Transforming Health and Social Care Nationwide: A Model of Success and Resilience
Preamble
Despite multiple grant rejections, including seven unsuccessful applications, Dr. Matt Harris and Dr. Connie Junghans Minton persisted in adapting Brazil’s Family Health Strategy for the UK. Their perseverance and securing an initial £100k in local authority funding led to the development of the Community Health and Wellbeing Workers initiative, which has since expanded to 23 localities nationwide, transforming health outcomes for thousands.
Introduction
Brazil’s Family Health Strategy has transformed healthcare by integrating primary care and public health, a model the NHS could adopt to address fragmented and reactive services in the UK. As GPs take on more commissioning roles, bridging the gap between primary care and community services is essential. Community Health and Wellbeing Workers (CHWWs) are pivotal in bridging this gap by providing holistic, proactive support at the household level.
Inspired by Brazil's Strategy, the Community Health and Wellbeing Workers Initiative offers a proactive, household-level approach to improving health outcomes. By enhancing epidemiological data accuracy and public health interventions, CHWWs could significantly reduce healthcare costs and promote equity across the UK.
The Brazilian Family Health Strategy
Established in 1994, the Brazilian Family Health Strategy is a primary care system that serves as a universal, free-at-point-of-use service covering 95% of Brazilian municipalities. The strategy involves a health unit consisting of a GP, nurse, and Community Health Workers who provide comprehensive healthcare services through regular household visits. Community Health Workers are essential in promoting health, addressing social issues, supporting chronic disease management, collecting accurate health data and facilitating public health initiatives directly within the community.
This approach has scaled in Brazil, with 250,000 Community Health Workers working in 37,000 primary care teams, serving 70% of the population. The strategy significantly improved population health outcomes, including reduced infant mortality, cardiovascular mortality and chronic disease hospitalisations. It is cost-effective and has broader social benefits, including increased labour supply and health literacy and school enrolment and GP registration in poorer regions.
The Journey
The first UK pilot was due to take place in 2015 in North Wales, where significant health inequalities exist, and both life expectancy and uptake of health services fall below national averages. Betsi Cadwaladr University Health Board partnered with various academic and research institutions to explore whether Brazil’s Family Health Strategy could be adapted for North Wales, and a methodology paper was published. The region, with a population of around 676,000 spread across 6,500 sq. km, experiences inequalities mainly due to health improvements being unevenly distributed between the most and least deprived areas. Key challenges included integrating the Brazilian model into North Wales' established and crowded healthcare system, ensuring language and cultural sensitivity, and overcoming scepticism about learning from a "developing" country like Brazil. Despite the UK’s broader policy push towards community-based care and task-shifting, the proposal was not funded due to the institutional culture shift required to implement this model. Nevertheless, interest in the Family Health Strategy spurred the funding of a delegation of senior leaders to Brazil for a one-week immersion in the Family Health Strategy.
In 2018, a modelling study was completed to determine the estimated numbers of community health and wellbeing workers needed to integrate a nationally scaled workforce in primary care, as well as the anticipated workload and likely benefits to patients. Conservative modelling suggested that 110,585 community health workers would be needed to cover England's general practice registered population, costing £2.22bn annually. Based on the modelling, if community health and wellbeing workers led to the successful screening of 20% of previously missed individuals, this would equate to an additional 753,592 new cervical cancer screenings nationally, with 365,166 new breast cancer screenings and 482,924 bowel cancer screenings, during the relevant time periods for each initiative. Successful referral of 20% of children who had missed immunisations would mean that each year, a further 16,398 children would receive MMR1 at 12 months, and 24,716 children would receive MMR2 at five years of age. Importantly, based on the above figures, if the model were implemented exclusively in the 20% most deprived Primary Care Networks in the country, it would only cost £300m per annum to deliver.
The COVID-19 pandemic further highlighted the importance of strong community support systems within the community to meet significant public health challenges. Recognising the importance of wider determinants led to Social Prescribing being a focus of central government policy. However, while social prescribing models in England focus at the level of individuals, communities or both, they depend to a large degree on referral processes or focus on targeted community characteristics and are therefore not inclusive. Adopting a household-based social prescribing model in the UK, inspired by Brazil's Family Health Strategy, will address the social determinants of health in a systematic, inclusive and integrated fashion at the household level. This approach, if implemented, could help mitigate the widening health inequalities exacerbated by COVID-19 and austerity, particularly among vulnerable populations. Addressing social determinants of health and improving access to preventive services could reduce hospitalisations and promote greater health equity across communities.
The Community Health and Wellbeing Workers were first piloted in Westminster in June 2021, funded by Public Health at the local authority, providing universal, comprehensive, and integrated geography-based outreach in Churchill Gardens to support 500 households with 4 CHWWs. The pilot successfully engaged 60% of households after 1.5 years despite logistical challenges due to the pandemic, inaccurate GP registration lists and difficulties contacting households. The pilot also demonstrated promising increases in prevention after only one year.
Comparing households visited by CHWWs to those that had not yet been visited, it was found that households receiving CHWW visits had a 40% overall higher likelihood of uptake of prevention services such as vaccination, cancer screening, or NHS health checks. The likelihood of vaccination uptake increased by 47%, while the likelihood of uptake of cancer screenings and NHS health checks increased by 82%. The initiative also led to a 7.4% decrease in GP consultations in visited households.
"(…) A concern when we started this project [WAS THAT] they [CHWWs] would be bringing a whole lot of work back to us [GP Practice] … But they have connected the community to all the other roles which are out there... In many ways, they've diverted work from me into a system which will help the patients." (local GP, 2023)
The team at Imperial College London created a first-of-its-kind composite outcome score for a complex intervention in health services research to measure the impact of CHWWs on changes in health-seeking behaviour and uptake of services.
Tracking multiple health-seeking behaviours, such as immunisations and screening, provided a more comprehensive evaluation of CHWWs' effectiveness in engaging communities with health services while at the same time allowing for variability of eligibility within households. It also offers practical insights into planning and sample size, showing how even minor improvements in service uptake can be measured effectively. Importantly, this process-centred approach offers a robust framework to assess the overall impact of CHWW interventions and further strengthen the evidence base for their role in community health.
The initiative was highlighted as a best practice case study in the 2023 "Next Steps for Integrating Primary Care: Fuller Stocktake Report" and featured in the House of Lords 'Integration of Primary and Community Care Inquiry', further solidifying its impact. Swayed by the evidence of the success, acceptability and feasibility of the pilot, Healthcare Central London (the federated Primary Care Trusts in Westminster) collectively decided to donate their ARRS funds to the poorest areas of the borough to fund 24 full-time CHWW posts in the North and South of Westminster borough. They commissioned the local community sector to co-host the CHWWs, integrating the Voluntary Care Sector [ACS1] and Primary Care on a shared workforce, shared data and close collaboration. In collaboration with Healthcare Central London, these posts were allocated to 72 “villages” of approximately 120 households in the bottom 20% of most deprived areas at random, stratified by North and South. This was felt to be the fairest way to allocate this resource while allowing for a potential randomised controlled trial by Imperial College London in collaboration with the George Institute. Using the Whole Systems Integrated Care data for Northwest London, the team hopes to look at the impact of CHWWs on A&E and hospital admissions, GP use, prevention uptake and more.
A blog written by Professor Bola Owolabi, the Director of the National Healthcare Inequalities Improvement Programme at NHS England, noted the positive impact of Community Health and Wellbeing Workers in some of England's most deprived areas. Visiting London, she witnessed firsthand the life-changing impact CHWWs have on individuals, including a resident who referred to her CHWW as a “saviour.” Professor Kamila Hawthorne, chair of the Royal College of General Practitioners, praised the model as an innovative way to improve health care for the community.
The Westminster initiative was the first of its kind in London and, since 2022, has expanded nationwide, including Calderdale, Bridgewater, Cornwall and Oxford, with over 100 CHWWs now supporting 20,000 households with the support of the National Association of Primary Care. Pilots are now nationwide, a testimony to its eminent scalability. Despite the cultural and healthcare differences between the UK and Brazil, the small-scale pilots demonstrate that the local population's integration of CHWWs into primary care is feasible and well-accepted. Local policymakers, healthcare providers, and community members express interest in the CHWW model. CHWWs contribute to better engagement in preventive health services, especially in communities with historically low participation. CHWWs tailor their services to each household's cultural and linguistic needs and navigate language barriers. This proactive holistic ‘whole-household-based health promotion’ approach enabled earlier detection of conditions such as diabetes, hypertension, and dementia.
"I'm surprised and amazed at the level of service and that someone "has got my back". We as a family have been struggling for so long, I got used to it. This service is more personal, not just signposting. Helping with my physical and mental health. The CHWW communication has been 'fresh air'. The care comes across as genuine and not feeling like idiots. It's vastly different to anything experienced before." (Cornwall resident, 2023)
Introducing CHWWs into the established health and social care system required careful task-shifting. This ensured that CHWWs added value without increasing complexity. Working directly with households, offering guidance on medication adherence, lifestyle changes, and chronic disease management empowered patients to take control of their health, improving health literacy and self-management skills. Targeted health advice on smoking cessation, alcohol use reduction, healthy diet, physical exercise, and contraception was personalised and tailored to individual households. The CHWW initiative in Westminster showed early promise in improving preventive health access, patient empowerment, and potentially reducing costs. The learnings from this small pilot facilitated the spread of the Brazilian Family Health Strategy within the UK.
The Community Health and Wellbeing Workers initiative, inspired by the Brazilian Family Health Strategy, is shown to have potential cost savings and workforce sustainability. Integrating CHWWs into the health system could help alleviate workforce pressures and reduce reliance on more expensive healthcare services, potentially leading to cost savings in the long run. By addressing health needs at the community level, the CHWW model aimed to reduce unnecessary hospital admissions and secondary care utilisation, offering a more sustainable healthcare delivery model.
Since 2018, several MPH student projects have supported the development and evaluation of the CHWW initiative. These projects have explored a range of topics, including cost-effectiveness (Wenyi Zou, 2023), the role of justice in community engagement (Isaac Nsiah, 2024), and the intersectionality of health inequalities (De Medina, 2023). Earlier work by Vidhya Sasitharan (2020) and Ching Wai See (2020) helped build the business case for the Westminster pilot, showing a projected £3 return on investment. Subsequent studies by Oscar Jakubiel Smith and Robyn Stephenson (2021) provided formative evaluations during the pilot, further refining the initiative’s implementation. Collectively, these projects have laid the groundwork for scaling and improving the CHWW model across the UK.
The role of ARC NWL proved pivotal in propagating the model. From providing evidence, acting as a connector between the different agencies in the locality, supporting the evaluation and dissemination of findings and supporting other sites who were showing interest in getting this model off the ground nationally. The ARC NWL team's contribution has been instrumental and invaluable in translating evidence-based innovation into practice.
Looking to the future
Cornwall’s evaluation showed that the CHWW initiative is a powerful way to improve patient activation and well-being, and the ICB in Cornwall has embraced this model and invested in ICS-wide change, with 45 CHWWs at present and further CHWWs planned, inspired by, and proactively sharing knowledge and resources with Westminster. The growth in both locations reflects the initiative's success. A PhD student is set to analyse this data from January 2025 in Cornwall, while an economic evaluation is currently assessing the cost-effectiveness and impact of the initiative on reducing multimorbidity. In Westminster, a PhD student is currently exploring the fidelity and adaptations of the model in the UK compared to the Brazilian Family Health Strategy to inform further scaling. In collaboration with NIHR ARC North West Coast and Liverpool University, a PhD student, co-supervised by Dr Matthew Harris, will evaluate the CHWWs' implementation in three locations (Westminster, Bridgewater and Calderdale), exploring the contextual factors that determine successful implementation.
To support propagation across localities, an operations manual was developed in 2021, which continues to be refined and is shared by the NAPC with localities committed to investing in this model. Quarterly learning workshops, led by NAPC, allow localities to share insights and challenges in rolling out CHWW initiatives across the UK. These workshops have established a national community of practice for CHWWs, with eight workshops held to date. All localities now use a unified logo on CHWW uniforms, and a co-produced maturity matrix is being developed to assess the progress of each locality in implementing the role.
Imperial College London hosted the first CHWW conference organised by CHWWs for CHWWs with the help of the NAPC. All CHWWs nationally share a WhatsApp group to exchange knowledge. A handbook of top tips for CHWWs is being developed between them.
In early 2025, the Imperial team will write a book titled 'Scaling and Sustaining Healthcare Innovation,' to explore the lessons learned from the CHWW initiative and its role in addressing health inequalities.
"It is fantastic that we've got this far, but at this moment in time, it is all still very fragile despite the enthusiasm locally. The funding is often piece-meal and for one or two years only. Without political backing and sustainable funding for the initiative as well as for robust evaluation, there is a real risk that it will all fall over and that we risk losing the hard-earned trust of already traumatised communities. " Dr Matthew Harris, NIHR ARC Northwest London Theme Lead
With national attention, the pilot showed promise for scalability and long-term impact, though continued funding and expansion are necessary. Funding for one or two years at a time will risk these amazing and promising green shoots withering on the vine. Political, ICS and research backing to enable further evaluation and implementation is vital.
Conclusion
Within Western industrialised countries, there is sometimes scepticism about what can be learned from the experience of emerging economies. Traditionally, the assumption has been that countries with fewer resources should emulate the health systems developed in high-income countries. However, health systems in many industrialised nations may now be unsustainable, and the rapid scale-up of innovative approaches in some low and middle-income countries provides a valuable opportunity for reverse innovation. Dr Matthew Harris’ book “Decolonizing Healthcare Innovation: Low-Cost Solutions from Low-Income Countries”, offers a pathway for the NHS to adopt low-cost but effective innovations from areas of the world traditionally seen as beneficiaries rather than providers of help and support.
Notable achievements in public health outcomes in emerging economies have been realised through relatively low-cost, simple, and effectively scaled interventions. The Community Health and Wellbeing Workers initiative, inspired by Brazil’s Family Health Strategy, has demonstrated significant potential for improving healthcare access and outcomes in the UK. It has shown promise in reducing hospital admissions, enhancing service uptake in under-served communities, and promoting long-term cost savings.
As the UK grapples with workforce shortages and rising healthcare costs, the CHWW model offers a blueprint for sustainable, community-driven care. With the forthcoming publication of 'Scaling and Sustaining Healthcare Innovation', the lessons learned from Brazil and their adaptation in the UK could reshape the future of primary and public healthcare, offering a more equitable and cost-effective solution for the nation's health challenges.
