How Community Health Trainers in Manchester enable positive lifestyle changes

When the NHS and local partners launched the Health Trainer Programme in Manchester in 2006, co-production was not much talked about. But as Governance International found out when we interviewed Delana Lawson, the Programme manager of this service from its early days, the idea behind the Community Health Trainers is not to tell local people how to live a healthier life but to empower them to develop and use their own skills to change their behaviour.

Health Trainers are based on the concept of getting help from your next door neighbours.  Most of us know the basic lifestyle messages given out by experts – indeed; we are bombarded by the media about them. However, we all find it difficult to put this advice and guidance into practice.  Health Trainers are local people who have been trained to have skills to help make a difference to the health of individuals.

Find out how the Manchester Health Trainer Programme has turned co-production principles into practice to achieve behaviour change.

In July 2005 Manchester was chosen as one of the first areas in the UK to pilot a new national initiative known as ‘Health Trainers’, first introduced in the government’s “Choosing Health’ White Paper. At the time, 15 of the 33 wards in Manchester were ranked in the top 100 most deprived wards in the country and Manchester, as a whole, was ranked as the second most deprived district in the country.

The White Paper proposed that Health Trainers should be drawn from local communities and would aim to reach people who want to adopt healthier lifestyles but who are not in contact with services. This programme is not about support for those who already enjoy good health - Health Trainers work with those communities in highest need of action to reduce health inequalities. 

Targeting disadvantaged groups and improving their access to services are identified as ‘big wins’ in ‘Choosing Health’. Communities most at risk of ill-health also tend to experience the least satisfactory access to preventative services because of a range of cultural and geographical barriers. Common barriers include:

• services which are perceived to be intimidating or stigmatising;
• access and transport difficulties;
• lack of interpreters and inaccessible service hours and
• difficult appointment systems.

In order to strengthen prevention and enable lifestyle changes in communities at risk, the NHS launched the Health Trainer Programme in 2006. The objectives of this national pilot programme are:

• to improve public and patient access to information and services
• to target vulnerable and marginalised individuals
• to address the major lifestyle determinants of health
• to support clients to achieve and maintain positive lifestyle changes 

Another key aim for the Manchester programme is to attract new people into jobs with the NHS who have had little or no employment experience previously, particularly in the NHS, but have a passion and insight into the needs of their local community. The Health Trainer is a relatively new employment opportunity aimed at local people who want to support others to improve their health. It represents a significant new pathway into the NHS.

In Manchester another key aim was to build on the strong collaborative links between the City Council, NHS  and the voluntary and community sector. The vision is to enhance the ability of different organisations and services to improve the health and wellbeing of Manchester residents through the development of a flexible, skilled and mobile city-wide workforce.

As a so-called ‘early adopter’ site, Manchester developed the Health Trainer Programme via a partnership arrangement comprising the Manchester PCT, the Local Authority (Joint Health Unit) and the Manchester Public Health Development Service. Key drivers at the time were David Regan (Leader of Joint Health Unit, currently Director of Public Health in Manchester), Chris Love (Deputy Head of Service Manchester Public Health Development Service, NHS Manchester) and Ged Devereux (Joint Health Unit Senior Strategy Officer)

Manchester Public Health Development Service is responsible for the recruitment and training of Health Trainers and also the line management of all programme staff. The first  challenge was recruiting and training a first cohort of Health Trainers. This involved advertising the posts through a number of channels in communities at risk, including the local radio, buses and community events. The recruitment drive met a lot of interest from local communities. Applicants took part in interviews and a workshop to establish mutual expectations and to assess social skills. As a result, 17 local people were trained up as Community Health Trainers by May 2006, including six men, representing 12 WTE posts. In this initial stage of the programme’s development, Health Trainers completed a 3 month training induction during which they were employed for 3 days a week to attend classroom-based training. Some of the Health Trainers of the first cohort moved on to find employment in health-related services. For example, two senior Community Health Trainers now work in an NHS mental health agency. In May 2007 ten new Health Trainers were trained up and were based within a range of different placement settings. They bring new skills and ideas into the programme, but, at the same time, the Health Trainer Programme benefits from the fact that the new trainers are supported by three trainers from the first cohort.

Altogether, in February 2014, there are 16 people who are employed as Health Trainers. It is intended that more will be recruited in the near future. The Health Trainer is an employment opportunity aimed at local people who want to support others to improve their health. NHS Health Trainers must have either acquired or be working towards City and Guilds National Health Trainer Qualification Level 3. With full training and support, Health Trainers provide personalised support to others within communities, enabling those most at risk of ill-health to access a healthier way of life. Health Trainers are currently required to make 15 client contacts per week (pro-rata) and contract with 85 unique clients each (pro-rata) over a 12 month period.

Health Trainers speak a number of languages; these include Somali, Urdu, Punjabi, Hindi, Arabic, Mirpuri, Gujarati, Dutch and Greek. Every effort has been made to attract people to the scheme from a range of backgrounds, many of whom may not have considered anything like this before. No formal qualifications or experience of employment in the health service are necessary. What is most important is the ability and desire to work with others and to bring about a real improvement in people’s health. The testimonial of Steve Hoy, a former wrestler based on Manchester United’s old training ground, provides a great insight into a day of the life of a Community Health Trainer.

Health Trainers have been based with Tung Sing Housing Association and Northwards Sheltered Housing Association Scheme thus providing direct integrated healthy lifestyle support to tenants across Manchester.  The programme works more generally across communities through “City in the Community”, Manchester United Foundation and the “Tree of Life Project”.  Consideration is now also being given to how Health Trainers can assist with enhancing the recovery of people who have suffered from stroke, hence placing a Health Trainer within the Community Stroke Rehabilitation Team. This has enabled the programme to effectively target the most marginalised, and people who may not be in contact with services. 

With the introduction of a more holistic health and wellbeing assessment, Health Trainers now work more broadly in Manchester. This also involves working with the Arts Council to improve the wellbeing of clients using creative techniques such as painting. They can now offer assistance around alcohol consumption, smoking, social isolation, stress and anxiety. The role of Health Trainers is not to give advice but to empower the client to develop and use his/her own skills to change their behaviour. The approach is person-centred with the clients making their own decisions. Interventions are also brief, with the aim being to assist clients to move towards specific self-defined goals. The first assessment session includes a health stock-take in order to assess the person’s opinion of their current general health, well-being and health goals. Health Trainers work with individuals, supporting them to identify barriers within their own lives which hinder them from adopting good habits and opportunities which could support healthy change. Health Trainers meet with clients on no more than 6 separate occasions. At each session, the clients’ progress towards goals is monitored and recorded.

The programme is both a third party referral and self-referral scheme. If the client has any pre-existing health issues, they are asked to see their GP before working on any changes. In many cases, clients will have had an assessment carried out by the referring agency, e.g. a physical activity referral scheme, which will eliminate inappropriate referrals to Health Trainers and ensure clients are able to access appropriate services more readily. In Manchester most clients have heard about the service through the NHS or word of mouth. Whereas in the early years of the programme self-referral was the most common form of referral, GPs have now become the biggest referral source.

The relationship between the Health Trainer and the client is a collaborative, equal and non-judgemental one. By offering practical support and guidance in key topic areas, they help individuals to make small changes that will make a big difference to both the quality of life and life expectancy. 

Usha, a mother of three young children, lives in Longsight, Manchester and was struggling to give up smoking.

Usha said that she wouldn’t have succeeded in giving up smoking if she hadn’t had the support and help of her Health Trainer – Jackie: “I know it’s bad for my children, and that my own health is suffering but it’s a habit, and when I’m under pressure I find it really difficult. In my culture it’s really bad for women to smoke, so I have to do it in secret. I had no idea that smoking services existed near to me.  Jackie put me in touch with a local group which was for ladies only and they helped me to come up with ways to take my mind off smoking, such as taking the children to the park, cooking or relaxing in the bath.  Each session I had with Jackie we concentrated on different things and the small steps have made giving up smoking more manageable – especially with having children to look after as well.  She has even phoned me when I couldn’t make a meeting to see how my progress was going.   I‘m looking at how to eat more healthily now because it’s important for the family to be healthy, so I’m off to a Cook and Taste session later this week!”

The Health Trainer’s job is to listen, support and encourage people to make sustained healthy lifestyle choices that fit in with their daily lives. Health Trainers encourage clients to take small steps to achieve their goals.                

Jackie’s experience:

Initial contact “In the first meeting with a client it is important to greet the client in a friendly and approachable manner, so that they are put at ease.  When I met Usha for the first time, she was concerned that other people might find out that she smoked and obviously this was a sensitive subject.  It is important to be non-judgemental and try to understand about people’s backgrounds and cultures.  I managed to find a smoking cessation group that was running at a nearby centre where a crèche was available for young children.  I went with Usha to the first session to give her some support but after this she went to the sessions by herself, as she felt comfortable with the surroundings.  Initially we came up with different ideas of how to take her mind off smoking”.

Continuing contact “I continued to meet with Usha for a few more sessions as she wanted to look at other areas of her health.  We have been looking at healthy eating and are attending a Cook and Taste session to learn more, gain recipe ideas and improve cooking skills”.

Outcome “In this role you can make such a difference to peoples’ lives, often just by listening to them and giving them the support they need.  It’s such a good feeling to know that Usha is successfully making healthy choices for herself and her family”.

A recent evaluation (1 April 2013 - 30 September 2013) of the Royal Society for Public Health shows that a key strength of this co-production approach is that the Health Trainers are being drawn from the populations they serve. From a record of 980 Trainers:

• 34% are drawn from the most deprived quintile of the population.
• A further 22% being drawn from the second most deprived quintile

^{Source: Royal Society for Public Health (2013, p. 9).}

In quintile 1 approximately a third of the clients are male and two thirds female, this proportion carrying on into quintile 2. As the evaluation report argues: “From an equity perspective, there is an argument for saying more men need to be recruited. However in respect to family and community health and well-being the proportion of females engaging with HTS may be an advantage. Women as partners and mothers in families tend to be the dominant force in controlling food purchase, family meals and other health related activities” (Royal Society for Public Health (2013, p. 12).

The performance information about the clients participating in the programme is equally revealing. From total records of 28,633

• Diet (63%) is the most frequent area individuals wish to change and improve upon.
• Exercise on (19%) is next most popular.
• Local Issue (8%) was the third popular.

^{Source: Source: Royal Society for Public Health (2013, p. 13).}

The 2013 evaluation also measures self-confidence for the first time and comes to the conclusion that “self-confidence along with Self Efficacy is an important quality in being able to manage life and its challenges”. The report shows considerable shifts in self-reported confidence scores:

• The greatest increase is recorded in quintile 2 – up a significant 41%.
• Quintile 1 up a respectable 25%.

^{Source: Source: Royal Society for Public Health (2013, p. 13).}

The national results for developing personal health plans for all clients need to be interpreted with caution: The pathways of over recorded 48000 clients shows that encouragingly 13356 (28% of total) were signed off after completing the full personal health plan but nevertheless 12,280 (25%) ultimately failed to fully attend or were lost at some point upon follow-up contact (p.17).

However, as the evaluation report points out it may not be so surprising given that the Programme deals with clients from very deprived backgrounds. “It is also worth reminding ourselves that the methodology used by the HTS is one which accepts clients will not always be successful at the first, second or even third attempts at change. The methodology is predicated that the process of trying to change is itself a beneficial and positive experience, the experience itself leading to greater personal insight and resourcefulness” (p.18).

A value for money assessment was undertaken on results for the financial year 2011/12. 509 clients were fully assessed, progressing through the Health Trainer intervention during this time and setting and achieving various lifestyle goals. This is not the total of all clients seen, as Health Trainers see many more clients who for various reasons are not willing or able to set lifestyle goals. Using the above data values in the assessment tool indicates that there is a net cost of £4784 per QALY (Quality Adjusted Life Year). Anything under £10,000 is considered good value for money for behaviour change, highlighting the success of the programme. If a treatment costs more than £20,000-30,000 per QALY, then it would not be considered cost effective.

^{Source: Based on calculations with Portsmouth Ready Reckoner}

The health promotion programme started with a focus on healthy eating and exercise but the active listening of the Health Trainers soon revealed that a ‘whole person’ or even ‘whole family’ perspective is required to facilitate behaviour change. For example, one Health Trainer observed that  “she needed to visit the female Asian cook in the family, who was adding too much salt to the food, in order to pass on the health messages for the benefit of her male client” (Willis and Regan, p. 76). In particular, some Health Trainers and supervisors recognised that the need to develop social contacts was a genuine goal for behavioural change.                 

The idea to ‘go where your clients are’ has been key to the success of the Health Trainer Programme in Manchester. Placing Health Trainers within different settings has meant that they have been able to reach out to clients who would not otherwise access support or professional advice.

Partnership working through integrated services is another key feature of the Health Trainer Programme. It has meant that Health Trainers are able to contribute to different initiatives across the City. These have included’ ‘Don’t be a Cancer Chancer’, Arts and Cultural facilities attendance, Employment Through Sport, and the NHS Health Check. 

Overall, one of the key success factors of the Health Trainer Programme has been its long life, as behaviour change takes time. At the same time, the Programme has been flexible and adaptive, working with new partners and groups and dealing with new challenges such as dementia. Sharing its achievements and insights with other local councils, the NHS and voluntary groups has also helped it to reflect on how to develop the Health Trainer Programme further.

For further information about Manchester Public Health Development Services please visit the website or follow them on Twitter: @McRHlthTrainers

Lerleen Willis & Clair Regan (2009), Manchester Health Trainers: Monitoring and Evaluation Report, September 2006-March 2008, Manchester Public Health Development Service.

Royal Society for Public Health (2013), Health Trainers Half Year Review 1st April – 30th September 2013.