They are the champions: volunteers in the community

Launched in October 2011 and aimed at leaders and decision makers, the Department of Health strategic vision for volunteering articulates an ambition to promote and support an increase in volunteering.

The document argues that demographic changes alone make it “essential that we nurture and release the capability, capacity and assets that exist within our communities”. This is an ambition that few would disagree with, but the real question is how to move from rhetoric to reality. Here we look at the community health champion approach as a practical way of engaging people in health.

‘Behind the success stories lies a health and social care programme that has developed a unique and systematic approach to engaging people’

Winner of the prime Minister’s big Society Award 2010, a finalist for the Big Lottery health awards 2011 and highlighted in the 2010 public health white paper and Marmot review, the community health champions movement has been quietly gaining momentum over the past few years. 

Making a difference

Community health champions are members of the public who motivate and help their friends, families, work colleagues and neighbours to lead healthier and happier lives. As volunteers they receive training and support to equip them with the skills, knowledge and confidence to make a difference. 

Community health champions, many of whom are recruited from disadvantaged communities, draw on their own life experience, ideas and understanding of their local communities’ needs and assets to design and deliver voluntary activities.  

Examples range from leading organised health walks, chair-robics for older people, men’s health groups, cycling for people with disabilities, self-help diabetes groups, information sessions around depression for older people and administering healthy heart check questionnaires. They also talk to people informally as part of their daily lives, providing individualised support if needed.

While this approach is reliant on the energy and commitment of health champions to be effective, activities do not just happen spontaneously. Behind the success stories lies a health and social care programme that has developed a unique and systematic approach to engaging people.

Altogether Better began in 2008 as a Yorkshire and Humber-wide five-year, £6.8m programme funded through the Big Lottery wellbeing fund. Initially the programme focused on prevention with an emphasis on increasing physical activity, promoting healthy eating and improving mental health and wellbeing.

Now it is being tested out in a range of settings focused on many different health outcomes, including long-term conditions, lifecheck, older people, preparing for pregnancy and working with Roma communities.  

The collaborative is now a social movement of many individuals and organisational partners that values, promotes and co-produces citizen involvement in health and wellbeing.

In its first years Altogether Better, which is now hosted by the NHS, has supported 16 projects across the region – 12 based in community settings and four in workplaces – and a learning network hosted by Yorkshire and Humber Public Health Observatory.

Essential infrastructure

Local project commissioners and delivery agencies provide some of the essential infrastructure; they recruit people to become community health champions, provide training and then support them volunteering.

This is not a top-down standardised package – training can vary from a three-hour introduction to a 14-week course – but common to all projects is an enabling approach where champions’ confidence is built and support is given to develop locally based healthy activities.

In these days of economic efficiencies, hard questions are inevitably asked about whether new approaches work, what benefits they might bring compared with traditional services and if they are value for money. 

Altogether Better has always recognised that long-term success depends on having built a strong evidence base and a robust business case. The Learning Network has drawn together practical learning and local evaluations as well as commissioning research to address evidence gaps.

The Centre for Health Promotion Research at Leeds Metropolitan University has been a key partner, carrying out evidence reviews as well as independent evaluations of the health champion role in communities and workplaces.

The result of this strategic approach to evidencing impact is a wealth of accessible evidence resources – all available through Altogether Better’s website.

Since the establishment of Altogether Better, more than 15,000 community health champions have been recruited and they have connected with a further 90,000 people in their communities and workplaces. 

Achieving scale and reach

This is one of the few public health and social care programmes that really has achieved scale and reach. For example, in Sheffield a network of more than 200 volunteers receive support to improve health in some of the most disadvantaged communities in the city. They have connected with in excess of 11,000 people in Sheffield and more than 50 champions who were previously unemployed now have jobs. 

One notable feature of the Altogether Better champion approach is its success at involving communities who face barriers to achieving good health and wellbeing. In the Leeds Met evaluation, champions reported how they were able to connect to people either because they were from the same community or had been through a similar experience, such as having struggled with weight problems.

People can decide their own level of involvement – some champions give hours of their time, others just take the learning from the training. This flexible and empowering approach is one of the key ingredients of success. It has meant that groups who have the poorest health can be drawn into healthy living activities making this approach a useful tool in meeting the health inequalities challenge.  

The evidence gathered so far shows that the community health champion approach works on two levels. First, there is a positive health impact on people who become a community health champion, and second, champions have an impact on those around them.

‘There is a positive health impact on people who become a community health champion and champions have an impact on those around them’

In the evaluation we found examples of people with better health knowledge and awareness, increased self-esteem, and improved wellbeing. For some individuals, becoming a community health champion was a transformative experience helping them rehabilitate, regain a sense of purpose or start on a journey to other opportunities, such as paid employment. 

Some of the case studies illustrate how involvement can lead to reduced use of health services. There are real challenges in collecting hard evidence that captures the wider impact in local communities. However, our qualitative research shows that the champion role is an effective mechanism to engage people in healthy lifestyle activities and once people are more connected that, in turn, promotes positive mental health.

Volunteer community health champions can add capacity to health service delivery; the Leeds Older and Active project, for example, supports champions in organising exercise classes for older people. The return on investment and contribution to improved quality, innovation, productivity and prevention is clear; community health champions can provide greater intelligence on needs and assets in communities, greater reach into communities with higher health needs and have success in supporting people to change behaviours and improve self-management of long-term conditions.

More confident and informed citizens also use services more appropriately. York Health Economics Consortium recently reviewed 15 individual case studies from the Altogether Better projects using social return on investment methodology and found that all showed a positive SROI with a range of returns observed. Although SROI can only provide an indication of return on investment, the results do highlight the potential value of the community health champion approach for funders.

Evidence base 

In order to support an evidence-based approach for programme development, Leeds Metropolitan University carried out three rapid evidence reviews. Drawing mostly on systematic and expert reviews, it looked at existing evidence on similar roles, like lay health advisers, and found a wealth of international evidence much of it from the US, where there has been a long tradition of lay health worker programmes, particularly working with African-American and Hispanic communities.

Positive impacts have been reported across a range of health and social outcomes, including:

• increased uptake of preventive services like immunisation;
• positive behaviour changes, particularly with low income or minority ethnic communities;
• improved disease management for those with long term conditions such as diabetes or hypertension;
• more appropriate use of health services, for example decreased emergency admissions and improved appointment keeping;
• evidence on benefits for volunteers including positive outcomes in relation to quality of life, activities of daily living, family functioning, psychological distress and depression.

Transforming involvement

The positive messages emerging from Altogether Better show that large-scale volunteer involvement around health and social care is possible. In the past four years the community health champion approach has been tried and tested, and it works.

Challenges remain around gathering sufficient evidence to really prove wider impact. However, the availability of an array of accessible evidence-based resources should help those commissioning and managing volunteer involvement in the NHS and local authorities.  

How can the NHS use such an entrepreneurial and community-oriented approach in order to improve health and support better healthcare? The structures, systems and professional mindset in the NHS do not tend to fit well with community development approaches, with the result that health services often see citizens as patients in need and fail to harness the wealth of community assets. 

Work carried out by Altogether Better and the university in gathering international examples suggests that in the UK we are missing a trick to connect up this community action into primary health care. 

In Canada, for example, the cardiovascular health awareness program, recently reported in the BMJ, was successful at involving older peer volunteers who carried out an impressive 27,358 blood pressure assessments in pharmacies over a 10-week period. A key feature was the high level of professional buy-in as 99 per cent of family physicians in the intervention communities took part. These types of integrated models could easily be adapted in the NHS involving community heath champions as a ready resource.

We believe that the community health champion approach offers the NHS a chance to scale up its volunteer involvement. Having a pool of motivated, trained health champions in local communities can be a resource to support people with non-medical needs and help managers and clinicians reach out to groups with the poorest health.

Ultimately, clinical commissioning groups have to demonstrate “meaningful engagement with patients, carers and their communities” – community health champions can offer a practical and locally based means of achieving this.

Altogether Better is now taking steps to share its learning on a national platform working in partnership with new local health systems and national influential partners such as the NHS Confederation and the London School of Economics.

Using co-production principles, Altogether Better is working with foundation trusts, local government, emerging CCGs and other partners to unlock the huge potential assets of citizens within different settings. Bespoke models in many forms include:

• volunteer health navigators in a foundation trust setting;
• supporting local health systems building a new integrated approach to preparing people for parenthood;
• supporting GP’s to effectively engage citizens;
• co-creating a new community fabric of Living Well Older Champions.  

These new activities are all part of the next generation of the evidence-based community health champion approach. Meanwhile Altogether Better’s existing community health champions are going from strength to strength, following new pathways into employment, enterprise and further education, recruiting their friends and families and influencing decision makers across Yorkshire and Humber and beyond.

Jane South is professor of healthy communities at Leeds Metropolitan University and Roz Davies is co-director of Altogether Better