Editorials

Linkworkers in primary care

An untapped resource

Growing awareness of the particular needs of health service users from minority ethnic communities over the past 20 years has resulted in various linkworker schemes across Britain, but their development has been patchy. Linkworkers provide a cultural bridge between doctors and patients in areas with ethnic minority populations. The continuing debate about skill mix in general practice, together with the responsibility on primary care groups to commission services for minority populations, has intensified interest in extending their roles. What do we know about linkworkers and how effective they are?

An immediate challenge is the diversity of labels used33 different terms in one review.¹ The role has encompassed interpreting, advocacy, health education, and health promotion. For many health professionals the need for help with interpreting is paramountsince mutual incomprehension on account of language renders all other considerations secondary.² The NHS certainly needs to extend its interpreting facilities, but the role of the linkworker has always been broader.³ Effective communication in health care relies on a common language, but also on culture, class, beliefs, trust, and many other factors.⁴ Linkworkers can mediate about the real, as opposed to the literal, meanings of words and gestures. They can explain advice in terms compatible with the patient's values, beliefs, knowledge, and assumptions. While general practitioners also act as advocates for their patients, they may not be fully aware of all the challenges facing diverse communities.

Moreover, many people have problems that transcend the boundaries of statutory organisations, and a linkworker can help in interactions with the primary healthcare team, local authority departments, and benefits agencies. From a client's perspective, such needs are inter-related. To bridge the gap between service providers and patients may require challenging the biomedical model of health.⁵ Many linkworkers have been assertive in challenging individual and institutional racism in the NHS. ^{6 7}

The literature suggests that linkworkers can make a valuable contribution in many services, such as new patient health checks, women's health, and mental health.⁸ Linkworkers have been employed to encourage the uptake of breast and cervical cytology screening, ^{9 10} but the evidence for their effectiveness in health promotion is mixed.¹¹ They have been successfully trained in managing patients with diabetes and asthma,¹²though there are medicolegal issues to be resolved if these clinical roles develop.

The research base needs to be strengthened if good practice is to be shared, but there are difficulties in evaluating linkworking, including the short term nature of projects and lack of funds for evaluation. Properly controlled studies are difficult to mount and appropriate outcome measures difficult to define. For example, in one of the few randomised trials Hoare et al found no difference in breast screening uptake between a group seen by linkworkers and unvisited controls. However, only 59% of the intervention group could be contacted and the scheme exposed major administrative shortcomings (such as inaccurate registers and naming systems). The impact of linkworkers alone was difficult to assess in a close knit community, where spread of information about breast screening might have "contaminated" the control group.

Few linkworker schemes are based on formally assessed needs. Many schemes have been established opportunistically with short term funding. Information on costs and sources of funding is therefore patchy. Linkworkers are usually on low administrative and clerical salary grades, which lowers their status in the eyes of other healthcare workers. Indeed, linkworkers often encounter suspicion from healthcare professionals, though these tensions can be alleviated if linkworkers are included in the wider primary healthcare team.¹² Their training is often poorly coordinated, though there have been attempts to tie training to accredited courses and higher education. If the work is to attract the status and rewards it merits, however, quality assurance of training is required nationally. Otherwise, we risk perpetuating unequal career development opportunities for minority ethnic healthcare workers. Rather, linkworking could provide a route into healthcare professions, where minority ethnic communities (especially women) have been underrepresented.

Linkworking should not be developed in isolation but needs to be considered in the context of local health improvement programmes. These offer an opportunity to adopt a more strategic approach to developing services for ethnic minority communities. As this happens primary care groups will become the judges of whether linkworking schemes and other forms of health advocacy have a place in the new NHS.

Stephen Gillam, director, primary care programme. 
Ros Levenson, visiting fellow. 

King's Fund, London WC1M 0AN