Clustering of unhealthy behaviours: Implications for NHS Employers? David Buck The King’s Fund NHS Employers Seminar, London, 5 th February 2014

What an opportunity! A real opportunity –300mn+ contacts with the NHS every year –1.4mn NHS workforce, with much broader reach in families and communities via peer and lay support –Increasing diversity of “channels” for behaviour change, from NHS staff to local authorities, to health trainers and health champions Future Forum and reforms an added boost? –Every Contact Counts policy highlighted and supported –Health and Wellbeing Boards But... –often see behaviours in isolation from one another –and from people’s individual & economic & social environment

Multiple behaviours: Why are we interested?

Some encouraging news on trends in single behaviours in recent years Source: Gregory et al (2012) Health policy under the coalition government: A mid-term assessment. The King’s Fund. Available from, government

..but having multiple unhealthy lifestyles has an increased “gearing” impact on health.... and more on mortality than on self-reported quality of life Source: EPIC-Norfolk cancer studies

But… most of our efforts are focussed on behaviours in isolation... March 2011 October 2011 March 2012

What we looked at and found

Our questions.. What has been happening over time? –How is the distribution of multiple risk factors changed? –Have multiple risk factors been polarising between socio economic groups? What might this mean for policy? –Implications for policy “silos”? –Design of incentives and guidance such as public health tariffs, QOF, the Public Health Outcomes Framework and NICE PH guidance. What might this mean for practice? –Wasting resources and increasing resistance by hitting the same people with separate interventions and messages –How to support people to change behaviour needs to be more nuanced

What we did Cross-sectional analysis of Health Survey for England 2003 and 2008 –Adults (≥16) in 2003 (n=14,607) and 2008 (n=14,912) –Four key risk factors – smoking, drinking, diet and physical activity –Definitions based on breaching government guidelines Analysis of –How these risk factors “cluster” in the population –Changes in clustering –Implications for inequalities (socio-economic, educational) –Policy and practice implications

We found real improvements over time Consistent with movements “down ladder” of risk –Shedding 3 and 4 behaviours, maintaining 1 and 2 –Overall about a 20% drop in 3+ behaviours for men and women –But, 70% of the population still have at least 2 behaviours

Within this there are 16 specific risk combinations, poor diet and exercise dominant Prevalence of combinations of multiple lifestyle risk factors in 2003 by gender Note: S=Smoking; D=Drinking; F= Fruit&Vegetable; P=Physical activity; Capital letters= presence of risk factor

Significant changes over time in some of these combinations Change in prevalence of combinations of multiple lifestyle risk factors between 2003 and 2008 by gender Note: S=Smoking; D=Drinking; F= Fruit&Vegetable; P=Physical activity; Capital letters= presence of risk factor; * = significant change

..but improvements come from some sectors of the population and not others Change in prevalence of multiple lifestyle risk factors between 2003 and 2008 for men in professionals and unskilled manual households People with no formal qualifications 3x as likely to have 3 or 4 behaviours in 2003 compared to those with the most..by 2008, this had risen to 5x as likely.

Implications for practice?

..sets the context for practice in your staff, and in your work with patients Be aware –70% of adults seen by services will not be adhering to government guidelines on 2+ unhealthy behaviours –Many will have had a recent record of success in other areas of behaviour change, can be built on –Health trainer evidence suggests “the visible” drives first contact, but the real issues & desire to change are often in other areas –Every relationship, not every contact that counts

… but some tricky questions remain… Effectiveness and cost-effectiveness –Should we still focus on single behaviours in practice, and sequential goal-setting? Does it matter which people attempt to change first? Does the answer change depending on whether we’re interested in effectiveness or cost- effectiveness? Some emerging evidence that “coaction” effective but depends on objective –Sweet and Fortier (2010) > meta-analysis weight reduction; individual interventions more effective at targeted behaviour but multiple at ultimate goal, weight reduction. –Everson-Hock et al (2010) > UK; qualitative interviews smoking advisers. Mixed views, big issue identified about correct timing for additional intervention in quitting process.

NHS Wales has worked on multiple behaviour change with its staff Champions for Health –Campaign aligned with Olympics –Asked staff to sign up to change 2 or more behaviours, supported through web and other material –Evaluation –1,320 staff signed up across Wales to change 2 lifestyles – most popular combination diet and physical activity –84% of those who stayed with campaign said they would continue post campaign, 35% thought health had improved –… but big decay rate…

Lots of live local testing and service response developing on this theme Local analyses of multiple lifestyle behaviours informing JSNAs

Lots of live local testing and service response developing on this theme Services starting to re-orientate towards “people”, not individual lifestyles

Conclusion A real opportunity –300mn+ contacts with the NHS every year –1.4mn NHS workforce, with much broader reach in families and communities via peer and lay support –Increasing diversity of “channels” for behaviour change, from NHS staff to local authorities, to health trainers and health champions Increasingly –Recognised that behaviours cluster, and relate to the individual’s social and economic circumstances –Although science of what works in early days, practice starting to show examples of more holistic approaches to behaviour change –Make every relationship, not just contact, count?

The King’s Funds work on public health Publication and posters/presentations to our conference on this, freely downloadable unhealthy-behaviours-over-time For more on our work on public health and inequalities health-outcomes