Agenda item

To provide an update on the impact and outcomes of the Brent Health Matters adults’ programme, including the achievements, challenges and future plans.

Nipa Shah (Director of Brent Health Matters) welcomed two Brent Health Matters (BHM) Community Champions, Viorica and Bee, to the meeting, who provided an outline of their role within the community. Viorica explained that her role was to promote health education and prevention, and provide information and resources to people to improve their health. She had a specific focus on educating people about diabetes, expanding people’s knowledge and facilitating them to take care of their own health and view their health as a priority. She highlighted that it was a very active role, attending many different events and speaking with many different communities, particularly as she spoke 4 languages. She had also had the opportunity to translate for the clinical team when needed. Bee volunteered as a Brent Family Help Parent Champion, doing outreach in nurseries, largely with under 5-year-olds such as through rhythm and singing exercises, ensuring a physical presence in spaces where parents gathered in order to provide information on the services provided in Brent. This also included attending libraries, schools, events and functions to promote Brent’s services, focusing on vaccinations and oral hygiene with an early year’s focus. She added that she had benefited from volunteering as she had learned more about the breadth of services available in Brent which she could then share with others. She worked closely with BHM co-ordinators in Kilburn, and she had connected Oxford University to Brent parents who had undertaken a study to understand the impact of social media on vaccination uptake. That study had been complimentary to Brent’s work on vaccinations and outreach during covid.

Nipa Shah then took the Board through the presentation included with the agenda pack, highlighting the following key points:

• She thanked Viorica and Bee for their remarks, highlighting their contributions as live examples of champions acting as the voice for services, helping to build trust amongst communities.
• She reminded members that BHM had been set up following the first wave of Covid, where Brent had been disproportionately impacted by the number of cases and deaths.
• BHM was funded by NWL Integrated Care Board (ICB), with the Council employed team and Health Educators funded through the Public Health Grant.
• NWL ICB had also funded the focused work on children and young people through the health inequalities pot, but that would come to an end in March 2026. A business case was being put forward for continued funding for the children and young people workstream.
• Post-covid, she felt that trust in the system had been at a minimum, and it had taken time and focus talking to communities to understand what was important to them and how they could be supported to be in charge of their own health to improve their health and wellbeing outcomes.
• BHM was in contact with around 500 community organisations in Brent and was slowly trying to get from an informing stage to a co-creation and empowering stage, where BHM was only there to support the community to take responsibility for health and wellbeing in their own communities.
• Part of that empowerment work involved community grants, and, in the past 5 years, three rounds of community grants had been allocated. There was now commitment through the Public Health grant for community grant funding to continue for the next three years, and she felt it was noteworthy that the number of grassroots organisations had increased each year, with applications received from over 120 organisations. BHM supported the community in applying for those grants and monitoring their outcomes so that they could use those outcomes as evidence when applying to other grants available across the country. She added that there were some good examples of Brent organisations being successful in grant applications following the monitoring support provided by BHM.
• One of BHMs unique key aspects of the approach included the outreach events that had been done, which included visiting faith centres, factories, community centres, schools, libraries and high streets. To date, 351 events providing health checks had been held, with other events also held for health promotion. From that, over 15,000 residents had been seen and over 14,000 health checks completed.
• Around 28% of attendees for health checks were from the Indices of Multiple Deprivation levels 1 and 2, which were the most deprived levels, but she felt that more work was needed to reach residents from those areas where it was known inequalities were higher.
• When BHM clinical team did health checks, if there was a need to escalate health issues to GPs then the team would do that. Data covering the previous 9 months showed that, of the 102 people escalated due to high blood pressure, 15 were subsequently diagnosed with hypertension, which would not have happened if BHM had not done those checks. Similarly, 10 people had been subsequently diagnosed with diabetes following escalation to their GP by BHM.
• Clinical focused work had looked at improving the percentage of people with diabetes completing their 9 key care process, which had increased from 47% in 2022 to 70% in 2025. She attributed this success to the collective work of the community teams, GP colleagues and BHM.
• There had also been focused work on bowel cancer screening, looking at those living in the most deprived areas of the borough, as the uptake of bowel cancer screening in those areas was significantly lower than more affluent areas of the borough. The number of people receiving bowel cancer screening in the most deprived boroughs had increased by 3.4% across 2 years as a result of those efforts.
• The mental health team had done additional outreach events, co-produced with communities, and engaged with a large number of residents including 1 to 1 consultations.
• Health educator work was provided by a consortium of volunteer organisations and had supported 170 people in just one year, including providing healthy lifestyle advice and digital upskilling, helping residents to register with a GP and for the NHS app. She thanked frontline Council staff, including library staff, for the support they had provided people in signing up to the app.
• The children and young people team had focused on 3 workstreams – asthma, immunisations and mental health – with a priority to reduce attendance at A&E in children under 18. She confirmed that there was now a positive trajectory with lower attendance at A&E in 2025 compared to 2023, and thanked the various community teams, GPs and BHM for that collaborative work. In relation to asthma, local residents such as Bee had been trained to become Asthma Champions, enabling them to have proactive conversations with the community about asthma and services. A particular focus for immunisations had been to improve uptake of the MMR vaccine in the Somali community, where uptake was lowest, and an Oxford professor of Somali heritage had supported that work. There was an action plan for improving that uptake and the clinical team now had approval to vaccinate in the community. A directory of services based on the thrive model had been created in relation to mental health for children and young people, and chat and chill sessions had also been introduced at 2 Family Wellbeing Centres.

The Chair then invited questions and comments, with the following points raised:

• The Board was encouraged by the positive outcomes of the Brent Health Matters programmes, particularly around bowel cancer, agreeing that routine screening saved lives. They particularly highlighted the positive that over 15,000 residents had attended BHM events and health checks.
• The Board asked how BHM streamlined their programme to fit with primary care and address issues with access, noting the case study included in the report which detailed the difficulties a patient had in getting a primary care appointment. Nipa Shah advised that was a work in progress, and whilst BHM worked to empower residents in accessing services, sometimes it was appointment times that caused barriers. Where those issues arose, BHM worked to support individuals to work with GP practices to tackle those barriers, such as supporting someone to use a phone app to book an appointment if they were not digitally literate.
• From a primary care perspective, Dr Rammya Mathew advised that it had been challenging to integrate BHM with primary care. For context, she highlighted that primary care capacity was  limited and services were stretched, and a strategic approach was needed to align the local primary care provision with the work BHM were doing to ensure synchronicity. She advised that the strain on GPs was increasing, with around 2,000 patients per GP. Funding was constrained and she clarified that GPs were not incentivised to put patients on prescriptions and were not receiving additional allowances to do that.
• Noting the slide showing the number of people escalated to primary care for high blood pressure compared to the number of people subsequently diagnosed, the Board asked why there was that discrepancy. Nipa Shah advised that the data provided had only been tracked for 9 months, so whilst BHM may have been escalating people, there had been no mechanism to track that back to GP notes previously. There were also some people seen by BHM who lived in Brent but did not have a GP in Brent, meaning BHM did not have access to their medical notes. In addition, one reading of high blood pressure could not be taken in isolation, and there was a need for a 24-hour measure in order to diagnose someone with hypertension. The readings helped to make people aware, and their GP aware, that there had been a high blood pressure reading, in order to continue to track that and make lifestyle changes where necessary to reduce blood pressure.
• The Board noted that the number of people engaged by the mental health team was high, particularly the number of people signposted, but noted that mental health was a wide bracket and asked for a further breakdown of that data. Nipa Shah advised that the figures were a result of conversations happening out in the community at outreach events, so covered a range of mental health conditions including stress, anxiety and severe mental health conditions. A wide variety of conversations were happening where the team would refer individuals on, including to talking therapies or specialists if needed. She added that having those personal conversations in community spaces presented challenges.
• The Board noted from the data provided that some ethnic communities were attending BHM events more compared to others, and asked whether that reflected the percentage of ethnicities within the community. Nipa Shah confirmed that on the whole, the figures did reflect the community. She felt that the figures also reflected BHM making progress with some communities. There were some communities that BHM still struggled to engage, such as some Eastern European communities, whereas some Asian communities were very willing for BHM to conduct health checks, so BHM had started with communities that were willing to have them in their spaces, and was then slowly using those examples to reach the communities it struggled to engage.

As no further issues were raised, the Chair drew the discussion to a close, celebrating the good work being done and highlighting the challenges patients faced when seeking services. He advocated for discussions involving BHM, social prescribers and GPs to do some learning, acknowledging that BHM planned to align services to the neighbourhood work and work much closer with primary care colleagues to join work up. In closing the item, he noted that the funding for BHM for children’s services was due to conclude but endorsed the business case for continued funding.