The Challenge of Implementing Peer-Led Interventions in a Professionalized Health Service: A Case Study of the National Health Trainers Service in England

In 2004, the public health white paper Choosing Health1 introduced health trainers (HTs) as new members of the English National Health Service (NHS) workforce. HTs would offer one-to-one peer-support to anyone who wished to adopt and maintain a healthier lifestyle, and health trainer services (HTSs) would be established in all primary care trusts (PCTs). Service users would be able to contact the HTS through the NHS (eg, via local health centers), but Choosing Health implicitly envisaged broader work for HTs in community settings in order to engage “hard-to-reach” individuals and communities with the new service. Although they would not be professionals (HTs were to be recruited from the local communities in which they would work), they would undergo accredited training and use evidence-based psychological techniques to help their clients decide on and reach their own goals regarding diet, exercise levels, alcohol use, and so forth. The rationale for the HTS lay in the observation that those communities experiencing the worst health often engaged the least with traditional health promotion and other NHS services. The use of peer rather than professional workers drew on the growing evidence base underpinning approaches that recognized the need for workers to be attuned to how these service users lived their lives.2,3 Although the HTSs were to be available nationally, Choosing Health identified them as a key component of the government's health inequalities strategy and indicated that the HTSs first would target England's most disadvantaged populations. Following the publication of Choosing Health, the Department of Health formed a team to develop the HTS policy further and to lead its implementation. The service was designed to be implemented in stages. A small number of “early adopters” were to be rapidly followed by service development in the 78 PCTs covering the most deprived areas of England, and then the service would be extended to all remaining PCTs. The service was not mandatory, however. The funds for implementing the HTSs were not ring-fenced, and although the PCTs could be advised that HTs were considered an important tool to reduce the burden of lifestyle-related diseases and to drive down health inequalities, ultimately it was up to the individual PCTs to decide how best to use these funds to meet the needs of their local population.4–6 In 2008 we began a review of the national implementation of the HTS policy in England. The data that have emerged from this review offer a unique, nearly complete story of a public health policy's conception, development, and implementation into the NHS as told by key stakeholders (policymakers, health care professionals, practitioners and managers, and the HTs themselves) and verified by triangulation with documentary analyses and interrogation of the performance management database developed to monitor HTS activity. This article presents longitudinal observations of the implementation patterns of 6 local HTSs in England. Rather than an unproblematic and stable implementation of services according to the vision set out in Choosing Health, we observed substantial shifts in HTS configuration and delivery as services sought to embed themselves in local health systems. Drawing on qualitative fieldwork and service activity data, we describe the initial model of delivery adopted by each service and contrast this with models that the services have then adopted during attempts to integrate with the local NHS. To explain these observations, we draw on a recently proposed conceptual framework to examine and understand the adoption and diffusion of innovations in health care systems. Following a brief description of our methods, we introduce our conceptual framework, describe and explain the changes observed in our case study HTSs, and conclude with a discussion of the implications for similar health promotion interventions targeted at improving health and reducing health inequalities.