In part two of our focus on community health and wellbeing workers (CHWW), GP academics Dr Matthew Harris and Dr Connie Junghans Minton highlight the shifts in perception that will be needed to unlock the potential a place-based model of neighbourhood care.
Community health and wellbeing workers (CHWWs) are frontline healthcare providers who live in and serve the communities they support, providing a crucial link between residents and health and social care services.
As we explain in our earlier column, these lay workers, who can be employed by PCNs under the additional roles reimbursement scheme (ARRS), could be a game changer when it comes to delivering a neighbourhood health service.
The system originated in Brazil in the mid-1990s and the country now has 400,000 CHWWs visiting the homes of almost three-quarters of the entire population. It has seen remarkable improvements in population health directly linked to CHWW activity, which is backed by robust evidence.
CHWW models of care are almost always cost-effective in any setting (whether in low middle- or high-income countries). The Kaiser Permanente approach to integrated care in the US also utilises CHWWs, recognising that a local approach that includes the entire community and proactively addresses need before it becomes entrenched and difficult to fix, is the way forward.
So, what gets in the way of commissioners and local decision-makers implementing this model in the UK given this evidence? Here are some concerns we picked up along the way.
Three barriers to overcome
1. Distrust of a lay workforce
The first barrier is widespread doubt that a non-medical lay workforce can be trusted in a health-related role to deliver effective care. But we know that CHWWs are not designed to be ‘barefoot doctors’ or replace a medical professional; rather, they work alongside health professionals.
The important work that CHWWs do – for example, in helping an individual to eradicate the damp and mould in their home, finding practical solutions to reduce their loneliness or isolation or simply identifying that someone is not looking well or that their health and wellbeing seems to be deteriorating, doesn’t require a medical degree. But it can make a substantial difference to that person’s health and wellbeing – avoiding unnecessary unscheduled hospital admissions and other crises.
2. Misunderstanding the meaning of 'population'
Second, as health professionals, we often consider a list of registered patients to be ‘our population’ – but a list and a population are not the same thing. Of 3,000 households allocated to the CHWWs based on patients in a geography from GP data, 27% turned out to be ‘non-viable’; for example, instead of homes, there are now Airbnb blocks or a department store in those locations.
Of the patients GPs see in their practices, there are many we haven’t seen before and know little about (other than what we can glean from their records). Even the ones we see more often, we may not know well.
For neighbourhood healthcare to work, health centres must have a defined ‘hood’ which they look after, getting to know the actual population for which they are responsible. Transience is often cited as a reason why we can’t do this, but CHWWs have uncovered that transience is often involuntary.
CHWWs advocate for their community and population and ensure that people get the help they need to stay rooted in the place where they have a social network, where they often work and where their children go to school.
3. Underestimating the value of proactivity
Finally, we seem to think people have to come to us for their healthcare. The idea of proactive home visits – of actively seeking out those with unmet needs, niggly issues and problems before they become enormous – is new for the UK. But it is the only way to tackle the rising and expensive inequities our communities face.
Our experience with CHWWs tells us that people overwhelmingly welcome the proactive outreach and consistency – a single preferred contact that ‘holds the cup’; many patients go under the radar with unknown and worsening health conditions that would not have been found for some time without the work of CHWWs.
Having personalised and appropriately timed conversations about prevention opportunities is the way forward, particularly in communities where households with complex needs are often targeted by multiple agencies simultaneously with information and engagement outreach attempts, increasing the likelihood of disengagement.
Adopting 'NATO-style' funding
Although there have been several different funding strategies used by localities implementing the CHWW role over the past few years – for example, inequalities funds used by Cornwall ICB and ARRS funds put towards the CHWW role by Westminster GPs, what will be key to scaling and sustaining the CHWW role is a government-led, cross-cutting, ‘NATO-style’ funding solution or participatory budgets.
Under this approach, NHS trusts, community trusts, public health services, adult social care, communities, housing and environment services, GPs, policing and education each contribute a tiny proportion of their budget towards the role. At the end of the day, this is all taxpayers’ money and savings across the board will benefit everyone’s budget and, most importantly, improve health across the neighbourhood.
The CHWW role features in the government’s NHS 10 Year Health Plan and is part of the National Neighbourhood Implementation Plan (NNHIP), which means there is a mandate to scale it even further into each of the 43 vanguard localities that are in the first wave of the NNHIP.
It’s also ready to go in a ‘lift-and-shift’ programme, driven by the National Association of Primary Care, complete with manuals, guides, resources and a community of practice to support localities as they embark on their CHWW journey.
All that’s needed now is the courage to do things a little bit differently – and to trust that our communities know, best of all, what they need to thrive.
Dr Matthew Harris is a clinical reader in public health medicine at Imperial College London and a GP who worked with CHWWs in Brazil between 1999 and 2003. Dr Connie Junghans Minton is a GP and senior research fellow at Imperial College London. She leads the Westminster CHWW Programme.