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ICSs should look to GPs for population health leadership

ICSs should look to GPs for population health leadership
By Jess Hacker
6 June 2023

Integrated care systems (ICSs) should focus on upskilling clinicians and managers in primary care in population health management (PHM), an NHS England advisor has suggested.

One of the core aims of the new NHS systems, PHM focuses on the wider determinants of health and has been touted as a ‘golden thread’ between ICSs and PCNs.

Speaking at a Pulse PCN event in Birmingham, Dr Maslah Amin, associate clinical director at NHS England, suggested that ICSs have a responsibility to equip clinicians and managers with the ability to factor population health into their work.

ICSs should encourage these staff to undertake Health Education England’s Population Health Fellowship, which would see them seconded for two days a week and train in PHM, he said.

The course focuses on reducing the occurrence of ill-health by having fellows work in communities and with partner agencies to address wider determinants of ill-health.

Delegates also heard about a Westminster programme deploying community health and wellbeing workers (CHWW) into deprived communities to address unequal access to primary care.

The model, devised in Brazil in the 1990s and piloted in North West London, sees CHWWs recruited from the local community delivering tailored support to households, including to assess needs and help navigate support services.

Dr Cornelia Junghans Minton, a GP at Pimlico Health and senior clinical fellow in primary care at NIHR North West London, said the Churchill Gardens pilot hired four community champions whoa re paid by the local authority and work on honorary contracts with GP practices.

She said: ‘Each one of them has about four buildings, and they look after them regardless of need and they stop in once a month.’

‘The primary remit is to build a relationship with the households that they are looking after, and with their local professionals on the patch so they will know their health visitors, children’s, housing and employment services, and the voluntary sector.’

She also highlighted that the a need for ‘proportionate universality’ meaning care is delivered according to the degree of need, adding that broad brush targeted approaches are not always the best.

Dr Amin suggested that primary care should be the driving force behind a PHM approach, highlighting its value in reducing the health and care system’s carbon footprint.

‘The NHS is the number one producer of carbon emissions of all public sector organisations in England. GPs see the vast bulk of patient consultations in the NHS and we naturally have the opportunity to influence that carbon footprint,’ he said.

The health service contributes around 4% to 5% of total UK carbon emissions, with the NHS in England responsible for 40% of the public sector’s emissions alone.

Dr Amin cited 2018 data that indicated the NHS is responsible for 5% of all traffic on England’s roads, which includes patient travelling and deliveries.

He said: ‘Because in general practice we see so many of the patient cases, lots of GPs already do effective population health management. The leadership is going to have to really come from primary care, just because of the influence we have over referrals going into hospital.’

PCN directors previously met with Pulse PCN to discuss their current population health management projects and whether or not the approach is working for their area.

And Andi Orlowski, senior adviser to NHS England on population health management, told Pulse PCN that PCNs should ‘not to wait for the ICS to come knocking but to actively engage with them now’.

More information on upcoming Pulse PCN forums can be found at

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