Summary
The health of individuals is deeply interconnected with the health of populations and the planet.
Population health can be defined as “an approach aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of all people within and across a defined local, regional, or national population, while reducing health inequalities. It includes action to reduce the occurrence of ill health, action to deliver appropriate health and care services and action on the wider determinants of health. It requires working with communities and partner agencies.”1 There is no widely agreed distinction between the terms ‘population health’ and ‘public health’2. Some regard ‘population health’ as making it clearer that the remit and scope of action are not limited to public health professionals.3 For the purposes of the competences set out in this topic guide, the distinction between the two terms is less important.
Global health considers the health of populations in a global context. Many of its basic principles are relevant to your daily practice – for example, global policies that affect population health, universal health coverage and the relationship between globalisation and infectious diseases such as Covid.
Planetary health (also linked to ‘one health’ and ‘sustainable health’) can be defined as “the health of human civilization and the state of the natural systems on which it depends”.4 As a field, it aims to understand and address the human health impacts of human-caused disruptions to the earth's natural systems.5 Disruption of these natural systems through, for example, climate change and biodiversity loss, has a profound impact on the social and environmental determinants of human health. Healthcare services are a major contributor to environmental damage; addressing this is also part of planetary health. Protecting those things that give us health can create positive feedback loops that support the health of our patients and population. GPs therefore have a wider role in protecting the planet and its inhabitants, resources and ecosystems.
These is no single accepted definition of these terms, so the definitions used here are to aid understanding and contextualise learning outcomes.
Applying population, global and planetary health approaches to primary care involves understanding complexity and systems thinking. This, along with unfamiliar subject matter, the scale of the problems that need addressing and possible tensions between protecting individual and community health, may seem daunting or beyond your sphere of influence as a GP. However, every individual primary care encounter can be viewed through the wider lens of the communities and planet in which we are embedded; doing this will allow you to practise, reflect on and reinforce the skills and knowledge outlined below.
The role of the GP in population and planetary health
As a GP, your role is to:
- participate in protecting and improving the health of populations
- apply an understanding of the wider determinants of health to address health inequalities and inequities6
- use resources and services judiciously, maximising their effectiveness while minimising harm to people and the planet
- assess, monitor and address the needs of local population groups
- understand, assess and communicate risk to individuals and local populations
- advocate for measures to improve the health of populations and the planet as well as individuals.
Knowledge and skills guide
Consider the following areas within the context of primary care.
Health improvement
Promoting health and preventing disease
- The concepts of ‘health’, ‘wellbeing’ and ‘lifestyle’ and how these terms may be understood by individuals and communities in their own cultural contexts
- Principles of primary, secondary and tertiary prevention of disease
- Principles of screening (such as Wilson’s criteria) and their application in practice
- Principles of sustainable clinical practice, including:
- prevention
- patient empowerment and self-care
- lean systems and pathways (ensuring the right patients are treated with the most effective treatments, minimising low-value activities)
- low-carbon alternatives (for example, when prescribing inhalers)
- Impact of human activity (including the healthcare industry) on the environment, and its subsequent impact on human health
- Health co-benefits of environmental sustainability (that is, measures that protect both human health and the environment) relevant to primary care – for example, reducing unnecessary investigations or treatments, sustainable diets, walking or cycling instead of car use
- For a range of common or important conditions (such as cancer, heart disease, diabetes, falls, sleep problems, stress, substance misuse and mental health conditions) consider the following:
- risk factors for these conditions in healthy individuals and populations
- influence of socio-economic, political, geographical, environmental and cultural factors
- impact of these factors on health, including the evidence base and in specific populations such as pregnant women, people with mental ill health and other vulnerable groups
- individual and population-level interventions, including pharmacological and non-pharmacological approaches (for example, diet and physical activity for weight management, engagement with nature for stress or blood pressure management)
- Effects of an individual’s health behaviours on their wider social network and the wider ecosystem
- Approaches to behaviour change and their relevance to health promotion and self-care
- Social prescribing and ‘green social prescribing’ (linking people to nature-based interventions and activities through social prescribing)
- Ethical issues around prevention, presymptomatic testing, therapeutic interventions in asymptomatic individuals, lifestyle choices, resource use and allocation, tensions between optimising the health of individuals and communities, and balancing the needs of humans, other living beings and the environment
Wider determinants of health and health inequalities
- The multiple social, environmental and economic determinants of health7 and their global nature (for example, air and water quality, climate, conflict and migration, education, gender, housing and the built environment, pollution, poverty, race and religion)
- Major direct and indirect health effects of climate change and their mechanisms (for example, extreme weather events, heat or cold stress, air and water pollution)
- The influence of ageing, dependency, multiple comorbidities and frailty on individual and population healthcare needs
- The relationship between the social and environmental determinants of health, planetary health and health inequalities8
- The ‘inverse care law’9
- The health of populations at risk of marginalisation and unequal outcomes, including refugees, asylum seekers, institutionalised groups, sex workers, homeless people, travellers, undocumented migrants and victims of trafficking and torture
- Risk factors and safeguarding for vulnerable patient groups (for example, elderly people who are frail, children at risk of accidents and people at risk of abuse including at home or in institutions)
- Positive impact of sustainable practices on health inequalities (for example, increasing access to green spaces)
Health protection
- Communicable diseases, including:
- disease prevention programmes for common and important communicable diseases
- NHS screening and immunisation programmes
- Environmental hazards, including:
- air pollution (for example PM 2.5, nitrogen oxides) and its impacts on human health
- water pollution (for example, toxic levels of pharmaceutical products in rivers)
- impact of planetary health on infectious diseases (for example Covid, zoonoses, distribution of malaria and Lyme disease, waterborne diseases)
- Health surveillance, including:
- notifiable diseases
- health surveillance systems involving GPs (for example, RCGP weekly returns service)
- NHS test and trace systems
- the role of the UK’s health protection agencies in managing outbreaks of infection
- Workplace health protection, including:
- health benefits of work
- occupational hazards and risk factors (for example, occupational cancers, respiratory diseases, infectious diseases, musculoskeletal disorders, risks of extreme temperatures, shift work)
- return to work and rehabilitation after illness or accident
- fitness for work certification and guidance on its use
- roles of other health professionals (such as occupational health staff, physiotherapists and counsellors) in managing work and health issues
- safe personal working practices (for example, use of personal protective equipment, infection control, ensuring safety of others)
Health systems and services
- Health needs assessment of local populations and subgroups (for example, working families, ‘sedentary’ children, smokers, pregnant women, older adults, Black, Asian and minority ethnic (BAME) communities, those living in poverty, homeless people)
- Personalised care principles to improve population and planetary health (doing what matters to patients rather than doing too much medicine that may cause harm)
- Implementation of health promotion programmes (for example, nutrition, exercise on prescription, alcohol and substance misuse, smoking cessation, psychological therapies)
- Health screening and population screening, including risks and benefits of screening programmes
- Leadership and participation in service design and implementation, including environmental impacts of patient pathways
- Environmental, social and economic sustainability of health services through measures such as:
- lean pathways
- carbon footprinting of different elements of primary care (including prescribing, travel, heating, paper, plastic)
- appropriate changes to prescribing (for example, use of dry powder inhalers, deprescribing) and patient pathways
- appropriate planning for, and adaptation of, primary care premises, purchasing, processes and waste management
- Structure, governance and financing of health services in the UK and their effects on access to healthcare
- Role of community health services, public health, third sector, voluntary and non-governmental organisations in UK population health
- Relevant national and global public health policies and guidelines that impact on primary care practice (for example, obesity, tobacco control, housing, environment, immunisation, infection control)
- Resource allocation and prioritisation in healthcare, including legal responsibilities for care provision
Health communication
- Use of a range of communication methods and styles to take into account differences in health literacy, including in colleagues and staff
- Personalised care and relationship-based approaches to conversations with patients (for example, about conditions and their treatments, healthier living, self-care, sustainability)
- Risk–benefit conversations in relation to health (for example, immunisation, screening, stopping smoking, preventative care, medications, environmental exposures). Consider risks beyond the individual, such as to the wider community and planet
- Respect for the role and value of different world views, health beliefs and types of knowledge; integration of experiential knowledge with evidence-based practice; the concepts of cultural competence and cultural humility
Additional global health skills and knowledge
- Major causes of global morbidity and mortality
- Impact of globalisation on health
- Key actors in global health, including international organisations, the commercial sector and civil society
Additional planetary health skills and knowledge
- Relevant basic terminology and science of climate change
- Relevant planetary health agreements and policies (for example, UN Conference of the Parties (COP) agreements, UN Sustainable Development Goals and the NHS net zero strategy)
- Planetary health theoretical models (for example, systems thinking, characteristics of sustainable health systems and Sustainability in Quality Improvement (SusQI))
- The value of assessing outcomes for patients and populations in relation to their environmental, social and financial impacts
Case discussion and questions
Jay Thomas is a 45-year-old self-employed taxi driver. He comes to you with a three-month history of intermittent cough and chest tightness. You see a diagnosis of asthma in his GP record, for which he has been prescribed salbutamol and steroid metered-dose inhalers. Jay reports that he only uses the inhalers irregularly, as they do not seem to help much. He smokes 15 cigarettes a day and is overweight. He lives in a third floor flat in a dense urban area with high air pollution. He lives with his wife, two teenage children and elderly mother.
Jay wears a face covering while at work; however, he is still hesitant about having a Covid-19 vaccine because he has read on social media that vaccines have terrible side effects that would stop him from being able to work. He acknowledges that life is very stressful right now. He requests a letter of support from you to apply for rehousing as his flat is poorly ventilated and has mould inside, and he believes that his symptoms are due to this.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How might Jay’s health beliefs affect my professional behaviour towards him? As Jay’s GP, how important is it for me to role-model a healthy lifestyle? How involved should I be in helping to resolve Jay’s housing problems; to what extent are they for him to resolve himself? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | To what extent is Jay’s smoking a lifestyle choice or an addiction requiring treatment? What kind of unconscious bias might a GP have in a consultation like this? Do the ethos and culture of my workplace encourage preventative care and health promotion? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | What techniques can I use to explore Jay’s understanding and beliefs about his health? What do I need to know about Jay’s health literacy, including digital health literacy? What health information would enable or motivate Jay to change his lifestyle to improve his health? How do doctors and patients make their conversations about factors such as smoking, diet, physical activity, stress and alcohol honest and productive? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What other information do I need to understand the cause of Jay’s respiratory symptoms? Is there likely to be a single cause? What other information do I need to understand the impact of Jay’s respiratory symptoms on his health and wellbeing? How would I assess Jay’s cardiovascular and mental health risks? How can the impact of wider environmental risk factors (such as air pollution and poor housing) on Jay’s symptoms be assessed? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What other examinations might be needed in the context of Jay’s symptoms or risk factors? What bedside tests might I consider performing? Do I know what different types of inhaler there are and how to teach their correct use? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | What differences might there be between my health promotion agenda and Jay’s perspective on his health? How could I support Jay in deciding how to manage his stress? What decisions do I need to make with Jay in relation to enabling his choices, improving his health and environmentally sustainable options? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What interventions do I know about that help with smoking cessation and weight reduction? What is the impact of metered-dose inhalers on the environment? What non-drug management options might Jay consider? What are the potential benefits to Jay of social prescribing or ‘green prescribing’ such as nature exposure, and how do I practically make them available to him? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | What social or environmental factors might be contributing to Jay’s problems (for example, air pollution, mould, precarious employment)? How might personalised care planning and supported self-management help to reduce risk and the need for health services? How will Jay and I together manage the uncertainty around the different factors contributing to his symptoms? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | Who else in the primary health care team is involved in health promotion and disease prevention? What roles might care coordinators, link workers or health coaches play in supporting and motivating individuals such as Jay? What are the pathways for effectively accessing further support for Jay for his obesity, smoking, stress or respiratory symptoms? How do GPs work with community health services and public health colleagues in managing the health of populations? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What are the characteristics of a good screening programme? What evidence-based population-level tobacco control measures do I know about (for example, taxation, the World Health Organization Framework Convention on Tobacco Control)? How might sustainable quality improvement be relevant to a case like this? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How can I make changes to our practice services to encourage prevention, self-care, healthy living and environmental sustainability? What role can I play in influencing the development of services for population health and preventative care? What might be the organisational challenges to introducing low-carbon respiratory products? How could these be addressed? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic, and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | Do I think Jay is in a good state of health? What might ‘health’ and ‘wellbeing’ mean to Jay? What assumptions have I made and what do I know about Jay’s social, cultural, and ethnic background? Might this influence the consultation and clinical outcomes? If so, how? Where does Jay’s knowledge about health come from and why is this important to this consultation? How might Jay’s social circumstances increase his health risks or influence his uptake of services and health and lifestyle advice? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What are the population characteristics of the community I work in, and how might this affect the types of health problem seen in practice? How does Jay’s health compare with that of the local population? How might I find the data needed to assess this? How do I identify groups with poor health within my practice population? Where locally can Jay take his current metered-dose inhalers when he has finished with them to ensure their appropriate disposal? Which would be more beneficial (and to whom): a one-stop community asthma service that GPs can refer to, or extra paid nurse time for chronic disease management in each practice? Why? |
How to learn this area of practice
Work-based learning
Population and planetary health skills can be learned in a primary care setting. All clinical encounters are an opportunity to apply the principles of population and planetary health. For example, as a GP registrar you should be involved in your practice’s health promotion, prevention and screening activities as part of the multiprofessional healthcare team. For your Quality Improvement Project, you can take a SusQI approach.
You may have liaised with your local public health team, health protection unit or public health office, or been involved in mass vaccination programmes –for example, during the Covid-19 pandemic. As a GP registrar, you may also wish to undertake formal attachments in these organisations to give you an insight into the work they do and how it links to primary care.
While working in hospital placements you will find many opportunities to explore population health activities such as screening (for example, breast screening services), infection control and occupational health. There will be opportunities to consider the impact of prescribing and deprescribing decisions beyond discharge, and the need for personalising ongoing care. There may also be scope to engage with a sustainability team at the hospital trust.
Self-directed learning
Population and global health
- elearning for healthcare includes Health Education England’s population wellbeing portal, which covers topics such as health inequalities, prevention, screening and health improvement.
- The King’s Fund has an overview of population health.
- The Faculty of Public Health is the standard-setting body for specialists in public health.
- The RCGP Physical Activity Hub includes information on how to embed physical activity in primary care for patients and staff.
- The Faculty of Sport and Exercise Medicine UK has useful resources on physical activity. Moving Medicine, initiated by the faculty, gives practical advice on how to integrate physical activity into everyday consultations.
- National and regional population health data is available via NHS Digital and the government Fingertips public health profiles website.
- The RCGP offers several eLearning courses on population health topics.
- The UK Health Security Agency has information on health protection and the Department of Health and Social Care website has information on health improvement and inequalities.
- The UK Health and Safety Executive website is an excellent central resource on health and safety in the workplace.
- The United Nations website contains information on the Sustainable Development Goals.
- The World Health Organization (WHO) is a key resource for global health, including Covid-19 and other infectious diseases, tobacco control and healthy food policies, climate change and the global burden of disease.
Planetary health
The RCGP has a comprehensive range of resources on sustainable development, climate change and green issues relating to health. These include links to:
- the Centre for Sustainable Healthcare (CSH), including a course on sustainable primary care and resources relating to sustainable quality improvement
- Greener Practice, which includes information ranging from how to change metered-dose inhalers to dry powder inhalers, to patient leaflets on nature-based interventions, and the Green Impact for Health (GIFH) Toolkit to help GPs improve planetary health in practice
- the UK Health Alliance on Climate Change, an organisation of healthcare professionals including the UK royal colleges. Resources include a guide to carbon literacy (that is, awareness of how everyday activities impact on greenhouse gas emissions).
The following resources relate to the wider picture of the climate and ecological emergency, including policy and evidence on the health impacts of climate change:
- Lancet Countdown includes annual reports and the EAT-Lancet diet report (a scientific review of what constitutes a healthy diet)
- NHS England guide to delivering a net zero NHS policy (there are different units in Scotland, Northern Ireland and Wales)
- the WHO’s 1.5 Health Report, a health-related summary of the findings of the Intergovernmental Panel on Climate Change (IPCC).
Learning with other healthcare professionals
Multiprofessional and transdisciplinary working are essential for good population health. In primary care you could work with nurses, health visitors, social prescribers, pharmacists, social care and public health specialists, for example – all of whom are likely to be involved in education or public health programmes. Learning with voluntary or third-sector organisations, including those outside the health sector, may help you better understand the wider determinants of health.
Additionally, you may wish to speak to health professionals or patients who have trained in or used another health system, to understand the similarities and differences compared with your own. You could then consider how systems, processes or innovations from other health systems might be applied to improve your own practice.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Health promotion, including in the workplace
- Screening programmes
- Environmental impact of prescribing
Simulated Consultation Assessment (SCA)
- A Bangladeshi man who is also overweight and smokes e-cigarettes attends for results of cardiovascular disease (CVD) assessment, which show impaired fasting glycaemia
- A woman in early pregnancy wants to discuss routine antenatal screening and monitoring care programme, stating that she wants minimal intervention
- A middle-aged man, who is in temporary accommodation in an inner-city area and not permanently registered with a practice, has chronic obstructive pulmonary disease (COPD) with frequent exacerbations.
Workplace-based Assessment (WPBA)
- Log entry about the baby immunisation clinic
- Consultation Observation Tool (COT) on discussing the benefits and risks of having a prostate-specific antigen (PSA) test
- Case discussion on the health beliefs of a patient who is convinced he has cancer.
References
- The King's Fund. A vision for population health: Towards a healthier future. 2018.
- For examples of differing definitions, see MPH Online. Population health vs public health and Advanced Data Systems Corporation. The difference between population health and public health.
- The King's Fund. A vision for population health: Towards a healthier future. 2018.
- Whitmee S, Haines A, Beyrer C et al. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health. The Lancet 2015; 386(10007): 1973–2028.
- Planetary Health Alliance
- Health inequities are avoidable, unfair and systematic differences in health between different groups of people. The term ‘health inequality’ tends to be used to refer to health differences alone, but sometimes also includes social injustice in its definition (see for example The King’s Fund What are health inequalities?
- See Dahlgren and Whitehead's 1991 model of the social determinants of health in Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for Futures Studies.
- Acheson, D. Independent Inquiry into Inequalities in Health. London: HMSO, 1998. Black, D. (Chair of working group). Inequalities in Health. London: DHSS, 1980 – summary available. Marmot, M. Fair Society, Healthy Lives: The Marmot Review: Strategic Review of Health Inequalities in England Post-2010. London: 2010. Tudor Hart, J. A New Kind of Doctor. London: Merlin Press, 1988, Marmot, M. et al. Health Equity in England: The Marmot Review 10 Years On. London: Institute of Health Equity, 2020.
- For example, Tackling the inverse care law.