Friday, 15 February 2019

If at first you don’t succeed, try, try, try and try again…

Posted by Suzanne Moffatt, Reader in Social Gerontology, Institute of Health & Society, Newcastle University

Ways to Wellness Link Workers provide support to people with
 long-term health conditions who are referred by their GP
Publishing a study protocol is always gratifying (even though it counts for nothing in the Research Excellence Framework!). Publication of this particular protocol evaluating the impact of social prescribing on health and wellbeing caused me to reflect on the 58 months that had elapsed between that initial invitation to develop an evaluation and getting the study protocol into print. Why on earth had it taken so long and what had we done in those months? Well, we weren’t twiddling our research thumbs, but we did get quite a few knock backs in our efforts to secure “the big grant”, and I thought it worth sharing with the research community as multiple failures before success is often untold.

We started with an outline bid to the National Institute of Health Research (NIHR) Public Health Research Programme in 2015 which was shortlisted, but not successful at the full proposal stage. Fortunately an application to the Cabinet Office was successful that same year, which enabled us to complete a qualitative study exploring the impact of social prescribing for service users and perspectives of ‘link workers’ delivering the intervention (work currently accepted for publication). In 2015 (busy year!) applications to the School for Public Health Research (SPHR) Public Health Practice Evaluation Scheme (PHPES) and School for Primary Care were both unsuccessful. But in 2016 we achieved success with a ‘cut down’ version of our SPHR PHPES application (capitalising on end of year finances, I believe) that allowed us to pilot questionnaire data collection (paper rejected and currently being prepared for re-submission). 2017 also saw us obtain a relatively small grant from Newcastle University’s Institutes for Ageing and Social Renewal, allowing us to follow up 24 out of our original qualitative sample of 30 service users, findings of which have recently been published.

Ukulele group, Throckley Community Centre, Newcastle upon Tyne
Despite our lack of success so far in obtaining the “big” grant, we had contributed a valuable body of work on the impact of social prescribing and into the bargain employed some excellent researchers – Mel Steer, Kirsty Laing and Jo Wildman. Yet, in spite of the apparently unstoppable popularity of social prescribing as a way of addressing long term health problems and tackling inequalities, a systematic review demonstrated that a robust evidence base about impact and cost effectiveness is lacking. When the 2017 NIHR Public Health Programme call for research on Community Groups and Health Promotion[1] (16/122) hit my inbox, it dawned on me that another application (our seventh in case you had lost count) fitted the bill. I felt a mixture of dread and exhilaration. Definitely the last chance saloon.

So, why was this bid successful? In essence, because it was more clearly focused on a specific condition (type 2 diabetes), our substantial body of underpinning research, the mixing of quasi-experimental and ethnographic methods and a really excellent team of researchers. So now all we have to do is deliver. But remember, if at first you don’t succeed, sometimes persistence pays off.

For more information about our evaluation of Ways to Wellness Social Prescribing, visit the project website.

Applications to the SPHR Public Health Practice Evaluation Scheme (PHPES) are now being accepted with funded projects expected to start from January 2020.

  1. This work is funded by the National Institute of Health Research, Public Health Research Programme, Community Groups and Health Promotion (grant no. 16/122/33). The research was informed by a NIHR School for Public Health Research (SPHR) funded project (project reference: SPHR-FUS-PES-WTW).

The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Friday, 1 February 2019

Universal Credit and the perspectives of ex-Jobcentre Plus staff

In last week's blog post, Mandy Cheetham wrote about the impact that Universal Credit is having on health and wellbeing in Gateshead.  In today's guest post, Kayleigh Garthwaite, Jo Ingold, and Mark Monaghan present their findings from preliminary research with former personnel from Jobcentre Plus.

Universal Credit has attracted considerable criticism from experts and politicians. Yet could it be that it has also caused civil servants associated with the policy to leave their jobs?

Throughout 2018, Universal Credit (UC) has been a prominent feature of political discussion, second only to Brexit. UC is an attempt to simplify the benefits system through the introduction of one single working age benefit and to improve incentives to work through the radical restructuring of the benefits and Tax Credits systems. The design and implementation of UC have been defined by austerity and large-scale expenditure cuts to central government departments and drives for greater efficiency following the (2007-8) financial crash. Consequently, the roll out of the policy has been beset with difficulties, magnified by a turbulent political environment (two General Elections, the Brexit Referendum and changes in Ministerial Portfolios).

Since the introduction of UC, which has consolidated both conditionality and punitive benefit sanctioning, there has been an accruing evidence base highlighting the detrimental impact of UC and social security reform more broadly, particularly for those living on low incomes and in poverty. Unfortunately, there is no clear sign of this research being incorporated into policy and so far, no sign that UC will be amended or abandoned.

Between us we have spent the last few years looking at various aspects and impacts of changes to social security policy in the UK, ranging from accounts of the social consequences of austerity, exacerbated by UC, which has led to rising levels of foodbank use; the role of evidence in the policy discussions within the Department for Work and Pensions (DWP) at the time of UC design; and the role of employers in active labour market policies. It became apparent that little work had been conducted with practitioners responsible for the rollout of the policy. This seems a significant gap bearing in mind the amount of negative publicity that has accompanied the rollout of UC, which sat alongside public statements that despite the difficulties, staff morale within the DWP remains the highest in Whitehall.

Despite a slight increase from 2017 to 2018, from around 2010 there has been a significant reduction in the number of civil servants which coincides with the design and development of UC. Little is known of the reasons for staff departures and whether the demands of working on a controversial policy such as UC played a role. Over the summer of 2018 we conducted preliminary research in the form of in-depth interviews (n=8) with former personnel from Jobcentre Plus in the North of England. We initially hypothesised that reasons for departure would include: financial packages on offer; timing; age; ill health; other opportunities in the labour market or career change; dissatisfaction with current role or manager; and a lack of opportunities in the Department or wider civil service. We were particularly interested in whether objections to policy were also part of the equation.

Amongst our respondents, dissatisfaction with their current role was perhaps the clearest theme to emerge as to why they departed the DWP. This wasn’t always linked to UC per se, but was part of the broader austerity landscape in which UC emerged and was linked to longer term ideological developments within both social policy and public administration, which coalesced around increasing use of managerialist forms of governance and austerity. As has been documented, the movements towards activation in welfare policies foregrounded as a means of reducing the deficit has required specific forms of governance to the extent that welfare-to-work organisations find themselves in almost permanent processes of reorganisation. For our respondents, it was this experience that produced the most consternation.

In terms of top down management targets, our respondents told us of the impact of initiatives within the DWP and how targets and objectives were impossible to hit as meetings with clients had become so truncated, but also because of inconsistency in targets:

… they changed the goalposts all the time. One Monday when I went in it would be all about getting so many people into work experience that week. The next Monday morning it would be getting so many people into sector based work academies.

This impacted most of the vulnerable who would fall through the system when the initiatives didn’t match their needs. This frequently ended in a sanction, leaving the staff feeling bereft and stressed from the predicament of their clients, but also their own working environment:

I just thought “this is awful”. I went home and I was really stressed, my jaw was stressed. And I just thought, “oh my god”. I just felt terrible. And I was annoyed with myself for letting her get to me like that. But it was just an unnatural situation really.

These issues were confounded by a key development in DWP: ‘digital by default’ service delivery. The target culture not only fed into individual appraisal where managers would closely, physically monitor the working practices of front-line staff; staff performance was also measured through digital monitoring. This contributed to staff feelings of dehumanisation. Our respondents reported that the move towards a fully digitized service not only led to feelings of de-skilling and autonomy, but also took away the public service motivation and ethos that drew our respondents into working in the civil service in the first instance. Staff described being permanently on the ‘back foot’, in that digital services were rolled out without staff being given the relevant training. There was also a profound shift in their own views of the public service ethos, which had changed to such an extent that staff reported to us that it was now ‘embarrassing’ to be associated with Jobcentre Plus and that their actions were making ‘vulnerable people more vulnerable’.

I wanted to do a good job, but at the same time my heart wasn’t in it, I was part of something that didn’t sit very comfortably with me. It was becoming embarrassing to say where I worked.

We are not suggesting that UC was solely or directly responsible for the findings we report here. Many of these issues reported to us predated the rollout of UC. But what we found seems to be a product of the direction of policy travel, as well as continuous reorganisation of the delivery of social security and public employment services are in the UK. What was apparent from our discussions with ex-Jobcentre Plus personnel is that under UC these factors were only getting worse. Time will tell whether this continues to be the case.


About the authors:

Kayleigh Garthwaite is a Birmingham Fellow in the Department of Social Policy, Sociology and Criminology at the University of Birmingham.

Jo Ingold is Associate Professor of Human Resource Management and Public Policy at the University of Leeds.

Mark Monaghan is Lecturer in Criminology and Sociology at the University of Birmingham. 

With thanks to LSE British Politics and Policy, and the London School of Economics and Political Science.

All articles posted on this blog give the views of the author(s), and not the position of Fuse, the Centre for Translational Research in Public Health; the five North East Universites in the Fuse collaboration, or funders.

Featured image: J J Ellison [CC BY-SA 3.0], from Wikimedia Commons

Friday, 25 January 2019

Universally discredited?

Posted by Mandy Cheetham, Research Associate, Teesside University and colleagues.

I listened to the budget in October 2018 in anticipation of an announcement about Universal Credit. We had just completed a study commissioned by Gateshead Council about the impact of the roll out of Universal Credit. I had been profoundly moved by the accounts of Universal Credit claimants with health conditions and disabilities who participated in the research. In a budget for “strivers, grafters and carers”, Philip Hammond announced that the “period of austerity was coming to an end”. He promised an additional £1 billion over five years to ‘smooth the transition’ to Universal Credit. Despite acknowledging “genuine concerns” about implementation of the programme, “Universal Credit is here to stay” Hammond asserted.

Two weeks after the budget announcement, I had the pleasure of meeting Philip Alston, the UN Special Rapporteur for Extreme Poverty and Human Rights, who was visiting the North East as part of his UK tour. We presented the findings of the Universal Credit research and he asked probing questions about the implications. We were not alone in drawing attention to concerns about the adverse effects of Universal Credit on people with disabilities. A statement of Alston’s conclusions can be found here.

Our research report was published on 15 November and the findings covered by the Guardian and Independent newspapers, local radio and television news.  Doctors’ concerns about Universal Credit were also highlighted in a British Medical Journal feature which cites our research.

The research team and Gateshead's Director of Public Health have received emails from people sharing their experiences and thanking us for raising this important subject. It has been highlighted by the Association of Directors of Public Health. I have met with local MPs, elected members, and senior managers in the Council and voluntary sector in Gateshead where I work as an embedded researcher. The findings have been shared with Department for Work and Pensions staff and we have been invited to the House of Lords. This kind of (inter)national interest is rare and a bit overwhelming! The research was made possible, because Gateshead Council commissioned it. Independent academic research of this kind is essential if we are to understand the impact of government policy on North East communities.

The findings raise questions (again) about public health advocacy and research. What is our role if not to work with communities whose voices are often unheard or ignored in policy to enable their views and experiences to contribute to debates (Smith and Stewart 2017[1]). This research demonstrates the power those voices can have when assembled using robust qualitative research methods and in the absence of any other data. The policy changes taking place under the guise of welfare ‘reform’ present huge challenges to public health and wider efforts to address health inequalities. If Universal Credit continues to be rolled out, vulnerable claimants will continue to endure hardship and destitution. Suicide rates will rise and the human and financial costs to the health and social care system will increase. As public health researchers, we have a duty to raise awareness of the effects of a policy which is undermining the health and wellbeing, employment prospects, food, financial and housing security of the most vulnerable people in society. It remains to be seen whether the government is listening to a growing body of evidence (Arie 2018[2], Cheetham et al 2018[3], Walton 2018[4]) about the impact of Universal Credit or whether, as Philip Alston (2018: 1) observed, ministers will continue to dismiss concerns and doggedly resist change in response to the many problems highlighted.

Mandy will present her research at the Fuse Quarterly Research Meeting: The impact of Universal Credit on health & wellbeing in Gateshead.  Find out more on the Fuse website.

About the authors:
Dr Mandy Cheetham Research Associate, Teesside University
Dr Suzanne Moffatt Reader in Social Gerontology, Newcastle University 
Dr Michelle Addison Research Associate, Newcastle University 
Alice Wiseman, FFPH, Director of Public Health Gateshead Council

The views expressed here are those of the authors and do not necessarily reflect those of the author's employer or organisation.

  1. Smith and Stewart (2017) Academic advocacy in public health: Disciplinary 'duty' or political 'propaganda'? Social Science and Medicine Sep;189:35-43. doi: 10.1016/j.socscimed.2017.07.014. Epub 2017 Jul 21.
  2. Arie, S. (2018) Doctors concerns over universal credit are mounting BMJ 363: doi: 10.1136/bmj.k5131 5th December 
  3. Cheetham, M. Moffatt, S. Addison M. (2018) “It’s hitting the people that can least afford it the hardest” The impact of the roll out of Universal Credit in two North East localities: a qualitative study. Gateshead Council, Teesside university and Newcastle university and Fuse, the Centre for Translational research in Public Health
  4. Walton, E. (2018) Life and Times A truth universally acknowledged: moving to Universal Credit leads to large debt and poor mental health British Journal of General Practice 68 (677): 577. doi:

Friday, 18 January 2019

Sustainable diets must be a public health priority

Guest post by Tom Embury, Public Affairs Officer at the British Dietetic Association

The publication this week of the EAT-Lancet Commission report on healthy diets from sustainable food systems makes it clear that our health and the planets are inextricably linked. As such, improving the sustainability of our diets must be a public health priority. This is something that the British Dietetic Association (BDA) has recognised for some time, and we have recently launched our One Blue Dot toolkit to help dietitians, as key public health actors, deliver on that priority.
Pale Blue Dot - photograph of Earth taken by the Voyager 1 space probe

One Blue dot – the only home we have

The BDA chose to name our Environmentally Sustainable Diets Toolkit 'One Blue Dot' for the famous image taken by Voyager 1. It is of the Earth from a distance over 3.5 billion miles, and in it our planet appears as a pale blue speck, less than one pixel wide, in the vast darkness of space. The astronomer Carl Sagan said of the image:
"To my mind, there is perhaps no better demonstration of the folly of human conceits than this distant image of our tiny world. To me, it underscores our responsibility to deal more kindly and compassionately with one another and to preserve and cherish that pale blue dot, the only home we've ever known"
Our eating habits are having an adverse impact on the environment and we are endangering the future of the planet – up to 30% of greenhouse gas emissions (GHGe) come from the production of food – and it’s the only one we’ve got. We also know that our current food system is not providing for human health either. Over 800 million people worldwide still do not have enough to eat, while nearly two billion are now overweight or obese.

We believe that eating more sustainably can be a win-win – good for us and good for the planet. It’s also the responsible thing to do. As Ursula Arens, one of the dietetic experts who helped us write the toolkit put it: "Eat healthily for you, eat sustainably for your grandchildren".

Practical help

The BDA’s 2017 policy statement on sustainable diets emphasised the central role we believe dietitians need to play, translating the complex science of environmental sustainability as it relates to food into practical dietary advice for patients and the public at large. The statement was well received by our members but they also made it clear that we needed to do more to support them to make this policy a reality. This is a big topic and can be daunting, not just for the public but for healthcare professionals as well. That is why the idea for a toolkit was born, designed to provide a summary of the key evidence, some practical tools and links for more advice.

So far, we’ve developed a comprehensive reference guide which looks in detail at the key elements of a sustainable diet, outlines the evidence on the impact of certain foods on areas like GHGe, land use and water use. We’ve included practical meal swaps, which highlight the relatively easy ways in which common meals can be made both more nutritious and have less impact on the environment. We then include detailed information on specific nutritional considerations, in particular those nutrients that may be lacking if red meat is reduced and dairy intake moderated, such as calcium, iron and iodine.

Key recommendations

The main two recommendations within the toolkit are to reduce red and processed meat (RPM), and to moderate dairy intake. These two actions will lead to the biggest reduction in GHGe in particular, and we know that there are positive health benefits from reducing RPM and shifting away from certain dairy sources such as cheese which have high environmental impact and are also typically high in saturated fat and salt.

Other considerations, like sourcing sustainable fish, eating more fruit and veg, consuming locally produced food and reducing food waste will also make an important contribution to public health. No one action will be enough on its own. It becomes clear once you delve into the science and evidence on sustainable diets just how complex this issue is, and that even seemingly innocuous differences in the way (or indeed where) food is produced makes a big difference to its environmental impact.

What next

This toolkit is not finished; it remains a live document which we hope to add to and update over the coming months and years. While the first part is focused on dietitians themselves, we know that the next phase will be to make this a public health message. We’ve already got some more materials planned, and been delighted with all the questions and suggestions from dietitians and others about what we could look to include in future iterations. If you have any further suggestions, including on how this message can be translated for public health audiences, they’re very welcome!

We know that changing our diets alone will not save the planet - we also need to make big changes in transport, energy, waste and many more besides. However, as the experts in diet and health, it’s the area in which we have the expertise to make the biggest difference.

You can find out more about the One Blue Dot toolkit on the BDA website:

Image: 'Carl-Sagan-Pale-Blue-Dot' by Owen Iverson via, copyright © 2006:

Friday, 11 January 2019

New Year, New You or is it?

Happy New Year - or is it too late to say that? Eleven days in and how are the resolutions going? In this, the first blog of 2019, two Fuse experts take a wry look at the healthy change rhetoric around at this time of year.

New year, new backlash?

Amelia Lake, Associate Director of Fuse and Reader in Public Health Nutrition at Teesside University

Annually we have a period of feast (December) followed by a period of resolution and attempted behaviour change. Is it just me, or is there a trend away from the new year new you pressure? While there is the January diet season and 'detox' season (which requires a blog post in itself), there is also the increase in gym membership (in this article in the Independent, one gym claims a 40% increase in web traffic between December and January). Also the Veganuary campaign, encouraging people to try a vegan diet for the month, which passed 225,000 sign-ups in its first week.

I may be stating the obvious here but we go from excess to aspired deprivation. Add into the mix the oh so helpful food environment. Did anyone else notice Easter eggs appearing in supermarkets on Boxing Day? Just as pestered parents (me) breathed a sigh of relief that the queue at our local convenience store (Co-op I’m looking at you) wouldn’t be filled with chocolate after Christmas – no…. we've already moved onto April’s feasting!

Back to the new year new you backlash, there seems to be a movement away from drastic change and a desire to be self accepting, more realistic and thoughtful about food. I have noticed a number of intuitive eating books thrust into the limelight and a trend towards body acceptance.

I appreciate that social media in general can be an echo chamber. In the world of nutrition on twitter and instagram, I try to follow people with qualifications in nutrition, as opposed to the general #nutribollocks which is so abundant at this time of year.

However #nutribollocks or not, intuitive eating or not, detoxing or not… we are surrounded (physical, advertising, online) with unhealthy options, also known as the Obesogenic Environment. Finding the healthy option still remains challenging. With the increase in popularity of vegetarianism and veganism[1], food outlets have a broader range available, for example the now infamous VeganSausageRoll - still not a healthy option, but what an incredible social media team!

So despite the rhetoric at this time of year about healthy changes, until we have systemic changes in our environment that make the healthy option the easy option, that make it easy and safe for us to build exercise into our daily life, that make alcohol less accessible, we are not going to have a healthy population.

Amelia is a dietitian and public health nutritionist.

The benefits of dry January and remembering Scotch & Wry

John Mooney, Fuse Associate and University of Sunderland Senior Public Health Lecturer

The late Scottish Comedian Rikki Fulton’s sketch entitled New Year’s day sums up perfectly the rationale and motivation that many might share for giving up the demon drink, at least for a while, as the New Year dawns. Learning of the events of the previous night’s ‘Hogmanay party’, during which he had gambled away his car in a poker game and set fire to and destroyed his own uninsured house, the revelation that he had won a 5 litre bottle of whisky in the raffle was precious little compensation!

For most people choosing to abstain from alcohol in January however, their reasons are usually less extreme! Indeed one of the criticisms of the concept of “dry January” is that those most likely to successfully abstain are probably already light drinkers in any case and the resulting likely health gains are correspondingly small. At the other extreme of course, for those who are dependent on alcohol (by clinical definition), impersonating the Christmas leftovers by going ‘cold-turkey’ with respect to alcohol, can have serious adverse health consequences such as convulsions etc. and should be avoided. An evaluation by de Vocht and colleagues published in 2016 showed that while ‘dry January’ led to an increase in attempts to cut down, any detectable impact on consumption remained elusive[2]. In an era in which excess alcohol consumption has become normalised and the price of alcohol in real terms has never been cheaper (in the absence as yet of minimum unit pricing for most of the UK), the overwhelming consensus is that most of the population would benefit from reducing their alcohol consumption, particularly if the resolution held all year round!

John is a public health specialist and a part-time public health stand-up comedian.

  1. "In May 2016, the Vegan Society commissioned Ipsos Mori to poll 10,000 people on their dietary habits and found that Britain’s vegan population had increased from 150,000 to 542,000 in the space of a decade (alongside a vegetarian population of 1.14 million".  Hancox, D. (2018).  The unstoppable rise of veganism: how a fringe movement went mainstream. The Guardian, [online]. Available at: [Accessed 10 Jan. 2019].
  2. de Vocht F, Brown J, Beard E, Angus C, Brennan A, Michie S, Campbell R, Hickman M: Temporal patterns of alcohol consumption and attempts to reduce alcohol intake in England. BMC public health 2016, 16(1):917.

Friday, 21 December 2018

The power of cookies

Posted by Peter van der Graaf, AskFuse Research Manager / Fuse Knowledge Exchange Broker, Teesside University

With the festive season upon us, many are looking forward to indulging in a mince pie or two and getting stuck in some extra helpings of turkey or brandy-soaked Christmas pudding. This often sparks some well-intentioned health warnings from public health folk about the risks of overindulging, binge drinking and the increasing obesity epidemic. Not wanting to dismiss these important messages, I would like to focus on a different message in this blog: food as a great tool for knowledge mobilisation (making information useable and accessible through working collaboratively).

If there is one thing that I have learned in my time as AskFuse Research Manager, it is that nothing is as useful as biscuits for bringing people together and contributing to a positive meeting between researchers and health professionals. 

This insight started from my own weakness: I have an incurable sweet tooth and my colleagues and students have quickly learned to exploit this asset for plying me with Dutch liquorice and other delicacies into supporting their requests and theses. So, I decided to turn their own weapons on them, with surprising results.

Stuck in a challenging debate about the usefulness of research evidence for commissioning local health services? Bring some cookies and fruit (to balance; I am a public health researcher after all!) and you will find that conversations all of sudden move in more fruitful directions.

Although my experience told me that cookies are a great conversation starter when brokering knowledge, I did not realise until recently that this was an area of serious academic study. In a recent paper published in Medical Education[1], Michael Hessler and colleagues from the University Hospital of Münster in Germany decided to put the power of cookies to the test and conducted their own Randomised Controlled Trial while delivering an emergency medicine course.

They were worried about the evaluations at the end of their course and suspected that these were not the measures of quality that the University was hoping for. Therefore, they were looking for a ‘content-unrelated’ intervention that would alter their evaluation results significantly and prove that their evaluations were seriously under-baked.

Third‐year medical students (n=118) were randomly allocated into 20 groups, 10 of which had free access to 500g of chocolate cookies during the course sessions (cookie group!) and 10 of which did not (control group). The groups had the same teachers and were taught the same content. After the course, all students were asked to complete a 38‐question evaluation form.

The results were very appetising: the cookie group evaluated teachers significantly better than the control group, they rated the course material as considerably better and overall satisfaction scores for the course were significantly higher. In summary: the provision of chocolate cookies had a significant effect on course evaluation.

One might conclude that course evaluations are seriously flawed but I prefer the ‘cookie-jar-is-always-half-full’ interpretation: providing cookies to participants is a great way to boost results! The German research adds baking powder to my own observations in UK knowledge brokering: cookies are a great way to boost exchange of knowledge and relationship building in conversations and meetings.

The ingredients of each meeting and conversation might be different but they all need a baking agent to rise to the occasion. So, whatever you do this Christmas, if you would like to avoid awkward questions during social and family gatherings about ‘what it is that you do as a researcher’ or ‘when are you finally going to finish your PhD?’, just bring a plate of cookies and subtly but swiftly change the conversation to a sweeter topic.

Happy Christmas!

  1. Hessler M, Pöpping DM, Hollstein H, Ohlenburg H, Arnemann PH, Massoth C, Seidel LM, Zarbock A, Wenk M. Availability of cookies during an academic course session affects evaluation of teaching. Medical education. 2018 Oct;52(10):1064-72,