Putting Community Health Workers at the heart of primary care

Four Community Health Workers walk down a street

Our Innovation and Evaluation Theme is transforming the face of primary care delivery by piloting a Community Healthcare Worker model in Northwest London with the aim of rolling it out across the country.

A tried and tested model

The CHW model was devised in Brazil in the 1990s, and called the Family Health Strategy, there are over 250,000 CHWs making it the largest primary care system in the world. Described as ‘the ears and eyes of the GP in the community’, CHWs in Brazil are full time members of the local primary care team and they focus on a defined location, usually 200 households, keeping in regular contact with the residents. By visiting households at least once a month the delivery of primary care becomes truly local and embedded into everyday life.

Brazilian CHW Model Diagram

‘Small interventions at scale’

Dr Matt Harris, Innovation and Evaluation Theme Lead, worked with CHWs as a GP in Brazil (1999-2003), and on his return to the UK he was struck that we have lost a proactive approach to primary care, as he describes:

“The key to the Brazilian model is that by the CHWs knowing all their families really well, small household interventions at scale have led to a huge impact on the whole population. In Brazil they have seen a decline in cardiovascular disease mortality of 34% in areas that have full implementation of the Family Health Strategy.”

With colleagues in the ARC NWL, Dr Harris estimated what the impact might be if the whole of England had a model of CHWs delivering tailored support to all households, proactively and regularly. In a paper published in the Journal of the Royal Society of Medicine in 2018, they found that it would significantly increase immunization and screening uptake and provide support for all people with chronic diseases such as diabetes and hypertension. As an attractive policy option to address population health across the country, they set out to pilot it in NW London.

Providing comprehensive integrated support

This hyperlocal approach leverages the advantages of recruiting from the local community providing improved local employment opportunities. The added benefit of this is that the CHWs are familiar with the surroundings, the challenges the residents face, and are a consistent familiar face that helps to build trust and rapport.

Above: Community Health Worker Asma Monir is a familiar friendly face

Churchill Gardens, a large social housing estate in the Pimlico area of Westminster, London is the trial location for the use of CHWs in the UK. Asma Monir, Nahima Begum, Comfort Idowu-Fearon and Maureen Katusabe have been recruited as the four CHWs and are working within the area to assess needs, health promotion, aid with navigation of support services and to triage and make referrals.

“When we come and knock on the door and sit with you, we see the whole person and the environment they live in. We become that bridge builder.”
Comfort Idowu-Fearon, Community Health Worker for Churchill Gardens

CHW Logo

Assertive outreach makes a big difference

Seemingly small early interventions are having a big impact already as demonstrated by these case studies.

Case Study: Building trust and relationships
A CHW called a resident to book an appointment, however he was reluctant to book but eventually was persuaded to meet the CHW in an open green space in the estate behind his house. During their meeting the resident informed the CHW that he is a victim of torture and war crimes. He had been wrongfully imprisoned for 8 years in the country which he fled from to seek asylum in the UK, where he now lived in a studio flat, feeling trapped and isolated. Social exclusion and past trauma led to him being suicidal, which the CHW was able to elicit.

The CHW got the GP on board who was able to help the resident and prevent harm coming to the resident. Dr Neogi reflects: “One of them [CHW] brought to me a patient who was suicidal, who hadn’t presented to us, so obviously we then dealt with that patient, and got them the care they need. I would have never known. This person could have been a statistic. So it does have huge value”. The CHW is regularly calling the resident on a weekly basis, which is appreciated, and the CHW feels he is becoming more amenable to accepting therapy and seeing the potential for things to get better.

Case Study: Personalised screening advice
One of the CHW's discovered early on in the pilot that some Muslim women declined cervical screening because in the countries they came from this service needs to be paid for. There was also a belief that married women did not need to worry about cervical cancer. Being Muslim herself the CHW was able to speak to the resident and clarify that cervical screening is free, important and relevant for all women regardless of marital status and get her to have the cervical screening done.

“We are definitely getting more appointments for smears, and I’m sure this is all Asma’s work, from people of different ethnic minorities, which never used to happen. They were the hard core patients, it was difficult to get them in. Actual hard numbers we don’t yet have but I think we will see that.”
Dr Neogi,
GP at Pimlico Health at the Marven.

Sustainability and scaling

When applied health and care research is most effective it improves service delivery by making it more efficient. Research conducted alongside newly implemented practices give a platform to generate further evidence on the impact. The cyclical process of continual improvement is demonstrated by the pilot of Community Healthcare Worker (CHW) model.

As the pilot continues it will produce more data as it intensifies the integration with existing services. A final report due mid next year (2022) will provide insights into the opportunities and challenges of spreading and scaling the model in other parts of the UK.

Dr Cornelia Junghans, GP in Westminster and Implementation Lead for the pilot, said:

“Although the pilot is only in its early stages of implementation, we are already seeing some significant impact on residents’ health and wellbeing and signs of scaling into other localities. Other boroughs in NW London are already planning to adopt this assertive, proactive outreach approach and two regions (Bridgewater, and Calderdale) have already commissioned it for their residents. It is also being supported by the National Association of Primary Care, who is promoting it into localities across the country looking for novel, cost-effective approaches to health and social care.

At a time when health services are stretched by demand, and Primary Care in particular is put under extra pressure the need for new ways of working is significant. The need to build capacity through innovative preventive public health and social care model, implemented and reviewed with high quality research methods, has never been more important. The CHW pilot in Northwest London is doing just that.

Discover more about the Community Health Worker model

Hear more about the development and implementation of the community health worker model and lessons learned for other areas around the UK interested to develop similar services in this webinar:

Building Back Primary Care & PH Webinar #5: Community Health Worker model

This project is funded by Westminster City Council, evaluated by NIHR ARC NWL with partners National Association of Primary Care and hosted and supported by Pimlico Health at the Marven.