In the fifth of the Gateway to Local Adoption series, Visions4Health spoke with Dr Priya Kumar, a frontline GP and specialist in Population Health Management (PHM) and tackling health inequalities, who sets out the case for PHM as the bridge between smarter care and fairer outcomes.
The NHS’s 10-year plan calls for a bold shift from “sickness to prevention.” While the idea is not new, what makes this moment different is the maturity of our data and the ability to truly understand the needs of our populations. PHM gives us the tools not only to predict risk but also to intervene earlier and more effectively.
In my practice in Slough, one of the most diverse and underserved areas in the UK, we use the Johns Hopkins ACG® System to understand the needs of the patients, from non-users to those with frailty. This simple but powerful approach has transformed how we deliver care, enabling us to match patients to the right professional, service, and setting first time.
A practical example is Pharmacy First*. By guiding patients to community pharmacies equipped to meet their needs, the initiative enhances patient experience and frees up GP capacity to focus on more complex cases. This shift has made care more accessible and responsive to individual needs. Applying a population health approach to primary care delivery, we released 13.7% GP capacity in the first year of transformation and observed a 10% improvement in HbA1c control among our diabetic population. This represents not only greater efficiency, but also better outcomes for the population. The wider vision is a shared language across primary care, urgent care, and community pharmacy, ensuring patients receive the right care promptly, without duplication or delay.
Health outcomes are not only about the NHS. Around 80% of what shapes health lies in housing, education, employment, and community support. Tackling inequalities requires working differently with councils, schools, the voluntary sector, and the life sciences industry. We must move towards “neighbourhood health,” where local services and residents themselves are empowered to shape healthier lives.
Scaling this approach is not simple. It requires digital infrastructure, workforce alignment, and above all, cultural change. But the prize is significant and by focusing on prevention and addressing inequalities directly, we can ease the relentless pressure on healthcare and build a more sustainable, patient-centred NHS.
*Pharmacy First: www.england.nhs.uk/primary-care/pharmacy/pharmacy-services/pharmacy-first/ (Accessed September 2025).
Dr Priya Kumar BEM is a GP Partner at Kumar Medical Centre and Senior Advisor at PPL, as well as a member of Visions4Health’s Healthcare System Council. Since 2013, she has led innovative work to reduce health inequalities, improve access, and deliver personalised, community-based care. She has held strategic leadership roles across Slough and Frimley ICB, driving initiatives tackling social determinants of health. Awarded Digital Innovator of the Year 2023, she champions co-production, integrated care, and equity-focused system transformation.
