From Recognition to Response: Strengthening the GP-Family Hub Link in Brent

Tamara was the first patient I ever referred to the Family Hub (in Brent known as Family Wellbeing Centres) as a GP.

As GPs, we are skilled at identifying issues. We notice subtle signs. We connect dots. We have unrivalled access to our population of patients and they trust us. They come to us at many points in their lives: from postnatal checks to chronic disease reviews, from annual health checks to appointments when their children are unwell. We know where they live, what conditions they experience, and often, the challenges faced by every member of their household. Families trust primary care. 

We also are uniquely positioned to identify hidden needs with searchable patient databases, consent-to-contact mechanisms, and trusted relationships. We are well placed to find patients like Tamara. 

But one thing we do not have in abundance is time.

When I realised I was only seeing the tip of the iceberg with Tamara, I knew she would benefit from the support offered at her local Family Wellbeing Centres.

She was seen by a triage officer there and had a holistic assessment. This uncovered a lot: her child’s nursery had asked her to provide one-to-one support during the day, meaning she had no respite and no capacity to work. She had been wrongly advised that she needed a diagnosis before applying for benefits and so she wasn’t receiving what she was entitled to. She was struggling to keep up with her bills. All of this explained why her diabetes was the last thing on her mind.

The Family Wellbeing Centres helped her access workshops and advice via Citizens Advice Brent who are co-located at the hub, advocated for her with the nursery so she no longer had to provide 1:1 support for her child, made a referral to the local baby bank, provided access to food parcels/ household items/ toys via a toy library, connected her into emotional health and wellbeing workshops, and offered one-to-one parenting support. It was a real help.

And that got me thinking primary care and Family Wellbeing Centres are such a natural match. Together, we form a pathway from identification to intervention, from recognition to response and from detecting first signs to providing meaningful community-based support. The smoother we can make this relationship and the communication between the two the better.

In Brent, as Clinical Lead for Children’s Services at the Integrated Care Partnership, I worked with Simon Topping, Family Wellbeing Centres Service Manager, to explore how we could work more closely together. Here are some of the initiatives we have implemented or are developing:

• In Brent we have child health hubs - clinics run by paediatricians and GPs from local surgeries which see children face-to-face. We have ensured that our Child Health Hub GPs are aware of the Family Wellbeing Centres offer, so that suitable patients can be referred directly and we have mapped Family Wellbeing Centres against our Child Health Hubs, so every GP knows which centre covers their area.

• Family Wellbeing Centres officers now attend our Child Health multidisciplinary teams (MDTs) and our GPs report their input on often complex cases has been invaluable. The Family Wellbeing Centres have reported they are made aware of vulnerable families who may not typically register with the hub, or take-up services or support, and can use the information from MDTs to reach out to families, helping to reduce barriers to accessing services. Parent Champions can also be used to contact less heard from families and complete outreach in specific communities with the aim of increasing take-up of Family Wellbeing Centres services.

• We are publicising the work and role of the Family Wellbeing Centres to GPs in lunch and learn sessions, primary care network (PCN) meetings and in GP training. We have created an easy referral route via email and are working with the Joy app to onboard the Family Wellbeing Centres to make referrals even simpler.

• During the induction of our GP trainees, one surgery took trainees on a walk to the local Family Wellbeing Centres so they can learn about the services available.

• We have collated all children’s services in the Brent Happy and Healthy Child Directory, which has been distributed to patients and GPs and includes contact details for every Family Wellbeing Centres.

• We have developed a new Locally Enhanced Service a comprehensive biopsychosocial health check for children aged 6–10, screening for mental and physical health concerns as well as social factors (using WHAM questions: household, finances, food security-  Making a different). GPs are encouraged to refer any families identified through this check to the Family Wellbeing Centres if they would benefit for it.

• We have recruited CYP community link workers who operate across the borough and support families facing social determinants of health. They have been helping to register more families with the Family Wellbeing Centres.

And there is more in the pipeline:

• One of our GP trainees is leading a quality improvement project to identify and support young carers, using GP records to flag potential carers and invite them to support events at the local Family Wellbeing Centres which the GP will also attend.

• Our local paediatricians have expressed interest in running clinics for children and families who are frequent A&E attenders for non-urgent issues with the aim of hosting these clinics within Family Wellbeing Centres.

• Family Wellbeing Centres are keen to offer some services at GP Surgeries where space permits, for example such as accredited parenting programmes, pop up and play sessions, registering families for Hub services, with the aim of strengthening partnership working between GP and Family Wellbeing Centres.

Brent is a hugely diverse and vibrant area of northwest London, but it also has the fifth highest level of child deprivation in the country. To truly address this, families need to be connected with the right support, at the right time, to stop problems escalating requiring potentially more costly intervention, and the whole family support system needs to be more joined-up and better connected. GPs are often the first to detect hidden needs, but with limited time and growing pressures, we cannot do it alone. Family Wellbeing Centres extend the reach of primary care turning brief moments of recognition in the consultation room into real, sustained support for families.

By building strong, practical links between GPs and Family Wellbeing Centres from mapping local hubs and sharing referral routes, to joint MDTs, trainee visits, and community link workers we are starting to create a joined-up pathway from detection to intervention. Strengthening this connection is the foundation of neighbourhood working for children, and the key to improving family wellbeing across our communities.

• Know your local Family Hub – Find out which hub covers your area and keep their contact details visible in your practice.

• Make referrals easy – Use an agreed referral route (email or app) and make sure everyone in the team knows how to do it.

• Ask the right questions – Simple prompts about housing, finances and food security can uncover hidden needs.

• Link up with MDTs – Invite hub staff to child health MDTs; they often have practical solutions for families.

• Show GP trainees the hub – A quick visit during induction helps new GPs understand what’s available for babies, children and families. 

• Share the message – Mention hubs in PCN meetings or lunch-and-learn sessions so colleagues are aware of the offer.

• Think family-wide – If you spot one issue, consider what else might be going on and refer for holistic support.

• Connect with practices – Attend PCN meetings and offer short updates on what’s available in the hubs locally. 

• Keep it simple – Provide a one-page summary of your offer and referral process for GP surgeries.

• Invite people in – Offer “walk and learn” visits for GP trainees or practice staff.

• Be flexible – Where space allows, run pop-up sessions or parenting programmes in GP surgeries.

• Reach out – Use Parent Champions and link workers to engage families flagged by GPs but not yet accessing support.

Dr Amina Al-Yassin- [email protected] Brent Clinical lead for Children's services 

Dr Simon Topping- [email protected] Family Wellbeing Centre Service Manager, Early Help Service, London Borough of Brent