Population Health

This Topic Guide explores part of the RCGP curriculum, Being a General Practitioner. It will help you understand important issues relating to population health by illustrating the key learning points with a case scenario and questions. It also contains tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources, including: Smoking, Alcohol and Substance Misuse, Long-term conditions including cancer and Metabolic problems and endocrinology.

The role of the GP in promoting health and preventing disease

The defining role of the GP is enacted in the consultation with the patient. However, GPs also have an essential role in the health of communities. Optimising the public's health requires co-ordination across three areas: health improvement, health protection, and health services.  

As a GP, your role is to: 

  • Take part in all three of these areas, for example by promoting healthy living, delivering screening and immunisation programmes, and using resources and services appropriately 
  • Understand the social determinants of health, from pre-birth to old age 
  • Assess the needs of local population groups  
  • Advocate for measures that promote good health in populations as well as individuals 
  • Address health inequalities 
  • Assess and communicate risk

Emerging issues in promoting health and preventing disease

Doctors were historically trained to diagnose and manage disease in individuals, rather than promote health in populations. The modern concept of health does not fit this traditional disease model, and GPs will need to keep up to date with a growing number of population health issues — for example, health inequalities, non-communicable diseases (NCDs), health service reorganisation, new models of healthcare delivery, sustainable healthcare, and climate change.  

As the world we practice in becomes increasingly interconnected and interdependent, the need to consider the wider environment, including global issues, also becomes important. You should understand the impact of globalisation on health and the basic principles of global health, many of which will be relevant to your daily practice; for example, local and global policies that effect population health (for example, in relation to tobacco, obesity and alcohol), the term 'universal health coverage' as defined by the World Health Organisation, and new infectious diseases (see RCGP Topic Guide Infectious disease and travel health). 

Knowledge and skills guide

Consider the following areas within the context of primary care:  

Health improvement

  • The concepts of 'health' and 'wellbeing'
  • The multiple determinants of health2
  • The relationship between social determinants of health and health inequalities
  • Socio-economic, political and cultural factors affecting people's lifestyle choices 
  • The impact on health of factors such as alcohol and substance misuse, poor diet, smoking, inadequate exercise and risky sexual behaviour, including in specific populations such as pregnant women, people with mental ill health, and other vulnerable groups 
  • Approaches to behaviour change and their relevance to health promotion and self-care 
  • Actions to address lifestyle factors that affect health (for example, nutrition, sleep, physical activity) and implement behaviour change 
  • Pharmacological approaches to addressing lifestyle risk factors (for example, weight management medications, treatments for alcoholism etc.) 
  • Clinical, social, and environmental risk factors in healthy individuals for a range of common/important conditions (for example, cancer, heart disease, diabetes, falls) 
  • Doctor-patient partnership in conversations relating to self-care 
  • Effects of an individual's health behaviours on their wider social network 
  • Ethical issues around prevention, pre-symptomatic testing, therapy in asymptomatic individuals, lifestyle choices, and tensions between individual and community needs 
  • Risk factors and safeguarding for different patient groups (for example, the frail elderly, children at risk of accidents, and people at risk of abuse including at home, in institutions etc.)

Health protection 

  • Disease prevention programmes for common and important communicable and non-communicable diseases  
  • NHS screening and immunisation programmes 
  • Health surveillance systems that that involve GPs (for example, RCGP Weekly Returns Service)  
  • Notifiable diseases and the role of the Health Protection Agency 
  • Risk-benefit conversations in relation to health protection, (for example, child immunisation)  
  • Health benefits of being in work 
  • Occupational hazards and risk factors (for example, occupational cancers, respiratory diseases, musculoskeletal disorders) 
  • Return to work and rehabilitation after illness or accident 
  • Fitness for work certification and guidance on its use  
  • Support and encouragement of disabled patients in the workplace  
  • Roles of other health professionals (for example, occupational health staff, physiotherapists and counsellors) in managing work and health issues. 

Service issues 

  • Resource allocation and prioritisation in healthcare, including legal responsibilities for care provision 
  • Ways of implementing and evaluating locally agreed health programmes (for example, exercise on prescription, alcohol and substance misuse, smoking cessation, psychological therapies) 
  • Health needs assessment of local populations and sub-groups (for example, working families, 'sedentary' children, smokers, pregnant women, the elderly, those living in poverty, homeless people) 
  • Audit and clinical governance 
  • Role of the GP in service redesign and commissioning 
  • Structure of health services in the UK 
  • Role of public health organisations in the UK 
  • Role of third sector, voluntary, and non-governmental organisations in population health 
  • Effect on health of government policies (for example, housing, environment, infrastructure, taxation, tobacco control)

Evidence and epidemiology (see also Topic Guide Evidence based practice, research and sharing knowledge)

  • The scientific discipline applied to healthy people as well as to those who are sick
  • The evidence base for and against interventions in healthy people, compared with the evidence for and against treatments in those who are sick
  • Risks and benefits of specific screening programmes for individuals and group
  • Concept of the hierarchy of evidence in relation to patients requesting Interventions Not Normally Funded (INNF) 
  • Sources of routinely available data about the health of local populations

Additional important content 

  • The influence of ageing, dependency, multiple co-morbidities, and frailty on individual and population-level healthcare needs
    The health of minorities and marginalised populations (including but not limited to refugees, asylum seekers, institutionalised groups, sex workers, the homeless, travellers, undocumented migrants, and victims of trafficking and torture)
  • Global factors affecting the health and wellbeing of individuals and populations (for example, climate change, air quality and pollution, health systems, pandemics, conflict and migration (including migration of health workers))
  • Global institutions with a health remit (for example, World Health Organisation)
  • The WHO global burden of disease
  • Models of healthcare delivery and financing

Case discussion

Anna, a 47-year-old self-employed cleaner, attends your surgery for a repeat blood pressure check following a pre-operative assessment for a laparoscopic cholecystectomy. She was told that her smoking and 'borderline' blood pressure meant that the health risks were too high for her to have her operation right now.  

Anna is angry at the delay. She has been intermittently off work with episodes of biliary colic. She is dismissive of her blood pressure as it has 'never been high before'. She tells you that it was probably high because she is very worried about her family: her 25-year-old daughter Eva recently had her first cervical cancer screening test and was advised that she needs a colposcopy. Eva is reluctant to have this and is suffering from panic attacks when thinking about hospitals. To make matters worse, Anna's mother is becoming frail and her husband has started drinking heavily again – this was also a feature of their early relationship but had improved until he recently lost his job. 

You note that Anna has a BMI of 33 and smokes 15 cigarettes per day. Today her clinic blood pressure is 158/94.  

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 Competence    
                       Questions           

Fitness to practise 
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 

 

 

 

Is Anna in a good state of health? Does she have a disease? 

How does Anna's attitude towards her own health affect my professional behaviour towards her? 

As Anna's GP, how important is it for me to role-model a healthy lifestyle?  

Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 

 

 

 

 

What action should I take if Anna's daughter doesn't attend follow-up after her cervical screening test? 

How involved should I be in helping to resolve Anna's family problems; to what extent are they for her to resolve herself? 

Is Anna's smoking a lifestyle choice or an addiction requiring treatment? 

Communication and consultation
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

 

What techniques can I use to explore Anna's understanding and beliefs about her and her family's health? 

How do I secure Anna's commitment to long-term lifestyle changes? 

How do I ask about factors such as diet and alcohol intake in a way that will encourage her to be truthful? 

Data gathering and interpretation
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 

 

 

 

 

What information do I need to reliably diagnose hypertension? 

How does Anna'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? 

Clinical Examination and Procedural Skills
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 

 

 

 

What is the correct way to measure blood pressure using a sphygmomanometer? 

What other examinations might be needed in the context of Anna's raised blood pressure? 

What bedside tests might I consider performing? 

Making decisions
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

 

 

 

 

How do I assess and make treatment recommendations based on Anna's cardiovascular risk? 

What differences might there be between my health promotion agenda and Anna's perspective on her health? 

How could I support Anna in deciding how to manage her stress?  

Clinical management 
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

 

 

 

What interventions do I know about that help with smoking cessation and weight reduction?  

What non-drug management options could Anna consider?  

What techniques can I use to help patients manage anxiety about hospital investigations/procedures? 

What interventions do I know about that help with weight reduction? 

Managing medical complexity 
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

 

 

How can structured care planning help to reduce risk and need for health services? 

What scope is there for a whole-family intervention to improve the health of Anna's family? 

What sources of support and advice could I offer to Anna in her role as a carer for other family members? 

Working with colleagues and in teams
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

 

 

 

How do GPs work with Public Health colleagues in managing the health of the population? 

Which other members of the primary health care team are involved in health promotion and disease prevention? 

Do the ethos and culture of my workplace encourage preventive care and health promotion? What are the factors that determine this? 

Improving performance, learning and teaching 
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 

 

 

 

 

 

 

 

What are the characteristics of a good screening programme?  

How effectively might lifestyle changes lower Anna's blood pressure? 

What local and national guidelines exist on obesity/malnutrition? 

What evidence-based population-level tobacco control measures do I know about (for example, taxation, Framework Convention on Tobacco Control)? 

What Quality Improvement Project ideas might relate to a case like this?  

Organisational management and leadership 
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 

 

 

 

How do I use my leadership skills to enable Anna to improve her situation? 

How can I make changes to our practice's services to encourage self-care and healthy living?  

What role can I play in designing or redesigning services for population health and preventive care? 

Practising holistically, safeguarding and promoting health
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

 

 

How might Anna's social circumstances influence her uptake of services and health/lifestyle advice? 

Consider the disclosure that Anna's husband is drinking heavily again. What effect might this have on my management plan? 

What do I know about Anna's social and ethnic background? Might this influence the consultation and clinical outcomes? If so, in what ways? 

Community orientation
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable health care. 

 

 

 

 

What additional local resources might I signpost Anna to? 

What is the role of a GP in population screening programmes? 

What is the role of the voluntary sector in the community where I practise?  

In the community where I practise, what are the factors that encourage or inhibit members of the community from supporting each other? 

How to learn this area of practice

Work-based learning 

All three elements of population health (health improvement, health protection and service improvement) can be learnt in a primary care setting, both inside and outside the practice. For example, as a GP trainee you should be involved in your practice's health promotion, prevention and screening activities, as part of the multi-professional healthcare team. You could also arrange to visit your local public health team, health protection unit or public health office (for example, Public Health England or the equivalent organisation in the devolved nations) to meet public health specialists and discuss the wider population health agenda. You may also be able to help with particular projects or undertake formal attachments.  

Most acute hospital boards have a public health strategy and action plan. While working in hospital placements you will find many opportunities to explore the public health agenda, particularly in the areas of screening (for example, breast screening services) and infection control. 

Self-directed learning 

As a GP trainee you should have access to courses on public health issues provided locally as part of training programme activities or by postgraduate deaneries working with public health specialists and primary care organisations. The RCGP offers various e-Learning courses on population health topics, which can be found via its website. In addition it has partnered with Cancer Research UK to provide a series of learning resources.

You can also find an e-Learning module(s) relevant to this Topic Guide at e-Learning for Healthcare

The Faculty of Public Health is the standard-setting body for specialists in public health. It is a joint faculty of the three Royal Colleges of Physicians of the United Kingdom (London, Edinburgh and Glasgow). The Public Health Textbook is an online resource which covers public health skills and competencies in relation to the Faculty Part A membership examination syllabus.  

Public Health England is an Executive Agency of the Department of Health set up as part of the reorganisation of health services resulting from the Health and Social Care Act 2012. It took on the role of the Health Protection Agency, the National Treatment Agency for Substance Misuse and a number of other roles including leading screening programmes delivered by the NHS. Key public health issues and developments can be found on the website.   

The UK Health and Safety Executive website is an excellent central resource on all aspects of health and safety in the workplace.  

National and regional population health data are available at the NHS Digital (formerly HSCIC) website and also via Public Health England.  

Learning with other healthcare professionals 

Many opportunities exist in primary care for you to be involved with nurses, health visitors and public health specialists, all of whom should be engaged in the practice's education and public health programmes. Learning with voluntary/third sector organisations, including those outside the health sector, may help you better understand the wider social determinants of health. 

Additionally, you may wish to speak to health professionals or patients who have trained in or used another health system, in order to understand the similarities and differences compared to your own. You could then consider how good practice from other health systems could be applied to improve the care you deliver. 

Structured learning 

The RCGP has developed some resources on public health as part of the Centre for Commissioning. The Faculty of Public Health is developing certificate courses for healthcare professionals from any discipline who wish to acquire recognised knowledge in this area. Several universities also award post-graduate diplomas and Masters' degrees in public health.

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT) 

  • Natural history of minor illnesses for example, URTI 
  • Screening programmes 
  • Appropriate advice for self-care

Clinical Skills Assessment (CSA) 

  • Overweight Asian man who smokes e-cigarettes attends for results of cardiovascular disease (CVD) assessment which show impaired fasting glycaemia 
  • Woman in early pregnancy wants to discuss routine antenatal screening and monitoring care programme, stating that she wants minimal intervention 
  • Middle-aged man, who is in temporary accommodation and not permanently registered with a practice, has COPD with frequent exacerbations due to poor medication compliance

Workplace-based Assessment (WPBA) 

  • Log entry about the baby immunisation clinic  
  • Consultation Observation Tool (COT) on discussing the benefits/risks of having a PSA test 
  • Case discussion on the health beliefs of a patient who is convinced he has cancer

Next: Respiratory health >

References

1 Blaxter M. Health (2nd edn) Polity, 2010  
2 Dahlgren and Whitehead's model of the social determinants of health 
3 Key publications on health inequalities include: Acheson D. Independent Inquiry into Inequalities in Health London: HMSO, 1998 Black D (Chair of working group). Inequalities in Health London: DHSS, 1980; Marmot Review. Fair Society, Healthy Lives. Strategic Review of Health Inequalities; Tudor Hart J. New Kind of Doctor London: Merlin Press, 1988 

The item has been added to your basket.

Continue shopping

Go to basket

This item is out of stock.

Continue shopping

The item is out of stock.

Yes Continue shopping

An error occured adding your item to the basket:

Continue shopping