“I wouldn’t push that further because I don’t want to lose her”

A multi-perspective qualitative study of behaviour change for long-term conditions in primary care

Presenter: Dr Cheryl Hunter, University of Oxford

Acknowledgements to CHOICE qualitative team:

Dr Susanne Langer, Prof Carolyn Chew-Graham, Ms Alexandra Stenhoff,

Dr Jessica Drinkwater, Prof Else Guthrie, Prof Peter Salmon

Research Context

Was part of 5-year NIHR Programme Grant (CHOICE) investigating

factors involved in unscheduled care use in long-term conditions

Current study: shifted attention to primary care

Aim: to understand how routine consultations influence

patients’ healthcare use over time

Background (1)

•Long-term conditions:

– Prevalent, multi-morbidity common over 50 years old

– Lifestyle and self-care play a key part in determining course of illness

Primary Care has a crucial role in prevention, early intervention, and maintenance of quality of life over the lifecourse

Background (2)

In recognition of primary care’s crucial role, a number of structures are in place to ensure quality of care:

1) Quality and Outcomes Framework

a. Clinical indicators for common conditions

b. Incentivised targets and standards of care

2) Routine screening and review

a. Prevention -- detection and modification of risk factors

b. Monitoring -- slow down/prevent deterioration

c. Communication -- health promotion and behaviour change

Background (3)

Behaviour change and self-management in LTCs

1) Push factors – increasing numbers, greater complexity, reduced budget → primary care can't do everything

2) Pull factors → need engaged patients for successful management, e.g. treatment adherence; evidence that behaviour change can improve outcomes; evidence that behaviour change techniques can work; patients want more patient-centred care

Study Rationale

Routine reviews as site of intervention into patient (self-led and practitioner-led) care

Little known about effect of routine reviews on patient's use of healthcare or their management of illness over time

Multi-perspective approach offers chance to:

Examine divergences and convergences in perspectives

Integrate perspectives to understand review process

Longitudinal element offers chance to:

Explore patient healthcare use over time

Data collection

6 primary care practices 10 healthcare practitioners – 5 GP, 5 practice nurse Mixture of chronic disease clinics and some patient-initiated appointments

Sources of data

No. of Patients 34

Consultations Recorded 29

Patient Baseline Interviews 27

Healthcare Logs 14 completed logs, from 4 patients

Telephone Calls Between 6-15 calls, with 22 patients

Patient Follow-up Interviews 22

No. of Healthcare Practitioners 10

Healthcare Practitioner Interviews 10

Patient Sample

Recruited for four core conditions: asthma, COPD, CHD, diabetes 65 patients approached, 34 were recruited into the study and agreed to audio-recording of their consultations.

Mainly White British (82.4%) 65% male

Age range between 34 and 87 Most with more than one LTC (73.5%; 29.4% had at least two of COPD, CHD, asthma and diabetes)

Analysis (1)

Consultation

Consultation

Consultation

1st Patient interview

1st Patient interview

1st Patient interview

HCP interview

HCP interview

HCP interview

2nd Patient Interview

2nd Patient

Interview

2nd Patient

Interview

Within Case

Acr

oss

ca

se

Integrative Framework Approach (adapted from Ritchie & Spencer, 1994; Salmon, Mendick & Young, 2010)

Analysis (2)

Multi-perspective analysis: Aimed not to privilege one perspective over another Consultation as starting point, framed other interviews and the analysis Identified moments to use in stimulated recall with patients and practitioners Initially explored consultations for:

– Context, focus, any additional issues brought up (and by whom), outcome/s, support discussed or brought up (and by whom), mood discussed or brought up (and by whom), self-management discussed or brought up (and by whom), exacerbations discussed or brought up (and by whom), unscheduled care use discussed or brought up (and by whom), any other issues brought up (and by whom)

How routine review was experienced by patients

1) Practitioner-led and controlled

2) Resource restricted 3) Retrospective and MOT-like – keeping the 'car' aka the body on the go 4) Diffuse sense as 'for the patient's good' but nature of this not determined by the patient 5) Rarely pro-active (occasional examples associated with practitioner expertise and psychosocial issues)

Behaviour Change as a Topic

Analysed consultations for talk around:

1) Smoking cessation (n = 10) 2) Diet (n = 9) 3) Medication use (*how to, not new*) (n = 9) 4) Alcohol use (n = 6) 5) Exercise (n = 4) 6) Self-management strategies (n = 4) 7) Social activity (n = 1) In 27 consultations, instances of each were rare

The rhetoric of health promotion…

Challenge patients’ health beliefs and offer encouragement General Practitioner: “[on smoking] so often patients will give you that

information in the first place. And I acknowledge they’ve given me that. I reinforce what they’re saying and encourage them to do it (… ) if they

say, “Well I don’t think drinking this amount of alcohol has got anything to do with it,” or, “I don’t think smoking’s got anything to do with it,”

then I’ll try and challenge that belief at that time”

Importance of holistic person-centred approach Practice Nurse: “So [the review] gives you that chance to pick away and look at everything as a bit of a whole (…) and try and guide them (…) it’s just about saying, yeah you’re right in thinking that, but what’s stopping

you in doing it (…) trying to get them to take them first few steps”

…vs the realities of practice

Perceived inability to effect change in the available time General Practitioner: “… to start to educate and change behaviour around diet

(…) at a minimum I’d say that that process would take half an hour to focus just on diet. So what could I do in this case [during a 10-minute consultation] (…) I could say, “Here’s an information leaflet or a little booklet,” (…) [it’s] that kind

of sense of despondency in some ways that giving him an information booklet I don’t think is what he probably needs to make those changes”

Poor success of BC weighed against dangers of damaging relationship General Practitioner: “… the success in smoking cessation is in people who want to stop. So unless you can find a way into that psyche, so it's usually when they

get ill unfortunately, it's quite difficult to engage people before they're ill (…) it's a resource issue, isn't it? And plus (…) you lose people if you are too

evangelical, you lose people for other impacts you might have”

Behaviour Change in Reviews – Sam’s case

Sam I’ve started smoking again though GP1 Oh, how many? Sam Oh a big packet of 50 grams will last me over a week, about nine days, eight/nine days. GP1 So it’s a lot then isn’t it? I know you spoke to - [assistant practitioner] mentioned to you didn’t she? Maybe did she? Sam What? GP1 About, [assistant practitioner]’s talked to you about, did she talk to you about smoking or stopping smoking or the? Sam I did stop for two month GP1 Yes and you’ve restarted again? Sam I’ve restarted again GP1 But that’s her area of expertise, helping people to stop Sam I think I’m a lost cause, if I’ve started again after that business GP1 Yeah, and the other thing just to mention just about [diabetes] …

Deflection to other HP

Not clear GP knows history

Deflection to other HP Motivation

unexplored

Back to biomedical agenda

Patient introduces smoking

In the consultation The GP comes across as diffident and fails to follow through on exploring and challenging Sam After the consultation GP talks about gauging motivation but seems to have nowhere else to go when motivation seems low: “…when it came up that he’d started smoking again [I was] just trying to gauge his level of motivation to want to stop which I don’t think was particularly high and he wasn’t taking the bait really”

Over time, Sam remains unmotivated to change and unconvinced change is achievable: “Interviewer: Do you still think there's nothing really that the practice can do? Sam: No. I think it's just a personal, the way you are. It's difficult to change isn't it”

Behaviour Change in Reviews – Sam’s case

From consultation GP2 You’re still smoking? Julia Yeah. GP2 Can’t stop you? No? Julia No, not at the moment. GP2 Not something you want to consider at the moment? Julia Not at the moment, no. GP2 Okay. Blood pressure was good. From GP interview (in response to above): GP2 …. If she doesn't want to change then I don't labour it, I don't see there's any point. I think it's an opportunity to at least highlight what we think might be a problem, and if it clicks anything in her conscious, then we can help her with addressing that… I wouldn't push that further, because I don't want to lose her sort of, her coming, or her compliance with other things.

Behaviour Change in Reviews – Julia’s case

Responding to visual cues? Back to biomedical agenda Trying to avoid loss of compliance

Communication Styles

Deflecting Style – practitioner controls the content of consultation, moves responsibility out of the practitioners' remit or outside the consultation, “next time”; “see the healthcare assistant” Potential impacts – patients socialised that this is not a topic for LTC review, patients left unclear about what to do, patients now responsible for raising topic in future, despite expecting practitioner not to be interested Diffident Style – doesn't explore motivation, moves away from deeper discussion, tentative about the topic, uses time or patient readiness as a reason to avoid discussion Potential impacts – again, patient left unclear, perhaps assuming no help is available or practitioner not interested

Minimisation of Practitioner Responsibility

1) Behaviour Change as Patient Responsibility - the impetus for change has to come from the patient

– “The driving factor, force, has got to be them” (GP) 2) Practitioners limited in what they can do - can give information, “sow a little seed”

– “that kind of despondency in some ways that [giving information] I don't think is what he probably needs to make those changes” (GP)

3) Value of the relationship outweighs value of behaviour change work - fear of damaging the relationship

– “you lose people if you are too evangelical... for other impacts you might have” (GP)

Failure of behaviour change (BC) as self-fulfilling prophecy

Practitioner believes behaviour change too much time/ won't work Behaviour change work not invested in or prioritised Behaviour change not seen as valid or useful in this setting – patient feels responsible Behaviour change rarely achieved in this setting

Original belief reinforced and behaviour change not prioritised

Conclusions

I. Practitioners espouse behavioural change but also offer justifications for not engaging/not being successful

II. In reviews, practitioners are shying away from challenging patients under the guise of:

a. Not damaging concordance (esp. with review attendance)

b. ‘Highlighting’ availability of help/importance of change is a valid intervention

c. Not infringing patient autonomy and right to choose

III. In reviews, (achievable, measurable) biomedical work takes priority

Implications

• Behaviour change in primary care as a ‘self-fulfilling prophecy’ & a missed opportunity

– Tensions in how patients are positioned requires critical attention

Patients as responsible & autonomous but unwilling/unable to engage in behaviour change

Danger that patient choice becomes an excuse

Patients may desire change but lack belief/motivation/skills

• Change needed in the primary care culture

Characterised by target-driven care & fragmentation of diseases/tasks

Need integration and to bring in long-term shared targets as well

Supported behaviour change (motivation work, share responsibility)

Agenda for research?

Transforming routine reviews or looking outside primary care – other models of caring, e.g. house of care, use of prompts/tools/questionnaires in control of patients, re-focusing on public health and community settings? Learning more about context - Exploration of work in primary care -how things are done, underlying theories of implementation Testing behaviour change techniques on practitioner behaviour - How to promote and sustain engagement in various activities, intrinsic versus extrinsic motivation Understanding and exploiting key moments for change - LTCs and 'sweet spots' of openness to change Tying this to longitudinal tracking of behaviour Learning from successful change

Acknowledgements

• This oral presentation presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0707-10162). The views expressed in this presentation are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.

Reference

Also, CHOICE NIHR PGfAR report will be published on: http://www.journalslibrary.nihr.ac.uk/pgfar