Population Health Management


The purpose of the Population Health Management project is to develop a systematic approach to population health management in Hounslow. 

The approach aims to:

  • Use data and engagement to understand the needs of our residents
  • Identify and target those who will benefit most from interventions
  • Develop evidence-based interventions
  • Embed evaluation to understand impact. 

The Hounslow Public Health team will be hosting the following Lunch and Learn events for all colleagues:

  • Research and Engagement Part 2 - Wednesday 13 March, 12pm - 1pm. Focusing on the best research tools to help gather insights when engaging with residents - Book here. 

Population Health Management Framework training materials are available via the BBP Resource Centre in the Population Health Management folder: 

  • Population Health Management Framework guide

  • Recordings and slides from Lunch and Learns

  • “Five steps to research", and a detailed Research Guide

  •  Logic Models & Six Steps to Evaluation, evaluation template and a detailed evaluation guide.


  • Greater number of staff trained in population health management approach
  • Improve data access and capabilities across the BBP
  • Linking data sets to build the understanding of our residents and the wider determinants of health
  • Using segmentation to identify cohorts of residents who could benefit from targeted interventions
  • Support and train BBP staff to use data to inform decision making
  • Use research, including evidence and behavioural science approaches, to inform intervention and service design and improvement
  • Encourage active engagement with representative groups to improve health outcomes and reduce inequalities
  • Embed evaluation in project plans from the beginning ensuring we can measure impact of projects and interventions

  1. Development of Population Health Management Framework for BBP
  2. Development of research, behaviour change, engagement, and evaluation guides
  3. Provide Population Health Management training and joint working with the framework
  4. Analytics support bringing data capabilities and systems together 

More evidence-based decision making and service design leading to reduced health inequalities, reduced cost to NHS,  prevention of and better outcomes for those with health conditions.

Next Steps/Forward Plan

Our fifth lunch and learn will focus on using research, including use of behavioural insights, to inform services and intervention design.

After that, lunch and learns will be quarterly and case studies will be presented at the BBP Huddle meetings.

Key projects using PHM will be supported including the Pre-Surgery Clinic project which launched in January 2024 and our CORE20PLUS5 projects which aim to use PHM to reduce inequalities.

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