NHS LifeCheck: self-care online

Empowering the socially-disadvantaged to manage personal lifestyle change

What measures should be taken to motivate socially disadvantaged individuals to embark on a programme of health-related behaviour change? How can a simple lifestyle quiz promote selfcare and reduce health inequalities? Could a website increase an individual’s capacity for change? How does NHS LifeCheck fit into a health professional’s toolkit and impact on PSA targets without increasing their workload?

Health trainers work with clients to assess their health and lifestyle risks. They have facilitated behaviour change, providing motivation and practical support to individuals in their local communities, since 2006. Users are given tailored advice, top tips and guided to further information and local support

Sometimes it’s good to be ahead of the curve. To be in a position where critics are suggesting something is perhaps too modern, too experimental rather than claiming the government has missed the boat or not seized the opportunity. When the Department of Health launched the interactive website NHS Teen LifeCheck in June, The Times was amused by what it termed the, ‘relentless quest to make health care cool’.

In fact, NHS LifeCheck is a good example of a health innovation.

Four years ago, the government launched a consultation, Your Health, Your Care, Your Say. Those who responded, made it clear that they wanted to take more responsibility for their own health and wellbeing. And three quarters of them identified regular health checks as a top priority to help them to do this. So, rather than making more demands on already stretched health professionals, the commitment made in the subsequent white paper Our Health, Our Care, Our Say , was bold and innovative. Services would be developed initially to enable three key age groups to assess and better manage their own health and wellbeing or that of their baby.

Today, thanks to an intense period of development, testing, evaluation and refinement, members of the public can log on to NHS Baby LifeCheck, for parents and carers of 5–8-month-old babies, and NHS Teen LifeCheck for 12–15-year-olds. NHS Mid-life LifeCheck for 45–60-year-olds

has finished piloting and is being amended ready for a future launch.

Each NHS LifeCheck uses the format of a simple lifestyle questionnaire with multiple choice answers. But within the friendly, easy-to-use quiz lies tremendous potential. Users are given tailored advice, top tips and then guided to further sources of information and local support. The consequences, for those people engaging in or considering risky lifestyle behaviours, are explained in a non-judgemental tone. But is this just the ‘nanny state’ in covert, online form?

The TeenLifeCheck.co.uk results page signposts young people

The role of government in health: NHS LifeCheck as a paradigm case

The government of course has a dilemma. It could just sit back and say that individuals have been given the stark facts about their future health outcomes, and that it is for individuals to decide and determine for themselves what to do about it. On the other hand, it could take the view that health is not just a personal commodity, but a national treasure that is too precious to be left to the vagaries of individual choice. In which case, some would argue, it is for government to intervene, using the force of law if need be.

But there are not just two extreme positions that government can take, namely laissez faire inaction, on the one hand, and nanny state interference on the other. There is a spectrum of interventions and approaches to public health, and it is the area between the two poles which NHS LifeCheck occupies.

In addition to providing useful personalised information, NHS LifeCheck facilitates behaviour change in a positive, helpful way by providing encouragement and support. It doesn’t leave people to sink or swim, but neither does it bully them into a particular course of action.

Users are given tailored advice, top tips and guided to further information and local support

Each version of NHS LifeCheck guides the user to a goal-setting section, focusing on the topic of their choice. They can either choose one of the carefully selected options or type in their own personalised goal.

For example: a first-time parent may elect to replace their eight-month-old baby’s bottle with a feeder cup, or pledge to only smoke outside; a 12-year-old may choose the option that they will tell a teacher about being bullied or that they will try not to skip breakfast; a 51-year-old may decide to choose tomato-based curries instead of cream-based dishes in order to begin losing weight, or to offer to be the designated driver on a Friday night and avoid drinking at the pub.

All of these things are small steps. But they could make a big difference. NHS LifeCheck is about empowering people with achievable goals. It helps them to take charge of their own lifestyle choices in a way that suits them. Providing a user-friendly service is an essential step towards helping people to make the changes in lifestyle that are so critical to improvements in health. NHS LifeCheck is a truly holistic self-care tool.

So NHS LifeCheck is a litmus test of the government’s ability to facilitate behaviour change at both an individual and a population level. But it is not by itself a behaviour change tool. It forms part of a set of tools which also include, for instance, the increased use of effective social marketing, health literacy initiatives 5 , the expert patient programme 6 and the health trainer workforce programme.

Health trainers reach out to people who are in circumstances that put them at a greater risk of poor health. They often come from, or are knowledgeable about, the communities they work with. In most cases, health trainers work from locally based services which offer outreach support from a wide range of local community venues.

Health trainers work with clients to assess their health and lifestyle risks. They have facilitated behaviour change, providing motivation and practical support to individuals in their local communities, since 2006.

NHS LifeCheck and health inequalities

Now it may be that NHS LifeCheck is the type of thing people say they want but it would be of limited value

unless it also helped to achieve a top priority of the government, which is to reduce health inequalities and aspire to Lord Darzi’s vision of ‘high quality care for all’. 7

We know, for example, that it is those who live in the most socially disadvantaged communities and areas who are at the greatest risk of poor health and early death. We also know that many health inequalities are a preventable consequence of the social patterning of the wider determinants of health, the lives people lead and their access to, and use of, services. All of these take place within a social context that leads to a social gradient in health outcomes. Health inequalities may also differ according to ethnicity.

And now, in the midst of a recession, it is even more imperative that we do everything we can to ensure that action on health inequalities is not slowed or downgraded because everyone should have the same chance to lead a long and healthy life. Also by improving people’s health, we can help to maximise their chances of improving their own social and economic circumstances.

We need more than an advertising campaign to raise awareness of NHS LifeCheck ❛ ❛

The design, the language and the marketing of NHS LifeCheck particularly targets the long-term unemployed, those who have never worked, and their children. The ‘pull factor’ is a carefully selected publicity and communications plan using images, slogans and techniques which have researched well with the core audience and that are culturally appropriate.. However, a significant proportion of the people targeted may not pick up the NHS LifeCheck message through the mass media and also have a lower level of home internet access compared with other groups We therefore need more than an advertising campaign to raise awareness of NHS LifeCheck.

This is where the ‘push factor’ comes in. A significant stakeholder engagement plan is underway, presenting NHS LifeCheck to professionals, including the readers of this very publication. The strategy aims to demonstrate how stakeholders such as teachers, health visitors, youth workers and other health and social care professionals could use or recommend NHS LifeCheck in their work with patients, clients and students from disadvantaged groups and areas. Convincing these professionals that NHS LifeCheck can help them meet their individual objectives, without adding extra work, will be essential to the success of the programme.

In order to get a head start on this task, NHS Early Years (as Baby LifeCheck was then known) and Teen LifeCheck were launched initially in 83 of the most deprived local authorities in October 2008 and January 2009. With some financial assistance, many of these areas have embraced the challenge with some dynamic and inventive ways of introducing NHS LifeCheck to the public.

Enthusiastic teenagers at the NHS Teen LifeCheck launch

For example, Sandwell focused on getting the NHS Teen LifeCheck message out through peer mentors at their own local launch. An event at a local secondary school started to spread the word, backed up by advertising on popular internet radio stations with a big regional following. A health information day at West Bromwich Albion’s football ground will give peer mentors from schools across the borough the chance to visit a ‘market place’ to hear about different initiatives and to attend a teen LifeCheck workshop.

In Corby, the challenge of bringing NHS LifeCheck to the rural villages a few miles from the urban centre, has been looked at holistically. The health MOT bus which already visits hard-to-reach areas to offer blood pressure, BMI and smoking cessation advice is being kitted out with computers to enable a core of young single mums to access NHS early years LifeCheck. A publicity campaign is planned in the villages the bus will visit and trainers will be on hand to facilitate if necessary.

NHS LifeCheck and the self-regulation of health-related behaviour

NHS LifeCheck aside, the formation of new networks across PCTs, local authorities and schools has been enormously beneficial. A children and young people’s lead from Camden described how, ‘NHS LifeCheck gave everything a home. It was like an umbrella which has all of our health improvement projects underneath.’ In short, NHS LifeCheck has got people talking to one another. This is reminiscent of the impact that some of those who took part in the expert patient programme had on their local communities 8 and demonstrates that the principles of self-management of long-term conditions, on the one hand, and the principles that underlie the self-regulation of health-related behaviour, on the other, are very similar. 9, 10 These in turn have much in common with the techniques of cognitive behavioural therapy initially developed to help those with common mental health problems and now in widespread use. 11

Understanding one’s health is essential if one wishes to improve it

It is very easy to criticise NHS LifeCheck by picking out imperfections but at this early stage, the flexibility of developing a service of this kind is invaluable. Questions can be added, changed or included. Responses can be rewritten to counter unforeseen misunderstandings. Online advice can be amended according to the latest evidence and research without the fear that thousands of incorrect printed leaflets are stacked on shelves around the country.

Using an intelligent system, NHS LifeChecks will very soon be able to signpost users to the local sexual health clinic, drugs advisor or Sure Start centre, based on the submission of the first four digits of a postcode or by selecting a local area. In this way, NHS LifeCheck will help us to judge whether or not our public health delivery systems are fit for purpose.

It is in fact NHS LifeCheck’s capacity to confront the cold realities of the world out there that will be the acid test for this programme, and all such programmes, no matter how well conceived they might be in theory. If, as we hope, it does work at ground level, then we will have won half the battle because understanding one’s health is essential if one wishes to improve it.

www.nhs.uk/lifecheck

NHS Baby LifeCheck

Launched nationally in August 2009 Aimed at parents and carers of 5–8 month old babies

Topics: development, playing and talking, feeding, healthy teeth, sleep routine, immunisation, safety, being a parent.

Includes: advice, topic-related videos, top tips, goal-setting and further information and support

Relevant strategy/policy: The Healthy Child Programme

NHS Teen LifeCheck

Launched nationally in June 2009 Aimed at 12–15-year-olds

Topics: being active, healthy eating, drugs and solvents, alcohol, safe sex, being healthy, smoking, feelings about yourself, feelings about school, bullying, self-esteem, home life, personal safety, crime, someone to talk to.

Includes: video text narration, topic-related videos, top tips, goal-setting, local and national links.

Relevant strategy/policy: Healthy lives, Brighter Futures; National Healthy Schools Programme.

NHS Mid-life LifeCheck

National launch planned for end of 2009 Aimed at 45–60-year-olds (may expand to 40–70)

Topics: physical activity, healthy eating, smoking, alcohol, emotional well-being, weight.

Includes: BMI calculator, goal-setting section including calendar and planner, simple interactive games to deliver topic information, on-screen video ‘doctor’ explaining confusing terms or definitions, local and national links, optional motivational emails.

Relevant strategy/policy: obesity; alcohol, drugs and tobacco; physical activity; sexual health; cancer screening; health and wellbeing; nutrition; health inequalities; mental health; carers; cardio-vascular.

This Paper was presented at conference ‘Legislation or Persuasion? Behaviour Change and the Successful Delivery of Health Outcomes.’ London, July 2008.

References

1 The Times and The Times Online, 11 June 2009. 2 Department of Health. Your Health, Your Care, Your Say consultation, 2005. 3 Department of Health. Our health, our care, our say: a new direction for community services. London: DH, 2006. 4 Department of Health. Developing the NHS LifeCheck: a summary of the evidence base. London: DH, 2008. 5 Department of Health. Health inequalities: progress and next steps. London: DH, 2008. 6 National Primary Care Research and Development Centre. National Evaluation of the Pilot Phase of the Expert Patients. Programme –final report. Publisher - NPCRDC? 2006. 7 Department of Health. High Quality Care for All. London: DH, 2008. 8 Gupta S. The expert patient programme. A challenge and an opportunity. Proceedings of ‘Guiding us forward: The national chronic condition self-management conference 12–14 November 2003, Melbourne, Australia. 9 Gupta S. Full engagement in health (letter). BMJ 2005; 330: 255. 10 Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Identifying effective change techniques in interventions designed to promote physical activity and healthy eating: a meta-analysis and meta-regression. Health Psychology, in press. 11 Gupta S, Umarji M. Behaviour change and social marketing.

Authors

Maria Reeves - NHS LifeCheck, Department of Health, England

I joined the NHS LifeCheck team at the end of 2008, with a brief to use my experience in communicating with hard-to-engage groups to help shape each NHS LifeCheck product and subsequent media campaigns. I started my career as a journalist before moving into marketing and communications. Before working on NHS LifeCheck, I spent four years specialising in adoption and fostering in Kingston upon Thames, developing and instigating strategies for communicating with children and adults.

Dr Sunjai Gupta - Deputy Director, Head of Public Health Strategy and Social Marketing Branch Health Improvement and Protection Directorate, Department of Health, England

As head of the public health strategy and social marketing branch at the Department of Health and part-time consultant psychiatrist at the Maudsley Hospital, I am greatly interested in the point where the two roles meet – namely the development of health improvement initiatives that involve a partnership between the public and patients on the one hand and health professionals on the other. I chaired the implementation group for the Expert Patient Programme, and have been involved in several White papers on public health. I am keen to see how elements of cognitive behaviour therapy and social marketing may be used by the government in creating formative tools, such as NHS LifeCheck, which facilitate behaviour change. Sunjai Gupta