The Community Health and Wellbeing Worker (CHWW) model, drawing inspiration from the Brazilian Family Health Strategy, proposes a proactive, preventative approach to healthcare delivered within communities. By recruiting local individuals to provide comprehensive care navigation and health promotion support to households within defined geographic micro-areas, the model aims to enhance access to services, identify unmet needs, and ultimately improve population health outcomes. This report synthesises insights from three pilot programmes implemented in Westminster (London), Calderdale (West Yorkshire), and Bridgewater (Warrington), exploring the contextual factors that shaped their implementation, the challenges encountered, and the lessons learned regarding the model’s feasibility, acceptability, and potential for sustainability within the English health and social care landscape.
The three pilots, while sharing the core tenets of the CHWW model, operated within distinct local and organisational contexts, leading to varied implementation pathways and outcomes. The Westminster pilot, hosted by Westminster City Council and integrated into a local GP practice, aimed for universal household coverage and proactive identification of needs in a deprived urban area. Calderdale’s programme, a collaboration between the Clinical Commissioning Group (CCG) and a mental health charity, focused on emotional and mental wellbeing and operated across multiple localities, notably without formal integration into primary care Electronic Health Record (EHR) systems. The Bridgewater pilot, run by an NHS Community Healthcare Foundation Trust, initially targeted universal support in a specific neighbourhood before shifting to a targeted approach focusing on cardiovascular risk within a Primary Care Network (PCN).
A consistent facilitator across the pilots was the value placed on the CHWWs’ local connections, cultural competence, and strong relationship-building skills. These attributes were crucial for building trust and rapport with residents, particularly in diverse or underserved communities. Residents often appreciated the proactive nature of the service, especially those who had struggled to access support through traditional routes. The ability of CHWWs to dedicate time to listening and understanding residents’ circumstances fostered a sense of being heard and valued.
Effective care navigation was another demonstrable strength. CHWWs successfully identified a wide range of unmet needs, spanning physical and mental health issues, social determinants like housing and finances, and barriers to accessing existing services. By leveraging their knowledge of local health and community service pathways, and in some cases access to clinical systems, they facilitated access to appropriate support. Collaboration with other local providers, both statutory and voluntary, was essential for effective signposting and referral.
The workforce development aspect was also successful. The pilots demonstrated the potential to recruit individuals with limited prior healthcare experience but strong interpersonal skills and local knowledge. Training, coupled with supportive supervision and a strong team dynamic, fostered confidence and resilience among CHWWs, enabling them to navigate the emotional demands of the role and take ownership of their work. The opportunity for personal and professional growth was a key motivator for retention. Hosting within a well-resourced organisation, whether a local authority, NHS trust, or large charity, provided the necessary infrastructure and support for the CHWW teams.
However, significant barriers were also apparent, particularly regarding integration into primary care. Despite the model’s tenet of integrating into GP practices, achieving functional integration was challenging and varied across the sites. Lack of consistent engagement and buy-in from some GPs and PCN leaders, coupled with existing pressures on primary care time and resources, hindered collaborative working and the embedding of CHWWs within practice teams. The Calderdale experience highlighted that even with positive relationships at the individual level, the absence of formal integration and access to clinical data limited the service’s visibility and perceived value among some strategic stakeholders.
Demonstrating tangible impact and cost-effectiveness emerged as a critical challenge for securing sustainable funding. While the pilots collected various forms of data, including household engagement, referrals, identified needs, and self-reported wellbeing, these often did not align with the population-level health metrics or cost savings evidence required by commissioners. The absence of robust impact studies, such as randomised controlled trials, made it difficult to make a compelling case for the model’s value for money compared to alternative interventions.
Operational challenges included navigating the unpredictable nature of door-to-door outreach, with low resident availability or willingness to engage impacting uptake rates in some areas. Some CHWWs also expressed safety concerns related to lone working and unpredictable home visit environments. The emotional toll of encountering complex social and mental health issues, sometimes without feeling adequately trained or supported, was another significant challenge. This highlighted the crucial need for dedicated, responsive supervision and peer support to foster worker resilience.
In conclusion, the CHWW pilot programmes in England demonstrated that the model holds significant promise for enhancing community-based health and social care by providing proactive, relational support to individuals and households. Key strengths lie in the model’s ability to recruit locally trusted workers, build rapport, identify unmet needs, and navigate residents towards appropriate services. However, achieving widespread and sustainable implementation necessitates addressing critical challenges related to formal integration into primary care, robustly demonstrating cost-effectiveness and impact on population health, and ensuring adequate support and supervision for the workforce navigating complex community environments. While the pilots faced hurdles that ultimately led to the closure of two programmes, the lessons learned provide invaluable insights for refining the model and developing strategic approaches to scaling that align with the needs and realities of the English health and social care system, ultimately contributing to the goals of preventative, equitable, and person-centred care.
Contact
Andrew Riley, University of Liverpool
andrew.riley@liverpool.ac.uk
Disclaimer
This report is independent research funded by the National Institute for Health and Care Research Applied Research Collaboration North West Coast (ARC NWC). The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.
Acknowledgements
This research was conducted as a doctoral project by Andrew Riley at the University of Liverpool, under the supervision of Professor Nefyn Williams, Dr Matthew Harris, and Dr Clarissa Giebel. It was produced with the support and collaboration of the CHWW programme teams across the three pilot settings: NIHR ARC North West London, Westminster City Council, and Pimlico Health @ the Marven in Westminster; NHS West Yorkshire Integrated Care Board and Healthy Minds in Calderdale; and Bridgewater Community Healthcare NHS Foundation Trust in Warrington. Sincere gratitude is extended to all contributors to this study.
