Featured on the NHS England website, as well as a requirement of the NHS standard contract and with its own Facebook group, Making Every Contact Count (MECC) is an ‘evidence-based approach to improving people’s health and wellbeing by helping them change their behaviour’ (NHS England, 2016).
The NHS contract states under Service Condition 8.6: ‘The Provider must develop and maintain an organisational plan to ensure that Staff use every contact that they have with Service Users and the public as an opportunity to maintain or improve health and wellbeing, in accordance with the principles and using the tools comprised in Making Every Contact Count Guidance’.
MECC guidance
This comprises a number of documents on behaviour change – everything from general approaches through adult weight management to stop smoking interventions. We’re interested in ‘behaviour change individual approaches’ – which links to National Institute for Health and Care Excellence (NICE) public health guidance 49 (NICE, 2014). This document deals in detail with a wide range of individual approaches and makes a number of recommendations as to who should take action.
Recommendation 9 identifies ‘Commissioners and providers of behaviour change services in health, local authority and voluntary sector organisations; trained behaviour change practitioners; staff working in health, wellbeing and social care services who have contact with the general public’.
Perception and practice
Given the weight of words alluded to, it would be natural to assume MECC should be working well among health professionals. However, a 2017 study by researchers at the University of Manchester suggested otherwise (Keyworth et al, 2018). They found that, while 31% of health professionals had heard of the MECC policy and 55.9% perceived a need among their patients, they did not deliver interventions on 50% of occasions in which they perceived a need. Further research into delivering behaviour change interventions was undertaken by the same team and the results published in 2020 (Keyworth et al, 2020a). The patient-facing health professionals included in this review only gave GPs, nurses and midwives as examples – not a comprehensive list of roles. Different themes were identified as below.
Barriers and enablers to delivering behaviour change interventions
Included under this heading were, for example, that ‘healthcare professionals perceived they lacked the skills or knowledge of the available resources to help facilitate behaviour change’, while, conversely, some ‘healthcare professionals perceived having the right skillset to deliver behaviour change interventions as an important enabler to professional practice’.
While some health professionals ‘highlighted the healthcare professional role as being a barrier to delivering behaviour change interventions, reviews in relation to pharmacists, GPs, midwives, and nurses all reported that healthcare professionals held positive views about the importance of behaviour change interventions within their role’. There was emphasis on the importance of having ‘access to appropriate resources and/or support from colleagues as an enabler to delivering behaviour change interventions’ and in some cases health professionals’ own health behaviour was perceived as a barrier to conveying information to patients about health behaviour: ‘Healthcare professionals who smoked themselves believed this could act as a barrier to delivering smoking cessation advice to their patients’.
Unique barriers to delivering behaviour change interventions
In some cases, there was a perceived lack of time to deliver behaviour change interventions and ‘a lack of prioritisation, both personally and in relation to the ethos of the organisation in which healthcare professionals worked, in relation to delivering behaviour change interventions’.
There were negative attitudes about the benefits of, for example, physical activity interventions and more generally towards the benefits of behaviour change on patients’ health – which affected the likelihood of delivering interventions. Generally, healthcare professionals were pessimistic about patients’ abilities and desire to change their health behaviour, which consequently affected the likelihood of delivering interventions.
Unique enablers to delivering behaviour change interventions
Appropriate training was perceived as an enabler, as were ‘having the time to deliver interventions’, ‘working in an environment perceived to be conducive to delivering interventions’ and ‘having an organisational system to support delivery of behaviour change interventions’.
Among primary care professionals, positive attitudes towards physical activity enhanced physical activity promotion practices and it was found that nurses’ attitudes towards delivering smoking cessation interventions were positively associated with their professional practice. The researchers suggested two key areas to be targeted for future interventions:
- Address health professionals’ perceptions about patient need for behaviour change interventions, and to facilitate health professionals to identify opportunities to deliver interventions during routine practice
- Provide training to address the barriers identified in this review across diverse professional groups.
They concluded that widening the scope of consultations and considering patients more broadly could mean focusing on prevention and the management of health conditions.
Patients’ views on opportunistic advice
A study in 2020 explored the views of patients of being offered behaviour change advice as part of a routine consultation in a general practice setting (Keyworth et al, 2020b).
The findings were summarised in an article on the National Institute for Health Research (NIHR) as follows:
- People are generally positive about GPs offering behaviour change advice as part of routine consultations in general practice
- Behaviour change advice is seen as a sensitive topic, but people think a good doctor–patient relationship can encourage these conversations and they saw doctors as appropriate people to give the advice
- Specific information that is relevant to the patient’s condition and tailored to them personally is more useful than general advice.
Also, ‘Overall, GPs were seen as trusted and positive role models. Behaviour change messages from GPs carried more weight than the same messages from other sources’.
Alcohol advice
Another study in 2020 looked specifically at patients’ views on alcohol screening and brief advice in routine primary healthcare (O’Donnell et al, 2020). Interviews were conducted with 22 primary care patients who had been screened for heavy drinking and/or received brief alcohol advice. It was found that patients were happy to discuss the topic with their clinician – compared to family or friends, GPs and nurses provided impartiality, appropriate skills and expertise and knowledge of specialist services.
The researchers concluded that, although alcohol is a sensitive topic to raise in consultations, [health professionals] ‘should be reassured that for many patients, such conversations are unlikely to cause offence’. However, they say it is clear that messages about alcohol-related risk are failing to filter through to patients in terms of changing views or relevant health behaviour.
They also suggested that the advice given should reflect how individuals actually drink and use strategies that patients already commonly use themselves, such as self-regulation.
MECC resources
There are several MECC resources to make use of:
- Public Health England has a menu of preventive interventions covering alcohol, tobacco and more. It is aimed at a broad audience and you’ll need to select information relevant to your circumstances
- The Royal Society for Public Health (RSPH) offers ‘impact pathways for everyday interactions’. These support health professionals to record their interactions (using MECC principles) with individuals and possible impacts. The 11 topics covered include adult obesity and physical activity
- There is a MECC e-learning programme from ‘elearning for healthcare’ (elfh) via the Health Education England website. The three sessions and optional Five Ways to Wellbeing are free if you do not require a certificate
- A number of areas have websites dedicated to their MECC programmes – e.g. Birmingham, Wessex, Coventry and more. Healthy Conversation Skills is joint initiative in Leicestershire between NHS Trusts and County/City Councils. Its training offer ‘allows staff to help people address their own health and wellbeing’. Subjects covered include MECC Healthy Conversation Skills Training, MECC Lite Training and Vaccine Confidence.
Conclusions
While commentators can speak as many as 400 words in a minute, the average rate for English speakers (albeit in the USA) is about 150. That suggests a 30-second MECC intervention will comprise around 75 words – not all of them yours, assuming the patient responds. In other words, as the title of this article makes clear, brevity is essential.
Before launching into brief interventions with patients (whether or not you have undertaken training as referred to above), it is probably wise to practice with (willing) colleagues, friends or family members. Once you have embarked on the brief interventions journey, sharing your experiences with colleagues should help you and them refine the processes. Thanks to the research highlighted here, you can be assured your patients are very likely to welcome your interventions.
Finally, a quote from Mary Codling, Primary Healthcare Lead Nurse for Learning Disabilities at NHS England, who is interested in communication within healthcare consultations:
‘Patients do feel the difference. They notice when they feel listened to and there’s eye contact – rather than the clinician being on the computer the whole time’ (NIHR, 2021).