Population Health and Health Inequalities in general practice

The RCGP defines a GP as follows:

A GP is a doctor who is a consultant in general practice. GPs have distinct expertise and experience in providing whole person medical care whilst managing the complexity, uncertainty and risk associated with the continuous care they provide. GPs work at the heart of their communities, striving to provide comprehensive and equitable care for everyone, taking into account their health care needs, stage of life and background. GPs work in, connect with and lead multidisciplinary teams that care for people and their families, respecting the context in which they live, aiming to ensure all of their physical and mental health needs are met.

There are a lot of common goals for General Practitioners and Public Health professionals.  General Practice focuses on the individual and their families, while also having some responsibility for health outcomes and health inequalities for their registered patient population and their local communities. A GP brings an understanding of health and wellbeing across the whole life course, of undifferentiated illness, of multi morbidity, and the intertwining of physical and mental health. They have experience of the potential benefits and harms of a medical approach as a determinant of heath. They are trained in how to deliver the unique frontline of Universal Health Coverage.  GPs see how their patients are served by all health and care services and know how poorly that often works for the socioeconomically deprived (and other groups). They already have experience of how the health care system delivers most of its preventative and proactive care, for individuals, families and communities. They are used to communicating effectively with people from all backgrounds. They are used to working in multi-disciplinary teams.

Most Public Health professionals focus on the health outcomes and inequalities at the more strategic population level, including at policy level. Although some will be engaged in personalised care such as smoking cessation support. However, collaboration between primary care and public health teams can sometimes be hampered, for example through different cultures, drivers and a lack of shared understanding.

A GPwER PH and HI is an interpreter and facilitator for greater collaboration between general practice, primary care and Public Health to achieve common goals.

GPs are expected to understand public health as applied at the level of the individual, and the local community that they are serving. The GP curriculum sets out the competencies that all GPs should have.

The extended role would include additional competencies, with the focus on population health approaches and health inequities, rather than the full range of public health functions.

The GP with an Extended Role in Population Health and Health Inequalities would therefore be expected to have a basic level of competency in the core public health functions relevant to population health, and to have higher levels of competencies in the functions most relevant to the specific role.

The GPwER should be engaged with a named public health team for peer support and have a public health specialist line manager or mentor (RCGP Mentoring platform). The RCGP Guide to Clinical Extended Roles states that “it will be important to include the name, scope of practice and qualifications of the clinical supervisor within the extended role (who should usually be a specialist)”

The GPwER should be able to provide assurance to the Responsible Officer (RO) that they have trained for their role as a GPwER and that they are staying up to date in that role.

Population health

We use the Kings Fund definition of population health 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 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

Figure 1. A population health system

The approach therefore tends to be place based, although the defined population could be simply geographic or a group within this (such as those with a protected characteristic).  

Within this system, GPs with an Extended Role are often working within the health and care sector. It is likely that many will focus on Health Care Public Health, as described by the Faculty of Public Health: 

Healthcare public health is concerned with maximising the population benefits of healthcare while meeting the needs of individuals and groups, by prioritising available resources, by preventing diseases and by improving health-related outcomes through design, access, utilisation and evaluation of effective and efficient healthcare interventions and pathways of care.

Health Inequalities

We use the NICE definition that health inequalities are:

The differences in health across the population, and between different groups in society, that are systematic, unfair and avoidable.

However, we note the view from the World Health Organisation and others:

Inequity and inequality: these terms are sometimes confused, but are not interchangeable, inequity refers to unfair, avoidable differences arising from poor governance, corruption or cultural exclusion while inequality simply refers to the uneven distribution of health or health resources as a result of genetic or other factors or the lack of resources.

Public Health

We use the definition of Public Health by Acheson in 1988 as: 

The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.  

It can be understood as a broader approach that makes us consider the social, political, commercial and wider determinants of health. Population health could be seen as subset of public health, focussed on a defined population and more place based. 

This Framework provides a guide for employers and GPwERs on how to define and develop the additional competencies for any specific role within population health and health inequalities. 

As a part of the GPs portfolio of work, work as a GPwER in population health would not usually involve direct patient care but generally include public and patient engagement.  The GPwER PH and HI is engaged in improving health outcomes at a population level through systems leadership and systems working. This may include ensuring that the provision of lifestyle interventions does not exacerbate health inequalities between those population groups who are less able to engage and those who are already more advantaged.

The job or role description should include a defined population, either geographic or a population with specific characteristics, or usually both.

These roles could be in any organisation, in the Public, Private or Voluntary, Community and Social Enterprise (VCSE) sector. The role could be at a local or regional or national level. The GPwER may work across organisational boundaries or in a specialist setting.

Although these roles would not usually involve direct patient care, they may involve patient and public engagement. The GPwER should have good communication skills and know how to signpost to appropriate services.

As a GP, the GPwER PH and HI should bring evidence that they are maintaining competence in this role to their GP appraisal. GPwERs employed outside their Practice should include a performance review by their employer or line manager and they should provide the outcomes as part of their whole scope of practice in their appraisal portfolio.

The GPwER should be engaged with a named public health team for peer support and have a named public health specialist line manager and/or clinical supervisor.

They should:

1. Evidence their performance, ongoing professional development, and engagement. This evidence may include authored documents and reports, audits (for example health equity audits or health equity impact assessments), educational activities, presentations and feedback from colleagues and the public.
2. Reflect on their experiences, challenges, and successes in managing the content of any job plans. Reflective discussions help identify areas for improvement and develop strategies to enhance their practice and patient care. Reflections could be logged in the GP portfolio.
3. Obtain feedback from peers, colleagues, multidisciplinary team members, and the public in line with GP Appraisal requirements.  If a significant part of an NHS GP’s work is as a GPwER then the GPwER could best demonstrate feedback in their role by additional colleague surveys of their colleagues and/or the public from this role in addition to their surveys as an NHS GP.
4. Maintain a CPD portfolio that documents their participation in relevant educational activities, courses, conferences, and workshops related to their GPwER role. This portfolio showcases a commitment to ongoing learning and development.
5. Obtain written feedback from their public health line manager, mentor or supervisor, and share this with their appraiser; it will be important to include the name, scope of practice and qualifications of the clinical supervisor within the extended role (who should usually be a specialist).

GP appraisal provides assurance to the Responsible Officer (RO) that the GPwER has trained for their role as a GPwER, that they are staying up to date in that role and that they are seeking and reflecting on feedback and outcomes in that role including the outcomes from a performance review with a line manager or medical director or employer.

GPs with extended roles undergo revalidation every five years, to maintain their licence to practise. 

These roles could be in any organisation, in the Public, Private or Voluntary, Community and Social Enterprise (VCSE) sector. The GPwER may work across organisational boundaries or in a specialist setting. The GPwER is likely to interface with multiple services that have a role in improving population health and reducing health inequalities.

The GPwER should be engaged with a named public health team for peer support and have a public health specialist line manager and/or mentor clinical supervisor. 

The time commitment for a GPwER PH and HI is flexible, ranging from a single session per week to a full-time role. Less than one session per week would likely be insufficient for maintaining competencies. 

The GPwER could be employed or commissioned by an NHS organisation or other Public, Private or Voluntary, Community and Social Enterprise (VCSE) sector organisation. The role could be across organisational boundaries with one organisation holding the contract or commissioning the GPwER on behalf of others. The GPwER could be a partner, a salaried GP, locum/sessional GP or could be self-employed and work on a consultancy basis. There should be a contract or agreement that stipulates that they are a GP engaged to provide population health and health inequalities expertise.

The GPwER is recommended to have a line manager and/or clinical supervisor with a public health background. If the line manager is not a public health professional, it is recommended that the GPwER has a named public health mentor, to support their developing and maintaining competencies for the role.