‘Prevention’ continues to grow as a focus of public health policy, seeking to enhance general well-being across a population and to avoid the potential future costs of treatment for avoidable conditions. Here, Chris Keyworth discusses one of the NHS’ flagship prevention initiatives, ‘Making Every Contact Count’.

• Making Every Contact Count has been designed to form a core part of NHS Contracts, but implementation remains challenging
• Research has shown that awareness levels and consistency of practice are commonly-encountered issues
• Wider application of behavioural science strategies can help policymakers with implementation and optimising the benefits of prevention

The public health policy, “Making Every Contact Count” (MECC), states that the prevention of health problems should be at the heart of every NHS patient contact. MECC policy was developed alongside a wide-ranging list of partner organisations including local authorities, Public Health England, the Royal Society for Public Health, the Care Quality Commission and NICE.

Attempts to implement the policy include laying out the principles as part of the NHS standard contract that requires healthcare providers to develop and maintain an organisational plan for MECC-related practice.

All healthcare professionals, regardless of discipline (from primary care staff such as doctors and nurses, to specialist professionals such as anaesthetists and midwives) are advised to, as a minimum, “raise awareness, motivate and signpost people to help them improve their health and wellbeing”. This can include conversations with patients about being more physically active, having a better diet, or helping people to lose weight or to quit smoking. Such conversations, or “brief interventions” can include anything from signposting people to weight loss clinics, or delivering brief interventions to support smoking cessation. Evidence shows that this can be done quickly, in a matter of 30 seconds for weight loss, even in a time-restricted GP consultation.

The challenges of implementing policy in the NHS

Embedding public health policies into clinical practice in the NHS is problematic. We know that implementing NICE guidelines, for example, face considerable challenges including lack of clinician engagement and a lack of clarity about the relevance of policy, a lack of time or resources to implement the policy, or a lack of managerial support.

Policy aimed at encouraging more conversations about healthy lifestyles may pose additional challenges, such as time-restricted consultations and fear of offending patients by discussing potentially sensitive topics. What is less clear about the MECC policy is: (a) whether healthcare professionals at whom the policy is aimed know about it, (b) if healthcare professionals deliver brief interventions in line with the policy, and (c) what helps or hinders conversations about healthy lifestyle and consequently implementation of policy.

Understanding the effect of policy on healthcare professional practice

Our research involved a national survey of 1,387 healthcare professionals working in the NHS, and follow-up interviews with twenty-eight healthcare professionals working across fourteen professional groups.

Findings highlight the challenges of implementing policy within the already heavily burdened NHS, and we outline the strategies that could improve implementation of policy and associated practice.

In terms of awareness and practice consistent with policy:

• There was low awareness of the policy and low levels of reported practice consistent with policy across all healthcare professionals groups; approximately one third of our sample reported having heard of the MECC policy. Even when healthcare professionals perceived that patients would benefit from a behaviour change intervention (approximately 32,946 out of a total 58,906 patients), they “Made Every Contact Count” in just 50.0% of these cases.
• A significant amount of time is already being invested in delivering healthy lifestyle interventions, equating to 35% of total consultation time.
• All healthcare professional groups valued and understood the importance of talking to patients about healthy lifestyle. However discipline-specific tasks were prioritised and healthcare professionals were not given the autonomy to add discussions about lifestyle to their consultations, which meant lifestyle conversations were not given the necessary priority.

How can engagement with policy be improved?

Low awareness of policy, combined with low engagement with practice consistent with policy, is a cause for concern. Policy makers must increase awareness of the “Making Every Contact Count” policy, by specifically ensuring strategies are in place to support healthcare professionals.

Our research suggests four specific strategies will help promote healthcare professionals’ engagement with policy to initiate healthy living conversations:

1. Ensure the environment is right for a conversation about healthy lifestyle (one-to-one settings rather than a busy hospital ward)
2. Focus on patient-specific needs, by identifying patients who would benefit from a discussion about healthy lifestyle
3. Empower healthcare professionals of all disciplines to talk about healthy practices during routine visits in a timely manner
4. Build a rapport with patients to encourage broader health discussions.

These strategies make it easier for any healthcare professional to discuss healthy lifestyle strategies with their patients. Better implementation of public health policy into clinical settings would benefit from drawing upon behavioural science frameworks.

The “Behaviour Change Wheel” (BCW), is being used increasingly in applied health research, by suggesting specific ways of implementing policy. Our findings suggest amongst those strategies is “persuasion” to increase healthcare professionals’ engagement with policy, by making specific changes to guidelines and improvements to service provision. Our study provides specific examples of how implementation of MECC policy can be improved using behavioural science theory. There is potential to improve the design and dissemination of MECC policy by ensuring the needs of all healthcare professionals are met, regardless of discipline. Improved training to support healthcare professionals to talk about healthy lifestyle with their patients, and better support from senior management encouraging greater flexibility to approaches to patient consultations are important steps towards more preventative approaches to healthcare.

National survey (Implementation Science): https://implementationscience.biomedcentral.com/articles/10.1186/s13012-018-0814-x

Interview study (British Journal of Health Psychology): https://onlinelibrary.wiley.com/doi/full/10.1111/bjhp.12368

Video byte: https://vimeo.com/329649809