Research pillar 2

Population Health Intelligence

Using linked health and social care data and AI to understand multimorbidity, inequalities, unmet need and complex needs at scale.

Focus areas

  • Linked health and social care data
  • Epidemiology of multiple long-term conditions
  • Population analytics and risk stratification
  • Health inequalities and underserved populations
  • Precision population health
Flagship

AIM / Cluster-AIM

Developing and validating AI-generated population clusters that combine health and social care determinants for people with multiple long-term conditions.

Videos

Study films & plain English summaries

YouTube channel films and local study videos (content differs).

AIM Cluster Study

Local study film — Cluster AIM.

Winter pressure (study film)

Local film — distinct from the YouTube winter pressures Plain English Summary.

Winter pressures and Multiple Long-Term Conditions — Plain English Summary

Qualitative study about integration of primary care and social services — Plain English Summary

Social care needs in multiple long-term health conditions — Plain English Summary

Selected publications

Evidence for this pillar

A multidimensional framework for mapping social need to electronic health records in people with multimorbidity

Isaac T, Simpson G, Smith L, Sabary A, Islam N, Santer M, Farmer A, Dambha-Miller H. Scientific Reports, 2026.

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Variations in social care need reporting amongst GP practices in England: a retrospective cohort study in people with multimorbidity

Burns D, Simpson G, Zlatev Z, Smith L, Dylag J, Santer M, Boniface M, Farmer A, Dambha-Miller H. BMC Primary Care, 2025.

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Variation in multimorbidity estimates due to clinical coding: a cross-sectional study of 7.2 million adults in England

Isaac T, Hasan MM, Farmer A, Dambha-Miller H. BMJ Public Health, 2026.

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Rate and timing of long-term condition accumulation among adults with multiple long-term conditions in England

Isaac T, Hasan M, Dambha-Miller H. Aging and Health Research, 2026.

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Variations in vaccination coverage by social care need: a scoping review

Dahil A, Hardisty D, Simpson G, Dambha-Miller H. Vaccine: X, 2025.

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Equity and inclusion in UK adult social care: a systematic review of trials

Kaminski F, Smith L, Dambha-Miller H. BMC Health Services Research, 2026.

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The association of loneliness and social isolation with multimorbidity over 14 years in older adults in England

Group output. Archives of Gerontology and Geriatrics.

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Trajectories in long-term condition accumulation and mortality in older adults: a group-based trajectory modelling approach

BMJ Open.

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