The case for care navigation

Health and social inclusion is a priority. Inclusion work around health and social inequalities usually takes two forms. The first is that we attempt to support people and communities access services. We open new clinics, change times and offer new aspects of the service to support this. The second form is to take services to people and communities - to have outreach clinics and workers. Both forms are valuable and powerful options that can make a real difference. The authors of this article believe that there is a third way which builds on the previous two forms but offers a radical orientation for genuine involvement and change. 

Leeds GATE (Gypsy and Traveller Exchange) is a member led organisation which exists to improve quality of life for its members and the wider Gypsy and Traveller communities. It describes itself as ‘value-based’ and these values include such things as ‘helping people to help themselves’ and ‘keeping people safe’. Leeds GATE has developed a reputation for community led approaches to improving health and well-being. Mutual understanding of the impact of social determinants of health, including structural inclusion makes natural bed-fellows of Leeds GATE and the York Street Practice.  This blog post arises from discussion between our organisations in which the proposed role of ‘Care Navigators’ has played a central part.

What is a ‘Care Navigator’? When we speak of care navigators we are proposing a new role which sees trained members of communities acting as a bridge between individuals with health needs and providers of healthcare. This could include services as wide ranging as dentistry, diabetes, maternity, or end of life care, to name but a few.  Our model of navigators is not intended to replace any clinical role, nor to gate-keep direct access to services. The role is better understood as providing a fast track to understanding and increased, effective dialogue between isolated community members and the professional healthcare support they need. A navigator would be the ‘go to’ person for community members needing additional support to understand and work their way through what is often a very complex care system, and for professionals seeking to ensure that their services are effective and don’t exclude groups of people traditionally regarded as ‘hard to reach’.

We imagine navigators spending time in their own communities, generating conversations and sharing information, and in clinical settings doing the same.  It’s not that navigators need to be ‘the expert’ but they would know who ‘the expert’ on any given topic is and would be able to effectively link patients and experts together whilst supporting developing trust and good communication. This care navigation approach, which has been successfully adopted to ensure that homeless people leaving hospital are navigated into services which assist in avoiding rapid re-admission, places people  at the heart  and action of services.  Care navigators can make significant impact on service access inequalities and can work with care providers to create viable, caring and realistic services that people actually need.

The vision of NHS England aims for people to have greater control of their health and wellbeing, supported to live longer, healthier lives by high quality health and care services that are compassionate, inclusive and constantly improving. The Health and Social Care Act 2012 introduced significant amendments to the NHS Act 2006. The Act introduces two legal duties, requiring clinical commissioning groups and commissioners in NHS England to enable:

• Patients and carers to participate in planning, managing and making decisions about their care and treatment through the services they commission
• The effective participation of the public in the commissioning process itself, so that services reflect the needs of local people.

The Marmot Review (Fair Society, Healthy lives) drew attention to the financial and social costs of health inequalities. It might be fair to suggest that many busy service providers and the infrastructure behind those services can find including marginalised people in commissioning, design and delivery of their services difficult to achieve. There is credible evidence available that proper inclusion significantly reduces cost and delivers real health improvement but for service providers making change happen, even just knowing where to start, can be easy to say but hard to achieve.

Care navigators could play a vital role in supporting community involvement and ensuring that the high values and vision of the NHS, and the social and financial savings associated with good care outcomes, are available and meaningful to all groups. Their position at the heart of their communities but, importantly, located as colleagues within professional care settings would enable effective dialogue to address outstanding healthcare inequalities. We believe there is potential to improve health of current and future generations via focus on developing community wide initiatives and individualised care plans on issues as mortality rates, long term conditions, mental wellbeing, etc. Navigators would look at prevention and early spotting of illness and conditions, promoting confidence in early intervention, raising awareness on key issues and, critically, advising clinicians on programmes of follow up action.

Care navigation represents person centred care in which the person and community are at the centre of the care provided. It supports best care in recovery after illness capitalising on tremendous care and support which already operates within communities. The care navigators can explore with the community how people can best manage their own conditions. They could look to develop 'health cell' groups in the community - small groups of community members - each devoted to a different health aspects such as men's health, depression and suicide, etc - the care navigator would help these groups learn, share and link to professional expertise - these cells would be centres of knowledge, accurate information, good signposting and support.

Another benefit, especially in light of the Francis Report findings, is that care navigators could act as barometers for measuring clinical effectiveness and safety, catching and reporting community and individual experiences of health care. The need for health and other services to be transparent and honest with patients would be enabled by care navigators supporting clinicians and providers to find appropriate language and methods to share information.

Care navigation offers a real innovation as it is a new paradigm for working with people from the different marginalised communities which will place the community at the centre of health and wellbeing. The care navigators would be co-located - in the community (understanding the community and relating to its gifts, issues and hopes) and within services. Co-location alongside professionals, as well as within community settings, would assist in linking to other relevant service sectors such as housing, social care, aiding awareness and practical responses to social determinants of health.

There is tremendous potential social and health value and impact present here. Care navigators would promote the dissolution of health inequalities, promote a culture of health inclusion, address in a practical and living way the stereotypes that people from communities face on a daily basis, promoting local community involvement and building potent links between services and people. Critically, it presents the possibility of a real culture of trust and hope to emerge, creating real access for the community to health and celebrating successful good practice and good service models.

We believe that this navigator model is based on a fundamental truth - communities and people have answers and assets. A meeting between these gifts and existing services is needed and holds tremendous promise. Inclusion from, with and for the community may be the greatest hope for health and wellbeing of communities. Health and social work would be based on and flow into communities and become enriched by the assets of the community. We hope this option can be seriously discussed, examined and tried. Care Navigation potentially offers a powerful key to dissolving some of the worst health and social inequalities people in this country face. We believe it is an idea whose time has come. We commend it to you.

John Walsh, Support Manager, York Street
Helen Jones, Chief Executive Officer, Leeds GATE  Health Practice