“I’d like them for all my patients”: The community members transforming a GP practice

It’s a simple but revolutionary concept. Trained community members are attached to a GP practice, and each regularly check up on the wellbeing of their neighbours.

In Brazil it is already cut cardio-vascular disease across the country. Now it’s reaching the UK – as a South London surgery integrates the country’s first Community Health Workers. And it’s already showing a different future for Primary Care – how we can ease the burden on doctors, detect and prevent illness early, and use the power of communities to create wellbeing.

We spoke to the people at the heart of the initiative – from academic, local government, GP and community sides.

The people in this conversation are:

• Nahima Begum (Community Health Worker)
• Dr Matt Harris – (Imperial College London)
• Comfort Idowu-Fearon (Community Health Worker)
• Dr Connie Junghans (Westminster City Council)
• Maureen Katusabe (Community Health Worker)
• Dr Sheila Neogi (Pimlico Health @ The Marven)
• Katy Oglethorpe (New Local)

Katy Oglethorpe:  If we start with the origins of this project, Matt, you worked in Brazil for many years. Can you tell us about how you came across Community Health Workers and why you thought it was an idea that should be replicated?

Dr Matt Harris: I worked as a GP in a single-handed practice in a rural part of Northeast Brazil between 1999 and 2003. The practice there was unusual, as it was very much based on a Community Health Worker approach to primary care. The community was divided up into four more or less equal geographies. And each one of those ‘micro areas’ was the responsibility of a single Community Health Worker to look after. And I worked really closely with those four Community Health Workers.

Each Community Health Worker would essentially visit every household in the micro area at least once per month. And that’s whether there was any expressed need or demand. I discovered that this was an unbelievably effective model of care.

Oftentimes, what we find here in the NHS is that we react to problems as they arise rather than preempt them. But the role in Brazil is really effective with Community Health Workers, because they understand their community so well. They understand their residents intimately, and they spot problems before they become big ones.

Brazil has seen this model scale throughout the entire country over the last 20/30 years. Today there are 250,000 Community Health Workers serving 70% of the entire population, and it’s so effective, it’s seen a reduction in cardiovascular disease mortality by 34% at a national level.

When I began to talk to colleagues about how much they were doing in Brazil around this sort of proactive approach, it was generally met with ridicule

So when I returned back to the UK and discovered that we didn’t have this role in the NHS, I saw immediately that we were missing a trick, missing a huge opportunity. And what became even more interesting to me was that when I began to talk to colleagues about how much they were doing in Brazil around this sort of proactive approach, it was generally met with ridicule, which made it even more frustrating because it became apparent that it was the fact that it was from a country that we’re not used learning from, that made it even harder to overcome the necessary barriers to implement these sorts of initiatives.

Katy: And so how did it move from being subject to ridicule to coming to life in this practice?

Matt: Well, it’s taken about 17 years to gain traction. But really, it was when Connie came on board, in her role at Westminster Council, and was able to join the dots and find funding for us to pilot the programme, where it’s really began to take shape.

Dr Connie Junghans: Yes, Matt came to us to talk about this model. And to me, it immediately made sense that there will be one person who has a relationship with residents who is able to do everything. Go into their house and see that the fridge is empty, or that the house is cold, or that they need help, that they’re struggling with something. And because they know the community and they know the services, and they’ve got a mandate being part of the GP practice, they’re able to actually help.

It was fortunate that at the time, we were thinking about Churchill Gardens as a little bit of a hard nut to crack. We know that Churchill Gardens is a very fragmented community. There are some people who move in and out of the community, and those who’ve been there for years, but are very isolated. There’s not much going on in terms of in terms of visible community. And when we walk through the community together, there are lovely, beautiful spaces, but it’s quiet and you didn’t see people. You didn’t see people sitting out you didn’t see people talking to one another. And this came along and presented itself as the perfect model to reach the community and connect people and get something happening.

The difference in life expectancy between Churchill Gardens and half a mile up the road in Belgravia is 15 years. And that hasn’t changed in the 20 years that I’ve been practising here

Dr Sheila Neogi: So for me, it was really interesting, having been a GP here for coming up to 20 years. Churchill Gardens is one of the poorest wards in Westminster. And the difference in life expectancy between Churchill Gardens and half a mile up the road in Belgravia is 15 years. And that hasn’t changed in the 20 years that I’ve been practising here, despite all the advances in medicine and everything else. Churchill Gardens I think was the biggest social housing project in Europe when it went up. So it is massive. And the amount of support and help that GPs can deliver to that size population has been limited.

What I like about this model is, as you say, it’s about the Community Health Workers knowing the people in the area. This takes me back to what the GP originally was, in 1947, if you had a village GP that lived out in the sticks, they would go around their daily business, they would pop in and see Mrs. Blogs, they would bump into Mr. So-and-So at the post office, they knew their community, and the community knew them.

Life has moved on, and we can’t do that anymore. But the beauty of the Community Health Workers, is that it puts some of that back: where the GP was the health person in the middle of a village, they knew their village, the village knew them. And the right help was achieved. And I think if we can develop this and make it up-to-date, so it’s a little bit more than just a friendly chat, that will have a knock-on positive effect on the communities.

And who knows, after a long time, maybe that differential in life expectancy will change because what the Community Health Workers are doing is prevention. And I think that is one of the biggest influences of change in life expectancy.

Matt: We try to distil the essence of the model in three features that make it unique and very radically different to what we’re doing in the UK.

The first is that the Community Health Workers are not a parallel service, which we often find in the UK with health trainers or voluntary groups or whatever it might be. Wonderful work they’re doing, but they’re not part of the system as such – they work in parallel to it.

The Community Health Workers here are actually part of the system. So they’re paid, they work with the GP in the practice, they have access to the IT information systems, they have an ID card, they’re almost part of the NHS infrastructure. And that’s really important, because then what they discover in the households can be resolved by referring into the GP practice, and other services; they’re recognised as part of the statutory system.

As people walk through the door in the GP practice, they have a singular concern, they’re an individual, whereas by working in the community and seeing the household as a whole can contextualise any issue that arises

The second thing that’s really important is they see the whole household as a whole, not just individuals and their concerns, which we often find in the traditional model. As people walk through the door in the GP practice, they have a singular concern, they’re an individual, whereas by working in the community and seeing the household as a whole can contextualise any issue that arises within the local environment.

The final thing that’s really important is this universal approach. There’s not a referral-based system, which we have in the UK predominantly, which is predicated on someone already accessing the system. Community Health Workers uniquely go out and find problems before they present themselves into the system. It’s very much that universal, proactive approach that’s completely unique for what we currently have in the NHS.

So putting the all three features together: the universality, the comprehensiveness, and the integration into the system, makes up what I think is a paradigm shift in terms of a model for the UK. It makes it very, very exciting.

Katy: Can we talk about what a Community Health Worker actually does on a day-to-day basis? What does it involve for you?

Nahima: So it starts off with us booking appointments with residents, to a time that suits them. And then going into the visit. We try and make it as normal and comfortable for them as possible. And we try to make them feel like they can talk about whatever.

In the beginning, they’d probably be feeling frustrated or down and not know why. Simply having that chat, that cup of tea with someone, makes a huge change in their mood, sort of lightens the weight in a way, because a lot of the time these people don’t actually speak to anyone at all. So it’s just having that contact with someone that makes them happy, and could make a huge difference to their health.

I see us as kind of ‘bridge builders’, bridging the gap between housing, employment and all the services around them.

Comfort: I see us as kind of ‘bridge builders’, bridging the gap between housing, employment and all the services around them. You might meet somebody who is having problems, but does he know who to talk to or where to go? And how to access a medical appointment? But I can text the GP here and simply say, ‘Could you see this person?’ And immediately there’s a response.

You might see somebody who is very lonely, they’re not talking to anybody. Well, maybe they just need you to say, ‘Oh, have you tried the centre, they have all these activities there, then you’re not sitting at home alone?’

We also talk about immunisation. They might say, ‘Remind me: am I supposed to go for any screenings?’ I can go into the system, so I can say, ‘Oh, well, they sent a letter three weeks ago, or three months ago, and we’ll help you.’ So we kind of bridge the gap. We’re not selling any products, but we know where the products are. And I think that’s the best thing – it’s having a link with the practice.

Nahima: I had this family that had just moved to the estate. And they had left behind a lot of troubles. And they just felt really lost, like they didn’t know who to contact, who to go to solve their problems, so the mum of two was very keen to have the Community Health Worker appointment. And then after the appointment, we managed to link the GP, social services, school, council everyone came together to sort this one problem. The mum was really happy because all these times she felt like it wasn’t getting done. And then pretty much you one go everyone came together to help reach a solution for the family.

Katy: And why does it matter that it’s you guys as members of the community doing this, rather than for example, hiring more GPs or professional public health workers to do it?

You could have as many GPs, as many social prescribers, they don’t see what we see.

Comfort: I think the one difference with us is the fact that we visit them at home. So we see beyond what that resident is telling us. Just by observation, you can pick up some more things and you can get to know more. You could have as many GPs, as many social prescribers, they don’t see what we see.

If you have a father, who is actually abusing, we can pick that up in the house. No GP, nobody else can pick that up, because they’re only listening to what that person is saying. And we talk to the children. You can tell when a child is free, or you just see the ones that just want to hide under the table. And that abuse could be the biggest problem for the family.

Sheila: I think the other thing which is important about the fact that the Community Health Workers are part of the community, is there is an element of trust there, between the residents and themselves, which there isn’t with us professionals. We are outsiders. Much as we try to be empathic, as much as we try and listen, we don’t know. Whereas I think they, the residents, take on board that you’re part of the community. So actually, you do know these issues, you understand these issues, in a way which I think that they feel that outsiders like myself, just do not quite get.

Connie: And it’s the familiarity. I was really struck by being out in Churchill Gardens with you guys, and people wave or come across and say hello. You haven’t been in that job for very long, but people know you and wave from the windows. It’s lovely.

There is an element of trust there, between the residents and themselves, which there isn’t with us professionals. We are outsiders. Much as we try to be empathic, as much as we try and listen, we don’t know.

Katy: Can I ask you what motivated you to become Community Health Workers?

Nahima: I’ve always wanted to work in a role that’s involved people, helping people and just making them feel better. I’ve always wanted to do something like social services, but I thought this job was even better, because there’s so many different services that you’re linked to. You’re still in one role, but you can work with so many different services just to help an individual and family. And that’s what appealed the most to me.

Maureen: And empowering them as well to do better for themselves.

Katy And as GPs what have you noticed has been the effect of having Community Health Workers alongside you?

Sheila: I think it’s eyes and ears. The Community Health Workers have picked up on people who we wouldn’t necessarily know about otherwise. That is always helpful, because at the end of the day, we have a responsibility for all our patients. The difficulty is that we’re not psychic, so we can’t tell when someone’s in trouble if they don’t call us first. Whereas now, it works. Because for the patients who are on the caseload of the Community Health Workers, you know that if anything crops up, we’ll know about it. In an ideal world, I’d like them for all my patients! Which hopefully we’ll get to.

Connie: I think there was a bit of a fear initially that Community Health Workers would go out and find problems and they’d find patients and bring them here, and we’d be even more overwhelmed than we already are. Do we risk bringing up things that don’t really need attention?

But we haven’t found that at all, we found that a lot of the calls that don’t need to be made to the GP are now not happening, whereas more appropriate consultations happen.

I feel you [the Community Health Workers] bring medical problems that need to be brought, that we wouldn’t be able to reach, but also take away some of the pressure that we’re facing, particularly around housing issues that are impossible for us to solve. You’ve got a direct link to housing, you can talk to people in a different way you can talk to them for longer, you can change their perspective, and that will make such a difference.

Katy: What stage in its lifecycle is this project at the moment? And where do you hope to go next?

There’s something really fundamentally human about this, that is not specialist. It’s about human connection and interaction.

Connie: So this is the first of its kind in the UK. There are only four Community Health Workers at the moment covering around 500 households. Where I see this going is really to show that there’s something really fundamentally human about this, that is not specialist. It’s about human connection and interaction. And there’s no technical skill involved or anything that makes it particularly strange for the UK.

For me, this is a proof of concept. We’ve shown that this is just as much workable in the UK as it is in Nigeria or in Brazil, and that it’s needed. We’ve uncovered in a short time that there are people in the community who need help who are unable to get it. We’ve uncovered that people who we expect to be able to reach out to services are not able to. We’ve discovered that it takes really tiny conversations to make big shifts.

We’re definitely seeing an uptick in the uptake of cervical screenings among hard-to-reach women in Churchill Gardens. More people are coming to us for health checks. And that’s definitely those little conversations that take one minute, ‘Why aren’t you having your cervical screening done? It’s really important you have it’, and a little bit of hand holding. We sometimes think a leaflet is enough. But people don’t read leaflets, or they’re pinned up somewhere and ignored. But saying, ‘I’ll come with you’ or ‘Somebody else is going’, or ‘I think you should really go’ is sometimes all it takes to get somebody to do something.

Maureen: Or having a conversation about why they don’t want to take it – maybe some misinformation. So we can we give them the correct information, and we dive deeper into why the reason why they would not want to take it.

Connie: I would want this to be scaled to all areas that are deprived and have profound need. We’ve got another two pilots starting up in Kensington, also initiated by the local authority, and we’ve got other models in Calderdale and Bridgewater, there are Community Health Workers already in training.

Matt: We are doing an evaluation of the pilots through Imperial College and its partners. But as you probably get a sense of this is an extremely complex intervention. So you have these wonderful ladies looking at the entire life course of all households in their community. And traditionally, when we evaluate any intervention, you have to focus on a very specific outcome. And it’s very challenging to do that in this case, because the Community Health Workers are likely to have a significant impact over time on a whole array of different things, whether it’s on immunisations or screenings, on mental health or suicide prevention, on identifying domestic violence, maternity, antenatal uptake, it could be on almost anything.

What we have to avoid is doing an evaluation that narrows the purpose of the work itself. So we’ve looked at the evaluation in stages that are relevant to where we’re at in the pilots. For example, at the moment, we’re looking at simple questions like, ‘Is it feasible to do this?’ Answering questions like, Is it acceptable to residents, that Community Health Workers visit them and knock on doors? We’re finding, at least in our interim report, that is very much acceptable to the vast majority of residents.

Over time, we’re expecting to see some really significant shifts around cardiovascular disease mortality, horizontal equity, and decrease in hospitalisations for ambulatory care sensitive conditions.

There’s an attrition aspect to this role, which means that the role really has to bed in over time. From the community’s point of view, they would begin to over time to see the value and see how it’s helping their neighbours and so forth. We certainly saw that in Brazil where they’ve had this model for 30 years. Residents now really can’t do without their Community Health Workers, but that didn’t happen right at the beginning – that took time.

So at this early stage, we’re looking at feasibility and acceptability. We’re certainly seeing that health workers are integrating well into the practice, that they’re navigating the system really well, that they can making the connections between the different services. At this early stage, we’re only four or five months into the pilot, we’re certainly seeing the green shoots of something that is eminently operationalisable, which is really encouraging.

Over time, we’re expecting to see some really significant shifts, like we saw in Brazil, around cardiovascular disease mortality, horizontal equity, and decrease in hospitalisations for ambulatory care sensitive conditions.

Connie: We’ve done some evaluation already, which showed that there was a return of investment of £3 per £1 spent in Churchill Gardens. We’ll do more work looking at how much money is saved for adult social care, for the NHS, for all these different agents. Our hypothesis is that having prevention early on is going to save a lot of money downstream to the NHS, to adult social care, to children’s services, to housing, etc.

Katy: What do you see as some of the barriers and the challenges to this quite radical new approach, especially from the NHS as an institution?

Sheila: Like any large organisation, we don’t like change much, and the NHS seems to change every three to five years. So this is yet another change when there’s a lot of change fatigue. Traditionally – although this has been broken down through Primary Care Networks – General Practice has always held on to their patients. There’s a sense of ownership of their patients. So trusting other people to actually keep an eye on your patients is not something GPs do well.

No one ever explained any of this population stuff, any of this community stuff, any of this social stuff, in our training. So it does take a leap of faith to actually believe this is going to make a difference and an impact.

I mean, no one ever explained any of this population stuff, any of this community stuff, any of this social stuff, in our training. We know about health, we know about disease, we know how to fix it – if we can fix it – and we know how to hold it. But all the rest of this stuff is something we’re not totally au fait with. So it does take a leap of faith to actually believe this is going to make a difference and an impact. And that’s going to take some time for it to embed into the medical community. We’re just getting our heads around care navigators, social prescribers… allied health professionals is a new term, and no one’s quite sure what that encompasses, but I’m fairly sure that Community Health Workers are part of the Allied Health Professional tranche.

It’s making sure that the traditional health professionals start to appreciate that whereas before there was just you, you’ll hopefully now have this sort of army that can feed you the relevant information, so that you can do the bit you’ve been trained to do well. I think getting that accepted is difficult for the medical community, because we’re not very good at that sort of shift and change.

Matt: There’s real risk, unfortunately, that when people hear the words ‘Community Health Worker’, their first reaction is, ‘But we’re already doing that’. We’ve got social prescribers, we’ve got health trainers, we’ve got community champions, we’ve got district nursing, NHS volunteers, as if it’s the same thing. And I think the important thing to just impress upon people is that this really is different. It’s really different – through its proactive nature, through the fact that it’s integrated into the statutory services and the fact that it’s focusing on all households.

Connie: And I don’t know about you, but in medical school, nobody told me that 80% of our health is determined by where you live, how you live, and only 20% is contributed to by good access to health care. So the shift has to be towards prevention and understanding that wider determinants are really key, and that we have to address them.

Do we invest in our residents and patients and say, they’re worth having a relationship with, rather than just parachuting in when somebody declares a need?

To me, the challenge is to change hearts and minds. It’s a real shift away from the transactional to the relational. Do we invest in our residents and patients and say, they’re worth having a relationship with, and looking after that relationship, rather than just parachuting in when somebody declares a need, which is not good enough?

Katy: What would it mean for the NHS as a whole, if every GP surgery had Community Health Workers?

Sheila: I think you would get clinicians doing what clinicians are trained to do, as opposed to firefighting, and trying to help with problems that we have no ability to help with. We are the free port of call for everybody. So if you want legal advice, people ring us. If you want social care advice people ring us. I mean, I’ve had people ask me about their pets. The trouble with that is that it’s very pressured. And we don’t have enough time to spend on people that actually have a specific health care need that we can help them with.

If you want legal advice, people ring us. If you want social care advice people ring us. I mean, I’ve had people ask me about their pets.

The beauty of it is having Community Health Workers helping with the screening, making sure the prevention stuff happens, stopping the patients get to crisis, when things are much harder to sort out.

You will then start filtering out the stuff we don’t need to be involved in, which will free up the time of medical professionals, because we don’t have enough of us and you can’t get enough people to train to do the job, or stay in the job. And therefore, hopefully, the capacity issue and the workforce issue that everyone’s screaming about at the moment will be addressed in some way.

Connie: Because this is driving GPs away isn’t it? We don’t have enough GPs, and they’re not doing the relevant work that they are trained for.

Sheila: Yes, so they leave and join charities or Médecins Sans Frontières because they feel they can do real medicine, as opposed to writing a letter for housing, which is just daft because they are needed to sort out the heart failures and the diabetics and the mental health crises.

Comfort: As Sheila has emphasised, the NHS is geared towards treating problems. There needs to be a kind of shift towards prevention. Five branches are looking after this one person, but nobody’s talking to each other. We need to speak to each other more. Community Health Workers focus on one person so the GPs can get on with their jobs.

If the NHS can begin to shift towards preventing rather than treating, and I can say to somebody, actually, you can do this [prevention measure] – you don’t have to go to A&E and sit there for six hours. Everybody’s social media is going on about people sitting in the corridor for six hours, but there shouldn’t be any need for that, because we can set in motion what needs to happen before they even go to A&E.

Connie: We were talking about the work you do, and somebody said, you’re able to catch people when they’re falling, not picking up people off the floor when they’ve been there for hours and days.

And it’s longitudinal – a GP as an entity is there when you need them. And the Community Health Workers are even more present longitudinally, because they build these relationships and go every month.

You’re able to catch people when they’re falling, not picking up people off the floor when they’ve been there for hours and days.

Sheila: It’s not an open-and-shut referral. All referrals to all these other services is: case open, case dealt with, case closed. There are no case closure with a Community Health Worker – they’re there. As long as you live there, you’ve got one. And I think that’s the fundamental difference. It is not about an episode of care being done and closed for the next episode to then be referred. They’re just they’re like us as GPs – we’re just there.

Matt: I’d add that Covid has been a really interesting burning platform. A lot of bad stuff has happened to a lot of people. But perhaps one good thing is that it’s perhaps changed the narrative away from only certain types of people as deserving of services because of their demographics or their ethnicity or because of where they live, or because of their prior clinical conditions, to a perception that actually any of us can need help at any time. And unless you’ve got a system in place that can capture that, you’re going to miss people continuously, of whatever social class, whatever background and it’s those people that then will require more intensive care later on.

Imagine what would have been possible during Covid, if we had had this infrastructure of Community Health Worker teams

Connie: And on the point, I think we’ve seen in Covid, as well, that there are people in the community everywhere in the whole country who want to help if asked. We have a lot of will, and a lot of assets, but no infrastructure to connect them all. So we had an army of volunteers sign up to the [NHS volunteer scheme] over a weekend, but nobody able to deploy them in a meaningful way. And imagine what would have been possible during Covid, if we had had this infrastructure of Community Health Worker teams, who were able to reach households no problem, to deliver food, to connect them up, to see who needed help.

Maureen: And we would have known who really needed help before the beginning. Without having to find out once they already don’t have food, can’t leave the house, we would already know who’s pregnant, who is housebound, who is alone.

Sheila: From a GP perspective, that would have made a massive difference to our workload. At the beginning, we were given the diktat to ring everybody who was at risk and who was vulnerable. And we tried to do that. But that was on top of picking up the people who were actually breathless and really unwell as well. And so the workload at the beginning was just phenomenal, whereas if we had the Community Health Workers in place, who would be able to do some of that work. It’s speculation, but it would have meant we could have focused on the sicker people more urgently.

Matt: My personal big regret is that 17 years ago, when we first started talking about this, that we didn’t get the traction needed. We might have been in a position at a national level to respond to Covid in a better way than we have this time around. So I’m hoping that through this work, if it scales nationally, we might be in a better position to be ready for the next pandemic – God forbid when that happens. But to be ready for the next onslaught, so that we know where the need is in a timely manner.

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