Communicating CVD risk: face-to-face contact and the NHS Health Check

The current context

In Public Health England’s latest NHS Health Check Programme Standards, published in December 2017, the question of risk communication is addressed in unambiguous terms. Despite the clear emphasis that these standards place on communicating risk in a face-to-face format, the team at Health Diagnostics have, over the years, encountered providers employing a varying array of working methods, some of which deviate substantially from PHE’s guidance. This article is concerned with the underlying reasons as to why face-to-face communication is central to the NHS Health Check, whilst also acknowledging the pressures on providers to work within time-constraints and other practical limitations. Looking forward, we’ll also consider the ways in which digital tools may be able to facilitate risk communication at a distance, notwithstanding the fact that removing the physical presence of the person conducting the health check does carry with it inevitable and perhaps unavoidable consequences for any conversation around behaviour change.

Section 6 on page 21 of PHE’s Programme Standards document is worth quoting at length given the clarity it provides on this topic and the extent to which it offers a foundation for the reasoning contained within this article:

“All individuals who undergo a NHS Health Check must have their cardiovascular risk score calculated using QRisk2 and explained in such a way that they can understand it. This communication should be face to face.

Staff delivering the NHS Health Check should be trained appropriately in communicating, capturing and recording the risk score and results, and understand the variables the risk calculators use to equate the risk […]

Individuals receiving a NHS Health Check should be given adequate time to ask questions and obtain further information about their risk and results.”

In spite of the explicit reference to the fact that communication “should” be face-to-face, instances have been observed of providers frequently giving this communication over the telephone. In fact, one general practice that Health Diagnostics colleagues were recently in contact with confirmed that the method they employ was only to send a letter to the individual communicating the results of their health check. For reasons that will be elaborated on below, this latter approach represents something significantly worse from a quality perspective. Yet, at the same time, for practices conducting path lab bloods (rather than point-of-care testing), the prospect of committing the resource to conduct two separate appointments (as would often need to be the case; one to complete the health check and another to communicate risk face-to-face once the results are in), is argued by some to be prohibitively onerous. What then is there to say in favour of the counter-argument? What are the key reasons why PHE say that it “should” be the case that consultations occur between two people, both of whom are present in the same room at the same time?

Why the emphasis on face-to-face communication?

According to Albert Mehrabian’s 1971 book, Silent Messages, 93% of what we communicate is non-verbal (55% of this is said to rest on body language, whilst 38% is argued to be attributable to the tone of voice). As a result, only 7% of what we say is, Mehrabian argues, actually communicated by the words we use. Whilst it’s important to note that these figures have been disputed by various individuals over the years, the thrust of the argument – that a huge amount of what we communicate is non-verbal – remains very widely accepted within the domain of psychology and beyond (regardless of whether or not critics agree with Mehrabian’s proportional breakdown). The implications of Mehrabian’s research for the question of face-to-face risk communication vs other methods is stark; if you choose to offer results over the telephone, you may be missing out on over half of the person’s communicated response. If results are sent by letter, the feedback that a provider receives may be almost non-existent. Only when sitting in the presence of another person are we able, the research suggests, to be wholly receptive to that person, their priorities and their mixed feelings about lifestyle change.

For individuals with low levels of self-efficacy (i.e. confidence in their ability to change), the stakes are especially high. When working with such individuals, a vital imperative is to provide a supportive space for the person to learn about their CVD risk and consider the factors contributing to their results. It is also likely to be particularly important that the person’s ambivalence about change is explored and that their options for support are clearly understood. The only way in which these objectives can be meaningfully achieved is through dialogue; as PHE’s guidance states in black and white, the individual “should be given adequate time to ask questions and obtain further information”. On perhaps the most fundamental level, it is for those people that don’t perceive themselves as possessing the internal resources to pursue a different path that face-to-face contact can prove invaluable. Indeed it may be the first time that someone has simply sat with that person, revealed something of their inner workings, shared the experience of perhaps hearing some alarming results, and reinforced the fact that they may not need to take change on by themselves, assuming that family, friends and/or local support groups are available, as often they are.

Finally, face-to-face communication in which CVD risk results are shared in a variety of formats – be that using numeric, visual or any other form of representation – is really the only way that providers can be completely confident that they are making every one of their contacts count. In other words, direct contact offers a uniquely reliable way for providers to convey results and ensure that they’re fully understood. This requirement to create digital tools that providers can use to demonstrate risk results in a variety of ways is precisely where Health Diagnostics have, for a number of years, placed a particular emphasis. The dynamic and visual displays that are such a feature of Health Options® software and which providers can use to develop meaningful change plans with people have been harnessed to extremely good effect on projects across the country. On one project in the North East, 8/10 of primary care staff surveyed stated that Health Options® was more effective for communicating CVD risk than any system they’d previously used. From the perspective of the person having the health check, 99.9% would recommend one to others (based on 1054 surveys).

The impact of digital technologies on the evolving National Programme

Whilst the message thus far does point to face-to-face contact as being the primary method of ensuring quality of delivery, it is nevertheless the case that certain providers do experience significant challenges in achieving this and are forced to communicate by alternative methods. The question is therefore raised, what can digital technology bring to the table to help support these providers? My Well Record, a secure online portal where individuals can access their results providing they’ve had a health check using Health Diagnostics’ systems, may provide a solution. Designed for ease of use and complete with engaging risk displays, people routinely use the website to access all their results after their health check and determine how behaviour change could tangibly affect their health. In addition, the full suite of national One You resources may be accessed via the site. To date, the tool has so far been extremely well received, with 93% of those using the site and leaving feedback recording the most satisfied option available.

It is this very tool, readily accessible from clients’ homes, that providers could combine with a call to facilitate a meaningful and interactive risk communication session, albeit one conducted at a distance using the phone and My Well Record simultaneously. Whilst this model would inevitably still mean that much non-verbal communication is missed, the fact that it would allow for a two-way discussion and for the client to thoroughly grasp their CVD risk, may ultimately justify its deployment as a significant improvement on some of the poorer alternatives. In conclusion then, whilst Health Diagnostics would always advocate face-to-face risk communication as the gold standard of NHS Health Check service delivery, should general practices and providers not have the resources to practically achieve this, new technologies such as My Well Record may be appropriated to supply a pragmatic fall-back option. It is vital to bear in mind however that such technologies, innovative and ambitious as they are, will always struggle to match the power of establishing “a professional relationship where the individual’s values and beliefs are identified and incorporated into a client-centred plan to achieve sustainable health improvement”, as PHE coin it in the latest Programme Standards. It is precisely this kind of relationship that face-to-face contact can prove such an important foundation for.