Comment Blog 6 September, 2023

Changing the front door to the health system: Westminster's community health workers

Hilary Cottam in her aptly named book, Radical Help, expertly summarises the problem with our current public service model: “Everyone suffers in a system where 80 per cent of the resource available must be spent on gate-keeping.” She goes on to say that “the blunt truth is that we have reached the limits of our post-war services and institutions. The welfare state is out of step with modern troubles, modern lives and much of modern public opinion.”

The solution is a radical shift from the transactional to the relational. The idea is as simple as it is beautiful: facilitate the system so that connections and relationships can flourish. Allow humans to do what they do best, co-operate, support and care.

Yet while our biggest asset is people, we have a health and care system built on the assumption that people cannot be trusted. In his book ‘Humankind’, Rutger Bregman dispels this myth, showing that humans are complex creatures for sure, but inherently trustworthy and collaborative. Tapping into this potential would mean flipping our system in its head: invest 80 per cent in people and 20 per cent into systems to support them.

Underpinning this radical shift must be another commensurate, and equally radical, shift: from crisis care to prevention. If 80 per cent of health outomes are determined by where and how we live, why are we spending so little on prevention and health creation – just 7 per cent of the entire health budget goes on prevention,  and just 12 per cent on primary care and public health.

It just so happens that there is an ideal, off-the-shelf solution: Community Health and Wellbeing Workers (CHWWs). Lay people, paid and trained in the community where they live, proactively visiting households on a geographical patch once a month. That’s the radical idea – change the front door to healthcare.

Community Health Workers vary in deployment globally, but the approach we believe holds the most promise is modelled on the Family Health Strategy in Brazil, where 70 per cent of the population is covered and over the last 30 years has delivered significant and measurable imporvements in health outcomes. Across multiple evaluations, the scheme has been shown to lower cardiovascular mortality by 34 per cent and stroke mortality by 31 per cent; to improve child health, chronic disease management, equitable access to health care; and to reduce unscheduled hospital admissions and racial inequality. Their design code has 4 strands: hyperlocal and place-based, integrated health and social care, comprehensive at the household level, proportionately universal.

And it can work in the UK. In 2021 four part-time CHWWs were employed and trained by a local authority and local GP practice in one of the most deprived areas in London, reaching out to 500 households registered with the surgery. In the first year, 40 per cent of these families have engaged, and this is increasing steadily. And crucially, once people are engaged, they stay engaged.

The Westminster CHWWs see themselves as the glue between services and people in the community, and they are providing crucial insights that can help us design and deliver services that better meet local needs. Insights gathered in the first year of operation include: fewer people are accessing either primary care or A&E than expected; of those who do manage to access one of the services, the experience is often less successful or impactful than we hoped; and there is a lot of need that people themselves do not recognise even if it’s plainly evident to a CHWW. In addition, people who we would expect to be able to organise help for themselves are not able to, and, perhaps unsurprisingly, people are not ready to talk about prevention services when they are struggling with housing or paying the bills.

Just as in Brazil, the outcomes speak for themselves: households visited by a CHWW were 47 per cent more likely to get immunised and 82 per cent more likely to have an NHS health check or cancer screening, compared to those households who had not yet received a visit.[1] This is what changing the front door – investing in people not process – looks like in a population we have traditionally badged as ‘hard to reach’.

Imagine if, when the pandemic hit, GP practices had this depth of local information at their fingertips. Imagine if they could have deployed their CHWW team to support those who were vulnerable, who had high-risk conditions, or who were pregnant or with newborns. Those community-embedded CHWWs could have organised support, mobilised residents to have the vaccine and ensured they could access it. Those early months would have looked radically different, the impact of Covid on health inequalities less devastating.

But is it realistic? If every household in England had a CHWW, we would need to find just over £2 billion a year. But if we focus only on the 20 per cent most deprived primary care networks, where need is greatest, that figure shrinks to just £300 million.

That’s money invested in people in their community, training them and helping them train others. And we already make money available for non-medical roles in Primary Care, who would all be more effective with CHWW amongst them, acting as the glue. This approach could play a fundamental role in delivering NHS England’s health inequalities initiative Core20Plus5 – bottom-up, not top-down; community-driven and people-centric; taking services to the people rather than expecting the people to come to the service.

When the majority of disease burden is now thought to be lifestyle related, investing in behaviour and systems change makes sense. And one of the most powerful tools for behaviour change is social contagion, or leveraging the power of trusted relationships. Achieving that means empowering communities themselves – it means changing the front door.

[1] Measuring the impact of the Community Health and Wellbeing Worker initiative in Westminster on immunisation, screening, NHS Health Check uptake, and GP consultation rates. Report for Westminster City Council. October 2022, Imperial College London.