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Population health improvement is the golden thread that runs through all NAPC work. We support healthcare systems to develop innovative approaches to personalised health, care and wellbeing that improve outcomes for people and the workforce that serves them. This in turn creates a more sustainable healthcare system. We have seen fantastic improvements in outcomes from smaller scale population health improvement initiatives just as much as we have from larger system wide care redesign.

Read the case study: The Impact of Early Frailty Support

Participants undertaking the national CARE programme can put their learning into practice by working on a population health improvement initiative, based on local need and their own interests. These projects cover a broad range of needs and have already demonstrated measurable improvements in patient health and wellbeing, predicted to reduce demand on GPs.

Read the case study: Redesigning care pathways for people with long term conditions

What our clients say

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"After nearly 40 years of working in the care sector, this is the very first time I have had supported leadership training towards innovation and integrated working. Everyone should have access to this course – NHS or not, as it offers networking opportunities to share experiences and best practice, enabling better patient care. An excellent component of the course is the ongoing mentorship that is on offer – this is a gold standard that puts any other course in the shade."

Dawn Osborn

Social Prescriber – GP Link Worker Herts Help Hospital & Community Navigation Service

Taking a population health led approach to planning using the services and estates planning toolkit has supported PCNs across West Yorkshire ICS to develop their clinical visions. To learn more about how population health priorities informed innovative models of care read our case study.

Read the case study

"Sarah has been assisting the PCN business managers with a piece of work relating to the future estates policy of the PCNs. With Sarah's outstanding assistance she has managed to convert the great work we do into a relevant and polished end product that does us far more credit. She made a real positive difference to our submission and I couldn’t have done it nearly as well without her help."

Andrew Athale

Brigantes PCN Business Manager - Conexus Healthcare

Health creation

When personalised care is coproduced with patients taking a holistic approach to their needs, this creates empowered communities with people who are better able to support themselves through proactive self management and self care. Creating the right conditions for people to be healthy and supporting them to remain healthy is the key to proactive, preventative care. A great example of this is the support provided by Community Health and Wellbeing Workers (CHWW) which has led to ‘health creation’ across a deprived housing estate in Churchill Gardens, Westminster.

Community Health and Wellbeing Workers (CHWW)

There are three core characteristics of the Community Health and Wellbeing Worker that makes them unique from other roles. These are: 

  • Universal – Based at a local level with a geography of 120-150 households, knocking on all doors in a universal way. This means that all households are in their mandate to approach, and unlike other similar roles, they do not just focus on specific or targeted conditions. Everyone in the household is included, they are universal. 
  • Comprehensive – covering ‘any and all’ issues that might arise within the household. This could include but is not limited to immunisation, mental health, dementia, management of chronic disease and breast feeding. They bridge the health and social care divide across the life course. 
  • Integrated – They don’t operate in parallel; they are employed by local authorities or primary care via PCN’s and are integrated into the primary care team with access to patient records. The play a variety of roles, from advising the team on potential safeguarding issues or liaising with the local authority if they identify housing or social care needs. 


The role of the CHWW is to ensure targeted populations in areas of deprivation receive tailored health and wellbeing support by visiting people in their own homes and looking after everyone in the household. CHWW are people selected based on their character rather than their characteristics; those who are helpful, problem solvers, confident and persistent whilst maintaining respect and confidentiality to earn trust of residents. The specially recruited teams get to know families and assess their health, social and wellbeing needs, promote healthy living, signpost to appropriate services and make referrals to NHS services.  

Benefits so far from the first scheme in London have included a 20% uptake in vaccinations per home, combating loneliness, identification of child carers, medicines compliance and early diagnosis of dementia – to name but a few. This shows that by offering holistic personalised care and support, a person is activated which creates a stronger foundation for their health and wellbeing in the longer term. For more information about how the NAPC can help support you to develop a CHWW initiative in your area, please contact

"Health and care services are under tremendous pressure, but we must make sure that patients do not bear the brunt of these challenges. We are calling for this initiative to be rolled out to even more neighbourhoods and communities, helping to improve the nations’ health and wellbeing, and reduce the pressure on overstretched healthcare services."