A workforce in the West Midlands uses its community knowledge to help some of the most at-risk and disadvantaged people, as Stuart Shepherd explains

Since its establishment in 2006 as a community interest company, Gateway Family Services has been tackling health inequalities within some of the West Midlands’ most disadvantaged populations and communities.

Our services are designed specifically to target those people that the indices of deprivation tell us are most at risk

“Our services are designed specifically to target those people that the indices of deprivation tell us are most at risk,” says chief executive Vicki Fitzgerald. “It is documents like the Marmot Review and Lord Darzi’s next stage review that help us build up that understanding as well as, at the local level, the joint strategic needs assessment.

“The broader determinants of these health and social care papers support us in developing solutions and delivering models that reflect a whole system, whole area approach, going beyond the purely clinical and into services that prioritise early engagement and prevention.”

Identifying those at-risk communities affected by economic hardship and health issues such as reduced life expectancy and higher rates of infant mortality is just one step in the process. Establishing services that can get life-changing health messages and interventions through to the people who will benefit from them most is another.

Conventional health promotion strategies have not been successful in helping the groups that Gateway targets to use preventative services and lead healthier lives. The inequalities gap was not closing. Responding to such a long-term problem, Ms Fitzgerald and her colleagues have found innovation to be showing them the way forward.

“We know from earlier work that if we can give skills and knowledge to people who already have experience of living and working in disadvantaged areas we can turn their understanding into advantage,” she says. “They can be the key to unlocking some of those entrenched difficulties.”

Within communities living in areas of multiple deprivation, Gateway has been using this insight to recruit and train workforces and develop service models to meet specific local health needs.

Furthermore, flexible solutions to longstanding and ring-fenced professional vacancies have been sought, as with the newly created pregnancy outreach worker role.

The service, initially given neighbourhood renewal funding in 2007 across each of the Birmingham primary care trusts, began with 24 whole-time equivalent posts. The role is designed to respond to what was a gap in provision - reducing infant mortality by finding women who either cannot access or don’t know about statutory maternity services.

Unmet need

“We knew there was a huge unmet need for vulnerable pregnant women,” says Ms Fitzgerald. “They weren’t getting what they needed - access to housing and benefits advice, domestic abuse and substance misuse services and specialist teenage pregnancy support - so we designed the role around these risk factors. We described a worker who is knowledgeable about the conditions that people live in, and the cultural barriers they struggle with, and can bring these women into the care pathway.”

Since 2007 the PCTs have picked up the funding. The programme is about to start a two-year randomised control trial that may show more clearly where the service fits into joint commissioning.

“The POWs work closely with midwives and social workers,” says Ms Fitzgerald, “and as a result of the further service gaps they have helped to uncover and the ‘case manager’ function they have taken on, Gateway now has a social worker to oversee non-clinical support and referrals.” (See chart)

For NHS Birmingham East and North, working with Gateway has been a partnership of development.

“We have been able to work together on the shape of new service models that didn’t previously exist,” says senior strategy and redesign manager for long-term conditions John Grayland. “In terms of recruitment they have been able to talk through those regulatory concerns we had about a workforce from non-typical NHS backgrounds and specific areas of deprivation.”

Gateway family services

Gateway Family Services employs more than 150 staff and, since its inception in 2006, has supported over 700 people through training, apprenticeships and its Year in Industry programme (offering paid NHS placements to gap year students).

The social enterprise offers a learning pathway that seeks to develop a workforce of trained “paraprofessionals” working alongside health professionals and filling new roles where gaps in service provision exist. Many of Gateway’s trainees go on to gain employment either within the organisation itself or in the NHS.

Gateway positive outcomes, data April to September 2009

In total for the six months there were 825 referrals across Heart of Birmingham and Birmingham East and North and South primary care trusts. These were through a combination of midwives, pregnancy outreach workers, self referral and agency referrals of those referrrals. Of the 825, 269 were category A (those who need the most support). The number of times category As were seen are detailed below


Referred to smoking cessation: The number of women who are referred to smoking cessation through pregnancy outreach worker intervention - 131 - 15.88%

Supported to be removed from domestic abuse situation: These are numbers of women removed from a domesic situation through pregnancy outreach worker intervention. Other women have been given support - 3 - 0.36%

Number referred for benefits advice - evidence of income maximisation: The numbers encompass many types of benefits the women have been given, including completing applications on their behalf and advocacy work. These include maternity grants and Healthy Start vouchers - 287 - 34.79%

Number referred to housing services: These are the numbers of women who have been supported with housing applications; filling them in on their behalf and advocacy work; calling housing services - 339 (64) - 41.09%

Number supported to attend and receive antenatal care: This is a key target to help reduce infant mortality by ensuring that women are put on to the care pathway and receive maternity support - 120 (5) - 25% = 30 14.55%

Number of Category A contacts supported - direct contact: These are the number of times that Category A (those needing the highest levels of support) women have been seen face to face 999 (292) - 25% =249 121.09%

Number of social services care plans participated in: These are the number of care plans, both core group and case conferences, that pregnancy outreach workerss have participated in through invitation from social services - essential to reducing stress that may be related to attending the care plan - 121 -(48) - 25% = 30 14.67%