It is Monday morning. My last patient of a busy morning is a young lady who I know well and have a good relationship with. She lives in a council estate with her family around the corner from our GP practice.

She is, like her parents, sisters and cousins, under mental health services, and has been for several years. She is on antidepressants, sleeping tablets and often opioid medication. She is morbidly obese, unemployed and lives in overcrowded housing. She is frightened of going out on her own and dropped out of a care worker college.

She is only 19. Her grandparents didn’t live past their early 60s after several years of living in pain and with chronic illnesses. I do what I can to help this patient in the 10 minutes I have with her each time. But I know in my heart that, at the moment, she is heading the same way.

But we can change this for others.

The NHS has been characterised many times as being a ‘sickness service’, rather than a ‘wellness service’. Good evidence shows that around 80% of factors that cause poor health are related to causes that are not directly influenceable by health services.

However, that should not be a reason not to deal with the wider, social determinants of ill-health. Indeed, the NHS should be even more dedicated to addressing these causes. If it isn’t, we will have to treat the resulting illnesses. As Sir Michael Marmot puts it, ‘why treat people and send them back to the conditions that made them sick?’.

For us to really improve wellbeing and prevent illness we need to be working with our local communities to draw all the organisations and groups together and find solutions. This is what we mean when we talk about ‘population health’.

Increasingly, those working at the front end of our health systems argue that those solutions need to come from the people affected by the problem. Most GPs will tell you that if the drugs aren’t working, make sure the patient is taking them. And if they aren’t taking them, find out why not. And then work out how to help them with that. Don’t just give them more drugs.

Primary care is well placed to lead this kind of approach, but cannot do it alone. These problems will only be fixed by using all the resources and services that are available to sort out the ‘causes of the causes’; stress, poor living situation, employment, poverty, tough family situation, and education, amongst others.

As a GP, this concept of population health resonates. One of the attractions of primary care work for me, and I know many others, is the potential to work with communities to do more for health and wellbeing than just managing a patient with an illness at the point of that illness.

If in primary care we can identify groups in our local population that without intervention will go on to become unwell, we can work with those patients and local services and teams to do something about it.  In particular, we can do something about health inequalities and about those patients who we know are heading for early chronic illness and death. This involves working in a different way, but I think ultimately a much more satisfying and productive way.

As part of the ‘Healthy New Towns’ NHS England programme, as a group of GP practices we are working with the local community of Barton in Oxford. Barton is an existing community of considerable social deprivation with an urban extension being built on to it.

We used intelligence from our GP data sets to identify groups who are at risk of falls, suffering from mental health problems as well as respiratory problems, (for example anxiety and COPD), and other groups. We then proactively invited them to commissioned community-based programmes run by the voluntary sector.  Those programmes included balance and safety classes, dance classes, workplace mentoring.

This targeted approach looks at specific problems within a whole population and places the focus on place rather than just one practice. It concentrates on need and prevention and uses social prescribers to help.

What we found is that the personalised approach from known GPs, as well as support from a community based social prescriber and peer support in the community, increased uptake of the interventions.

No doubt many GPs reading this will be thinking; ‘how am I supposed to have the time to do this?’ This is where the wider team comes in. There is an opportunity here to use the assets of the NHS, Local Authorities, Voluntary and Community Sector and people themselves to help.

This is already happening in places such as Fylde Coast, part of Healthier Lancashire and South Cumbria, where life expectancy rates for men and women are poor, as is prevalence of long term conditions. In Fleetwood, a small town on the Lancashire coast, they are dealing with prevention at scale and, using data and partnerships to identify and target, looking at larger populations to improve health using these methods. There has been a significant focus on wellness and resident empowerment through the ‘Healthier Fleetwood’ movement.

If we can get population health management right it could give us the tools to help break the cycles of poor health for people such as my patient last Monday morning.