serving patients in the Greater Manchester area.

For the past couple of years, I have been working in non-operational, service development as a Transformation Delivery Manager. This work has included developing a new rotational workforce model, rotating paramedics into primary care and supporting a range of initiatives around reducing avoidable conveyance.

I am looking forward to learning how to use our rich data to understand our patients better and to expand our strategies for supporting them earlier in their journey.

Project summary

Inequalities in cardiac arrest outcomes: 

The North West Ambulance Service (NWAS) attends approximately 10,000 out of hospital cardiac arrest (OHCA) incidents a year, in which resuscitation is attempted in about 3,000 incidents. Return of spontaneous circulation (ROSC) is an outcome measure for the pre-hospital cardiac arrest pathway. Initial analysis of NWAS data from April 2016 and March 2021 (n= 16,413 incidents) showed a ROSC rate at hospital handover of 33.7% (n=5,502). Survival to ROSC was analysed at Middle Layer Super Output Area (MSOA), with ROSC rates varying from 0% to 78%. Gender, age, response time, deprivation and rurality were also significantly associated with survival. Further work is required to understand variation in ROSC. This project aims to: 

 - Calculate the gradient in survival to ROSC at local authority level by assessing the disparity in survival rates between MSOAs 

 - Identify targeted geographical areas for further investigation 

 - Audit and evaluate a sample of cardiac arrest to understand the key factors that may have influenced the outcome 

 - Conduct a deep dive to better understand the socio-economic and wider determinant features of each MSOA and evaluate any impact of these on survival rates 

The findings from the project will be used to support decision making within NWAS in regard to the placement of community based Automatic External Defibrillators (AED) and to guide targeted interventions for new Community Resuscitation Officers employed by the Trust. The project will contribute to population health by providing a more detailed understanding factors that can influence outcomes from out of hospital cardiac arrest. We hope to work with local authority public health teams to gain a better understanding of local inequalities and agreeing areas for action. 

About Rhianna

I completed my medical school training at Manchester University and fell in love with the city so never left, and I am now in my 5th year of Paediatric training in the North West. I’ve always wanted to work in Paediatrics and then, at university, discovered that I was passionate about paediatric safeguarding and trying to ensure that every child has a safe and loving household to be brought up in.

Since postgraduate training I’ve tried to be involved in safeguarding as much as I can, whether that be; attending training courses or MDT meetings, providing teaching or helping to set up a North West Paediatric Trainee Safeguarding Specialist interest group.

I’m really looking forward to the opportunities that this Public Health Fellowship will give me to help make changes within the city and help develop my understanding of population health and how this can influence my clinical practice.

Project summary

Using sport to empower vulnerable girls and help reduce violence against women and girls:

Violence against women and girls is unfortunately a global issue that although many interventions have been trialled it still remains a prominent issue within society- with 1 in 4 women expected to experience sexual or domestic abuse within their life in the UK. Gender based violence was brought to the forefront of news again following the tragic murder of Sarah Everard and again put pressure on the need for change.

Within Manchester there has been a 10 year strategy produced to focus on reducing gender based violence and supporting those victims- which The Greater Manchester Violence Reduction Unit (GMVRU) have been closely involved with. The GMVRU operates using a Public Health approach to try and reduce violence across the region and improve outcomes for the populations within Greater Manchester. As the host organisation that I am based within, they are supporting this project which will focus on reducing violence against girls.

The project I am proposing is to use Netball to empower and support vulnerable girls in a region of Manchester. Manchester has one of the highest number of most deprived areas (measure by the IMD) - ranking 6th in the UK for average score of most deprived local authorities. Within these deprived areas there is only a small amount of recorded provision for single sex sport, especially for girls in the early high school period. With this lack of single sex sport provision, there are reduced opportunities for girls to learn important skills through the use of sport (such as team work, communication and healthy lifestyles choices) and reduces the opportunities for girls to support each through their shared experiences and empower each other. The aim of my project will be to initially create an experience day- where the girls will be supported to learn some simple netball skills and fitness, exercising alongside female youth workers and hopefully some of the local police force to help improve community relationship and encouraging even more empowerment of these girls. This is to be supported by the North West England Netball division and will hopefully be supported by follow up sessions to encourage girls to come weekly participate in general fitness activity and also develop their team building skills.

About Ojali

I graduated from Kings College London with a Pharmacy Degree where I developed an interest in infectious diseases. I then went on to complete my foundation training at Chelsea and Westminster NHS foundation Trust and Imperial College NHS Trust and undertook my postgraduate Clinical Pharmacy diploma at University College London; later, becoming a HIV and Sexual Health specialist Pharmacist and completing the Independent Prescribing qualification at the University of Manchester.

I now work as an Independent Prescribing Pharmacist in a Primary Care Network within the Nottingham and Nottinghamshire Integrated Care System. In addition to my role as a PCN Pharmacist, I work as an Integrated Urgent Care Pharmacist in Derbyshire.

I am passionate about being part of a health service which looks to and desires to improve access and engagement for those who have poor access and are less likely to seek health and social care services.

I believe that as frontline health care professionals we are in pivotal roles to really help shape and provide insight on how best our services should operate for the benefit of the local populations we serve and I am excited to be a part of this fellowship to learn, share and grow with past and current fellows in such an important fellowship programme.

Project summary

A service evaluation to explore service user experiences on the use of Telehealth within the Improving Access to Psychological Therapies (IAPT) service:

Lincolnshire Partnership Foundation NHS Trust (LPFT), a mental healthcare provider based in a predominantly rural county in the East Midlands, has rapidly moved most of its services online during the Covid-19 pandemic, including steps2change, Lincolnshire's Improving Access to Psychological Therapies (IAPT) services. With an acceleration of the ‘Digital First’ agenda during the pandemic, the current delivery of IAPT is predominantly delivered via 'Telehealth', which uses telephone and Information Communication Technology (ICT) where service users and providers are separated by distance. The steps2change service provides talking therapies for people 16 years and older experiencing mild to moderate mental health issues such as anxiety, depression, stress and offers help with issues like bereavement or the impact of a traumatic event.

This service evaluation will complement and enhance existing work on staff experience of IAPT telehealth use by providing context to the existing clinical and research evidence from a service user perspective. This evaluation will allow LPFT to understand the extent to which Telehealth provision is currently meeting the needs of patients and will facilitate priority-setting decisions regarding the ongoing delivery of Telehealth and digital services. It can also provide essential learnings for the broader mental health and NHS systems concerning the broader digitalisation of services. The objectives of the service evaluation are:

 - To explore which factors, facilitate or impede patient engagement with IAPT via Telehealth delivery.

 - To explore service user’s perspective of telehealth in the future of mental health services delivery.

For this evaluation, the HEE Population Health Fellow and Evaluation Lead (Ojali Yusuff) will conduct a series of semi-structured interviews with patients in receipt of steps2change. We plan to use purposive sampling to identify participants who are having difficulties engaging with and/or accessing digital services as well as those who have engaged effectively. Data collection will include a series of telephone, face to face and/or video interviews depending on participant preference.

The findings will support LPFT service leads with real-life patient experience data to inform the future delivery of the digital-based IAPT/steps2change service. The findings from this evaluation could also inform strategies to mitigate digital exclusion and inequalities in mental health services in the broader NHS system. 

About Vanessa

My Fellowship is hosted by the Northamptonshire Clinical Commissioning Group alongside clinical work at Northamptonshire Healthcare NHS Foundation Trust. 

I have a long-term interest in reducing inequalities and innovative practice.  My MSc Advanced Occupational Therapy mixed method research made recommendations to promote inclusivity for socially disadvantaged adults using simple interior design techniques in the GP consulting room (2016).

Previously, as part of the Colour for Wellbeing Changing Minds Pilot, we explored using occupation and colour to improve wellbeing, which was popular within the local community. Adult learners chose to present their improved mental health outcomes at an International Colour My Wellbeing Conference, which was hosted by the University of Northampton and Journal of Applied Arts and Health (2013).

I am keen to bring learning from the Fellowship into my current role at NHFT, reducing inequalities and supporting local Children and Adolescent Mental Health Services. I look forward to working with the NCCG and the Population Health team, making a positive difference within our county.

Project summary

Hosted by Northamptonshire Clinical Commissioning Group (CCG), working with Northamptonshire Healthcare NHS Foundation Trust.

Project 1 Falls prevention in West Northamptonshire. Working with the CCG and Optum 22 Week Population Health Management Programme our aim is reducing countywide health inequalities using anonymised patient health and social care data. Data is analysed in the context of wider determinants of health which are known to impact 80% of a person’s health outcomes. This emerging technique permits proactive care and best use of collective resources.

Project 2 Population Health Training and Development:  Working with the CCG and Health Education England we are developing training programmes and sustainable resources to support the uptake of Population Health Management both locally and nationally. 

About Alice

I am a GP trainee in the Shropshire Deanery with an interest in population health and lifestyle medicine.

My training at Cardiff University led to placements throughout Wales in both rural and urban populations, with varying degrees of affluence. These experiences led me to question the social determinants of health and how we could work to reduce health inequalities in economically deprived areas.

During this time, I also gained experience in practical leadership skills as an Honorary Midshipman with Wales University Royal Naval Unit. I believe fundamentally in the concept of “make every contact count” and treating patients holistically, incorporating this into my everyday practice.

Alongside my clinical work, I am involved in the organisation of GPVTS teaching in my area with a particular emphasis on raising the profile of issues such as population health, lifestyle management and veteran wellbeing.

I plan to develop my leadership and quality improvement skills through the fellowship as well as gaining a thorough understanding of population health and its future within our healthcare system.

Project summary

My fellowship project will be carried out with Shropshire Council, where steps are being taken to review provision of the NHS Health Check and there are provisional plans to pilot an ‘outreach’ approach to delivering health checks, focussed on the farming community. The expectation is that the post-review NHS Health Check model will include an increased emphasis on outreach for higher risk populations who may be less likely to take up their invitation for a health check. PCN planning guidance in relation to reducing health inequalities includes an objective to detect undiagnosed hypertension (ie. case-finding). There are also plans to establish a social movement to promote physical activity across Shropshire. This presents an opportunity to promote physical activity more generally but in particular to population groups likely to benefit most, which includes those at risk of long-term conditions such as hypertension and/or diabetes.

My project will be assisting this by addressing the case identification and management of undiagnosed hypertension together with the impact of physical activity and other lifestyle interventions on long term management. I will be considering the use of lifestyle interventions for other client groups, such as those having NHS health checks and I am hoping that my project will develop my skills in population health demand and outcome analysis as well as identifying opportunities to improve patient outcomes through service redesign and the introduction of lifestyle interventions. By working with a range of services and partners, I hope to be able to inform the approach to 'case finding' undiagnosed hypertension with an emphasis on developing a generic model that can be applied to case finding in other disease areas – considering in particular how pathways into primary care are best designed. The project will also promote a range of physical activity opportunities which can be delivered to patients diagnosed with chronic diseases (starting with hypertension) and targeted at population groups who are known to need the greatest support, thereby enabling the potential for reduced health inequalities.

About Lauren

Lauren Waterman is an ST6 General Adult Psychiatry Trainee and Academic Clinical Fellow at South London and Maudsley NHS Foundation Trust; a member of the RCPsych Working Group for the Health of Asylum Seekers and Refugees; a Mental Health Research UK-funded MD(Res) doctoral scholar at King’s College London; and the Praxis Section Editor for the BJPsych Bulletin. She is also the medical service lead for a charity ‘drop-in’ service for asylum seekers in North London.

Lauren has an interest in improving the health inequalities faced by migrants in the UK and has written about the difficulties they experience in medical journals. She recently contributed to the RCPsych Position Statement on immigration removal centres and is currently undertaking research into the experiences of migrants following release from immigration detention into the community.

Lauren also has a special interest in insomnia treatment, sparked by her clinical experience that people with insomnia rarely receive treatment; despite CBT for insomnia being a highly effective NICE-recommended treatment, and chronic insomnia impacting quality of life significantly. She also runs an insomnia treatment service at her mental health trust and will be investigating sleep and insomnia in North Central London CCG during her population health fellowship. 

Project summary

I am working for North Central London CCG, supervised by Sarah Dougan. I am conducting a population health needs assessment on insomnia in North Central London. For this, I have been doing background reading on insomnia, including into: the prevalence of insomnia shown in epidemiological studies; how insomnia develops and what are its risk factors; how insomnia may be affected by factors such as neighbourhood, level of deprivation, noise levels, occupation, shift-working, ethnicity, age, physical health and mental health; the bi-directional relationship between insomnia and other mental and physical disorders; how insomnia is treated and the effectiveness of treatments; and what is known about health inequalities relating to insomnia. I have also been looking into what work has been done elsewhere in the UK and outside the UK on the population health needs for insomnia treatment and on addressing these needs.

From my background reading, it seemed that very little work has been done on the population health needs relating to insomnia in the UK, including in North Central London. My background reading found that insomnia is a highly prevalent disorder that severely affects quality of life, often leads to the development or worsening of other mental and physical disorders, rarely resolves without medical intervention once chronic, has a highly effective treatment that is recommended by NICE (Cognitive Behavioural Therapy for Insomnia), is likely to be worse in people who are older or from socially deprived groups, and is undertreated in much of the UK.

I conducted a mapping of current services to treat insomnia in North Central London. I discovered that there is very little, if any, treatment available for people with insomnia, other than sleep hygiene advice being provided by GPs and other healthcare professionals (which, according to research studies, has limited efficacy as a monotherapy). IAPT (Improving Access to Psychological Therapies) is not nationally commissioned to provide treatment for insomnia as a core service, and whilst some IAPT services elect to provide treatment for insomnia as an additional service, North Central London IAPT services do not provide this. Many online health websites for the public in North Central London direct people with insomnia to mobile apps that provide self-help treatment, however these apps are not actually currently available to NHS patients from London.

In order to make a case for services to be commissioned to meet this unmet need in North Central London, I am currently conducting an analysis of the pseudonymised GP data from three of the boroughs, to quantify the scale of the unmet need by in particular looking at rates of diagnosis, rates of referral for treatment, and health inequalities based upon age, gender, geographical deprivation score, and ethnic group.

I have also been liaising with the medical and commissioning leads for primary care, secondary care and IAPT in North Central London, and plan to present my findings to them by the end of my fellowship, and to make a case for services to be made available. I have been liaising with sleep specialist clinicians and have sought their opinions on the reasons why insomnia is not being taken as seriously as many other mental illnesses, despite its prevalence, treatability and impact upon quality of life. I have contacted the National Collaborating Centre for Mental Health, who write the IAPT manual, to discuss whether insomnia could be considered a ‘common mental illness’ to be treated nationally by IAPT services in the near future. Additionally, I am writing two articles to be submitted for publication in peer-reviewed journals – one, on the use of sleeping tablets in primary and secondary care, which is being commissioned by the BJPsych Bulletin; and another on the unmet need for insomnia treatment in the UK.

About Anna

I am a respiratory specialist trainee in North East Thames. I have taken some time out of training to work in education at both undergraduate and postgraduate level, and have completed a postgraduate diploma in medical education for clinical contexts. 

I have a strong interest in sustainability and planetary health as both a clinician and educationalist, and this, combined with a growing awareness of the limitations of our traditional individualist approach led me to Population Health, and this fellowship – which I’m really excited to be part of!

I will be working on projects looking at improving outcomes in respiratory health in Lewisham with a primary focus on COPD.  I also hope to be involved in projects aiming to improve asthma self-care in children and young people, and working with the council on health outcomes related to air pollution.

Project summary

My project makes use of Lewisham’s population health management system, Health Intent, which draws data from primary and secondary care and the mental health trust. The system has a registry for chronic conditions including COPD, and from this we know that there are roughly 5,400 individuals living with COPD in Lewisham. However, research tells us that roughly two thirds of people with COPD are undiagnosed, therefore the real figure is likely to be more like 15,000 people suffering from COPD in Lewisham. The first part of the project was to validate the data in the registry. In doing this we found that spirometry is only documented in the system for 1% of those with a diagnosis of COPD. This reflects an issue with coding, which we are taking steps to rectify by instituting online requests for lung function. Concurrently we are developing a search strategy to find people with symptoms of and risk factors for COPD who we will then invite for spirometry. We hope that this will enable us to start to find, diagnose and treat people living with undiagnosed COPD and improve their health while also identifying disparities in respiratory care across the borough.

HEE have interviewed Anna about the fellowship. In this interview, Anna discusses why she applied for the fellowship, her aims for the work she will do and how the fellowship will help her and others to deliver the best care possible for people diagnosed with COPD.

About Yan Ning

Yan Ning (or Johnson as he prefers to be called) is a senior ophthalmology registrar of the North London deanery in the final stages of his training to become a consultant eye surgeon. He currently works across sites at both Western Eye Hospital, Imperial College Healthcare NHS Trust and Moorfields Eye Hospital. Johnson is passionate about population health and ways to overcome inequality in access to healthcare. He is particularly interested in preventable causes of visual impairment and health promotion. His research on whole population visual screening during his academic foundation years had influenced how childhood visual screening is conducted in England.

Since joining ophthalmology residency in London, Johnson has had a strong track record in leading quality improvement projects which translated to improved patient care locally and regionally. He was awarded the coveted Health Education England / London KSS School of Ophthalmology Leadership Prize for four consecutive years. He is a board-certified fellow of the Royal College of Ophthalmologists, European Board of Ophthalmologists and Higher Education Academy UK.

His host institution would be The King’s Fund in London.

Project summary

My first project is a qualitative study and thematic analysis which aim to summarise clinicians’ perception on what population health is, and what they perceive are the enablers and barriers for integrating population health into their clinical practice. A wide range of clinicians are included in the study: hospital doctors, general practitioners, allied healthcare professionals, nurses and community pharmacists to ensure a fair representation of viewpoints. This is an important piece of work, as clinicians play an important role in contributing or (for some) even leading work on population health. Findings of the study will also tap into clinicians’ awareness and understanding of the existing population health frameworks, resources and various partnerships that would help them shape a population health system for the population they care for.

My second project is naturally ophthalmology related (given my tradesman job). Contact lens related keratitis (CLAK), in other words corneal ulcer caused by inappropriate use or care of contact lens, is one of the most frequent causes of A&E attendance. Contact lens users normally receive contact lens advice from their dispensing optician, which include not to shower or swim with contact lens / not to store or clean contact lens with tap water / not to overwear or sleep with contact lens etc. There is however an ongoing rise in the incidence of CLAK and therefore, we aim to survey these patients on the barriers for compliance to the contact lens advice before targeting population health interventions e.g., health promotion, partnership with manufacturers, health behaviour modification etc.

About Veronica

My professional journey started in 2008 in Spain when I qualified as a general adult nurse. Shortly after qualifying, I became a Mental Health Nurse, and a few months later, I moved to England, where I worked as a general nurse before becoming a Midwife in 2013. Since 2014, I have been working at the University Hospital Southampton NHS Foundation Trust in various roles, including in-hospital antenatal, intrapartum and postpartum care, research, and maternity audits. My passion and devotion for midwifery and research led me to complete an MRes in Clinical and Health Research in 2017, where I had the opportunity to develop a qualitative research project focusing on women’s experiences of maternity bladder care.

In recent years, I have become more interested in health inequalities and childbirth activism. As a result, I volunteer for several national and international organisations that provide breastfeeding support, fight against obstetric violence, and improve the Maternity Services. Moreover, I am collaborating in the Erasmus plus project posmat to improve the maternity experience of women diagnosed with cancer during pregnancy.

I feel very privileged to support women and improve their health and the care provided to them, their babies and their families.

Project summary


COVID-19 poses significant risks to both mother and baby, and therefore, pregnant women are particularly vulnerable to becoming severely ill from COVID-19. Although the Covid-19 vaccine is currently offered to all pregnant women in the UK, according to the latest UKOSS study of COVID-19 in pregnancy, more than 98% of women admitted with symptomatic covid-19 in pregnancy were unvaccinated. Only 3 out of 235 women admitted to intensive care had received a single dose of vaccine, and none had received both doses. Data from MBRRACE-UK also shows that maternal deaths from COVID-19 continue to occur, with most women unvaccinated. Regarding ethnicity, pregnant women from ethnic minority groups are disproportionately affected by Covid-19.  Data from Public Health England shows that deaths were almost 3 times higher in this period in Black, Mixed and Other females, and 2.4 times higher in Asian females compared with 1.6 times in White females.

Therefore, the aim of my project is to undertake a Health Equity Audit to assess Covid-19 vaccine uptake among Black, Asian, and Ethnic minority pregnant women/people in Southampton. I will be analysing maternity vaccination data to identify vaccine uptake by ethnicity. This quantitative insight will be strengthened by a qualitative component by engaging with Black, Asian and Ethnic minority women to identify barriers to the Covid-19 vaccine uptake in the local context. This quantitative and qualitative data will be supported by a rapid review of the current evidence on vaccine uptake in Black, Asian and Ethnic minority pregnant women. The resulting evidence will produce a report containing recommendations to improve vaccine uptake among Black, Asian, and Ethnic minority pregnant women.

About Sally

I worked as a health visitor in Hampshire for several years having qualified as an adult and paediatric nurse before taking a post in a community NHS trust as a paediatric research nurse in addition to health visiting. 

I became a research champion for the NIHR and Institute of Health Visiting (iHV) to promote greater research activity in health visiting practice and to establish networks between health visitors and research units. This role has developed within my trust and more widely in Wessex.  I have worked on a number of research studies and learned about the process of research implementation.

The health visiting role involves the delivery of public health programmes for children and families, with each child and family receiving the Healthy Child Programme in England.  I am looking forward to developing my understanding of population health and developing this in practice.  I also welcome the opportunities to work within my host organisation and develop a project which will be focused on children and families.

Project summary

Mind the Gap?

There is consensus that obesity has detrimental health consequences to all individuals (1).  There are many calls to reverse the current trends in rising obesity levels among the UK population (2).  An increasing evidence base acknowledges the influence of a child’s early years on their life outcomes (3).

  ‘The foundations for virtually every aspect of human development including physical, intellectual and emotional are established in early childhood’ (p. 3).

The Healthy Child Programme (HCP) (4) is the means of delivering universal and targeted public health intervention to children and families aged 0-19 years to promote their best start in life. 

Health Visitors are responsible for delivering the Healthy Child Programme (HCP) in England to all children and their families from the Antenatal period until a child commences school at which point School nurses continue the HCP 5-19 years. 

The premise of the HCP (5) is ‘Health needs will be identified in partnership with parents, children and young people using an approach that builds on their strengths as well as identifying any difficulties.’

The HCP is undergoing modernisation to align with the direction of other policy such as the NHS Long term plan and the Maternity Transformation Programme.  This modernisation will weave into the HCP the need to build programmes that are “place based, and asset based” with more deliberation than perhaps previously and a re-commitment to the importance of maternal health. 

There appears to be a gap in our knowledge about what parents and carers think or want or expect, relating to healthy weight in young children starting in pregnancy within the delivery of the HCP. 

We risk the social gradient of unhealthy weight amongst children in higher areas of deprivation continuing and increasing without wider approaches to engagement and potential co-production of support and interventions (6). 

The aim of this project is to optimise on the potential to support children and families in their early years, to explore potential within the HCP to promote healthy weight and engage with parents and carers and ask them about their views and experience of healthy weight conversations within the HCP.  It will also seek to consider what responses mean for population health and if there is learning for healthy weight across the lifespan.

The project will aim to capture the views of parents and carers from pregnancy to school entry about healthy weight conversations within the HCP.  Anonymous questionnaires with follow-up semi-structured interviews will be used to capture such views. 

It is anticipated that the findings from this project will be disseminated.  There is an expectation to share within the Population Health Fellowship 2021-2022 cohort but in addition,

1) findings will be shared in poster form with organisations involved in co-producing and supporting the project,

2) an application will be made to present at the annual Evidence Based Conference run by the Institute of Health Visiting September 2022,

3) a presentation will be offered to management leads within the 0-19 service in Solent NHS Trust and relevant networks within OHID.



1. Obesity | The Nuffield Trust [Accessed 18/02/2022]

2. Time to Solve Childhood Obesity (publishing.service.gov.uk) [Accessed 18/02/2022]

3. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/969168/Commissioning_guide_1.pdf [Accessed 18/02/2022]

4. https://www.gov.uk/government/publications/commissioning-of-public-health-services-for-children/health-visiting-and-school-nursing-service-delivery-model [Accessed 18/02/2022]

5. https://www.gov.uk/government/publications/healthy-child-programme-0-to-19-health-visitor-and-school-nurse-commissioning [Accessed 18/02/2022]

6. https://www.instituteofhealthequity.org/in-the-news/press-releases-and-briefings-/build-back-fairer-the-covid-19-marmot-review[Accessed 18/02/2022]


About Sara

Having qualified as a dentist, I have worked in various health care settings including general dental practice, Hospital Trusts, the prison dental service and primary care community services. I have also been involved in teaching undergraduate dentists and have enjoyed volunteering for rural community health projects in developing countries.

Currently I am training as a Specialist Registrar in Special Care Dentistry in the South West based at Bristol Dental Hospital and regional community dental services. This involves planning and enabling the delivery of oral care for patients with complex needs, often as part of a multi-disciplinary team.

I am passionate about providing inclusive, holistic care with a strong focus on prevention. I have developed an interest in tackling health inequalities and improving the health of vulnerable groups in our society.

I look forward to the opportunities for leadership and collaboration this fellowship will bring. In future, I hope to embed the population health knowledge and skills I have gained to raise awareness, influence positive change and to address our local population health challenges.

Project summary

Determine actions needed to improve mouth care training and support for care homes for adults across Bristol, North Somerset and South Gloucestershire (BNSSG) Integrated Care System (ICS):

Good quality mouth care and oral health is associated with good general health and wellbeing. Data from Public Health England highlights that care home residents experience worse oral health than the general adult population and appear to have a poorer oral health related quality of life. There is inconsistent oral care in care homes and significant variation in the knowledge, training and support for care home staff regarding mouth care for their residents. 

NHS England has outlined its ambition to strengthen support for care homes and there is a commitment to implement the ‘Enhanced Health in Care homes’ national framework which includes an oral health component, as part of the NHS Long Term Plan.

The aims of my project are to identify what mouth care support and training is currently in place for care home teams across the ICS and to better understand what the gaps and unmet needs are and how to address them. Through context and stakeholder mapping I hope to bring together relevant key partners from the health and social care and residential care sector to form a sustainable network that is working towards improving oral health training and support for care home teams.

The information and learning gained can be used by the ICS to establish what additional resource may be needed to improve mouth care training and support and to facilitate implementation of the national guidance framework, with the ultimate goal of improving the oral health of the care home population across BNSSG. 

I am also hoping to support the wider oral health strategy for the ICS by supporting the work of the oral health leads.

About Amy

I am a junior doctor working for the National Health Service. Originally from Bristol, I completed my medical degree in London and my foundation training in Scotland. I returned to Bristol in 2018 to train in General Practice.

During my time as a doctor, I have been exposed to a variety of exciting and challenging clinical environments, from a busy General Practice surgery in inner city Glasgow, to a High Dependency Unit in a large tertiary hospital, to medical wards in Uganda’s largest government hospital.

I recently completed a Masters in Global Health & Development at University College London. During my Masters, I developed a special interest in the political and macroeconomic processes that underlie health inequalities. My dissertation topic was how the food industry uses its economic power to influence public health policy.

I hope to use this Fellowship to develop new skills in population health which I could use to reduce health inequalities in my community in the future.

Project summary

Inequalities in access to the Long COVID clinic in Bath and North East Somerset, Swindon and Wiltshire:

This project aims to identify areas of unmet need in Long COVID, which currently affects an estimated 1.2 million people in the UK (1). The project is based around the theory that those who most need medical care are the least likely to receive it (2). To identify unmet need in Long COVID, I will use local data to compare the characteristics of people who tested positive for COVID with people referred to the Long COVID clinic. I will approach communities with low referral rates to clarify their experience of Long COVID and co-produce an intervention. I will use existing community connections to help achieve this, particularly those established through COVID vaccination outreach. The aim of the project is that the Long COVID clinic will treat a cohort of people that more fairly represents all groups that have been affected by COVID. The project will contribute to population health by engaging hard-to-reach groups, improving equity in access to outpatient care, and strengthening partnerships with communities and across the Integrated Care System.

1. Office for National Statistics. Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK [online]. Available: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/2december2021 [Accessed 21 December 2021]

2. Hart, JT. The inverse care law. Lancet; 1971. 297(7696):405-412.


About Solomon

I am a final year GP trainee and one of the Cohort 2 HEE National Population Health Fellows. I have a strong interest in leadership, public health policy and community health. I am a medical doctor with nearly 19 years of clinical experience. I am a native South African but grew up and studied in the United States. I have lived and worked five countries and three continents with exposure to several different health systems.

My experience varies from being an anaesthetic registrar, working on the island of St Helen- the second most remote inhabited place on earth to working at Chris Hani Baragwanath hospital which is the third largest hospital in the world and the largest in Africa. Part of my experience also involved voluntary military experience with the South African National Defense Force where I deployed on two UN Peace Keeping Missions.

I hope to embed population health thinking and practice into everyday clinical and social care practice. I believe population health must be more than activities but rather an ethos and mantra we all live by. I hope to be part of the part of the group that will make strides to reduce health inequities, and promote health both nationally and globally.

Project summary

Community Screening of Hypertension:

This project recognises the impact of cardiovascular disease on health outcomes, health inequalities and poorer COVID outcomes.

The project aims to: 1. Empower individuals to know and manage their blood pressures as part of a healthy lifestyle 2. Reduce the burden on primary care for the diagnosis and determination of concordance of hypertension

The project involves installing M8 Integrate Health Monitors in libraries and community health hubs for member of the public to use the machines to collect biometric data, receive lifestyle information, and interact with health coaches. They can also participate in an innovative library loan scheme of blood pressure monitors to facilitate home blood pressure monitoring and atrial fibrillation detection. The pilot will be in the Taunton Library with the aim of extending the programme throughout Somerset. This machine has been chosen for its potential to directly transfer data to the EMIS system which is used by all GPs in Somerset.

About Rebecca

I am a GP trainee in Exeter. I studied in Leeds and have worked in the Southwest for 4 years, working in both Devon and Cornwall. I have cared for patients from diverse backgrounds including those with multiple conditions living in rural and seaside communities, where access to healthcare can be a major determinant of health.

My interests include respiratory medicine, in which I worked for 15 months during the COVID-19 pandemic. I saw how health inequalities and the wider determinants of health play a massive role in outcomes for patients, both in COVID and other pathologies such as COPD. I had the opportunity to work on projects in respiratory service development, including the exploration of patient experiences living with long term conditions. My experiences thus far have cultivated an interest in population health and health inequalities.

I am delighted to be working in the fellowship program. I will develop my understanding of population health, and work 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.

Project summary

I am a Population Health Fellow based in Exeter hosted by Devon County Council. I have been working on two projects in this role.

1. Equitable Access to services – The Long COVID service

The pandemic has widened health inequalities in the UK. Long COVID is defined as ongoing symptoms 12 weeks after an infection. Ongoing research strives to understand why COVID19 effects people differently, including the development of complex and chronic symptoms. The term Long COVID is used to describe a plethora of symptoms that a person can experience including fatigue, ‘brain fog’, breathlessness, chest pains and many more. Treatment is mainly symptom management and involves a multi-disciplinary team of Allied Health Professionals. Prolonged symptoms impact quality of life and health outcomes, particularly when a person was already experiencing health inequalities. Across the country a ‘Long COVID Service’ has been developed to support patients and GP’s in management. This project will look at the service in terms of access. Inequitable access to services impacts people’s health outcomes, experiences, and health status. This project aims to use data on prevalence and referrals to audit equity of access. The data will guide recommendations and potential interventions. The methodology of this work could be applied to future work assessing equitable access to other NHS services.

2. Making Every Contact Count – Vaccine Uptake

This piece of work will explore improvements in COVID and flu vaccination uptake. I am leading a workstream to look at how using the principles of Making Every Contact Count (MECC) in harder to reach groups across Devon. We are currently exploring different avenues including MECC training and increasing staff confidence in addressing vaccine hesitancy.

About Gráinne

I am a registered Dietitian having worked clinically in the acute healthcare for 19 years.  My work as a service manager overlaps with every specialty and therefore collaboration and service development are a core part of daily life.

I am passionate about the skills and opportunities that all AHPs can bring to the population health agenda. Being an active member of the Dorset AHP council brings me together with healthcare, academic & local authority colleagues to work on the national agenda for AHPs at a strategic level.

I am enthusiastic about stronger partnerships between our education and health care providers. I am a clinical supervisor to a PhD student on a matched funded partnership programme with Bournemouth University. Together we are investigating how organisational culture influences accountability for nutrition and hydration in hospital patients. This is an exciting and innovative project which will help to improve the care processes across multidisciplinary teams.

My ambition is for our healthcare system to be a shared partnership between all professions including medics, AHPs, nurses and scientists. I’m eager to work towards more AHPs in advanced practice roles supporting physical & mental health services in all settings and revolutionising our population’s experience.

Project summary

My project is part of a wider Dorset programme of intervention design which seeks to address elective healthcare inequalities using population health approaches. The programme uses the Dorset intelligence and insight service (DIIS). By bringing together data from across health & care into a linked data model, we can get a holistic view of population health, including the impact of health inequalities.

Through this linked data set we can better understand local populations and individuals.  Within the programme we are working across a diverse set of healthcare organisations that provide care to the population of Dorset. The data shows a range of significant correlations between people on waiting lists, deprivation, particular risk factors and various negative outcomes.

Within the programme we have selected two cohorts of patients considering wider determinants of health.  We discussed and considered a way to tackle health inequalities in elective care using a population health management approach. We have had many sessions where we have together questioned the data in real time to refine the group we focus on. We have also refined the intervention by considering & questioning the ethical and safety considerations, agreeing the scope of the intervention, the appropriate cohort and outcome measures.

It’s been a great opportunity for me to build relationships with people that I haven’t had the opportunity to work with before. It’s also helped me to understand the health inequalities facing Dorset patients waiting for elective care.

I am involved in the cohort of 150 people who are overweight and on an elective orthopaedic waiting list. I’m working within a smaller group of healthcare professionals designing an intervention to trial with a small numbers of the population to allow adaptation. The interventions aim is to change how long patients wait or what care they get whilst they wait. We are designing a menu of options that are currently in operation from voluntary, health and wellbeing services and via social prescribers. We hope to move to the pilot stage of this intervention within the next few weeks.

About Manuela

I graduated from Manchester medical school in 2017 with an intercalated degree in pharmacology and physiology and I currently work as a GP trainee in the Bradford region.

I have always been interested in the holistic side of medicine and my career goals are to serve the community and be an advocate for better health. This is what drove me to choose general practice, as I feel it is the medical specialty that most aligns with my goals and values.

Working as a junior doctor and, seeing first-hand, large social disparities and differences in health outcomes has spurred me onto wanting to understand the causal factors for health inequalities at a systemic level.

My experience of the population health fellowship so far is that it’s an exciting journey - I believe that I am part of a growing movement of clinicians that want to see transformational change in our health and care services to create a fairer society.

Project summary

My project is being undertaken in an integrated care system (ICS) in the Yorkshire area called West Yorkshire and Harrogate Health and Care Partnership. Specifically, I have been working within the adversity, trauma and resilience network around the intersection between complex trauma and migrant health needs. 

It has been identified that vulnerable migrants are a population group that are at risk for experiencing trauma. Asylum seekers and refugees can face adversity throughout the migration journey and when accessing health and care services in the UK. A trauma-informed approach in the context of migrant health may be a framework by which to address and mitigate trauma experienced when vulnerable migrants enter our health and care systems.

As yet, this is not a model of care which is universally understood or used. I will be working with different stakeholders in the ICS to increase awareness around trauma-informed care, help embed trauma-informed policies into the partnership strategy and deliver training across sectors that work within the ICS.  

About Sheila

I am currently an internal medicine trainee in Greater South Manchester who graduated from Bristol Medical School. I have been involved in quality improvement and audit projects throughout my training. My most recent project involved auditing the first consultant-led Giant cell arteritis fast track pathway in Greater Manchester. I have also been fortunate enough to be able to practice medicine in New Zealand during the Covid pandemic. This enhanced my clinical understanding of population health by introducing me to a different healthcare system and how it affects the type of and way that may patients present.

Studying a master’s degree in public health at York University, further developed my passion for understanding the impact social determinants have on health behaviours and I was able to present my dissertation topic at the annual royal college of obstetrics and gynaecology academic meeting.  With the shifting medical and social landscape, it’s not enough to expect public health practitioners to solely deal with population health; the recent pandemic is a great testament to this.

My aim for this fellowship is to develop the core population health approaches that would give me the confidence to manage population health projects within my locality. This would ultimately contribute to improving patient outcomes in the long term.

Project summary

Service Evaluation study; Exploring the impact of social prescribing in Elective orthopaedic patients awaiting surgery in Primary care.

Current observational data shows that patients who are measured as most deprived wait longer for secondary care in comparison to those least deprived1 and this difference increases with age2.

COVID has gone on to further prolong waiting times for elective procedures particularly orthopaedic joint replacements which ultimately means at risk groups are likely to be waiting even longer and unwell for procedures3. 

Patient’s waiting for elective orthopaedic procedures are likely to utilise analgesia more and require more time off work. The objective of this project is to Improve patient wellbeing during the waiting period for elective surgery, measuring the impact the waiting period has in the patients overall health, engagement in society and economic output. We will use Pseudo-anonymised data of all adults waiting for hip or knee joint replacements in ISSA medical practise with a P3/P4 code and provide social prescribing interventions to this group. To measure this outcome of this service we will assess differences in Patient activation scores, WEMWBS, EM3 codes, Patient activation score (ONS4 well being scores alongside PAM scores and GP appointments.

About Samuel

I am an internal Medicine trainee working in various sites around the North of Manchester. I have a special interest in refugee health and the design and delivery of health-focused interventions and programmes.

I have worked internationally in a variety of roles, including in refugee settings in Greece and in research in Malawi with the Malawi-Liverpool Welcome Trust. Before returning to Manchester, I worked in the private sector in Mali and was responsible for the delivery of a number of community infrastructure, education and health improvement programmes.

The Fellowship is a unique opportunity to bridge the gap between clinical care and the health improvement as a cross-profession concern. I hope to carry this throughout my career and help shape the way we address, and improve, our wider determinants of health.

Project summary

Exploring and improving the causes behind intervention decay and inequality in secondary care pathways:

Bury Council is working in close partnership with the CCG and Northern Care Alliance to take a population health approach to minimising inequalities in healthcare. This approach, informed by the King’s Fund model of Population Health, draws on the intervention decay model and focuses on ensuring equitable and effective healthcare for everyone, regardless of deprivation, ethnicity or any other protected characteristic.

My project is to identify and assess data available pertaining to a single referral pathway (identified as a strategic priority area for improvement), exploring data quality and possible information gaps. From this, we aim to estimate (and characterise) unidentified need, and apply the intervention decay framework to the pathway- working with service providers to target specific areas or needs.

This is the beginning of a larger body of work, as this project will be re-evaluated after its interventions have been applied. We also aim to produce a framework that can be mapped onto other care pathways, allowing the same process to be applied elsewhere in the future.

About Rachel

I am a registered dietitian, currently working for the NHS in SW London in a community focused role. I have had varied dietetic experience over the past 12 years and am passionate about reducing health inequalities and preventing nutrition-related health issues.

After completing a BSc in Exercise Health & Nutrition, I worked for the NHS in a Community Health Development role in London, where I was introduced to health inequalities and community-based approaches to address them, before consolidating with a Master of Nutrition at Nottingham University and gaining my professional registration.

My interest in public health led me to spend a year with VSO in Papua New Guinea building local nutrition capacity, and 6-months in Cambodia supporting rural community projects through an HEE Improving Global Health fellowship. I also completed an MSc in Nutrition for Global Health at the London School of Hygiene and Tropical Medicine (LSHTM), conducting my research project on dietary diversity and stunting in Malawian adolescents with the Malawi Epidemiology and Intervention Research Unit (MEIRU). These experiences further highlighted nutrition issues and health inequalities worldwide, and my passion to work in this area.

I am excited to embark on this Population Health Fellowship, hosted by Gloucestershire CCG and Gloucestershire County Council, which presents a unique opportunity to develop my knowledge and skills in population health approaches and to draw on the expertise of a range of people working across this partnership. I hope to develop my leadership skills and identify ways to apply this learning to dietetics for the future.

Project summary

Exploring the completeness of weight and BMI data recording in primary care across Gloucestershire and how we can support improvement in this area, with a particular focus on addressing obesity-related health inequalities.

Only 40% of patients in our county data have a recorded BMI which is at odds with nationally reported prevalence data.  BMI is often used as a basis for decision-making in weight management services, including identifying cohorts for population health management interventions.  If we are not confident in the quality and coverage of the data (i.e. who is missing or what data is missing/inaccurate) then we risk introducing services which do not have the impact we hoped, and potentially widening existing inequalities of access and outcome. 

This project sets out to better understand why our data completeness is not good, and to make recommendations for how we could improve it.

About Susan

I am a Paediatric Dentistry Registrar with a passion for reducing health inequalities for children and young people.

After graduating from the University of Leeds, I worked on general dental practice in New Zealand before starting specialist training in Paediatric Dentistry at Leeds Dental Institute and Wakefield Community Dental Services. Alongside training I am carrying out research on management of dental anxiety, looking at the efficacy and acceptability of Cognitive Behavioural Therapy resources within the Community Dental Services.

I recently undertook a leadership fellow post in Quality Improvement at Leeds Teaching Hospitals Trust. Here I carried out work to improve dental pathways with paediatric oncology teams and helped launch “Mouth Care Matters” throughout the Trust; a programme to improve the mouth care of hospital inpatients. During my leadership year I developed a passion for population health, and I am excited to expand my knowledge and skills through this fellowship. Working in children’s oral health has shown me the stark inequalities, both within my own specialty, and in wider health.

I started my Population Health Fellowship in September within West Yorkshire Health and Care Partnership, carrying out a Health Needs Assessment for children within West Yorkshire.

Project summary

My fellowship is based in the ICS of West Yorkshire Health and Care Partnership. Since starting in September my main project has been co-leading a health needs assessment for children and young people within West Yorkshire. This has taken an epidemiological approach gathering data from the 5 districts within West Yorkshire and focusing on inequalities. The project has changed slightly and will involve writing a more concise report on health inequalities for children within West Yorkshire, setting out the key areas of inequality and the needs of this population.

Another project I am now starting involves forming an expert group for children’s oral health to set system recommendations and priorities for oral health within West Yorkshire for the ICS. The aims of the group are to evaluate current evidence, review access and quality of services, and determine the needs of the population. Areas of good practice will be identified to consider opportunities to scale up successful prevention schemes.

About Rhiannon

I am currently a second year GP trainee in Shropshire. Prior to medical training, I completed a BSc in Psychology and MSc in Clinical Neuropsychiatry. As part of my academic training in these areas, I was fortunate to have the opportunity to be involved in multiple research projects and clinical audits.

Being involved in the Population Health Fellowship provides a unique opportunity to combine all my skills and areas of interest to date. I really look forward to working with like-minded people to help drive systemic change, which better serves the people of our communities.

Project summary

My Population Health Project aims to explore the reasons why as a system in Shropshire, the life expectancy gap between those with Severe Mental Illness and the rest of the population is one of the worst nationally. We are initially looking at patient level data from two primary care networks (North Shropshire PCN and Wrekin PCN) to understand the breadth of provision of services to support people with mental health need. It is believed that there are specific issues around complexity in this patient group, along with data collection gaps. As part of the project, we aim to work with local Intelligence teams, mental health commissioners, primary care and a wide range of providers in the voluntary and community sectors to help understand the scope of the problem.

About Charlotte

I currently work as a Junior Clinical Fellow in Paediatric Emergency Medicine at the Royal Manchester Children’s Hospital. In 2010, I graduated from the University of Liverpool Medical School and then completed Foundation Training in London. After foundation training, I co-founded StreetDoctors; a national charity teaching young people impacted by violence live-saving first aid skills. During this time, I also worked part-time as a forensic examiner in a Sexual Assault Referral Center, caring for people immediately after a sexual assault.   

In 2017, I completed a Masters in Medical Anthropology at Harvard, where I researched mental health services, homelessness, and incarceration in Los Angeles. This research has led to the publication of several journal articles and international presentations.  My academic research and approach to Population Health are informed by theory and activism, calling for the abolition of the prison industrial complex, and for housing, environmental and economic justice. I plan to train in General Practice with a particular interest in Population Health and Paediatrics.

Project Summary

Screening for Sexual Assault when accessing Emergency Contraception at a Pharmacy:

This intervention aims to identify and support people who have experienced sexual assault and are accessing emergency contraception through a pharmacy. The pilot will train pharmacists in trauma informed care and add a screening question asking if sex was consensual to the questions for patients requesting emergency contraception. If someone has experienced sexual assault, they will be given information about the range of the support services available to them including forensic examination without or without police involvement, psychological support, and medical care.  

After an assault someone may confused and disoriented and struggle to know how to access care.  People who do not want to involve the police may not be aware that they can still have a forensic examination and decide later if they would like a legal case to move forward. The time period when forensic evidence can be collected is limited (samples should be taken as soon as is practically possible and are only possible up to 7 days after sexual assault) so unless someone is aware of the potential for a forensic examination (with or without police involvement) within 7 days they would not be able to make that choice. The goal of this project is to reduce psychological distress and improve medical outcomes for survivors of sexual assault.

About Esther

I am a year-seven Paediatric trainee, completing my special interest module in gastroenterology, hepatology and nutrition working within the Oxford University NHS Trust. I obtained my medical degree from Imperial College London before starting my paediatric training in the Thames Valley Deanery. 

As a Paediatrician, I am in a privileged position to care for children and their families both in the acute care setting, and as part of the wider integrated care system. In recent years, I have become more aware of the health inequalities faced by many of my patients and their families, and the importance of preventative care measures to improve patient outcomes. I have spearheaded quality improvement projects and maximised opportunities to address these at a local, regional, and national level.

On this fellowship, I look forward to developing my knowledge of population health and building a network of like-minded professionals dedicated to integrating it into our everyday practice. I am excited to continue to pioneer sustainable changes addressing health inequalities to improve our national health and wellbeing. 

Project summary

Clearing the blockage:

Overall am of the project:  To improve the quality of life and care of children suffering from constipation through education and increased awareness of its prevalence and burden on patients, families, and the NHS.

Outline of project

Constipation in children is common with figures as high as 30% of which 75% are functional or idiopathic. The aetiology of constipation is complex and multifactorial, with contributing factors including medications, a family history of constipation and life evets e.g. toilet training and starting school.

The signs and symptoms of constipation are often not recognised, and its impact underestimated with reduced quality of life for patients and their families including physical and mental wellbeing and loss of education time. It also results in a significant burden on the health service through volume of consultations and cost of treatment. There is clear guidance on the diagnosis and management of childhood constipation (NICE guidance) however in practice the management is complex requiring ongoing follow up and often the deviation from the guidance.

The current management approach is a reactionary one rather than a preventative proactive approach as much less is known about the impact modifiable risk factors. Evidence shows that early recognition and management of constipation improves outcomes. Therefore, by educating professionals and families around the importance of including constipation as part of routine health promotion and the impact of appropriate early management and follow up would improve patient experience, outcomes and reduce its impact on the health service.

As part of my project, I have the privilege of working with many pioneers in care of children with constipation and their families including charities, national working groups, national health leaders involved in health promotion and education, health care professionals to understand the ongoing work trend and enabling me to ensure my project is appropriately focused to where the greatest need is currently. I am excited to continue to work within this network to improve the health and wellbeing for children with constipation now and in the future.