Interviews and focus groups were analysed for common thematic content (Braun and Clarke, 2006). In the following section, we describe some of the shared experiences of the CHWWs, their managers and organisations during the setup stages of the project and the first nine months of delivery after CHWW had been employed.
Engaging the community -trial & error
The active element of the CHWW’s work separates it from areas such as social prescribing. Like any activity, there is a learning period to determine the best way to interact with the public. For example, learning to go door-knocking was described as "quite nerve racking" initially. This was an area where staff employed a trial-and-error approach to engagement methods, seeing what did and didn't work and making adjustments in how to approach the public, owing mainly to the unpredictability of the activity - "you just don't know what you are going to get."
Often, people assumed that the CHWWs had come to promote their VSCO organisation: "People have some preconceived ideas because of the organisation". It is a double-edged sword as if the householder knows the organisation its "not just a random person turning up at their doorstep, it gives us a bit of credence". However, the CHWWs have to find a way to steer the conversation towards their objective and remove the idea that they are at the doorstep to promote an organisation. They worked on ‘lines’ that showed that they were "not there to sell them something", to overcome this initial hurdle.
Changes in engagement approach
Two sites chose to present themselves as "working alongside the GP" in addition to their own charity to communicate that there is a health focus but not to tie themselves to the NHS explicitly. They suggest this was the most effective approach to date. i.e., to communicate it's a local charity working with a healthcare professional. Formally, the CHWWs as voluntary sector providers don't work with the GP; rather, it's other PCN staff members that patients might have as a first contact, but it transpired that the public would not recognise the job roles of those different positions. Residents think, "If there's a GP involved, you must be able to do something." It was thought that this gives their approach "officialness" and "gravitas of the GP and the positive message of the community hub, you need all of that to come together" to make the doorstep delivery effective. From a systems’ point of view, the irony is that to avoid people going to the GP and overloading primary care, CHWWs have to trade on the name of the GP that people will recognise to prevent them from actually going there. Because, it is the only identifiable part of the healthcare system for most people who don't have an advanced understanding of the NHS structures.
This trial-and-error method is well encapsulated by one CHWW who said, "We played around with how we introduced ourselves, we said 'would you like to hear about….' and they just said no and closed the door". The approach was designed to build rapport from the start of the interaction by opening with a statement unrelated to the service itself "oh, your garden looks lovely…".
Another factor that has to be accounted for was the effect of changes in weather on resident's receptiveness. Two areas found that door-to-door work is less effective in bad weather. Door knocking was one of the first engagement methods used. CHWWs discovered after walking in the rain that residents do not respond to door-to-door interaction when the weather is very bad, so it is not a time-effective method for staff to walk around in the wet. It was found to be better in these instances to be present at community hubs and attend community indoor events, which were more effective for generating leads, as that is where most people will congregate. Conversely, door knocking in good weather produced much better results, as residents were more willing to engage.
In the first instance before door-knocking, leaflets were distributed in the target areas. Each area was permitted to customise them depending on the local needs. For example, some areas used the faces of the CHWWs in the literature, finding it to be more productive; other locations did not take this approach.
Learning for Spread
This section covers how the pilot project could be scaled and spread to a county-wide delivery model. These include insights into training, project structure, and funding, which might need to be adjusted.
Training
In terms of training, while different pilot sites encountered different issues in supporting their population, one common issue was enrolment in training and the lead time required to book spots. For example, a site identified the need for CHWWs to prioritise mental health and suicidal ideation courses, but booking onto these courses had a waiting list of months. Starting in a new area could involve initial identification of need and in-advance enrolment of training requirements.
Secondly, as door knocking had been shown to work as part of the community engagement, more role-play about door interactions before sending teams out in the community was required. i.e., to have CHWWs more prepared for how to speak to residents and what types of reception they might get. In addition, the scenarios the CHWWs are experiencing are being noted for future training activities in the event of the scale and spread of the programme.
Training Management and Co-ordination for Scale
The CHWW Programme Manager designed and ran the programme induction, ongoing training and CPD. Right from the project bid stage, she participated in the recruitment process and role design.
The introductory training was delivered face-to-face to support the CHWW’s collegiate interactions. This was seen as an essential function of the training, establishing them as a community of practice and building skills/capabilities as individuals.
Fundamental to the CHWW programme manager’s role was their previous experience of delivering the same position but for social prescribers, "We are replicating that to a degree, but this has other strands to it." Hence, there was something to build off; but rather extending some of the training that was already known to work.
Similarly, each site has coordinated line management for social prescribers and CHWWs. As such, we find that at a site level, social prescribers and CHWW are coordinated via joint line management, and so are their training provisions, and this has allowed the CHWWs to sit in a wider support net.
In the staff's opinion, it was possible to scale the CHWW programme county-wide because they have an existing model in the Social Prescriber programme - "it's not like starting from scratch." It became clear through the data collection that training and scaling activities of the programme were facilitated by staff with experience delivering social prescribing initiatives in the past in Cornwall.
Scale and Community Hub & Rurality
One VSCO manager suggested that the designated community hubs would be a great way to expand the CHWW programme in a spoke and hub model. They also highlighted that this would help with any issues regarding the current CHWW provision being predominantly urban. The model has an untested question about how to deliver support in very rural areas.
Local Implementation
Learning from the project occurred both across and within sites. In this section, we cover some of the learning that we uncovered locally, specific to each area.
Site 1 (VSCO - inland, urban)
In this location, the provider's reputation was said to be very important in brokering initial relationships with residents. Because the VSCO partner is well known, this created a positive image right at the start, i.e., for successful interactions with households, VSCO brand recognition matters as an ice breaker. From this, we can learn that the history of organisational activity is essential to smooth the interaction between CHWWs and residents.
In this case, the clarity of this message related to it not being changed by association with GP practices, as one interviewee said, "I think it is helpful for organisations that aren't attached to the Primary Care Network". In this instance, brand recognition worked better without the NHS association. However, we will see that this is not always the case.
In terms of the local approach to engaging residents, door knocking and leaflet dropping had minimal returns, but physical presence in the over 50s club produced "a small queue of people wanting to speak to her [the CHWW]", to which another added, "being out in the community is really really key". The CHWWs found successful engagement could come in any form, reaching out to all community assets, including crafting clubs, school nurses, or allotments. The strategy was to break down their total geographical area into natural neighbourhoods and work hard one at a time rather than spreading themselves thin over a larger area.
Site 2 (VSCO in PCN inland, urban)
In this site, the CHWWs are hosted within a GP Surgery while still employed by the voluntary sector. This approach had benefits but also presented some challenges. The town's residents have a collective memory of the events surrounding the closure of GP surgeries; "there is a lot of resentment about it". Hence, introducing themselves as being explicitly associated with GP services was not initially well received.
While there is a clear difference here in approach with the previous site, there is also a similarity in that the CHWWs are in part hostage of the organisation's legacy of what has happened in their neighbourhoods. In summary, the NHS- relationship was described as helping "in some ways, because access to doctors, for some people, if they have had a bad experience, it is a big barrier".
Hosting a CHWW in a PCN also affected how budgets could be raised and spent compared to the voluntary sector. For example, printing all the communication material, such as calling cards, leaflets, etc., to distribute to residents in the first instance was slower for this site as they had to wait for the PCN to sign off on the spending. The finance regulation in an NHS organisation had "more hoops”, which delayed some of their implementation.
Counter to this, one of the benefits of being in the PCN was the "easy access" to NHS staff and systems they needed. The site found it was slower setting things up and were captive of the local NHS reputation, but had a more direct route into the healthcare system. Hence, there is a trade-off in having this relationship.
Site 3 (VSCO inland, rural and urban settings)
Interacting with the NHS plays out differently at different pilot sites. The local NHS "has been slow to pick up" what the CHWWs were doing. This contrasts with site two because "they [GPs] don't understand it…they haven't had that initial interaction to what the role [CHWW] could be". There had been site meetings with the NHS GPs, NHS leads etc. So it's not a case of a lack of exposure. One of the potential downsides of not being located inside a PCN is the reduced clarity of the CHWW role for GPs and primary care staff. It transpired that in this location, some GPs thought that the CHWW role would increase their workload rather than reduce it - "there is more understanding and education to do in certain areas, but it is difficult to get into very places, to make sure the receptionist understand, that other roles understand."
Site 4 (VSCO in coastal town)
The site used what they term a "multifaceted approach" to communication that goes beyond door-knocking (which was used as a first approach) and built on other ways to reach people. Due to its long-running history, the VSCO partner is already well-connected locally but has existing relationships with the other site delivery partners. Hence, the ecosystem and exchange of information partly pre-dates the CHWW pilot site partnership. Furthermore, they have also delivered programmes with some of the other VSCOs in the past, meaning that it’s not just a network connection; in some instances, they have been delivery partners. The site also highlighted the role of an active GP in the area, who had already had a good relationship with the VCSO partner and was already exploring collaborative activities.
In addition to social prescribers, site four also had other types of community workers already in position who worked closely with the CHWWs. Specifically, they have a peer support worker on the front desk who triages people who walk into the community centre needing help. This person directs cases to the CHWWs. Consequently, in addition to the social prescriber, and CHWWs there is an in-house support and signposting role. This NHS-VCSO joint-funded role is an example of another NHS-VSCO collaboration but with a different, specific function. This position has been running for two years already, circa mid-2023.