Insight to inform the NHS Health Check implementation in Leeds

1. Insight to inform the NHS Health Check implementation in Leeds Lucy Jackson – Consultant in Public Health lucy.jackson@nhsleeds.nhs.uk

2. Why Insight? • We face a huge challenge: EVERYONE aged 40-74 within Leeds to attend a Health Check AND access suitable support services for Smoking, Obesity, Exercise, Alcohol and the Vascular diseases,( over 260,000 people!). • To achieve this Effectively, Efficiently, Consistently and Sustainably with Quality Health Outcomes the team adopted a MARKETING lead approach to the project design and delivery. • Essentially we have taken the ‘patient perspective’ in everything that we have chosen to do and then identified how to make that achievable within the constraints of the NHS. • A deep, true, evidenced understanding of peoples attitude to their health and health professionals is essential to inform all our decisions.

3. Aim of the Research • To understand the initial target audience for the Health Check Programme in more depth • Explore their general attitudes towards health. • Understand awareness, views & opinions of vascular risk • To understand the relevance of a Health Check and reactions to an invitation to attend an assessment at a GPs surgery. • To explore the motivations & barriers to taking part in the proposed Health Check programme. • To explore expectations of the Health Check, any follow-up treatment and programme management.

4. Research Approach • Research was conducted in 10 ‘deprived’ Leeds neighbourhoods, with adults aged 40-74 (Scott Hall, Chapeltown, Harehills, East End Park, Middleton, Holbeck, Beeston, Armley, Seacroft, Crossgates) • Group discussions were held with mixed groups of ‘peers’ to understand the impact of family/friends on attitudes. • Group discussions were held with single sex, age specific groups who were asked to represent the views of their ‘community’. • Individual discussions were held with individuals to probe behind the issues raised by the groups. • 2 video diaries were kept to give an element of anecdotal feel.

5. Audience Insights summarised into 4 main areas • General attitudes towards health • Views of GP Practices • 3. The Health Check; Expectations & Reactions • 4. The Health Check Communications

6. 1. ATTITUDES TOWARDS HEALTH

7. Overall Attitude • Health is pivotal, but can often take a backseat to daily life priorities. • Health is recognised as being crucial to making everything else possible but means different things to different ages. • It’s not about high aspirations. Is grounded in emotional well being, agility and maximising the quality of life. • Both rational and emotional thoughts drive emotion & rational outcomes. • Easy to visualise how it feels to be physically healthy; spiritual well being and mental agility are less easy. • Being physically able to do what you want crosses all age brackets – this is a universal motivation.

8. Overall Attitude • The biggest issue surrounding improving your health is that it takes a backseat unless: • there are some obvious symptoms, • there has been a poignant trigger or • generally feel that you are experiencing poor health/well being Realistically ‘Being Healthy’ is about ‘Not Feeling Unwell’. It means beingphysically able to do what you want • It is very easy to allow the barriers and daily life commitments to over shadow improving health and motivation to action.

9. Maximising The Quality Of Life Ability To Indulge Time With Family & Friends Living A Long Life Able To Do What You Want To Do/Enjoy Agility Being Active More Energetic No Restrictions/Not Missing Out Realistic & Grounded Aspirations Feeling Contented Stress Free/Less Anxiety The Realism ‘Not Feeling Unwell’ Happiness Emotional Well Being What Does Being Healthy Mean?

10. “Motivation seemed to come from family and wanting children to be healthy by being more aware of diet & exercise” Female, 40 - 49yrs, LS15 “The people I spoke to were all of a certain age and it had been the loss of a loved one that had prompted them to start to make another life for themselves” Female, 60 - 69yrs, LS11 “I’d like to lose weight and look how I did when I was younger. Chocolate, fast food and wine are too tempting, it’s hard” Female, 50 - 59yrs, LS7 “Feeling better is the big motivation that will keep people going” Female, 40 - 49yrs, LS15 “I decided to stop smoking after my son took up smoking and I realised it wasn’t a good example to set. I was motivated by the fact that I didn’t want my younger son to start as well” Female, 50 - 59yrs, LS7 “Being healthy helps you to live longer, you see your family grow up and you get to do the things you still enjoy. I love coming to the social club and doing trips, I go as far as my bus pass will take me” Female, 70 - 74yrs, LS14 Motivation To Be Healthy Women

11. “I try to keep myself motivated and live life to the best, my family motivated me after my knee replacements as I want to keep going as long as I can” Male, 50 - 59yrs, LS14 “The main motivations are either witnessing others being ill or waiting until ill health gives a kick in the ****. Only a couple had made conscious changes but only after being told to by loved ones” Male, 40 - 49yrs, LS8 “If I’m not healthy I can’t work and I need to be able to work so that keeps me on track” Male, 60 - 69yrs, LS7 “Fright can often be at the bottom of it. You have to have a shock to make you realise” Male, 60 - 69yrs, LS7 “It’s important to keep going for as long as you can. Walking is free and very enjoyable” Male, 60 - 69yrs, LS7 “I always keep moving about and keep doing things. I like window shopping & meeting friends at the betting shop, it makes me feel good and happy to keep active” Male, 60 - 69yrs, LS7 “People want to make changes to feel better about themselves but sometimes they start smoking again or only have a brief diet due to weakness but they try try again to carry on for better health” Male, 70 - 74yrs, LS11 Motivation To Be Healthy Men

12. Barriers; Are Prevalent & Multi-Tiered Logistical – Financial – Ability & Belief – Attitude - Environmental Motivations; Are Easy To Visualise With Long Term Gain – Rational & Emotional Benefit BUT Hard To Be Motivated, Sustain Effort & Achieve Full Goal Benefits Are Recognised To Outweigh Barriers But Benefits Are Less Forefront & Felt To Be Hard To Reach Whilst Barriers Are More Ingrained, Habitual & Wide Spread Health Lifestyle Motives & Barriers

13. Motivations & Barriers • Realistic aspirations around health exist but leading a healthier life style is often forgotten in daily life. • The benefits of being healthier are easily recognised and outweigh the barriers, BUT are less forefront & felt to be more hard to reach • Barriers are wide spread, habitual and multi-tiered providing easy routes out • Reasons for being healthy are driven by a complex set of internal and external influences, touching on both emotional & rational triggers • These factors evolve with age

14. Healthy Life Style Barriers The barriers to healthy lifestyle fell into four key categories: • Impact of lack of money focussed on poor eating with the expense of ‘good food’ compared to cheap fast/convenient food being made. • There was a general theme of time pressure/lack of time among the under 70s.The lack of focus on ‘me time’ was linked to pressure, prioritising family & friends • Temptation , enjoyment, sociability , safety and general environmental pressures were key to people continuing with bad habits. • A lack of self confidence, self belief, will power and motivation, alongside elements of ‘fate’ stopped many having the attitude to make a change.

15. Barriers by age • 40s – being invincible & feeling healthyGenuine time/convenience barriers, lack of self-belief to adopt any changes • 50s – most difficult age bracket to entice - squeezing the last pips of temptation/luxury – need to understand the serious consequences but are starting to recognise the possibility for health decline • 60s – possibility the easiest to engage (some feeling neglected anyway and greater external pressures to look after themselves) – peer pressure & experience have a greater role to play in this age group • 70s – easy to engage, pragmatic audience, more used to potential medical consequences so trepidation is less, mobility & independence are important but opportunity & ability are barriers

16. Barriers To Change Women “Most people do want to be healthier but lack the time, money & energy. Stress is such a big factor and can make people binge on booze, cigs and food” Female, 40 - 49yrs, LS15 “People lack motivation to start to make a change, there’s lots of excuses like lack of money, but walking costs nothing. There’s just no time to cook everyday or invest in a slow cooker, then cook & freeze at weekends” Female, 40 - 49yrs, LS15 “Most people I spoke to hadn’t yet made big life changes, but felt they should, like stopping smoking. Most were stuck in the same old secure routine” Female, 40 - 49yrs, LS15 “People need to plan more and stick to it, it’s getting the know-how and plan, if you don’t you lapse” Female, 40 - 49yrs, LS15 “I think most people would like to improve their health but it’s not always easy. It depends where you live. There are too many temptations in some areas like take-away shops” Female, 50 - 59yrs, LS7 “People find it difficult because of the cost of food especially organic food and there are not enough facilities in the area to keep fit” Female, 50 - 59yrs, LS7

17. Barriers To ChangeMen “People find it difficult because of money, if fruit & veg was cheaper it would be better. The local sports centre is not very nice and the gym is expensive” Male, 60 - 69yrs, LS7 “I think it’s in your genes I know people who have died of cancer who have never smoked” Male, 60 - 69yrs, LS7 “People probably lapse because a healthy life style is boring and hard to maintain” Male, 40 - 49yrs, LS8 “Work seems to get in the way of everything. Everyone knows what to do but it’s difficult to do it. There seems to be a ‘if it’s not broken don’t fix it’ attitude” Male, 40 - 49yrs, LS8 “People don’t want to sacrifice so called luxuries such as drink or tobacco” Male, 50 - 59yrs, LS14 “I stopped smoking to try and save money but I was so worried about the house and not being able to afford to keep it that the stress made me start smoking again” Male, 60 - 69yrs, LS7 “Elderly people are scared to come out of their houses, we can’t do the things we used to anymore, youngsters have no respect, they don’t appreciate us older folks, it’s limiting” Male, 70 - 74yrs, LS11

18. 70+ MRSA Being Active - General Mobility, Breathlessness Arthritis Angina/Diabetes Gynaecology Heart Disease Stroke, Cancer Blood Pressure Cholesterol Family History Female Male Less Sporty & Active Poor General Well Being & High Life Demands Slower/Less Energy Mental Exhaustion Sleep Deprivation Aftermath Of Social Living Liver & Lung Disease Angina Weight/Obesity 40+ Health Concerns

19. Conclusions • Health is important, but back of mind for the majority until something ‘goes wrong’. • It is seen as ‘hard’ to improve healthy lifestyle and ‘easy’ to slip. • Benefits are NOT immediately apparent/real, so we need to create ‘evidence’ of change. • Attitudes do seem to shift with age (mortality!!) • We have to work hard to make change the EASIEST option, REAL, ACHIEVEABLE & FUN

20. 2. VIEW OF GPS & PRACTICES

21. Public’s View of GP Practices • There are a number of barriers to visiting or seeing your GP covering logistical issues, attitudinal, service & resolution • The research specifically targeted medium to light users of the GP and have unearthed some quite negative thinking around GPs as well as prevalent barriers • Hard receptionist • Phone line busy – inaccessible • Better by the time you get an appointment • Difficult to get an appointment • Inconvenient appointments/inflexible • Long waiting times If feel okay – can cope • GPs not personal anymore/not a family GP • Never see same doctor • Feel a burden to NHS – others need it more • Accepting illness as part of old age, or just cope when younger “It’s hard to get in, you can’t go during the day because you’re working and your job comes first” Male, 60 - 69yrs, LS7 “I just don’t find them very flexible, they don’t react when you want them to and you can’t see them when you want to” Female, 60 - 69yrs, LS11 “You never get seen on time” Female, 40 - 49yrs, LS15

22. Public’s View of GP (Doctor) There is a dominant attitude that you see the GP if something is ‘wrong’ & to resolve an illness, not for general well being support. GP is respected when executing more serious follow-up medical advice, referrals or tests. But, initial attitude is often seen as unwelcoming and unengaged. “I respect the doctor, it’s a trained opinion. The local doctor here is nice but it’s not always the same person that you see” Male, 60 - 69yrs, LS7 • Always rushed out - resentful • Jargon talking • Intimidating, moody, above everyone else, fallible • Conflicting advice • Reduced faith in doctors • Unresolved problems • They don’t listen - quick to prescribe • Will get a lecture – higher risk • Fear/trepidation – higher risk/family history “You never get the same one, so there’s no relationship. Years ago you’d have a personal GP” Female, 40 - 49yrs, LS15 “They’re not as good as they used to be, they just don’t spend the time with you anymore, it’s not the same” Female, 70 - 74yrs, LS14

23. Relationship With GPs • 40s have little personal contact with GP, but have quite good relationships through children – more likely to self-prescribe with internet, ring NHS direct or use pharmacy • 50s have little relationship with their doctors. Don’t want to hear a lecture so don’t go! • Males in their 60s have little relationship with their GP. Relationship possibly stronger with practice nurse!! • Females in their 60s tend to feel neglected as they are now outside of many previously regularly checked areas. • 70s have good relationships with their doctors through regular visiting/servicing. They tend to go with one thing and spontaneously get everything else checked at same time . “I used to go when I took my kids now they’re grown up I don’t go, I don’t even know the names of my doctors I haven’t been for so long” Female, 50 - 59yrs, LS7 “I feel very able to go, I’m very happy. When you go to the doctors you go for one thing but I ask about other things so they go through everything when I ask them” Male, 70 - 74yrs, LS11

24. Public’s View of ‘Practice Nurse’ The practice nurse is more approachable and more aligned with general well being matters There are many reservations and barriers around GPs executing the health check, but the strong role of a practice nurse effectively overcomes many of the barriers respondents raise, reinforcing the positioning of a grounded, down to earth, realistic well being check The need to understand mental well being must not be under estimated , and the practice nurse is well placed in order to make this programme effective, easy & simple to engage with They are felt to have more time and to be building a relationship, so right person for ADVICE, but still GP for TREATMENT “I go to the nurse and I feel more comfortable. I think they do a lot more than they used to do, it’s just like being in a room with a friend” Female, 50 - 59yrs, LS7 “I like to see the nurse rather than the doctor, unless it’s something serious” Female, 40 - 49yrs, LS15

25. Further Views “I think I’m healthy but I think you have to be careful as there’s always problems around the corner, but until you feel them you don’t go to the doctors unnecessarily” Female, 40- 49yrs, LS15 “People need the doctor more than me, it’s an age thing so you just put up with it until you need to go” Female, 40 - 49yrs, LS15 “If you don’t go regularly you don’t feel as important, you feel like you’re wasting their time, they don’t seem to want to see you” Female, 60 - 69yrs, LS15 “I don’t go because I can’t always get an appointment and I don’t want to get a lecture about smoking” Male, 50 - 59yrs, LS14 “They write the prescription before they’ve even asked what’s wrong with you” Male, 40 - 49yrs, LS8 “I don’t go because it’s just a waste of time, they make you feel like it’s just your age and they can’t do anything for you” Female, 70 - 74yrs, LS14 “I’m not one for going to the doctors, but when I do, I feel like they don’t know what they’re talking about. They just want to get you out of the door” Female, 60 - 69yrs, LS7

26. Conclusions • Respect for GP a real issue for light users. • However, when it is serious GPs still highly trusted • Practice nurses much more appreciated. • So, Nurses much better placed to engage patients, discuss broad issues, perform test and then refer to GP as necessary. • For Healthy Living support/advice surgery attitudes must change – people must be, and feel, welcomed and valued. • It must be clear that sufficient time and importance is placed on visit by all practice staff. • If the above isn’t achieved, then Health Check ‘reputation’ will be damaged!

27. 3. HEALTH CHECK EXPECTATIONS & CONCERNS

28. The Health Check • Peace of mind is a common motivation to attending the Health Check; either to lower risk or prevent onset of disease (under 60s) orget chance to put it right (over 60s) • The final goal is clearly about staying well & healthy, achieving a better quality of life & well being and adding time to your life – a potential common motivation for ALL preventative services. • A general approach to improve public health also reassures and reduces any barriers to engagement created by being ‘singled out’

29. 70 -74s 40-49s Request these ‘all the time’ A regular ‘check-up’ Some associations with ‘physical’ Specific checks or wellbeing checks Thought to be for older generations The Term ‘Health Check’ Understood As A General Check Covering A Few Different But Crucial Areas - Assumed To Be Regular – A Check & A Monitor The Onus Is On You To Decide Whether To Take Advantage Little Experience Of A General Health Check Except Among 70+ ‘Health Check’ 50-59s 60-69s Some associations with ‘physical’ and full-on check which can be invasive Some opportunistic ‘health checks’ Some ‘working’ people associating health check with ‘physical’ Don’t get it unless ask

30. FREE NHS Stands out Quality ‘Private’ Feel Will Save Money For NHS In Long Run Prevention Less Scary More Universal Prevention Is Better Than Cure Help Lengthen & Improve Quality Of Life • Sounds Interesting • An MOT • Clearly Communicates A General Check Of The Inner-Core • Helping YOU Prevent • Puts Onus On You & Means Effort Clearly References Main Killers Easier To Understand Than Vascular Health Check Key Elements

31. A Wide Scope Of LIFE STYLE Understanding Expected WHAT? THE OBVIOUS SUSPECTS Diet & Exercise Smoking Family History A GENUINE UNDERSTANDING Mental Well Being/Stress/Happiness Self Deprivation Money/Debt & Security – Daily Struggle Me Time – ‘Time Out’ - Mental Escape Strain Of Relationship Breakdowns Emotional Pressure Of Caring For Others Personal Loss New Life Adjustment & Anxiety Generally Feeling Down Or De-Motivated THE FURTIVE TOPIC Drinking At the back of their mind, is intrusive, thought to be judgemental and harbours concealments & lying Negatively Impacts On Ability To Implement Health Check Advice Health Check Expectations

32. Simplicity Easy To Understand (Plans/Leaflets) Easy Plans To Implement Providing Clear Reasoning Non-Judgemental Friendly/Understanding On My Level Realistic Small Steps Small Goals Not Too Optimistic Manages Lapsing Low Cost In Keeping With Area Providing Choice, Inclusion & Ownership To Engage Patients & Encourage Them to Implement Not Being Singled Out Or Alone Generic Advice Non-Conflicting Support, Morale, Groups @ GPs Practice Nurse & GP Distinct Roles Depending On Severity & Urgency Life Style Advice - Positioning

33. Barriers • Common place barriers across most age brackets are 4-fold: - • Fear & apprehension around the results • The niggles & negatives around a GP • The logistical issues around fitting the health check in • Feeling okay and therefore thinking the health check is unnecessary • Inclination to change and a lack of self-confidence & belief also exist among the under 60s. This is especially the case if big changes need to be sustained • Even the most likely to participate would naturally forget to make an appointment and expect an inconvenient & inaccessible programme!!

34. Conclusions • In principle people like the idea of a ‘Health Check’ and see it as helping prevent or identify future problems. • But, there are lots more important things to do that take precedence!! • Communication has to ensure expectation and experience are positive, supportive and value the individual. • People need a ‘positive’ outcome. Clear advice and conclusions. • Practices have to ensure sufficient time given to each attendee.

35. 4. HEALTH CHECK COMMUNICATION

36. Muscles Angina No Previous Thought/ Awareness Of Term Blood Clots/Thrombosis Sounds important but easier to dismiss when not familiar or understood. Once understood know it is important. Ultimately still related to the working ability of the heart. Liver Heart Not A Natural Subject Veins Circulation Don’t know Fatty Build Up Stroke Clear Hesitancy Arteries Blood Flow Blockages Cardio Process Of Guessing Breathing Problems/Lungs/ Respiratory High Need For Confirmation/Validation NOT well understood -> Health Check Public Understanding of Vascular Check

37. Importance of Clear Communication “Most people thought it was to do with keeping the heart healthy, but they didn’t understand too well. People thought it sounded important and some were curious to find out more” Female, 40 - 49yrs, LS15 “Most think it’s about a healthy heart although no-one seems sure. Some said blood flow but they were guessing. Some were ignoring the consequences” Male, 40 - 49yrs, LS8 “When I was talking to people about it most had no knowledge of it and if answers were down they were just guessing this. There was a lot of confusion and they kept asking me” Male, 70 - 74yrs, LS11 “The general opinion was blood & heart, but I don’t think people understand much about it, I know I don’t. You don’t want to know until you’re poorly” Male, 70 - 74yrs, LS11 “The majority think it’s veins and I think this is true. It sounds scary but important as well as confusing” Female, 50 - 59yrs, LS7 “It’s your ticker and you need to look after it. But it’s not an everyday word” Male, 60 - 69yrs, LS7 Use Language People Understand (They Aren’t Health Professionals)

38. Health Check Works! • The term ‘Health Check’ is quite a usual and recognised term for respondents but can be all encompassing so any supporting clarification is crucial when managing expectations • Health Checks tend to be classed as relatively informal, without obligation, but with strong recommendation and positioned as general ‘well being’ checks • Whilst informal and relaxed in nature, a health check is recognised as being a check that will normally cover crucial aspects of health and implies a regular monitor rather than a one-off • The Health Check logo is strong, impactful, informative and clear in its preventative nature & scope

39. Engaging People & Motivating Action • Communication should focus on: • accessibility, • end benefit to your life (better quality of life & adding on years) • peace of mind check can provide • It appears that: • Shock tactics, - Highlighting community variance or inequalities • Jargon or dense prose, - Connection with money/financial implications • Pulling at emotional heart strings, - Statistics, may impact and resonate but do very little to motivate action or influence positive attitudes or behaviours!!!

40. ….in summary….. • Spending just ½ an hour getting a health check can prevent heart related diseases, add years to your life and make you feel better. • The trade off between ½ an hour and adding on years/quality puts the benefit enormity into perspective in terms of the little time you have to sacrifice now.

41. High Impact Anyone Wished You’d Spent More Time With Application of Possible Health Check Messages ½ Hour Could Put Years On Your Life What Turning Your Back On Quick, Easy & Peace Of Mind Communications Themes Lead To Blindness & Amputation ½ Hour Can Save Years 2,500 People Could Die In Leeds Low Appeal High Appeal You Owe It To Yourself & Your Family Get Checked Out Before It Happens MOT For The Body Low Impact Positive messages received very well, and seen as motivating

42. Draft Leaflet “It’s nice, it’s personal and it answers a lot of questions” Female, 50s, LS8 “If I saw this I would pick it up & read it, it should be everywhere” Male, 50s, LS14 Image largely seen as appropriate & clear Consumers generally understand the cog in this context of the body as a machine to keep ‘ticking over’ Well received; due to clarity of explanations and layout Simple & easy Expected to be available within the invitation to the health check & suggestions for a number of other accessible locations; community centres, surgeries, sports centres, social clubs, dole office, libraries, supermarkets, health clinics etc. Shown in A4 but expected to be A5 for ease of portability & distribution Fresh & clean Logo again works well and cog/clock wheels make more sense in context of leaflet imagery Overall; described as informative & easy 60+ like big writing Required in different languages

43. Simplify Communication Your health check will show the chance of you developing vascular disease in the next ten years • The traffic light system in principle works well, - remain simple ,rough in guide so as respondents feel that there’s scope to influence and change the risk level • Good visual aid for the doctor/practice nurse to use, - not as a take-away aid. • Want a simple take-away plan of action to highlight the more personal and achievable elements to try and implement; act as a motivator to continue good behaviour • Greater than 20% risk – Need for immediate action • 10% to 20% risk – Need to make changes • Less than 10% risk – Need to maintain your lifestyle

44. Life Style Changes- key messages • Optimism is a clear trigger • Visualise and identify small steps – make it achievable and real • Simple, small and grounded steps most effective to feeling that life changes are achievable. • No such thing as failure!! It’s just one day slower progress, we are not all perfect! • Help people feel and notice the differences of any recommended life style regimes.

45. Conclusions • Simple, Clear , Positively motivating communication can work. • Make positive benefits VERY clear. • National programme endorsement does bring credibility and gravitas ( the NHS brand). • If possible, provide meaningful feedback to take away and a clear, simple, achievable action plan.