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

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Colleges, School and Institutes


In 2004, the English Public Health White Paper Choosing Health introduced “health trainers” as new members of the National Health Service (NHS) workforce. Health trainers would offer one-to-one peer-support to anyone who wished to adopt and maintain a healthier lifestyle. Choosing Health implicitly envisaged health trainers working in community settings in order to engage “hard-to-reach” individuals and other groups who often have the poorest health but who engage the least with traditional health promotion and other NHS services.

During longitudinal case studies of 6 local health trainer services, we conducted in-depth interviews with key stakeholders and analyzed service activity data.

Rather than an unproblematic and stable implementation of community-focused services according to the vision in Choosing Health, we observed substantial shifts in the case studies’ configuration and delivery as the services embedded themselves in the local NHS systems. To explain these observations, we drew on a recently proposed conceptual framework to examine and understand the adoption and diffusion of innovations in health care systems.

The health trainer services have become more “medicalized” over time, and in doing so, the original theory underpinning the program has been threatened. The paradox is that policymakers and practitioners recognize the need to have a different service model for traditional NHS services if they want hard-to-reach populations to engage in preventive actions as a first step to redress health inequalities. The long-term sustainability of any new service model, however, depends on its aligning with the established medical system's (ie, the NHS's) characteristics.


Original languageEnglish
Pages (from-to)725–753
Number of pages28
JournalMilbank Quarterly
Issue number4
Publication statusPublished - 10 Dec 2014


  • health trainer, health inequalities, policy implementation