A blog by Dr Connie Junghans Minton
I first came across social prescribing when I visited the Bromley by Bow community centre (BBBC) with a number of fellow GP trainees many years ago. I knew that patients often come and see their GPs with non-medical issues or illnesses as a direct consequence of poor housing, chronic stress through relationship issues, financial or legal problems that caused poor mental health and an exacerbation or deterioration of existing illness. GPs can often do very little about a patient’s circumstances, so addressing this with people who can actually help made a lot of sense.
Dr Sam Everington, the pioneering GP in BBBC, described how GPs were able to refer such patients to a social prescribing ‘link worker’ who would sit down with the patient, talk through their various non-medical issues and connect them to whatever help they need, setting goals and following up. I remember him saying he did not see less patients because of it, but more appropriate issues with medical problems he was actually able to fix. This impressed me deeply, I loved the fact that social prescribing Link Workers created better capacity for the important work doctors do, and doctors could be more effective and save more lives.
The introduction of Social Prescribing Link Workers (SPLW) and Health and Wellbeing Coaches (HWC) was undeniably a significant and impactful shift. It represented a move towards a more holistic, personalised and preventative approach to healthcare. I had a LOT of patients who could really do with social prescribing, so I referred as many as I could. There was only one problem. Often the ones who needed social prescribing the most were also the ones who refused to engage.
Then I met Dr Matthew Harris. Matt had been a GP in Brazil in the early 90s. He worked with Community Health Workers or Agentes Communitarias de Saude (ACS), people from the community, who were trained and paid, part of the medical team. They were each allocated 150 households in a defined geography, whom they visited once a month or more if needed, for example if someone was breastfeeding, pregnant, discharged from hospital, going through a crisis or similar. Their remit was to build relationships with their households, support them socially, promote vaccinations and cancer screening, health checks, help with housing, and connect them to the GP or other services if needed.
When Matt came back to the UK, he made it his mission to introduce the role to the UK, having seen first-hand how amazing it was to work hand in hand with these workers. It made complete sense to me from a medical perspective.
The Public Health team at the council, where I work one day a week, saw the potential of this role to address some of the issues in one of the most deprived wards in the country with persistently high morbidity and low prevention uptake.
With Public Health seed-funding, we set out to pilot whether the Brazilian model was feasible in our much more busy service landscape. We recruited four people from the community, persuaded a visionary local GP to work with us, and started door-knocking in May 2021 to reach all of the patients on the estate registered to the practice. I met with them once a week to discuss cases and make sure they were ok.
The education I received was phenomenal and swift. One of the things we discovered early on is that there was deep distrust in the community. It took on average 11 door knocks to secure a visit, but once that hard-earned trust was won, people didn’t disengage. We saw remarkable changes in a short period of time, that just blew me away.
The second thing we discovered was that generally people did not want to talk about vaccines and cancer screening or blood pressure, they wanted to talk about housing, about crime in the neighbourhood, concerns about school, damp and mould, doors that didn’t shut, lifts that didn’t work. My first epiphany was that people needed to have these issues addressed first before they would talk about the things that really mattered: NHS health checks and cancer screening.
I could not have been more wrong. The residents are right to want to talk about the mould and damp that triggers their children’s asthma. Fixing this would make a much bigger difference than the annual asthma review and me prescribing more inhalers.
The way that the CHWWs operate is the ‘secret sauce’. They look after the entire household, addressing any issue that arises and bringing people in to help as needed. They follow people up over time, never discharging and never needing a referral to be made. They tailor their approach to the household in front of them. Being from the community they serve, they have intimate knowledge of the local services and proximity to local languages and culture.
They can build an entire team around the residents, and because they are universal they don’t just pick up people at the sharp end who have an identified need, they can be alongside people and spot things early on.
From one month to the next, the majority of their residents will be fine, while a small number will need them with intensity. This allows them to be with someone who has just given birth, is dying or going through crisis, and they can handhold not just signpost. And because they are integrated with the GP practice, they get proper support for the emotional labour they give every day.
But the most important thing is that they grow to truly care for their residents; the work they do invests into their own community.
CHWWs uniquely combine social prescribing- bringing services they know well to people’s front door- with wider benefits of building community social infrastructure; a powerful combination. The Octopus in Westminster shows that they can build a sustainable and connected ecosystem, ‘warming people up’ to engage for more intense working with a SPLW or a health coach, and following up long term. Most of all they are a trusted near-by contact that people can call on when they need to.
Will CHWWs help us create the compassionate and connected communities we so desperately need? The Westminster pilot started a grassroots movement of CHWW initiatives propagating across the country, supported by the National Association of Primary Care, currently with 25 sites and over 180 CHWWs in England. Funding is precarious, apart from Cornwall, where 60 CHWWs have been given 5 years to grow and bed in.
This GP is a convert. I think CHWWs and social prescribing are far more important for the health of our population than GPs. They are literally life-savers. As Nigel Crisp says: “Health is created at home, doctors are for repairs.”
