Knowsley is a metropolitan borough on Merseyside with a population of just over 150,000 people.
It has higher than average levels of chronic ill-health, including heart disease, respiratory disease and cancer (especially lung cancer), and has been identified by the Department of Health as a Spearhead area.
NHS Knowsley has made huge investments in the local health economy to address these health challenges – for example, building a number of brand-new primary care resource centres with a wide range of facilities in some of the most deprived areas of the borough.
NHS Knowsley has also developed a systematic programme of health promotion and prevention activities designed to address underlying causes of ill-health. Early in 2007, in response to the White Paper Choosing Health, we set up a health trainer programme to complement existing provision.
Knowsley health trainers
Health trainers were intended to be local people, trained by the NHS (but not themselves health professionals), who could work one-to-one with other local people to help them make sustainable lifestyle changes – providing “support from next door” rather than “advice from on high”.
In keeping with the goals of the national programme, Knowsley health trainers were recruited and trained to meet four key competencies:
- Establishing and maintaining relationships with communities
- Communicate with individuals about promoting their health and wellbeing
- Enable individuals to change their behaviour to improve their health and wellbeing
- Manage and organise their own time and activities.
One of the central aims of our health trainer service was to bring individuals into contact with mainstream services and medical advice. To achieve this, the health trainers (6.6 full time equivalent) were initially managed by heath visitor managers in mixed teams covering each of the three localities of the borough.
Though clients appeared to respond positively to the service, levels of referrals remained stubbornly lower than anticipated. We commissioned a full-scale evaluation of the service in 2008 to look at how this could be addressed.
Evaluation of the service
Few previous evaluations of health trainer services had been published, but an authoritative evidence review had emphasised the importance of looking at qualitative processes as well as raw quantitative data.
The evaluation strategy was designed to gather a wide range of perspectives on the health trainer programme using largely qualitative methods. It encompassed the following strands:
- Client feedback
- Health trainer feedback
- Health trainer training
- Health trainer coordinator feedback
- Stakeholder perceptions
- Segmentation of client base
- Data analysis
We hoped to identify the main outcomes of the programme and better understand the factors that were influencing Health Trainer performance.
Some key findings
The evidence indicated that health trainers had been successful in working with some service users to facilitate behaviour change. Staff were perceived to be approachable and user-friendly and able to support clients without falling into the trap of appearing to be “instructors.” Health trainers were also found to be accessible in community settings in response to need.
However, room for improvement was found. The name of the service was perceived to be misleading. Clients said “the title is deceptive” and “it makes you think of personal trainers”. There appeared to be few benefits to the location of health trainers within health visitor teams, which primarily worked with children not adults. Stakeholders themselves did not always understand the remit of health trainers and the “unique selling point” of individualised behaviour change support and were sometimes reluctant to refer clients.
As the findings of the evaluation became apparent we were able to take action to get referrals back on track. We linked the work of health trainers with a local programme of checks for cardiovascular disease, which provided an immediate significant rise in referral numbers. The management of the health trainer programme was restructured to work closely with the existing community health development team. And the publicity material was revamped to reflect the focus on lifestyle-related issues, with health trainers themselves being rebranded as lifestyle advisors.
Over the past 12 months performance of the health trainer service has exceeded all targets and the service contract was extended for 12 months to take advantage of this.
The changes made in response to the evaluation made a big difference to the overall management and presentation of the service resulting in improved referrals. Ultimately the level of impact on health inequality will depend upon demand within the population, particularly from those most in need, so future work must focus on marketing and developing the service to continue to raise awareness of the support it offers.