Why most community health programmes miss the people who need them most

Building the referral relationships that standard pathways miss

The referral network I have built in East Riding has come from showing up in person: at community events, through partnerships with dental practices and probation services, through social prescribing networks and a lot of word of mouth. One contact I made in Bridlington has generated ten separate events for me in the past year alone. That kind of reach does not come from an email campaign.

Rather than setting up standalone events and hoping people come, I tag on to things that are already happening. A carers health and wellbeing event, a veterans group meeting, a community fair that families already attend. The people are already there.

In East Riding, 32% of programme referrals now come through community and partner routes rather than traditional GP or self-referral pathways, demonstrating how critical these relationships are to reaching underserved groups.

It is also worth being honest about where we started from. When Xyla first took on the East Riding contract, the programme was seen as a big private company, digital-first and not particularly human in focus. People were not rushing to engage. Building trust from that starting point took time and it took presence, as well as online communications.

Adapting to communities rather than expecting them to adapt to you

I’m proud to say our Quit Smoking programme has supported over 3,500 people to quit smoking, with high levels of sustained engagement. But outcomes like these depend on people being able to access support in the first place.

People with serious mental illness face compounded barriers: stigma, cognitive load and the difficulty of navigating another referral pathway alongside existing support relationships. Our approach is to work alongside the trusted contacts they already have, including social prescribers and community mental health workers, rather than creating a separate entry point they are expected to find independently.

Carers are another underserved group. People caring for family members frequently do not access health services because they are entirely focused on the person they care for. Tagging on to existing carer events is one of the most effective ways to reach them, because they are already gathered and the topic of their own health is, for once, on the agenda.

Veterans require a different approach again. Engagement in this community runs on peer recommendation and visible presence at veteran-specific events, not letters or online portals. I recently delivered a nutrition talk to a veteran’s group and walked in expecting a small session. There were 30 people in the room. That turnout happens because a trusted contact had vouched for me, which only happens because I had shown up before, without an agenda, and built the relationship first. Those relationships cannot be inherited by a new provider or replicated by a self-referral campaign.

Reaching the populations that standard services consistently miss

I describe my approach to community engagement as being a bit of a chameleon. Not just what I say or how I say it, but sometimes what I wear, how I present myself. For example, I wouldn’t walk into a community shelter wearing a suit as it can make people feel uneasy or judged. The way I approach each situation is what determines whether someone engages or switches off.

I was once at a community food provision session and overheard a health professional giving dietary advice to a family collecting from the food bank. The advice was to eat more salmon and avocado. The family had a loaf of bread and a tin of beans. That kind of mismatch doesn’t just fail to help. It tells the family the service wasn’t built for them and you rarely get a second chance after that.