NHS Health Check learning resources digitally published online

In a bid to increase access to Health Diagnostics’ library of published materials, a large amount of content has been made digitally available online. The contents of this library can be viewed as online magazines through a range of devices including computers, tablets and phones. Having been closely engaged with reporting on the national programme since its inception, the hope is that these materials will enhance the rich array of free NHS Health Check learning resources available online. So what’s included in Health Diagnostics’ digital library?

NHS Health Check News

The first edition of NHS Health Check News is featured in the library, as will be a forthcoming issue. The newspaper's first issue - released at Public Health England’s February 2014 conference - includes a range of articles that focus on issues such as the latest research and developments in provider competencies. The centerfold features a case study on County Durham’s Check4Life programme and documents how the ‘end-to-end’ solution is being implemented in the North East. Click the title link to view the newspaper.

Example Training Materials

This section features the Motivational Interviewing workbook that’s supplied to providers on training days. The workbook is intended to give guidance and advice on how to encourage constructive lifestyle conversations that promote positive lifestyle change. Whilst Health Diagnostics offer a number of training materials and guides to providers, this workbook is the only example that’s made freely available online for public use. Get in touch to find out more about Health Diagnostics’ range of training resources. Click the title link to view the workbook

NHS Health Check Leadership Forum

This report contains the summary and findings from the first NHS Health Check Leadership Forum. The forum took place during the 2013 Commissioning Show where public health professionals came together to share learning and experience of NHS Health Check programme delivery. An expert panel presented the findings from a range of local projects and public health researchers reported on the early indications from the national evaluation. Click the title link to view the report.

Picture of Health Reports

During 2012 – amid unprecedented changes being made to the commissioning and delivery of NHS services – Health Diagnostics sponsored the production of the Picture of Health reports. This series of three reports and a case study offered clear and comprehensive information on the transition of public health from PCT to local authority control. Produced by Andy Cowper, editor of Health Policy Insight and Achieving Commissioning Excellence, the documents were made up of interviews with experts from around England. They continue to offer unique insights into the commissioning and delivery of NHS Health Checks through local authority. A case study on the North East of England’s service model is included. Click the title link to view the reports and case study.

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.

Published findings from the NHS Health Check Leadership Forum

On 12th June, the first NHS Health Check Leadership Forum took place during the 2013 Commissioning Show. Initial findings from the National Evaluation were announced and discussed by public health experts from around England. Ambassadors from successful programmes also presented on innovative strategies for commissioning, delivery and management of NHS Health Checks. The event was filmed and key findings have been collated as video and PDF thought piece. These are freely available at www.healthdiagnostics.co.uk

The long-term outcomes of the NHS Health Checks have yet to be measured. However, Dr Michael Soljak, Clinical Research Fellow at Imperial College London, kicked off the Forum by presenting encouraging early results from his team’s National Evaluation of the programme. These indicate that uptake has been greater in more deprived areas, suggesting the health checks had been targeted effectively to address those at highest risk from cardiovascular disease, stroke, diabetes, liver or kidney disease. The findings have been accepted for publication in the Journal of Public Health.

The Leadership Forum identified the ‘top five’ factors key to successful provision and uptake of NHS Health Checks:-

1.      Flexibility to fit local needs
2.      Complete quality assurance
3.      Delivery of the check in a single session
4.      A patient-focused IT solution
5.      Seamless data transfer to patient records

Jayne Herring, Public Health Contracts Manager for NHS Tees, explained the need to be flexible and to fit local needs. Tees Public Health has carefully targeted the NHS Health Checks to over 65,000 local individuals, 20,000 of whom were found to be at high risk. Underpinning this project – which has achieved year-on-year DH performance targets – is reliable and efficient IT support. Herring went to lengths to say: “I cannot overestimate the importance of investing in good primary care informatics and IT solutions for the health checks.”

The need for total quality was underlined by panel member Jacqui Deakin, Quality and Health Improvement Lead for Durham County Council. In an article featured in the Guardian on 10th July, Deakin described her team’s approach as a ‘‘non-medical lifestyle intervention’’. Many of County Durham’s NHS Health Checks are carried out in community settings rather than surgeries or hospitals, making the quality of delivery essential if GPs are to trust the data landing on their clinical systems. Deakin also emphasised the importance of, “Doorstep provision, making every contact count (MECC), and offering choice so that individuals feel they ‘own’ their care pathway.”

Julie Evason, Managing Director of Health Diagnostics, drew attention to the advantages of delivering checks in a single session using Point of Care testing, (as opposed to asking patients to return to their GP to collect results). ‘‘Individuals can then be given brief opportunistic advice immediately after they’ve had a pin-prick blood test and received their health check results. This is about maximising every single intervention.’’ Similarly, a software programme which is patient-focused and designed for use during a consultation can enable individuals to conceive of their level of risk easily through the use of intuitive illustrations, graphs and imagery. Evason explained ‘‘Health Diagnostics have tried to incorporate all of these practical features into Health Options®.’’

Recent innovations in paperless data transfer to patient records were also announced. Evason stated, “If we’re not getting the data back, it simply won’t count towards local authority targets,” adding that data should be getting onto clinical systems within a matter of clicks. The paperless approach doesn’t require data to be re-inputted by GP surgery staff, therefore avoiding the potential for human error and reducing administrative costs to practices. Ultimately, it enables those at particularly high risk to be immediately flagged as the data is sent to the patient’s record quickly and securely.

As the Guardian Healthcare Network stated earlier this month, “We don’t need to wait around for technology to improve to meet this challenge, but instead use the technologies available to us now, to leapfrog our way closer to 2018, when Hunt wants the NHS to go paperless.”

Using Motivational Interviewing during NHS Health Checks

Among the most keenly discussed topics at this month’s NHS Health Check Leadership Forum was the need to make every contact count. The approach aims to ensure that NHS Health Check providers maximise every opportunity to talk to individuals about their health. What’s more, meaningful and motivational consultations are essential if the programme is to achieve the impact it promises.

In reality, the process of encouraging individuals to consider behaviour change is a delicate task. However, having constructive conversations can be greatly assisted by practicing certain Motivational Interviewing (MI) techniques. A central idea of MI is that individuals are far more likely to be convinced by their own arguments than those imposed by others. As such, the method looks to elicit an individual's inner motivation to change. Above all, a non-judgemental attitude that facilitates a conversation that’s relevant to the concerns of the person having the health check is essential.

Achieving these objectives is possible through a combination of techniques outlined by Miller and Rollnick in MI-3. However, given the specific circumstances offered during a health check, brief interventions often need to be – as their name would suggest – brief. As such, delivering a 20 minute counselling session is often not possible. The question for health check providers is then, ‘how can we make a difference in the minutes that are available to us?’

In order to provide guidance on precisely this matter, Health Diagnostics have produced a pack of training and consultation materials. These are provided to anyone trained at a Health Diagnostics training day. (See below for image). The pack includes:

• A booklet that condenses the techniques outlined in MI-3 into a framework for approaching NHS Health Check consultations
• A range of Top Tip cards which may be used by practitioners to offer bite-size practical advice on lifestyle choices
• Access to a video demonstrating some of the MI techniques in action

Due to the time pressures during a NHS Health Check, using visual tools as a support is an invaluable way to encourage behaviour change. With this in mind, Health Diagnostics have built a number of tools into Health Options® in order to aid the user in explaining and eliciting information about lifestyle. Targeted use of these tools is covered in the pack materials, as well as being featured in the forthcoming video of the recent NHS Health Check Leadership Forum which was hosted by Health Diagnostics earlier this month.

During the Leadership Forum, a number of topics were examined by public health experts implementing and delivering health checks. The audience and panel discussed many issues, including how to cleverly target the checks, transferring data electronically to the patient’s record, and innovative ways of boosting uptake. The initial findings from the national evaluation were also presented by Dr Michael Soljak, Clinical Research Fellow at Imperial College London.

As a follow up to the event, the findings will be published on www.healthdiagnostics.co.uk as both as a video and PDF thought piece in early July. More details on the panel can be accessed here.

In addition to the aforementioned resources, there are some useful interactive online learning resources provided by the NHS that can be accessed through the professional learning environment.

(above: the Motivational Interviewing pack)