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.

New NHS Health Check training videos: service users share their experiences

March 2014 is set to be a significant month for the NHS Health Check campaign, with the release of the JBS 3 cardiovascular prevention guidelines and a series of comprehensive new training videos for providers and service users.

Featuring full-length consultations, the training videos will offer providers an invaluable insight into what best practice looks like in action. The individuals carrying out the checks are all experienced Check4Life providers who’ve been responsible for delivering a consistently high volume of checks for a number of years.

In addition, the materials – which will be freely available on YouTube – will serve as an information source for any member of the general public interested in finding out what having a check is all about.

With the health checks being real as opposed to staged, the videos really capture the impact that effective, non-judgemental consultations can have. Keith and Bruce, two men that received consultations as a part of the project had only positive things to say about their experiences:

Bruce, 40 years old, from Durham, was given a health check by Dawn from John Low’s Medical Centre in Consett, County Durham

Bruce before his first health check five years ago

‘‘It was really interesting. I actually came for a health check five years ago when the scheme was first being introduced and functioned as a bit of a guinea pig for the pharmacists to train on!

The results I got today are phenomenal in comparison to last time. When I came first time around, I was leading a completely different lifestyle to what I am now and it was a real eye-opener when I saw my results. I was drinking a huge amount more than I am now and I was a heavy smoker as well. As a result of the health check, I put a stop to both these habits and began eating a lot healthier.

In short, the health check had an extremely positive impact, so much so that I’ve since been able to complete a number of Ironman challenges and am planning to race seven marathons in seven days across the Sahara this year! I couldn’t even run to the pub five years ago!

Even last time, I remember Dawn being really professional and very non-judgemental in her style. Today was no different, I felt very relaxed and comfortable.

I’d recommend it 100% to others. Five years ago, I thought that I was pretty healthy because my job’s always been fairly active. It turned out that I really wasn’t doing enough though. In fact, because of my lifestyle I was building up real problems for myself. My results today have confirmed that I’ve been able to turn all this around.’’

Bruce in August, 2013

Keith, 55 years old, from Durham, was given a health check by Nicola of County Durham’s Check4Life team:

‘‘From the greeting onwards, I thought the whole thing was really professional. Nicola explained everything really well for me and I understood precisely what was going to happen.

What was quite surprising was how I wasn’t being judged in any way, shape or form. I wasn’t told I was fat, drinking too much or not exercising enough, Nicola just gave me the information and let me make my own judgement about it.

The health check has certainly given me the evidence and incentive to make more changes to my lifestyle.

I’d definitely recommend it to anybody; there’s nothing to be frightened of. Even the finger-stick sample is nothing really. The thing is, it lets us find out how we are because we don’t know what we’re like inside until somebody helps you to see what you are.’’

The training videos will be officially released in March. Keep an eye on this blog for details.

NHS Health Checks in pharmacy: Hillingdon’s high performer

(Rishi Verma from Ruislip Manor pharmacy takes a patient through an NHS Health Check)

The context

In recent weeks, Public Health England (PHE) declared that 15 million NHS Health Checks will be delivered between now and 2018/19. In an article with Pulse, Prof Kevin Fenton, Director of Health and Wellbeing at PHE, stated the opportunity this represents for pharmacy:

‘‘What we’re also seeing as local authorities take up leadership of the programme is that they’re beginning to identify other key partners in the primary care family who can also be a part of health checks. This may involve community pharmacies, particular voluntary or community sector providers who can also be involved in the risk assessment and management activities associated with the community.’’

However, in order for pharmacy to make a meaningful contribution to the programme, a proactive and engaged mind set is key. A common discussion topic amongst those who commission and manage the delivery of the NHS Health Checks has been ‘what level of value can pharmacy bring to a health check delivery network?’

The answer is that it depends entirely on how committed and enthusiastic the pharmacies are. The variation in performance can be wide, however when done well pharmacy carries the potential to be an incredibly valuable weapon in the public health arsenal.

Making it happen in Hillingdon

Of the 20 pharmacies delivering the health checks across the London borough of Hillingdon last financial year, a standout performer was Ruislip Manor pharmacy. The person responsible for driving the CVD assessments is Rishi Verma, the pre registration student at the pharmacy.

Of all the health checks conducted in the pharmacy last year – of which there were well over a hundred – the overwhelming majority were done when Rishi began working in the pharmacy and took it upon himself to champion the health checks.

‘Every interaction is an opportunity’ Rishi explained; ‘delivering the health checks can be really rewarding and they’re great for building patient rapport... Crucially, if you offer someone good care, they’ll keep coming back to you.’

The impact of Rishi taking responsibility for the checks underlines how important strong leadership is at every stage of health check delivery. Regardless of if you're commissioning the service or delivering the checks, the success of the programme depends hugely on energised individuals taking the reins.

‘It’s about creating an atmosphere of positivity and opportunism’ said Rishi. ‘The pharmacy team all got on board and found potential patients in the client group. This gave us a good cohort to target. Additionally however, if anyone comes into the pharmacy and they’re over the age of 40, I let them know that there’s a brilliant scheme to help them find out their risk of developing cardiovascular disease. What surprises a lot of people is if I tell them that the same test done privately could cost the upwards of £80.’

Rishi openly admits that he’s obsessively driven to do the best he can possibly achieve; so much so that he’s taken it upon himself to go round local businesses handing out leaflets during his lunch hour. One particularly motivating factor was identified as a training day that was run by Health Diagnostics last year. ‘We were really enthused by the PCT meeting where the agenda was set and the staff trained’ explained Rishi.

Going forward, Rishi has big ideas for hosting community events in his locality: ‘I’ve even engaged a local library where I’ve been delivering health checks. The libraries have community targets to meet so I said to them that I’d come in and deliver the assessments for a day; all they’ve needed to do is promote the event.’

Having championed the checks at Ruislip Manor and completed a university project on public health which fit closely with the NHS agenda, Rishi has accumulated some valuable learning. For those providers who’d are looking for advice on how to boost your numbers, Rishi has a series of recommendations:

-  Mention it to anyone and everyone that looks eligible

-  Have yourself a ‘pitch’ at the ready

-  Stick your individual pharmacy stamps on the leaflets so that people register your venue as the place to get checked

-  Word of mouth can work wonders. Tell people to inform their loved ones who may be eligible

-  Pharmacies can use MURs to determine eligible clients

-  Maximise any community events that go on in the area. Ruislip pharmacy, for example, do well off the back of the local fun day that runs twice a year where local businesses open up a stall on the main street

If pharmacy is to ‘stand up and be counted’ in the reformed NHS – as Chemist and Druggist put it in an article published in April – this kind of innovative and ambitious approach will need to be exploited by pharmacists everywhere. And with PHE aiming to do 15 million NHS Health Checks, the opportunity is certainly there for those that want to make a name for themselves and their business.

Sanjay Doegar, the pre registration tutor at Ruislip Manor had this to say: 'Rishi's performance in health checks is outstanding and his drive to bring on new services has been exemplary. Through his actions we have successfully taken on the free condom service a key performance target for both prevention of STI and teenage pregnancy. We are also a high performer in the Chlamydia screening service.'

(Rishi Verma and Sanjay Doegar at Ruislip Manor)

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)