Wednesday, 5 November 2014

Motivational Interviewing and the NHS Health Check


The big picture

When it comes to the UK’s heart disease problem, the social and economic costs are dizzyingly high. Every year the condition is responsible for around 74,000 deaths; the cost to the economy comes in at £29 billion. At the current rate, Britain is spending more of its health budget on heart disease than any other EU country. 

Whilst the figures are bleak, many of the risk factors associated with the condition – including high cholesterol, high blood pressure, smoking, inactivity and diabetes – are largely, if not entirely, preventable. This being the case, the simple answer to reversing the trends lies with the not-so-simple process of changing collective lifestyle behaviours. It’s with precisely this preventative agenda that the NHS Health Check programme is concerned.


Despite representing the most comprehensive effort to proactively bring down the national burden of ill health, the success of the programme lies, according to Public Health England (PHE), ‘in part with the ability of the chosen provider to inspire behaviour change in those attending’. To this end, the practice of Motivational Interviewing (MI) has become a central feature of the programme delivery framework.

The inclusion of MI is not without justification. According to the research, MI is ‘effective when delivered in brief consultations’ and has the potential to have ‘robust effects across outcomes’ when used in medical care settings. This consensus is perhaps unsurprising however if we accept that health and care are improved when patients are at the forefront of any decision-making. Such patient-centeredness is exactly what effective MI is able to support and enhance.

Integrating MI into the NHS Health Check framework

As was emphasised in the previous blog post on Reviewing the evidence base for NHS Health Checks, quality is key to the success of the programme. Whilst a number of factors go in to making a quality consultation – from the professionalism of the provider to the functionality of the systems – on a personal level, they’re fundamentally characterised by engagement, empowerment and respect. As was highlighted during a recent MI workshop for the Health Diagnostics team, these are precisely the principles fostered by a truly motivational session.

The coordinator of that two-day workshop was Brett Nicholls (pictured right), Chief Executive of Get Berkshire Active and MI trainer. With nearly two decades of experience using MI in his role as an RAF officer, Nicholls brought to the table both a high-level overview of MI philosophy and a host of nuanced insights on how the techniques can be used in different settings. Focusing in on the NHS Health Check, the core objective in this instance was to further develop the ways in which Health Diagnostics support the process of making every contact count.

Working on the principle that ‘people learn best that which they discover themselves’, Nicholls and the Health Diagnostics team explored how the behaviour change techniques originally developed by Drs Rollnick and Miller can be adapted and applied to the context of a 20-30 minute cardiovascular health check. Despite only offering a brief window of opportunity, the reach and availability of the checks mean that people often use them as a gateway to lifestyle change. Whether this change is catalysed by an individual realising what the future may hold for their health, or simply gaining a knowledge of the local support services on offer, many who’ve had a check confirm that the personal discoveries they make cause them to stop, think and very often take action.

How then do we maximise the opportunities offered by the health check? In short, by an approach that draws out and bolsters commitment to lifestyle change when it emerges in the session. In this regard, a chief finding from the workshop was that ‘the spirit’ of MI should be present right from the point at which the client walks through the door (rather than the provider only thinking within an MI framework when results are being discussed). In other words, the entire consultation should be defined by the understanding that:

  • A non-judgemental style that favours collaboration, evocation and autonomy will offer the best chance of success.
  • Motivation to change is elicited from the client, and not imposed from the outside.
  • It’s the client’s task to resolve their mixed feelings towards their lifestyle behaviours, not the provider’s.
  • The provider is there to encourage this reflection and offer the tools with which the client can generate insights and pursue their own goals.
  • Expressing empathy, affirming self-competence and helping to strategise clients’ next steps are key provider qualities.
       (Insights drawn from Brett Nicholls' MI course manual and training days)

Whilst these elements form the backdrop of a motivational approach, a number of specific strategies and skills are on hand to facilitate a discussion about the client’s personal concerns and potential changes. Ranging from asking open and evocative questions that establish the priorities of the person having the health check, to showing attentive engagement by reframing and reflecting client statements, these and other techniques give MI its signature quality. Despite requiring training and practice, when used well, the basic skills can often have the powerful effect of helping individuals connect with the things that are important to them. Health Diagnostics have produced a digital workbook for any providers seeking more in-depth guidance.

As the name Motivational Interviewing would also suggest, the techniques are particularly well suited to reinforcing a client’s ability to take control of their lifestyle. Whilst the principle of a ‘non-judgemental style’ is regarded as key to exploring and imparting this confidence, it remains the case that making certain judgements may in fact have the effect of encouraging behaviour change. Although resisting negative judgements is essential to the practice of MI, it should be noted that making the assumption that clients have the capacity to achieve their goals can, in itself, influence behavioural outcomes.

Dubbed the ‘Pygmalion effect’, research has found that people may be positively and negatively influenced by the expectations of others. In other words, holding high expectations can positively affect real performance. For the NHS Health Check provider then, preconceived ideas of a certain type may in fact be beneficial. In addition to helping avoid unnecessary resistance and bringing about a constructive conversation, a positive approach that assumes clients have the capacity to change their lifestyles may itself be a factor in bringing about behaviour change.

Whilst maintaining faith in the possibility and benefits of change, the latest research on Evidence-based risk communication also underlines the importance that providers are able to ‘effectively communicate evidence’ on the harms of certain lifestyle behaviours. Working on the principle of patient-centeredness, Health Diagnostics has developed interactive tools with which providers can demonstrate to clients their current cardiovascular risk and the effects that any lifestyle change could have. 

Intuitive icon arrays, ‘heart age’ calculations and simple-to-understand betting probabilities are used to express both ‘current’ and ‘what if you change’ risk scores to the client. What’s more, thanks to these uniquely personal risk calculations, clients are free to draw their own conclusions without providers needing to extol the virtues of a healthy lifestyle. Providers are therefore able to fill the role of supporting and reflecting any concerns, as well as helping to strategise the next steps that clients may be motivated to take.



Whilst this blog offers only a snapshot of how MI is being integrated into Health Diagnostics' systems and training, the principles of behaviour change are at the core of a number of exciting software and service developments. If you'd like to find out more about how Health Diagnostics are advancing and enhancing the NHS Health Check delivery model for local authorities, please contact info@healthdiagnostics.co.uk. To find out more details about MI training opportunities contact brett.nicholls@getberkshireactive.org.

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