Why public health needs Community Health and Wellbeing Workers

Ask people what keeps them well on a day-to-day basis and few would immediately say hospitals. They would probably talk about a warm home, a steady income, good neighbours, knowing where to turn when something goes wrong. 

Estimates vary, but clinical care is commonly thought to account for only around 20% of our health outcomes. The other 80% is shaped by the places we live, the work we do, the connections we have and the choices those circumstances allow. If we want to change health, we have to reach into that 80%. Community Health and Wellbeing Workers (CHWWs) do exactly that. 

The origins and growth of community health workers 

The model grew from Brazil's Agentes Comunitários de Saúde, first trialled in Ceará in the late 1980s and later scaled nationally through the Family Health Strategy. The principle was simple: recruit local people, give each a defined patch of households, and have them visit every home regularly, whether or not anyone is ill. 

These are not outside professionals parachuted in. They are residents who already know the community's assets and its problems, who notice when a curtain stays closed. Brazil now has hundreds of thousands of these workers, and the evidence associated with the model, including substantial reductions in cardiovascular and stroke mortality, has drawn attention worldwide. Brazil, for me, represents the gold standard of Community Health Workers. 

In England, the model was adapted in Westminster, where CHWWs are recruited from their communities and embedded in primary care teams and the community sector to proactively support households.[3] Its design rests on four principles:  

One role, every domain of public health 

What makes CHWWs remarkable is that they tessellate across the whole of public health. 

Health protection: During the pandemic, trusted local faces did what leaflets could not: supporting contact tracing, checking on isolating households, and encouraging testing and vaccination among people wary of official messages. 

Health promotion: Because advice is tailored to each household, it lands. In Westminster, households were 47% more likely to have the immunisations they were eligible for and 82% more likely to take up cancer screening and NHS Health Checks. The first-year evaluation estimated that, at scale, more than a thousand additional people could be screened for each of breast and bowel cancer, alongside extra children receiving MMR vaccines. 

Health creation: CHWWs connect people to each other, not just to services. We found the work increased resident interaction, improved wider determinants through bringing residents together and strengthened community connectedness. Loneliness, isolation and a sense of powerlessness are health problems, manifesting in cardiovascular risk akin to smoking a pack of cigarettes a day – a regular knock on the door is part of the cure. 

Healthcare public health: CHWWs keep people well and out of hospital, supporting continuity of care and managing long-term conditions closer to home. Rather than creating demand, they reduced it, while finding people who need care but do not seek it. After Westminster's expansion, areas covered saw A&E attendances fall by 7% and hospital admissions by 10% compared with the previous year, while prevention activity and scheduled GP reviews increased.

Academic public health: Our CHWWs are trained in participatory evaluation and act as research champions, helping communities that are routinely under-represented in research take part on their own terms. That improves inclusivity, and it improves integrity; research shaped by the people it studies is better research. They also gather local insights and population-level data on need that no dashboard can capture. 

Building toward health careers  

Perhaps most importantly, many CHWWs start as volunteers and step into paid roles. In Westminster, 29 local volunteers have been trained and employed as CHWWs. That means the programme creates jobs in the very neighbourhoods facing the greatest inequity, and raises health literacy not just among residents but among the workers themselves and their families. 

It also opens a door for them. The NHS faces a shrinking pool of highly trained professionals, while our communities hold a growing pool of talented, motivated people who are eager to learn but lack the qualifications, confidence or resources to get a foot in the door. The CHWW role bridges that gap, offering a foundation from which people can progress into midwifery, nursing, medicine, paramedicine and social care, bringing lived experience of their community with them. 

And our CHWWs love the work. It is relational, visible and meaningful. It is more than a job. 

What public health needs right now 

None of this happens by magic. The role needs sustainable investment: a recent review in Wandsworth found CHWWs lacked reflective supervision, digital tools and clear integration into care teams, and warned that prevention requires time, follow-up and consistent presence. Supervision, training pathways and sustainable funding are not extras – they are the infrastructure. 

But the case for CHWWs is compelling. They were mentioned in the 10-Year Health Plan, and the ambition to shift care from hospital to community, from treatment to prevention, needs people on the ground to make it happen. Community health and wellbeing workers are that people-powered infrastructure: rooted, trusted and able to reach the 80% of health that my GP clinics never reach. If we are serious about prevention and equity, this is where we need to start. 

From recognised role to recognised profession 

In Brazil, community health workers are no longer seen as the last mile of a health system. As early as 2002 community health workers were recognised as health professionals by law.  

What is striking is what Brazil treats as essential to the role. Brazil's constitution allows the public selection process for these agents to be restricted by place of residence, because the worker must live in the community they serve and be known locally in order to enter homes and follow up households. In other words, knowing your community is a job requirement, written into law. 

That is the point we need to make in the UK. A CHWW's knowledge of their patch, who lives there, who knows which families are struggling, which assets can be mobilised, which doors won't open to a stranger, is a technical skill. It is learned, practised and refined, and it is as specialised in its own way as a physiotherapist's knowledge of movement or a radiographer's knowledge of imaging. 

The foundations for professional recognition already exist. There is a national Level 3 Community Health and Wellbeing Worker apprenticeship standard, typically a 12-month programme, whose purpose is working in partnership with individuals and communities to identify and address health and wellbeing needs, prevent ill health and reduce inequalities. And the Royal Society for Public Health and the National Association of Primary Care have announced a new Level 3 Certificate in Community Health and Wellbeing, designed to provide standardised and regulated training, supporting the recognition and development of this emerging role. 

A standard, a qualification and a growing evidence base: these are the building blocks of a profession. The next step is to recognise CHWWs formally within the health workforce, with a professional identity, a career framework and a place alongside allied health professionals.   Their role in building community, building trust and supporting the wider determinants of health is crucial to the success of a truly local health service.