Dr Cornelia Junghans Minton
Clinical Lead, Community Health and Wellbeing Workers (CHWW) Programme, Westminster, Healthcare Central London
Image credit: Grainge Photography
About Me
I’m a GP and Public Health Specialist based in Westminster, where I’ve worked since 2001. I live in London with my husband, our two teenage boys, and our cat, Chips.
My Career Journey
I came to medicine later than most, after completing a Master’s degree in Social Sciences and a PhD in Epidemiology and Biostatistics at the University of Bristol. My early career in Public Health research shaped the way I think about healthcare – always looking for causes, not just symptoms.
While training as an academic GP at Imperial College London and Imperial NHS Trust, I also worked part-time as an epidemiologist at Westminster City Council. My research informed my consultations, and my consultations deepened my research.
In acute medicine, I often saw patients caught in a revolving door – people with chronic lung disease like asthma returning again and again because of poor housing and social conditions. We treated their flare-ups but not the causes. It felt like re-applying a plaster to a festering wound. That frustration pushed me to explore Social Prescribing and wider-determinant approaches – the bridge between clinical care and lived reality.
Discovering the Community Health Worker Model
During my time at Westminster City Council, I helped build a partnership with Imperial College London to foster evidence-based, research-friendly local practice. Through this work, I met Dr Matt Harris, who introduced us to Brazil’s Family Health Strategy. A model where Community Health Workers (CHWs) are trained and paid members of primary-care teams, each responsible for a small geographical patch, visiting households regularly to support both health and social needs. The idea resonated deeply: one trusted person, embedded in both healthcare and local services, caring for households holistically. It was social prescribing brought home.
With the vision and backing of Dr Jeff Lake, Deputy Director of Public Health for the Bi-borough, Westminster City Council greenlit and funded a two-year pilot in Churchill Gardens – one of the most deprived estates in England, with high morbidity and low preventive-care uptake. We also had crucial support from Dr Sheila Neogi, a local GP of over 30 years, who immediately recognised the value of this model and offered her practice as the pilot site.
Launching the Pilot
We recruited four part-time Community Health and Wellbeing Workers (CHWWs) – Asma Monir, Maureen Katusabe, Nahima Begum, and Comfort Idowu-Fearon. From the first interviews, we knew they had the resilience, warmth and determination to make it work.
Each was assigned around 500 households, and together we co-created the pilot. As clinical lead, I met with the CHWWs weekly to discuss cases and challenges, and we held six-monthly milestone reviews to analyse data and refine our approach.
The pilot wasn’t about proving the model’s theoretical effectiveness – that was well-established internationally through the work of Michael Marmot, Julian Tudor Hart, and Geoffrey Rose. Our key question was acceptability: would proactive, universal outreach work in a UK urban setting?
It did – though it took persistence. On average, it required eleven door-knocks to secure a first visit. By the end of year one, we had reached 40% of households, 60% by 18 months and 70% at year 2. Even though the pilot wasn’t about effectiveness, the pilot showed the CHWWs to be very effective in a short amount of time: they reduced unscheduled GP visits by 7%, and increased uptake of vaccinations, cancer screening, and NHS Health Checks. Our CHWWs loved their roles, and the community responded in kind. Coffee mornings that began with one or two attendees soon became packed as trust spread by word-of-mouth.
Leadership and Expansion
Westminster benefits from four federated Primary Care Networks (PCNs) that take a shared, population-based view. One of their Clinical Directors, Dr Saul Kaufman, championed the model. Together, the PCNs agreed to allocate ARRS funding to sustain and expand the CHWW programme into two full teams, in North and South Westminster, delivered in partnership with local community organisations.
This created 24 full-time CHWW roles, randomly distributed across 72 high-need micro-areas (each around 120 households) within the most deprived 20% of the borough. The randomisation enabled a robust randomised controlled trial, led by Imperial College London, to evaluate outcomes at scale.
In November 2023, the Paddington Development Trust recruited a team of 12 CHWWs in North Westminster – including two from the original pilot, now team coordinators.
By February 2024, The Abbey Centre had recruited 15 CHWWs in South Westminster, again retaining two of the original Churchill Gardens team as mentors.
This was essentially a new pilot all together – two large teams spanning 32 GP practices, working through new NHS-community relationships. Progress was slower at first. By the end of year one, CHWWs had reached only 25% of households, in part because a third of assigned addresses were non-residential or unviable and new processes had to be worked out. By mid-2025, reach had risen to 40%, and it now takes an average of four door-knocks to secure a visit – strong progress toward our goal of 60–70% coverage by 2026.
Early data from the Integrated Care Board’s Business Intelligence team (Jan 2025) are encouraging: 10% reduction in hospital admissions in CHWW areas (versus a 15% increase in other deprived areas), a 7% fall in A&E attendances and smaller declines in preventive metrics – e.g. NHS Health Checks fell only 1% in CHWW areas versus 16% in the remaining Core20 Postcodes. Even with partial reach, CHWW postcodes are bucking negative trends.
Their relational way of working and tailoring their approach exactly to the person and household in front of them impressed Dr Saul Kaufman so much he started the Octopus Integrated Neighbourhood Team in a basement of a community hall in Church st one day with just a handful of front line roles. This soon snowballed into quarterly Octopus summits and we are about to have our 12th summit, with increasing organisational representation and more varied frontline roles.
Building Capacity and Learning
Our CHWWs are deeply committed to personal and community development. Their energy at milestone workshops is unmatched. Last year, several CHWWs organised the first national CHWW Conference, hosted by Imperial College London with NAPC support. Since then, they have: co-authored a handbook of Tips from CHWWs for CHWWs, adopted the OctoLink App (developed by Healthcare Central London) to record activity and outcomes, trained in Justice in Listening techniques to improve communication and self-care, engaged in participatory evaluation with Professors Andrea Cornwall (King’s College London) and Rene Loewenson (TARSC) and begun training as NIHR Research Champions (starting November 2025). Many also joined colleagues from Cornwall at the second annual CHWW Conference at the Eden Project – a moment that captured the movement’s growing national cohesion.
Recognition and Future Vision
Since the pilot, Westminster’s CHWW programme had secured Core20+5 funding for training and integration for 2023 and 2024, gained ESRC/UKRI funding for reciprocal learning with Brazil – including exchange visits with Brazilian CHWs, been shortlisted for multiple awards: MJ Award and RCGP QI Award (2023), HSJ Community Improvement Award (2024) and best of all, featured as a best-practice model for neighbourhood working in the NHS Long Term Plan. Westminster is named one of NHS England’s national neighbourhood pilot sites.
The programme has attracted a lot of attention with visits from a House of Lords committee, Professor Bola Owolabi, the national health inequalities lead, Dr Sarah Woolnaught, CEO of the Kings Fund, Professor Kamila Hawthorne, the Chair of the Royal College of GPs, Professor Hilary Cottam, social entrepreneur and innovator, Sarah Mullaney, Archbishop of Canterbury, Professor Claire Fuller, Director of Primary Care for NHS England, Alexandre Padilha, health minister of Brazil and Stephanie Al Qaq, British embassador to Brazil. It has inspired an exchange programme with Brazilian CHWWs to learn together and two of our CHWW teams are twinning with two teams in Brazil. This has inspired and motivated both the CHWWs here in the UK and the CHWWs, or Agentes Communitarias de Saude, as they are called in Brazil, understanding that they have a leading role in helping their communities flourish.
I now serve as national co-lead for the CHWW programme alongside Dr Matt Harris and Dr Caroline Taylor, working with NAPC to develop the national support offer. Looking ahead, the CHWW model is proving to be a credible cornerstone of future primary-care infrastructure – enabling the shift from hospital to community, from reactive treatment to proactive prevention, and from isolated patients to flourishing neighbourhoods. I very much hope that local leaders continue to invest in the collective vision and am excited to see where this movement goes next.
