Primary care is the ideal place to offer lifestyle and mental health advice; millions of people visit every month. The briefest of conversations can make a difference. New research from the NIHR offers advice to staff on how to maximise the impact of each encounter.
GPs and nurses can be reassured that individuals value their advice; no topic need be avoided. Personalised information, inclusion of key details early on, and open-ended questions can make these brief exchanges even more effective.
“I was surprised that there is any doubt about whether or not healthcare professionals should have these conversations. They definitely should. Primary care is the perfect place for this.’’ - Fabiana Mariscotti, public contributor
“Every consultation is an opportunity. Whilst we should deal with the presenting problem, it is important to also consider the patient’s other problems and take the opportunity to offer advice about how to stay well. ’’ - Carolyn Chew-Graham, GP
Public health issues such as obesity, smoking, alcohol, and mental health are complex and affect a significant proportion of the population. Primary care consultations - often for unrelated reasons - can provide a golden opportunity to address such issues.
Long-standing guidance encourages healthcare professionals to offer opportunistic advice, in as little as 30 seconds. But research suggests that these conversations often do not happen. Tackling sensitive issues can be challenging and might require training. Primary care staff may fear that the discussion could be time-consuming, and could upset patients. They may believe that patients are not open to advice.
Research funded by the NIHR provides insights into patients’ views on GP advice, and reveals how to optimise these conversations. It shows that people welcome advice on weight, alcohol, and smoking. They prefer tailored, individualised information. Conversations on alcohol, for example, should explore people’s reasons for drinking, build on the strategies they already use to limit it, and include information on the long-term health risks.
People with obesity are more likely to accept a referral to a weight management programme if healthcare staff use key phrases early in the conversation. The briefest description of a programme - that it is ‘like Slimming World’, it is local and free of charge for 12 sessions - can result in more acceptances.
Open-ended questions are important when asking about self-harm and suicide. It is important to ask about each separately and to encourage people to expand on ambiguous responses. Language that may add to feelings of shame is unhelpful.
This research can reassure healthcare professionals that no topic need be a no-go zone. Individualised tips, inclusion of key details early on, and open-ended questioning can lead to more successful exchanges. Brief conversations have great potential to improve health and wellbeing.
Read the Alerts (research summaries) included in this Collection:
1. Most patients welcome advice from GPs on changing their behaviour to improve health
2. Alcohol advice needs to address how and why people drink, not just how much3. Specific phrases about weight management programmes help GPs make successful referrals4. GPs may help people at risk of self-harm by asking open questions, acknowledging distress, and exploring positive reasons for staying alive
“Every consultation is an opportunity. Whilst we should deal with the presenting problem, it is important to also consider the patient’s other problems and take the opportunity to offer advice about how to stay well. This is the exceptional potential of each consultation. We talk about it in the RCGP curriculum. But these ‘health promotion’ conversations may not always happen: it varies by practice and healthcare professional. Consultations are often transactional: especially so with remote consulting. And you can see it in waiting rooms - there are posters that say ‘one problem per consultation’.
Good rapport is key
When you have an established relationship with your patient, it’s easier to start these conversations. Continuity of care is important, as you can discuss general wellbeing and advice about lifestyle over a series of appointments. If a patient is presenting with one problem, you can link your questions to their current problem. For example, for a patient with a respiratory infection who is a smoker, you can ask, “have you thought about whether your smoking might be affecting this?” Or, if a person has osteoarthritis and is overweight, you can ask if they’ve thought about wanting help with weight management. Establishing rapport in any consultation is key, especially when a person is distressed and there is a need to explore risk. Learning how to ask sensitively about self-harm and suicide is vital for all primary care clinicians.
Missed conversations are missed opportunities
The COVID-19 pandemic has changed general practice. Fewer people are coming in, and we are consulting remotely – mostly by telephone, sometimes video, and increasingly responding to online queries. If you’re speaking to a new patient on the telephone, you can’t see them. You can’t tell what size they are, and it can be trickier to have conversations about weight. If you’re asking about self-harm or thoughts of suicide, you can’t pick up on visual cues: people looking away, avoiding eye contact, or crying. You can’t see if someone is looking uncomfortable or hesitating. It can be easier for the clinician to avoid opening up these conversations when it’s a remote appointment.
But missed conversations are missed opportunities. These moments can have a big impact. Long term, we’d have a healthier population. It’s also gratifying for healthcare professionals when our consultations go well: seeing that your patient who used to smoke 20 cigarettes a day has stopped, or your patient who used to drink six bottles of wine a week has cut down to just weekends.
The messages in all these papers should resonate with GPs. It’s important to know that patients are receptive to discussing sensitive topics, and may actually be expecting to have these conversations. All these studies emphasise the importance of qualitative research in being able to explore what people or patients find acceptable, and should influence our practice.’’
Carolyn is GP Principal at The Chorlton Family Practice, Manchester. She is also Professor of General Practice Research, and Co-lead of the Mental Health and Wellbeing Research theme, at Keele University. She is interested in the primary care management of people with anxiety, depression, and multiple long-term conditions. She has expertise in qualitative research, focussing on answering questions that are important to patients, their families, and healthcare professionals.
“It’s all about understanding the root cause of the problem for each individual, and why people do what they do. For example, someone with obesity might also have fibromyalgia. Their habits might be linked to their pain. They may not be able to move around much, and end up spending a lot of time sitting around and eating. Open-ended questions work well, such as simply asking, ‘I’d like to be able to help you with this, is there anything I can do?’
Extra training in communication and behaviour change techniques would be useful. 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. Behaviour change plans should be personalised ‘shared agreements’ between patient and professional. The best plans allow patients to monitor their own progress, and reflect on what is or isn’t working.
Practices should ask patients what they want. There may be interest in a support group - perhaps outside of normal practice hours, in the evening. Listening to each other's problems, and agreeing to tackle issues together, can help. If patients want someone to speak to, practices could look at employing a counsellor. It’s helpful to have other professionals on site to refer to. There might not be enough time to unravel everything in a short appointment, but you can refer someone to a dietician or a counsellor to continue the discussion.
Nobody likes to talk about these issues
Encouragement to have these conversations has fallen aside this past year, with the added pressures of the pandemic. But in some ways virtual consultations can be better. Patients are in their own homes, in a comfortable environment. They are not anxious about being in a new place or a busy waiting room. Their behaviour can be different, they may feel more relaxed and willing to be open. Consultations might feel more focused and confidential, without the distractions of a busy practice environment.
Everybody is aware of these issues, but nobody likes to talk about them. Mental health issues are known to be common in teenagers, but the topic of self-harm is rarely approached. Some patients may try to hide the signs, for example with long sleeves. But if they come in for a blood test and roll up their sleeves, you can spot it. It’s an important opportunity. Once you’ve asked, it gives them the chance to be heard. These conversations can make a difference. It’s a chance to ask, and to provide patients with useful tools that they can use to help themselves.’’
Mary is Primary Healthcare Lead Nurse for Learning Disabilities at NHS England. She is interested in communication within healthcare consultations, and has expertise in developing training for healthcare professionals.
Public contributor comment
“I think these health issues are important and should be covered by GPs and healthcare professionals more often. However, it should be done in a planned manner. A good relationship needs to have already been established with the patient, and it needs to be conducted based on motivational interviewing skills, for which training is likely required. The conversation should be a continual process over a period of time, preferably with goals agreed with the patient.’’
Emily is a public contributor and formerly a nurse.
Public contributor comment
“I was surprised that there is any doubt about whether or not healthcare professionals should have these conversations. They definitely should. Primary care is the perfect place for this. Many non-communicable diseases might result from lifestyle choices such as diet, physical activity, smoking, drinking, or substance abuse.
Ideally, these conversations should be happening before people are seriously ill. It should be all about prevention, so people can get it right before the issue gets out of control.
These conversations could trigger the change at the right time or, even if someone isn’t ready to change then, the seed is sown and it could leave them thinking. Often you go to the GP because of a health scare, so it might be the perfect moment to make that change.
The advice still lives with me
When I first came to the UK, I was feeling quite low during the winter. I had a chat with my GP and she suggested I try to go for a daily run or a walk. That advice still lives with me, if I’m feeling low I’ll go for a walk or a run and feel better afterward.
It doesn’t matter if it is a Doctor, a Nurse, or what their title is, as long as they are a good role model and you respect them. It is key to have a good rapport, usually built around continuity of care, and feel comfortable to discuss your problems. I have been with my GP for quite some time now, and I trust her advice.
Advice must be relevant to me
The tone of voice is important. Advice shouldn’t sound patronising, or like you’re being lectured. General advice doesn’t work, it needs to be personalised - it must suit my lifestyle, and be relevant to me. You need to feel like the professional is really engaging with your problem and putting themselves in your shoes.
I am aware that time is a big issue in the consultation. For example, I would like more conversations about nutrition. I love cooking for family and friends, but I’m not always sure about the nutritional aspects. I wish there was tailored nutritional support or advice to rely on. Doctors or nurses are busy and in the short allocated time, the priority is to solve the problem at hand. Primary care professionals need to create an environment where it feels like there is enough time to discuss issues. That way, I think the GPs or nurses could take a more holistic view of the person.
These conversations are really important and should be happening regularly. Prevention is key - we need to start teaching healthy lifestyles early, to create healthy habits, before we become too ill that the issue is unmanageable.’’
Fabiana is a public contributor. She is a mum of three boys, based in Cambridge. She has recently finished a master's (MSc) in psychology and is volunteering as a research assistant. She has a special interest in mindfulness and behaviour change.