Can members of the public with few skills but a lot of life experience really make a difference to the health of their community? Mark Gould reports on a truly local approach
- Health trainers are used to change the behaviours of some of the most hard to reach people.
- Since the scheme started in 2005 there are now 126 health trainer services, covering 88 per cent of primary care trusts.
- There are concerns there is a lack of evidence to support the scheme.
The wood panelled and slightly overheated conference room in the bowels of the oldest wing of the Department of Health’s Whitehall headquarters buzzed with excited chat, kissed cheeks, embraces and handshakes. The dress code was more wedding reception than civil service event. The guest list included former offenders, recovering alcoholics and people expecting to rely on benefits for their lifetime.
“Across the country there are a lot of different patterns and different people acting as health trainers”
But the guests had made the trip from Hampshire to talk about how they are helping others to tackle drug or alcohol abuse and health problems as a result of becoming health trainers (see box below). Two of them, Gail Newman and Carole Leigh, had just come from Buckingham Palace, where they had lunch with Princess Anne after she had presented them with the Butler Trust health improvement award, which is made for innovative work in criminal justice.
The Richmond House guests were among 3,100 health trainers now working in the community and GP surgeries, having been recruited and trained in only five years by the NHS.
The trainers are now working in their local communities to help people with everything from exercise and fitness to smoking cessation, healthy eating, drug and alcohol awareness and sexual health issues.
The scheme’s success is not confined to the health service. The Army has trained 2,450 physical training instructors as health trainers, there are 80 in the prison and probation service and similar schemes are now being introduced in organisations as diverse as the Salvation Army and Royal Mail, which started its own scheme a year ago and has since recruited and trained 35 health trainers.
The first NHS health trainer services were established in England in 2005. There are now 126 services - covering 88 per cent of primary care trusts. The latest figures show they have worked with and trained 58,000 clients.
The concept drew on a Pakistani scheme, where a health workers programme was established in the early 1990s with the aim of promoting health and reducing poverty by bridging the gap between health services and communities.
Its use in England was first suggested in the 2004 public health white paper, Choosing Health: making healthy choices easier, which committed to establishing a service that would deliver advice, motivation and practical support to people in their local communities.
The programme aims at those considered hardest to reach and aspires to deliver long term health improvements by changing behaviours. It also encourages “the appropriate use and uptake of local NHS services”.
But some observers have their doubts. Professor of health psychology at the Institute of Psychiatry Theresa Marteau is pleased the Department of Health has commissioned a handbook for health trainers, which is based on behavioural psychology principles, but queries the lack of evidence behind the scheme.
“The question is: does this work in practice? There is no evidence presented by the DH to say it does,” says Professor Marteau.
She cites a January 2008 paper published in The Lancet, which examined the effectiveness of employing health trainers to improve the physical activity of people with diabetes.
“It demonstrated employing health trainers was no more effective than an information leaflet. Changing behaviours is tough, but I am all for evidence based services, such as the NHS smoking cessation service, which is the envy of the world. It is free, easy to access and works. But the jury is still out on whether health trainers work.”
Association of Directors of Public Health president Frank Atherton says his organisation has always welcomed the idea of training local people to target those who are hardest to reach. But he has “anxieties” that the health trainers scheme was rolled out too fast without sufficient pilots.
“It seems that across the country there are lots of different patterns and lots of different people acting as health trainers, from local people to health professionals, while there are still questions about what the most effective model for health trainers is going to be,” says Dr Atherton.
“And while there is good evaluation going on at local level, what is happening at a national level to show that they are having any impact? It’s a fundamental point that a lot of public health initiatives are very slow acting and so hard to measure in the short term.”
DH national programme lead for health trainers Rachel Carse and others say there are signs from around the country that the scheme is a victim of its own success. People who become established in the role frequently move on to better paid jobs within the NHS - anecdotal evidence suggests 60 per cent do this - but that is welcome.
To ensure consistency and quality across services, a range of competencies, job descriptions and pay bands are being developed and health trainers can obtain national accreditation, including the City and Guilds level three national health trainer certificate and a Royal Society of Public Health level two qualification.
Ms Carse says the scheme does not pretend to replace any existing services but the evidence for its effectiveness is demonstrated by the fact that it is reaching the target groups.
A national evaluation by Birmingham University is under way.
“A significant number of health trainers are drawn from the communities with which they work and they are having a positive impact on the health and lifestyle choices of their clients,” claims Ms Carse.
“Nearly half of the 58,000 clients accessing health trainer services are drawn from the 20 per cent most deprived areas. More than 92 per cent are registered with GPs, but only 22.7 per cent are referred to health trainer services via their GPs, while some 5 per cent are not registered with GPs.
“This shows trainers are reaching people who would not otherwise engage with local health services,” she says.
Over 36 per cent of clients have so far been found to have achieved goals set out in their personal health plans, which are drawn up with the support of health trainers.
But not all clients draw up specific plans and a third are given information or “signposting” only.
Ms Carse says the British Psychological Society team that helped design the health trainer workbook believed that no single behaviour change theory has a sufficient evidence base to warrant an intervention designed from just one theoretical perspective.
“Instead, they reviewed the evidence and used techniques derived from a variety of viewpoints that have the most compelling evidence.”
Three years into the programme, Ms Carse believes there is “a growing evidence base” that supports the success of this approach. This she says is highlighted in the most recent data collection and activity reports from health trainer services around the country, which capture relevant data such as the numbers of health trainers employed, clients seen, issues addressed, actions taken and outcomes.
Faculty of Public Health president Alan Maryon-Davis is happy with the scheme’s developments.
He says: “Although lots of local public health people are involved it has largely grown from local communities with a little bit of early help from outside. These are really barefoot educators. They are not seen as outsiders or people in white coats, so it is seen as helping people to help themselves.”
And while it may be a grassroots movement, Professor Maryon-Davis is pleased it is underpinned by sound psychological principles to encourage positive lifestyle changes. He is also pleased the scheme is academically accredited, but wants signs from central government that the long term investment is in place to ensure these schemes are sustained to maximise effectiveness.
Academic evaluation of the project must understand and measure the small scale, nuanced improvements health trainers can help achieve, he adds.
“Lots of evaluations look at outcomes in terms of mortality and morbidity. The health trainers are doing things now that might take many years to measure in those terms, so I hope any assessment is more sensitive and looks at some of the more immediate aims.”
Ms Carse meanwhile is glowing with pride at the success of the health trainers from Hampshire. She feels the scheme could be a springboard for a career at the very top.
“Wouldn’t it be fabulous if a health trainer went on to become director of public health?”
Gateshead: ‘Small steps’
Gateshead primary care trust was one of the early adopters of the health trainer scheme, launching its version in 2006. It now has 14 health trainers, who work in targeted housing estates and wards. Focusing on alcohol reduction, weight loss, smoking, sexual health, drug use and mental health, they are largely local people, some recruited from estates where they live.
“We spent a long time looking at who we recruited because in some areas health trainers are simply other workers who have been re-badged. We wanted to recruit people from the grass roots,” says PCT health improvement practitioner Maggie Woodward.
She says she has seen clear evidence of people who have changed their habits because they have seen people around them changing theirs.
“We set up healthy eating groups in local church halls where we introduced couscous, something they had never heard of before. Before Christmas we introduced healthy eating groups on the High Lanes estate; it was just a small group, but of eight people they lost a total of four stone between them. People need time and support to make these changes, but it’s about small steps.
“For instance one of our health trainers managed to get a client to stop piling salt in their hands and licking it off while eating. That’s a tiny thing but it could be very significant in terms of the health of that person.”
Ms Woodward says there is still some reluctance on the part of GPs and practice nurses who feel there is no evidence base to justify health trainers and that health promotion work is something they already do, but adds that GPs are beginning to refer to the scheme.
Hampshire: ‘I was on smack and crack’
The Hampshire health trainer scheme was established in 2006 as a partnership between the local probation service and four primary care trusts. Recruits are subject to a strict vetting procedure before being employed and trained by the PCT. Based in probation offices as part of the wider community health team, they provide health advice to offenders and other vulnerable groups. The health trainer team is now 14 strong.
“They meet each new young offender on their first visit to the office and have business cards with mobile phone numbers so they can arrange a follow-up - it is voluntary but each health trainer has had around 100 referrals each. The probation services in 10 other areas, including Manchester, Liverpool and Norfolk, are interested in the scheme,” says probation service health trainer lead Brian Leigh.
One of the health trainers, Andy Blakely, had just finished probation, was on benefits with paid for housing and says he had no particular aspirations when he heard about the scheme.
“I was comfortably in a routine and didn’t want to break it. But I went along to an induction day and listened to what they had to say and thought well, if I could help one or two people, it would be good.”
His colleague David Perrin says he was from the sort of run-down estate featured in the television comedy drama Shameless.
“I was on smack and crack, drinking every day, not giving a monkey’s about myself. If that’s all you know that’s all you know. I became a petty criminal to finance my drug habit and was in and out of prison.”
He heard about health trainers from the probation service.
“I thought, why do the people who have always had this power over my life want to employ me? But I trust the probation service and like the idea of reaching out to the unreachable. My past is my biggest asset; I can talk the talk - I have been there.”
He is proud of his achievements in his own community.
“There was one 20-year-old lad with tattoos all over his fingers. He sat at home all day doing nothing but mentioned he was going home to fix his motorbike. I said there was a college course in motorcycle maintenance. I put the idea in his head and now he is going to college. Others I have gone along with to their first 12 Step [Alcoholics Anonymous] meeting.”
Another Hampshire health trainer, Sarah Biddlecombe, says it has been a “whirlwind” since her probation officer put her name forward for the scheme. She says she has many proud moments where she feels she has helped change someone’s life for the better.
“One that stands out is a man who was sleeping rough. He was bladdered by 10am. He had lost his job after he crushed his hand in an accident and was trying to fight the benefits system, because he was being told he wasn’t eligible. We got him £850 of sick pay he had been owed and got him into his own home. He has met a partner, is now getting regular payments and not drinking anymore.”