To build a more preventative health system, we also need a more person-centred one

‘If you’re holding a hammer, everything looks like a nail’. And when a health system prioritises clinical interventions, rather than health creation, everything starts to look like a healthcare problem. Despite NHS England’s stated ambition to provide much more care in the community, and intervene earlier, its continued emphasis on managing specific conditions and expanding access to clinician-led care, continues to crowd out essential action to keep people in good health for as long as possible.

However across the river from Skipton house, in Pimlico and Westminster, as well as a growing number of locations around the country, a radical new approach is emerging based on Brazil’s model of primary care. Central to this approach are ‘Community Health Workers’ (CHWs): people hired directly from their communities to carry out regular visits to residents regardless of expressed – or indeed unexpressed – health need.

Unlike social prescribers, care navigators and similar roles, people are not referred to a CHW nor are they discharged once a care episode is complete. Instead, the support provided by CHWs is continuous and universal. There are no formal qualifications required to be a CHW; they are hired for their ability to be compassionate, emotionally intelligent, and to help residents on their own terms, with the things that matter most to them.

On a recent visit to a CHW patch in North West London, I heard first-hand how this allows CHWs not only to fulfil the ambition of ‘early intervention’ – addressing problems before they escalate and reducing demand on other services – but also reaching people who would never otherwise consider or be able to reach a GP practice or an A&E ward.

One told the story of an older lady who had multiple locks on her door and had turned away the CHW on all their initial visits. Through sheer perseverance, they were eventually welcomed in, building a genuine bond with the resident which led them to admit they couldn’t trust anyone else but really needed support. Another described their role as giving people the “feeling of being human”, especially when other public services had overlooked them or let them down. While a home visit from a doctor or nurse could have led to a referral or prescription, CHWs described how they could support residents – by “having the time for a normal conversation” – in much more personal and practical ways.

For example, one person had been admitted to A&E after mixing different types of blood pressure medication. After realising why, a CHW helped them write down what they’d taken and set up alarms on their phone: something the resident hadn’t thought or been told to do before. In less than five minutes, the CHW performed what countless visits by social services or GP appointments would likely have missed.

It’s perhaps no surprise then that an early evaluation of the initiative has found a 7 per cent drop in unscheduled GP visits in areas covered by CHWs. Or that a clinician on my visit described having to “check the data twice” when they found that population health outcomes improved “across the board” in these areas – from healthy BMI results to rates of screening uptake.

At the same time, the CHW initiative has succeeded in spite of the level of national support for these initiatives, not because of it. While the NHS’ Alternative Roles Reimbursement Scheme (ARRS) has led to a proliferation of healthcare-adjacent roles in primary care, the CHW role, being a ‘non-healthcare’ role, does not explicitly qualify, despite its immense impact on health outcomes. Those who have become aware of the CHW scheme in Westminster, and set up similar initiatives, from Cornwall to Battersea, describe having to “work against the grain” of the dominant NHS culture to get funding.

If we want a truly preventative health system, we’ll also need one that’s more focused on people, and the kinds of non-clinical and social interventions which can support them to lead healthy, independent lives. In turn, to create a more person-centred health system, we’ll also have to give local leaders much more power and flexibility to shape health roles around the needs of their local populations.

The CHW offers a compelling example of the innovation that’s possible when public services meet people on their own terms (and in their own communities and homes). Meanwhile Reform’s new paper, ‘Close enough to care’ sets out the system shift that it will take to see approaches like this become the norm, so that leaders of the future no longer need to work against the grain to make transformative change happen.