National Institute for Health and Care Excellence

PUBLIC HEALTH GUIDANCE – Behaviour Change (partial update of PH6) Consultation on the Draft Guidance from 5th June 2013 – 31st July 2013

Comments to be received no later than 5pm on Wednesday 31 st July 2013

Stakeholder Comments

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3 7 We are supportive of the necessity for quality assurance and fidelity checks. There are well developed and validated technologies for QA and fidelity in Motivational Interviewing including the Motivational Interviewing Treatment Integrity (MITI) scale and the Behaviour Change Counselling Index (BECCI). 4 8 We agree that the importance of practitioners being supportive, motivating and empathetic should be an important aspect of training. The relational aspect of working with patients to promote behaviour change is in our view under-emphasised in PH6 at the expense of technical/behavioural interventions and we feel that this point could be helpfully brought more to the foreground. We note that the evidence review for PH6 supports this recommendation. 9 We are supportive of the point that staff should be supported in delivering behaviour change interventions, including feedback on practice. This point could be strengthened to promote feedback using validated coding instruments such as the MITI and on-going supervision from trained trainers/supervisors.

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6 11 We welcome the move to manualise intervention techniques, though note that in some MI studies manualisation is associated with lower efficacy, possibly corresponding to a constraint of experienced practitioners (Miller and Rose 2009). We do not believe that evidence supports the necessity for constraining a manual to a taxonomy at this point: see notes to section 3.34 below. 7 12 We welcome the recommendation that all NHS staff should be trained to deliver brief interventions. We would also welcome a statement that such interventions should be client/patient centred in spirit. 8 13 We welcome the statement on the importance of client assessment. This could be usefully expanded to include a statement on the importance of client/patient strengths e.g. 'the personal and social resources they possess that can be recruited/employed to support any change' The substance use field is into 'recovery capital' and it might be appropriate here.

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9 14 We welcome the statement that it is important to recognise that there are times when people are more open to change, however it is also important to recognise that there are times when people are not ready or ambivalent. We believe that the stress on action planning and goal setting this document is not always appropriate and can be counter-productive at the wrong time or in the wrong situation. Clearer guidance should be given for clients/patients who are less ready to change as effective approaches do exist for this group. 10 15 See previous note. We believe there is an over-emphasis on technical/behavioural approaches in this document. There are times when patients will not be ready for these techniques and where they can be counter-productive. Barriers to change in healthcare settings are often relational/interpersonal and an over- emphasis on technical/behavioural approaches will not address this issue. 12 16, 17 We welcome the recommendation for the use of trainers with proven skills and knowledge and that training is monitored, and for the necessity of refresher training. We welcome the recommendation for evaluation of training. However we note that the evidence base for what works in training is limited (e.g. Madison, Loignon and Lane 2009).

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13 17 We welcome the recommendation for wide adoption of behaviour change knowledge and skills. We believe that the ask-advise- assist model is an expert led, non-patient centred approach which is at odds with other current UK policy guidance recommending more patient centred approaches e.g. the DH (2013) Helping people make informed choices about health and social care or DH (2010) Equity and Excellence: Liberating the NHS, both of which promote shared decision making and patient centred practice. 14 18,19 We welcome the general principles for training, particularly the recognition of the need for time and resources. The evidence from studies in the motivational interviewing field (e.g. Miller 2004 and beyond (e.g. Heaven et al 2006) suggest that there is very little skill retention from one off training events and that on-going supervision, monitoring and education is an essential part of producing change in most practitioners. 15 19 We welcome the comments in this section around developing motivation through reflective listening and empathy. We agree that it is important to ensure practitioners develop skills in encouraging and enabling people to change and to manage their own behaviour, though would say that it is also important (in the service of empathy and client/patient centeredness) to know when and how to hold back on these skills.

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16 20 We welcome the recommendation for recording of sessions and using reliable observation tools with recordings or transcripts. This may not be feasible or appropriate for very brief interventions. We largely welcome the recommendations around feedback. Good practice in adult learning suggests that rather than give the learner clear targets, that targets should be negotiated and co- produced between trainer and learner as adult learning self efficacy is correlated with performance (e.g. Phillips and Gully 1997).

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3.34 24 We have some concerns regarding the relative weight placed upon the taxonomy of Abraham and Michie. We applaud the fact that behavioural scientists are trying to establish which components of behaviour change interventions might be helpful to patients, and appreciate the efforts that have been made to that end. However, we need to be cautious about placing too much emphasis upon a taxonomy, which is clearly still evolving, at the present time.

No evidence is presented within the draft guidelines this is a valid and reliable way of categorising interventions as they currently stand. We are particularly concerned that the taxonomy does not seem to be a good match for some of the theoretical basis of motivational interviewing (Miller and Rose 2009) or for some of the interventions of motivational interviewing (especially those centred on relationship building as a core component of the intervention), particularly as the evidence base for motivational interviewing is growing. We believe that, at the current state of play in behaviour change research, where effect sizes are generally small whatever the theoretical school of the practitioner, it is premature to attempt to categorise effective interventions in anything but a tentative and provisional way.

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Any categorisation or taxonomy should be strictly informed by the evidence and should not be used as a set of criteria for accepting or rejecting evidence that is difficult to fit to the model. The document cites the MRC complex intervention guidelines (2008) which state that ‘A good theoretical understanding is needed of how the intervention causes change, so that weak links in the causal chain can be identified and strengthened’. The Abraham and Michie taxonomy does not seem to fit this description as it seems to preclude elements of MI (particularly those that relate to relational process) regarded as essential by its proponents. In this respect, we question whether the reviewers may have inadvertently followed the path described by one of the contributors to the expert review, Ray Pawson, who notes that ‘many crucial elements of behavioural change are overlooked because of the way programme evaluation is pursued’.

3.34 32 See previous note.

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3.37 32 The statement on initiation of a conversation and rapport building is weak, possibly reflecting the theoretical bias previously identified. We suggest that this section be strengthened with attention paid to the detail of how rapport is built through thoughtful and constructive conversations with a similar level of attention to that which is given in the document to specific behavioural interventions. We note that one of the experts in the review, Colin Greaves, identified this as ‘a critical skill set’ before listing ‘using a guiding style; open ended questions; affirmation; reflective listening; rolling with resistance’ – key components of Motivational Interviewing. This would be consistent with the findings in evidence review 3 (see below).

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1.2 50 The literature review for Motivational Interviewing is dated, possibly reflecting the theoretical bias already identified. There have been many individual studies and several good meta- analyses since Dunn 2001. We suggest a further review of the motivational interviewing literature, perhaps using the bibliography at http://www.motivationalinterviewing.org/bibliography as a starting point. A more recent review which may be more helpful and includes a meta analysis of the available data (Lai, Cahill, Qin & Tang, 2010), from the Cochrane Database of Systematic reviews. Although they still note caution in interpretation due to variability in interventions and fidelity, and the possibility of publication bias, they concluded that MI yielded a modest but significant increase in quit rates in comparison to brief advice or treatment as usual – a different conclusion to the Dunn review cited.

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1.7 52 We have serious concerns that Motivational Interviewing is characterised as a ‘poorly defined term’ and would refer the authors to Miller and Rollnick (2013) for a clear definition.

We have serious concerns that Motivational Interviewing is described as ‘intervention function: Persuasion’. This is a major misrepresentation of Motivational Interviewing which is often contrasted with persuasion. We are particularly concerned that this is not an innocent error but is again a product of an attempt to prematurely fit interventions into a scheme that is not yet sufficiently well developed to describe all effective interventions for behaviour change. Although we are concerned at a conceptual level about the taxonomy and ‘behaviour change wheel’, if it is thought necessary to incorporate motivational interviewing into such scheme, a better fit may be IF9 enablement rather than IF2 persuasion.

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General (external 65 We note that the authors did not have time to contact study authors for evidence review 2) more information about their interventions. This is less than ideal practice in conducting systematic reviews of complex interventions. We are concerned that this may have contributed to the poor understanding of Motivational Interviewing previously identified (note 1.7 p52), and therefore potentially other behaviour change interventions too. Additionally, by only applying taxonomy labels to the interventions as labelled within the articles (which are likely to have been restricted by word and space limits by the publisher) the authors are likely to have failed to identify codable, fundamental components of behaviour change interventions that actually took place. It seems they may also have taken the risk of assuming components that did not occur within those interventions were present, by using their judgement from information they have read elsewhere about those interventions. There is also a high probability that intervention components and functions falling outside the taxonomy and behaviour change wheel have gone unrecognised, and opportunities may have been missed to further inform these models. Within MI for example, some of the intervention components that appear to have been missed would include affirmations and reflective listening. This perhaps reflects a poor understanding of the intent of the taxonomy by the company performing the review, rather than an intrinsic problem with the taxonomy itself (taxonomies are constantly evolving frameworks, rather than rigid structures 'set in stone').

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General (external 25 We would suggest adding an MI competency framework to this evidence 3) section. A suitable framework is Cornwallis, E. Competency Framework for Motivational Interviewing, 2012. [Online] Available from: http://cornwallisassociates.co.uk/news.html General (external 50 et seq We welcome the detail provided on relational processes in this evidence 3) part of the evidence review. We would recommend that the conclusions here are emphasised more in the final document (see note 3.37 p32 above). General (overall In summary, although there is much to welcome in this document, approach and we are concerned that the methodology of the evidence review conclusions) had significant flaws which has led the authors to significantly understate the broader clinical imperative to engage patients as the foundation for any effort to promote behaviour change. We hope that this can be addressed in the final version.

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NB: The Institute reserves the absolute right to edit, summarise or remove comments received on during consultation on draft guidance where, in the reasonable opinion of the Institute, they may conflict with the law, are voluminous or are otherwise considered inappropriate.