52 weeks of public health research, part 12

Posted by Lynne Forrest and Jean Adams

From Lynne Forrest: Whilst buying a coffee for taking on the train, I noticed that Costa now list the calories in each cup. My flat white had 145 calories, which meant that two cups contain the calorie-equivalent of a Mars bar. This seemed shockingly high to me and I’m sure I can’t be the only person who had no idea of the large ‘hidden’ calorie count in drinks. Apparently most of the big coffee retailers use full-fat milk as standard. Perhaps we need a public health campaign (similar to those that aim to reduce hidden salt and sugar in food) to get them to switch to semi-skimmed as default.

From Lynne Forrest: As very much a fair-weather cyclist, now that the weather has improved I’ve started cycling in to work again. I’m trying to embrace the idea of active transport and cycling has the added advantage of being quicker than the bus. Most of my cycle is across Newcastle town moor, which isn’t the most scenic of routes but is traffic-free. Later in the year there are usually lots of cows blocking the path (which scare me!) but it’s currently blissfully cow-free.

From Jean Adams: I love a bit of retro-branding-as-art, but was particularly struck by this image in a hotel room I stayed in recently. How did a soft drink brand manage to become part of popular culture? When will we work out how to do that for apples?

From Jean Adams: Last week was my last visit to Ashridge for NIHR Leadership Training. Despite my initial reservations, I've really enjoyed the experience and hope I've learnt some useful things. I will particularly miss the splendid early 19th century country house setting. And the fabulous food.


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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

Sometimes you know what the answer will be, sometimes you don’t

Posted by Jean Adams

Quite often, I’m pretty sure I know what the results of a piece of research will be before we start it. I’ve never written my pre-thoughts down, so who knows how good I am at predicting the results, and how good I am at gradually changing my mind as the results become available and convincing myself, post-hoc, that I knew that all along.

We have just finished a systematic review of the effectiveness of financial incentives for changing health-related behaviours. Before we started, the general chit-chat on incentives was that they work for short-term, simple behaviours, but not for long-term, complex ones; that the effects don’t last much beyond the period that you give the reward for; and that you probably need to give people quite a lot of money to have an effect. It wasn’t absolutely clear to me why people thought this, but some prominent people, who I respect a lot, said at least some of it in some high profile journals. So I assumed I was missing something.

Our review was justified because no-one had ever tried to bring evidence on financial incentives on all health-related behaviours together in one systematic review. But I was pretty sure it was going to be one of those worthy-but-not-earth-shattering bits of work that would just confirm what everyone says already.

Like all good (or maybe bad) systematic reviews, this one seemed to go on and on. And on. The whole ‘rule book’, register your protocol, approach to systematic reviewing makes me think that it should be a nice, clean, linear, no decisions made on the hoof, sort of research method. Maybe that’s how it is for you. But it never seems to be for me. I think I’ve been entirely explicit with my inclusion criteria, but then they don’t seem to be any use for screening the articles the search found. I think we’ve finally identified all the included articles. Then some inter-library loan we’d forgotten about turns up and the reference list identifies another five papers to screen.

I find all of this unexpected messiness a little unsettling. Obviously, the number of times I’ve experienced it means it shouldn’t really be that unexpected anymore. But it is. The messiness makes me think I’ve somehow done it wrong. At which point I start to enter the bad part of the creative cycle and it is way too easy to get stuck there. Especially when it takes a year and about 30 rejections to get your review published.

The creative process

I don’t know why it took so long to get our review published. I don’t think (by which I mean please tell me this wasn’t the reason, it took so long) it was that it was badly done. It seemed to be more that everyone thought that a systematic review on the effectiveness of financial incentives was not news. We know about them - they work for short-term, simple behaviours, but not for….see above.

But it turns out that that wasn’t what we found at all. Most of the evidence we found that met our criteria in terms of study design was on smoking - a long-term, complex behaviour. We found financial incentives to be more than twice effective as usual care or no intervention for helping people to quit smoking. Effect size for smoking cessation dropped off in those studies following up for more than six months after incentives had been withdrawn, but not entirely. The effects for short-term, simple behaviours, like coming for screening or vaccinations, was similar - about twice as effective as usual care. Effect didn’t seem to be vary massively with incentive size.

I still haven’t managed to convince myself I knew this all along.

52 weeks of public health research, part 11

Posted by Amelia Lake, Beki Langford & Jean Adams

From Amelia Lake: Recorder and earpiece at the ready for my first telephone interview after a relaxing week off. Next job: to tackle too many emails!

From Beki Langford: After a very busy week and far too many hours spent in the office working to a deadline, it was wonderful to get out into the sunshine at the weekend and see that spring had finally sprung.

From Jean Adams: preparing teaching materials on the office floor early one morning, I had a sudden flash back to the days when every grant application involved sending 22 hard copies, organising great piles of print outs on the floor, and a final sprint to the post office to catch the last post before the deadline.

From Jean Adams: some of this year's students on our MSc in Public Health and Health Services Research. I'm always taken by surprise when MSc teaching starts in September and then can't quite believe it can all be over so soon come March. Actually it isn't - there are still more classes, assignments, exams and dissertations to get out of the way. Just no more of me standing up in front of the class. This year's students were lots of fun and VERY opinionated - a great combination that makes a teacher's life so much easier.

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Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

52 weeks of public health research, part 10

Posted by Bronia Arnott and Jean Adams

From Bronia Arnott: In a meeting with a policy-practice partner and I was given this funky glass which tells you about alcohol guidelines and also provides unit measures for different drinks. I was only drinking water out of it though!

From Jean Adams: when we moved into our purpose-built new offices a few years ago they were, understandably, a little stark and bare. This year a whole series of plants have mysteriously appeared in public parts of the building. They are very welcome new occupants.

From Jean Adams: the small cafe in our building sells a good range of food. But it makes me a bit sad that the cheapest hot option is a bowl of chips.

From Jean Adams: I tend to work on trains when I travel for work purposes. I feel a bit guilty if I don't and it's good, uninterrupted time for getting reading and thinking done. But at 8.45pm on a Friday evening it's okay to knit and read, isn't it?

-------------------

Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

The C word: care

Posted by Jennifer Remnant & Libby Morrison

I am a carer. I currently work on a ‘casual’ (another ‘c’ word!) basis for a mental health company. Prior to that, I worked chiefly with people with learning disabilities, and also spent some time as a PA to teenage twins with a physical impairment. Being a carer is hard work. Hard, underpaid, undervalued work. It reflects the emptiness of the rhetoric that society (and academia?) uses for service users, and the workforce that supports them. Being a support worker/care assistant/health assistant/personal assistant/care worker can be emotionally and physically draining. It involves the basics; knowledge of food preparation, hygiene and cleanliness and personal care in predominantly tiring shift patterns. If you’re going to attempt to work through Maslow’s hierarchy of needs (which I try my best to do – though it’s a mostly ideological attempt) you need to know how to keep another human being safe, how to feed them and how to keep them clean, whilst also offering service users opportunities to make real choices and where possible maintain personal autonomy, eg; ‘Would you like a piece of cake or an apple?’; ‘Would you like to be obese?’. Carers earning as little as the minimum wage are expected to make difficult and often quick decisions to support service users (often with complex needs) – when trying to balance health and safety considerations against individual choice and autonomy. 

One service user that I used to work with many years ago in a mental health service particularly tested the team I worked in; a typical exchange would be something like this:

Me - ‘Can you go to the toilet please?’

SU - ‘the toilet?’

Me - ‘yep, the toilet’

SU - ‘what for?

Me - ‘to see if you need to go’ (this person is regularly doubly incontinent )

SU - ‘what happens next?’

Me - ‘lets just take this one step at a time’

SU - ‘will I get stuck?

Me - ‘no you won’t get stuck, you didn’t get stuck last time, or the time before’

SU - ‘where do I need to go?’

Me - ‘the bathroom’,

SU - ‘the bathroom?’ (like that is the strangest thing he’s ever heard)...etc.

About 45 mins to an hour after first asking him, he might be on the toilet, he might not. He might go he might not. He might say he can’t, and then when you explained that you had other residents you needed to see and returned to the office, he might follow you there and urinate and defecate there in front of you. Or in the kitchen. Or in the corridor. Which despite not knowing either way, felt like a dirty protest – though in his defence, from macro to micro levels, there was a lot to protest about. 

He moved very slowly a lot of the time, but could also be impressively speedy. His level of understanding was very good, and so was his memory. He liked to talk about sexual violence, especially if it was a locally publicised crime, because then he could discuss with female workers the safety of their chosen route home. He worried about whether staff liked him, and asked them directly. He asked staff if they were his friends. He sometimes called the emergency services in the middle of the night because he woke up terrified that he was going to die. He has been exploited financially throughout his adult life. He was unique. He was witty, funny and thoughtful.

It was harder still to work with this service user when I found out that he regularly found the energy and time to hop into a taxi, travel down to a local brothel and pay for the company of young women. He had a preference for eastern European women. In a painful irony, many of the women service users I work with, especially with the current welfare reforms, have, or do, prostitute themselves.

This man was only one of ten residents in the mental health service he lived in. He started with 24 hour support, but as the money drip-dripped away, so did his support. The team that work with him have not had a pay rise in 4 years because they are not NHS staff.

I think for this example in particular the welfare state and its provisions are an interesting fit. I don’t even know how the staff that work with him now are going to begin to approach the ESA50 form when it comes, or the distress it will cause. In the last 6 months (in a different support role) I have supported various people to fill out ESA50 forms, and despite being as sure as I could be that all would go straight into the support group, the wait was unbearable. All of them smoked, and all of them increased their cigarette intake at this time. A number had to go to the doctors and have their anti-anxiety medication increased and those that drank reported drinking more.

Doing this job highlights the stark difference between the rhetoric at the top and the reality at the bottom. Nothing is packaged up smartly and neatly like some legislation would suggest that it is.

It also forces me to ask big ideological questions about what I’m even doing in a university – and what I want ‘impact’ to mean in terms of research.

Crumbs.

52 weeks of public health research, part 9

Posted by Bronia Arnott, Amelia Lake and Jean Adams

From Amelia Lake: years of hard work condensed into a succinct & excellent presentation. Ashley Adamson introduces Rachel Tyrrell's PhD presentation just before her viva. As one of her supervisors I'm still excited by the research Rachel conducted!

From Jean Adams: a welcome splash of colour on our desk/kitchen table at home reminding us that winter never lasts forever, and that mental well-being is as important as physical health.

From Bronia Arnott: at the train station again on the way to another meeting. Only to Durham for an askfuse meeting this time.

From Bronia Arnott: this is what my commute to work looks like - why not share a picture of yours?

-------------------

Just to remind you:

Each Thursday of 2014 we’ll try and post around four pictures on the Fuse blog that capture our weeks in public health research, from the awe-inspiring to the everyday and mundane. Given that more of the latter than the former exists in my life, I foresee problems compiling 208 images worth posting on my own. So this is going to have to be a group project. Send me an image (or images) with a sentence or two describing what aspect of your week in public health research they sum up and I’ll post them as soon as I can. You don’t have to send four together – we can mix and match images from different people in the same week.

Normal rules apply: images you made yourself are best; if you use someone else’s image please check you’re allowed to first; if anyone’s identifiable in an image, make sure they’re happy for it to be posted; nothing rude; nothing that breaks research confidentiality etc.

Also, this doesn’t mean we wont also be posting words. You word-based posts are, as always, much appreciated.

The New Public Health System at Nearly One

Posted by David J Hunter

With the public health system changes in England approaching their first anniversary it’s a good time to take stock and reflect. Much remains to be done as new relationships are forged and structures bed down but already some matters are becoming clearer. They pose a mix of threats and opportunities.

The new English public health system has nearly reached its first birthday

It’s in the nature of local government that some local authorities will rise to the challenge presented by public health more readily than others. But to assume that Whitehall, in the shape of the Department of Health or Public Health England, can step in and sort things out is both simplistic and naïve.

As a new report from the Institute for Public Policy Research on the relational state concludes, complex problems defy solution by central government and require all stakeholders, notably local government, to work in new ways to reshape public services. A reliance on bureaucratic and market-based tools is no longer ‘fit for purpose’ if it ever was.

So what are some of the key issues with which the new system is grappling and which will set the future direction in the run-up to the general election in May 2015 and beyond? I briefly explore four here.

Place-based budgeting

The prize in having public health return to local government is the opportunity afforded to adopt a place-based approach to harnessing resources to improve population health across whole communities and neighbourhoods.

Forget the ring-fenced public health budget. This is an often unhelpful distraction and is certainly likely to be time-limited. The real agenda is about pooling local resources from a range of bodies and determining how best to allocate them to meet identified needs.

Already community budgets are being developed in some local areas and there is scope to take this approach much further perhaps picking up from where the Total Place Pilots left off under the last government in 2010.

Role of Health and Wellbeing Boards (HWBs) and managing unrealistic expectations

A paradox of the public health changes is that Health and Wellbeing Boards (HWBs) have acquired huge prominence and expectations are high. They are seen as the system leaders locally charged with the task of promoting integrated health and social care, public health and overseeing the reconfiguration of health services in local areas. Yet they have virtually no powers.

These are significant and complex responsibilities and there must be doubts about HWBs’ abilities to deliver what is needed across all of them. The risk otherwise is that HWBs are being set up to fail. The wiser HWBs will not allow themselves to be stretched beyond their limits and will identify their key priorities and stick to them. Nevertheless, the temptation to take on responsibility for the entire health system will be hard to resist.

Role of Public Health England (PHE)

The new kid on the block is Public Health England and considerable uncertainty surrounds its place in the new architecture, both nationally and locally. Concerns exist over its independence from the Department of Health and this has yet to be thoroughly tested although the omens are not promising.

On minimum unit pricing for alcohol, PHE rested its case on the evidence which ultimately the government chose to ignore. And this is the problem – the evidence rarely speaks for itself. But for a body whose existence is predicated on presenting the evidence what options are open to it should those to whom it reports choose to ignore its advice? ‘Speaking truth to power’ is much more complex and political than simply marshalling and presenting the evidence in the hope that good sense will prevail.

In a new report on PHE, the House of Commons Health Committee is critical of what it sees as an ‘insufficient separation between PHE and the Department of Health’. It concludes that although PHE was created ‘to provide a fearless and independent national voice for public health in England’ it does not believe that ‘this voice has yet been sufficiently clearly heard’.

Local authorities remain wary and puzzled by PHE and the new centres appearing in their midst. They instinctively feel they do not want a central presence overshadowing their work. Conceivably, PHE can offer valuable support and resources but building effective, high trust relationships is proving tricky. It also takes time which is at a premium.

With an election looming in just over a year’s time, PHE will be under growing pressure to prove itself and demonstrate impact. Few cherish ‘quangos’ or arm’s length bodies, especially new ones.

Changing nature of workforce in terms of skills and capacities

Perhaps the most threatening challenge to the public health system, or possibly the one that offers most hope for real progress depending on where you sit in the new landscape, is the public health workforce and the changes which beckon. The issue divides opinion sharply and is intensely political since it confronts long-standing and fiercely held professional views.

There is no doubting that many moving into local government from the NHS are struggling to find their place in the new system. For the most part this comes down to a lack of understanding or appreciation of local government and its political dimension.

The leaders in local government are not the officers but the elected members. Many bring to public health issues considerable extant knowledge and experience of their communities and while this may not represent evidence in the conventional sense, it remains a key factor in decision-making.

I predict that the public health workforce in a few years’ time will look and feel very different. There will be casualties and not all local authorities will get it right but if local government is to serve public health better than the NHS, with exceptions, managed to do, then it’s time for a change in the workforce and its skills base.

The new public health leaders need to be politically astute, able to communicate well with different audiences, form relationships that enable things to get done, and assemble the business case for investing and disinvesting in public health. There are some Directors of Public Health who get it but many still don’t or have no wish to. They live in hope that what has happened to them will, like the floods affecting large parts of England, magically disappear so that life can return to normal.

Looking ahead, the challenges facing public health are hugely complex and require careful assessment and reflection as they unfold. None offers easy answers. While there are risks that the system will be unable to cope and fail to deliver, there is also renewed hope that what is being put in place offers an opportunity to promote health and wellbeing in a way that was only rhetorically advanced prior to April 2013.