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GP motivational chats 'fail to improve patient lifestyles'

GPs trained in motivational techniques are no better at getting their patients to adopt healthier habits, compared with those who have not, claim UK researchers.

The research found that patients were no more likely to achieve improvements in terms of alcohol, smoking, diet or exercise if they received advice from a GP or nurse who had received specialised counselling training.

The findings come as the Government continues to emphasise GPs’ role in stemming the growing tide of chronic disease by counselling patients on lifestyle.

The study, published in the BMJ earlier this month, included 1,827 patients, recruited by their GPs at 27 general practices, who had at least one of ‘risky behaviour’, such as smoking, drinking too much, unhealthy eating or an inactive lifestyle.

GPs and nurses in half the practices received a behaviour change counselling training programme - called Talking Lifestyle - and the remainder gave patients usual GP care.

The primary outcome was a composite measure of patient-reported changes, defined as a 20% decrease in the alcohol use disorders identification test (AUDIT)-C score of alcohol intake, the number of cigarettes smoked per day and the dietary fat subscore of the DINE (dietary instrument for nutrition evaluation) and an increase of 120 metabolic equivalent minutes per week in the IPAQ (international physical activity questionnaire) score.

Results at three months after the consultation showed that a successful change in one or more behaviours was achieved by 43.6% of the patients in the trained clinicians’ group compared with 40.6% of patients in the control group, a difference that was not statistically significant.

Similar results were seen at 12 months, with no significant difference between groups in patients’ success rates, although the authors note that greater absolute increases in IPAQ score for physical activity and DINE healthy eating score were seen in the intervention group.

More of the patients in the trained group than the control group reported being engaged about one of the behaviours (91% versus 55%) and that they intended to change their behaviour (72% versus 49%). Furthermore, they were 1.4 times as likely to report both trying to change and making a lasting change to one or more risky behaviour.

However, while re-analysing the primary outcome for those patients who reported having relevant discussions with their clinician favoured the trained group slightly more, the difference was still not statistically robust.

There were no improvements with the intervention in hip to waist ratio or body mass index measurements taken at the 12-month follow-up, nor in blood pressure or cotinine levels.

‘Lasting behaviour change and improvements on biochemical and biometric measures are unlikely after a single routine consultation with a clinician trained in behaviour change counselling without additional intervention,’ concluded the authors.

NICE recently advised that GPs should screen all adults for their exercise levels, while QOF indicators on brief interventions for alcohol use are currently being piloted and the new NHS constitution is set to mandate GPs to deliver lifestyle advice at every consultation under the ‘make every contact count’ initiative.

Co-investigator Professor Paul Kinnersley, director of teaching at the Cochrane Institute of Primary Care and Public Health at Cardiff University and a part-time GP in Llanedeyrn, Cardiff, admitted they had failed to demonstrate any meaningful lifestyle changes, but that patients were more engaged if their GP or nurse had the training.

He told Pulse: ‘The skills-based approach we have developed could be used by GPs and nurses in their routine consultations. It would enable them to target the behaviour change counselling to those patients who seem most motivated - or for whom there is greatest clinical need – and to re-enforce the message and provide further support at subsequent consultations.’

Scottish GPC deputy chair Dr John Buist said that more follow-ups with patients would ‘undoubtedly’ lead to better results with the intervention, but questioned how many patients would come back specifically for this.

He said: ‘You have to choose the right time to get these messages across, the patient needs to be in listening mode – so smoking when they have a chest infection, weight when their knees are hurting because of obesity, alcohol when they get heartburn etc.’

Dr Buist added that offering advice at every contact is ‘inappropriate and a waste of resources’, and that such counselling would be better given by specialised healthcare professionals with sufficient time to spend on it.

Rather than delivering lifestyle changes through the QOF, he would prefer to have the resources to employ more staff or have attached staff offering healthy lifestyle interventions, he said.

Dr Rachel Pryke, GP in Redditch and RCGP Clinical Champion for Nutrition for Health, welcomed the research and said the findings were very promising.

She said: ‘We have to recognise that these are long-term journeys. We know that on average it takes five attempts to quit [smoking]. The fact they were able to demonstrate straight away an impact on people’s attempts to change and intention to change is very positive.’

Dr Pryke added this showed how GPs can ‘help people to embrace change, get in the right of frame of mind address their individual barriers – that’s a profound step forward’.

Dr Richard Vautrey, deputy chair of the GPC, said that GPs very much want to promote good health and encourage lifestyle changes, but that they need to be able to use their professional ability to ask ‘the right questions at the right time’.

He also questioned how far GPs would be able to keep following up on lifestyle advice with patients without additional resources.

He said: ‘Any suggestion that GPs should see even more patients, more frequently is unrealistic, given the limiting resources that practices already have and the huge pressure that they are under to deliver care to those patients who need to be seen, as opposed to those who need only need preventative advice.’

Dr Vautrey emphasised that each consultation has to be primarily led by the patient’s agenda.

‘It’s important that we get the best out of each consultation, and tailor each to the needs of the patient - it should not be dominated by anyone else’s agenda, in particular the government’s,’ he said.

BMJ 2013; 346: f1191

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