How do healthcare professionals discuss unhealthy behaviours with patients? An ethnographic analysis of NHS Health Checks in general practice
Over recent years, general practice policymaking in England has increasingly focused on preventative care, and in particular the need to support patients to ‘get serious’ about changing their lifestyles. Policy frequently emphasises the need for healthcare professionals to ‘engage’ patients to make changes to unhealthy behaviours. For instance, best practice guidance for delivery of the NHS Health Check programme recommends strategies such as ‘motivational interviewing’ and other similar behavioural techniques. However, policymakers continue to be concerned at the prevalence of unhealthy behaviours and the burden of disease to which these will lead.
This paper is based on observations of NHS Health Checks and motivational interviewing training, supported by interviews with healthcare professionals and patients, which were conducted as part of an institutional ethnography (Smith 2005) of CVD prevention in general practice. Using institutional ethnography’s theoretical approach to analysing people’s ‘work’, I highlight what happens during Health Checks, focusing on the work of healthcare professionals delivering Health Checks.
I show that, as healthcare professionals worked through the Health Check template, they were organised (through institutional systems which determine the format of the checks) to ask questions about lifestyle behaviours, but to systematically inhibit meaningful discussion of the underlying issues surfaced by these questions; it was healthcare professionals who appeared to ‘disengage’ from patients’ attempts to discuss health concerns. Behavioural techniques such as motivational interviewing were not employed. Interviews with healthcare professionals, and observation of motivational interviewing training, highlighted the challenges of negotiating such interactions with patients and therefore suggest possible explanations for healthcare professionals’ reluctance to employ the technique. Healthcare professionals are required to both ‘open up’ patients’ lives and lifestyles to scrutiny, whilst also placing strict limits on the support they are able to provide, in order to fit the intervention within the constraints of standardised appointment times.The findings presented here challenge dominant narratives that improvements to prevention work should be focused on interventions to ‘engage’ and ‘motivate’ reluctant patients. Using the institutional ethnographic approach to analysis, I suggest that patients’ ‘disengagement’ may, in part, be shaped by the way in which they experience interactions with healthcare professionals. I trace the organisation of healthcare professionals’ apparent lack of interest in patients’ own health concerns to the institutional structures of preventative healthcare — to economic models which determine the length of Health Check appointments, the competencies of staff who routinely deliver them, and the activities which should be included (and omitted).
The interactions produced by current models of preventative care limit the opportunities for healthcare professionals to form constructive relationships with patients, which will support their own attempts to change unhealthy behaviours. GPs involved in developing policy (and other policymakers) should consider the unintended consequences of these recommended models.