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Community health wellbeing workers challenge an NHS based on clinical need

By Dr Johnny Marshall, OBE, council member, National Association of Primary Care
7 May 2024

Despite one of the NHS founding principles being that care should be based on clinical need the inverse care law still pervades the delivery of NHS services with significant health inequalities throughout England. Essentially, those who most need healthcare are the least likely to receive it. Addressing this sort of health inequality is good for all of our health as it results in social value and economic growth.

Having a principle that defines an equitable NHS specifically based on clinical need may sustain the very inequity it is trying to prevent. People are not defined by their clinical needs. They have much broader health and well-being needs around what matters to them. Healthcare only contributes to about 10% of a population’s sense of health with about 90% attributed to wider determinants of health such as lifestyle, education, poverty and social connection.

Simply focusing on people’s clinical needs without considering these wider aspects of health can result in an unnecessary or escalated healthcare solutions, such as hospital admission, to address a “clinical” need because of an unmet social need around personal care or safety. As hospital admissions are associated with a risk of hospital acquired “clinical” need through issues such as infection, decompensation or anxiety; such action is potentially harmful and those with the greatest social need are most likely to find themselves in this position.

An NHS focus on clinical need and healthcare can often result in a culture of dependency and reliance on professional care and support rather than enabling people to be advocates of their own health. Activated people are more able to manage their own health, less likely to require professional support and experience greater health for less NHS cost. By giving regard to the wider health needs within our populations we would be much better placed to support their improved health and wellbeing.

Because of this interdependency between our physical, mental and social health is it not time in a truly person-centred NHS to look beyond clinical need to what matters to people in the round and shape our support offer around that principle?

Achieving equity in such a principle would require a more progressive approach to health and wellbeing needs than currently exists within the NHS. While responsibility for addressing this problem does not lie completely within the control of the NHS, a greater emphasis on the proactive understanding of families’ health and well-being is a positive step that the NHS could adopt. Such an approach enables better access to formal prevention, diagnostic and treatment services resulting in better health outcomes and reduced health inequality.

The adoption of integrated neighbourhood teams across the NHS presents an opportunity to look at this afresh. Based on evidence from Brazil, where there are 265,000 community health wellbeing workers (CHWW) working across 43,000 family health teams serving 209 million people, the NAPC, in partnership with Imperial Healthcare, has established a pilot of CHWWs in Westminster, which has now been extended to other areas around the country, to do just that.

CHWWs work with all the households in a defined local area, about 100 to 150, which they then visit on a regular basis. At the visits they deal with any pressing issues within households across their physical, mental and social health; thereby directly bridging the health and social care divide across the life course. They work with the wider system including primary care networks and local authorities supporting residents’ health around what matters to them.

CHWWs live and work within their communities, earning the trust, engaging with and supporting entire households across the spectrum of physical, mental and social health needs. They enable people, arguably those with the most need, to become participants, activated in their own health and care more effectively.

Individuals were recruited as CHWWs based on character not on qualifications; people who were natural problem solvers; had the right attitude; and recognised the need to be persistent, respectful and maintain confidentiality. 

It has taken up to a year to reach 70% of households who are ready to engage and trust the CHWW sufficiently for them to pick up on issues that were detrimental to health and wellbeing in addition to encouraging immunisation, vaccination, health screening and improved lifestyle choices.

Breakthroughs into health conversations are now occurring in complex families because the CHWWs support them with their more pressing concerns around the wider determinants such as housing, unemployment and antisocial behaviour. More importantly, these wider determinants are often the direct cause of the conditions which drive inequalities in physical, mental and social health. Addressing them will not only make room for prevention conversations but actively improve health and wellbeing. 

Strong leadership and support to CHWWs in the primary care networks and local authorities has been pivotal to the success of the scheme.

CHWWs present a very real solution to health inequality by challenging the principle of an NHS being based on clinical needs. In response to society’s greater awareness of issues of inclusion and how addressing them benefits us all perhaps this principle needs refreshing and more proactive person-centred support should be made available particularly to those with the greatest health and wellbeing needs through greater investment in initiatives such as CHWWs.

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