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Taking general practice to the heart of the community

Community health and wellbeing workers are providing proactive outreach to a London community; building trust and relationships, and offering wide-ranging support to residents, reports Kathy Oxtoby

Time and again, Comfort Idowu-Fearon experiences the job satisfaction that comes from being a community health and wellbeing worker (CHWW). ‘It’s a privilege to be in a role where I can visit people’s home to talk about the help and support they need,’ she says.
Ms Idowu-Fearon is one of four part-time community health and wellbeing workers providing proactive outreach to the community in Churchill Gardens, a large housing estate in Westminster, London. Ms Idowu-Fearon and her fellow CHWWs visit around 500 households regularly - building trust and relationships to increase health literacy, uptake of prevention and screening opportunities, and chronic disease support, as well as helping with housing and employment, and bringing in services as needed.
Their role is the ‘perfect bridge’ between midwives and health visitors, social workers and other professionals and the residents. And CHWWs are also the ‘eyes and ears’ of general practice in the community, given that in today’s pressurised practice environment, GPs will rarely have the capacity for traditional home visits.
The role of community health and wellbeing workers was developed in Brazil, which has the largest primary care system in the world. This approach was brought to the UK by Dr Matt Harris, a GP in Brazil, and now a clinical senior lecturer in public health medicine at Imperial College London.
In Spring 2021, Imperial College London, Westminster City Council and Pimlico Health at The Marven general practice, launched a pilot scheme of CHWWs in Churchill Gardens. The CHWWs work with a set list of residents registered at the GP practice, and offer their services directly through phone calls, calling cards, messages and door knocking.1
‘The need for this initiative arose because Churchill Gardens has persistent poverty, low immunisation and screening rates and a high chronic disease burden. This proactive longitudinal, and integrated outreach felt like a good way to reach the communities in Churchill Gardens,’ says Dr Connie Junghans Minton, a GP at Pimlico Heath at the Marven.
Dr Junghans Minton explains the four CHWWs – who are from, or live near the estate – visit about 120 households each. They are integrated at local authority level, and with two of the GP practices, Pimlico Heath at the Marven and Millbank Medical Centre serving Churchill Gardens. ‘This initiative is hyperlocal, integrated, universal, and comprehensive. This is different from most of the roles we have that are targeted to a particular demographic or clinical area, which are often referral based or providing episodes of care,’ she says.
Excellent listeners, non-judgemental, knowledgeable about local services, enthusiastic and supportive and passionate about their community, the CHWWs know the services and professionals in the locality well and are seen as being a fountain of knowledge about what’s available in the area.
Usually CHWWs are non medically trained. However, Ms Idowu-Fearon trained as a general nurse, working in healthcare for some 35 years before retiring to become a ‘community champion’ at The Abbey Centre, a community centre in Westminster where she was involved in promoting health and wellbeing activities. In 2021, she saw an advert for the role of CHWW, and attracted by the flexible hours and opportunity to do more work in the community, she applied. Her appointment made her one of the first to take on the role in England.
For these CHWW pioneers there is no typical work routine. ‘Every day is different,’ says Ms Idowu-Fearon. She gives support to residents living in five high rise houses in Churchill Gardens. ‘I book an appointment with a resident then visit to talk to them about their health,’ she says. ‘But I don’t just focus on health – for example I look at making sure their immunisations are up to date, And I let residents know about the things which are available to them in their community, like exercise classes,’ she says.
Building trust with residents is a vital part of the role, she says. ‘People don’t easily open their doors to others. So we have gentle ways to build trust, and to make them feel community health and wellbeing workers really are there to help them.’
Since taking on the role Ms Idowu-Fearon has been building up trusted relationships with residents, and her work, and that of her CHWW colleagues, is benefiting them in so many different ways. She recalls how spending time with one resident revealed they were having suicidal thoughts, and had many underlying issues at home and work. Through her support, and a counselling referral, they are now receiving the help they need.
Then there was a patient who had come home from hospital without instructions about how to take their medication. A note to their GP from Ms Idowu-Fearon meant that, almost immediately, they had access to the necessary information.
She says many residents have social concerns, and that the stress these can cause – such as not having a job, and concerns about paying bills – leads to other health issues. In her role she will work together with residents to help them with their concerns, such as talking to utility companies to organise bill payments over a longer period.
The CHWWs regularly receive training to help them deal with residents’ different issues. ‘But we don’t pretend to residents that we know everything or can fix everything – we let them know we will do what we can,’ says Ms Idowu-Fearon.
CHWWs are also helping to ease GP workload pressures and prevent unnecessary appointments. Ms Idowu-Fearon signposts residents to a wide variety of support, such as social prescribers. And she is able to spend that precious time that GPs and other health professionals lack, listening to residents’ concerns, and identifying health and care needs.
‘Doctors have just 10 minutes or so to see a patient. Someone who is really burdened cannot express what they want to say in 10 minutes. Our role means we can be there to listen to, and understand them,’ she says.
Members of the wider health and care team who work closely with CHWWs have also witnessed their value. Wen Foo, community matron at Central London Community Healthcare NHS Trust says: ‘Community health and wellbeing workers offer housebound patients a long-term, one-to-one therapeutic relationship and are closely integrated with different parts of the NHS, including GPs and community services. They’re able to pick up subtle changes in patients’ wellbeing and can request clinician input promptly if needed.
‘Community health and wellbeing workers help to give patients confidence that their wellbeing is continuing to be proactively monitored when they are discharged from the community matron service, which can help to reduce the risk of deterioration in the future,’ she says.
Jo Davis, head of clinical services - Central London Planned Care at Central London Community Healthcare NHS Trust, says that as a manager of community health services in Westminster, ‘I can see huge potential in how community health and wellbeing workers can help address health inequalities and multiple wider factors that influence health, such as employment and housing, in our most deprived areas’.
‘I would describe CHWWs as ‘knitting the community together’ along with residents, health, social care, the voluntary sector, and community organisations. They are amazing advocates for residents and can act as sign posters for health services in the community. The trust they build with residents is so important, and they often play a vital role in identifying isolated residents and early risk factors of health conditions.
‘One of the most important and fantastic aspects of having CHWWs is that patients do not need a referral or to meet a list of criteria to access the service. This means that the CHWWs will see a household of different ages with different physical and psychological health or social needs and be able to help and support everyone within that household.’
The initiative has also inspired a more ‘relational approach to how all the roles work together on the patch, with regular workshops where old and new, medical and non-medical roles in the community get to know each other, how they work and how they can work together better’, says Dr Junghans Minton.
Following its launch, the scheme took about 18 months to reach 60% of the population, a percentage that has been ‘increasing steadily and people stay engaged, which is encouraging’, says Dr Junghans Minton.
An evaluation of the project’s first year found that those who had been visited by staff at least once took up prevention opportunities 40% more than those who hadn’t had a visit.
For cancer screenings and NHS health checks specifically, uptake increased by 82%, and immunisation by 47%.2
The evaluation also suggests the scheme can help reduce pressure on general practice. Local GP services have had a 7.4% average fall in appointments per household, as a result of the community workers directing people more efficiently to the appropriate care.2
Cllr Nafsika Butler-Thalassis, Cabinet Member for Adult Social Care, Public Health and Voluntary Sector at Westminster Council says: ‘Our community health and wellbeing workers have achieved spectacular results by working consistently with residents within their own communities in Pimlico. This enables residents to navigate services and receive the help they need, underlining our role to provide high quality health and care services for all residents.’
Pioneering the role in England has not been without its issues. ‘Some of the challenges include the time it takes to integrate at the practice and to get to know key people, and the fact that residents are also not used to a proactive regular outreach service - however, their response has been much better and more positive than expected,’ says Dr Junghans Minton.
She says the four PCNs in Westminster and the voluntary sector have embraced the CHWW model and are ‘hoping to scale this to more areas with persistent deprivation across Westminster’.
The scheme has also been rolled out in West Yorkshire and Cheshire, and there are plans for further expansions in Norfolk and Cornwall.2
Many more communities could benefit from the CHWW approach, says Ms Idowu-Fearon. ‘Communities are dealing with multiple problems, and many issues are being dealt with over the phone and to a time limit. But CHWWs are face to face with residents - and don’t have time limits,’ she says.
To other nurses, including those who are perhaps thinking of retiring, she says the CHWW role is ‘an opportunity to work closely with communities and to make a real difference’.
In Churchill Gardens, CHWWs are also encouraging the community to become closer. ‘We’ve started having coffee mornings once a month with residents from the same buildings. At first the residents didn’t know each other, but now they look forward to these mornings, not just for the coffee, but the friendships,’ says Ms Idowu-Fearon. Now the coffee mornings have become a popular fixture, and, as with everything about this approach, it has been about building up trust over time, she says.
Just recently, she was reminded of the value of this approach, and how rewarding her role can be. ‘One of the residents would normally only talk to me outside their home. The other day they said: ‘Come in, Comfort’. It’s taken two years to be invited into their home. I went inside, and we chatted about what support they needed for quite a while.’  

Kathy Oxtoby is a freelance medical writer
1. Community Health and Wellbeing Workers pilot in Churchill Gardens | Westminster City Council [Internet]. [cited 2023 Aug 30]. Available from:
2. Brazil-style healthcare initiative levelling out health inequalities as leaders call for expansion [Internet]. National Health Executive. [cited 2023 Aug 30]. Available from: