Friday, 15 March 2019

Have you haddock enough?

Posted by Louis Goffe, Research Associate, Newcastle University

That smell. That distinctive saline scent. Your subconscious has your saliva glands brimming before you’re cognisant of what you desire.

Fish & chips is arguably our most iconic contribution to the culinary arts. This most harmonious pairing of Jewish-style fried fish with chipped potatoes, first engaged in the 1860s and have been besotted with each other ever since. At their peak during the inter-war years, there was an estimated 35,000 shops around the country, while in today’s diverse and competitive fast-food market, there remains around 10,500 chippies.
Fish & chips Edwardian style

The interrelating factors that derive our weight are as unique as our fingerprint and untangling and finding solutions is a global challenge. There is no single determinant and competition for a slice of the obesity research funding pie, is as cutthroat as the local high street takeaway shop cluster.

Takeaways are not the prime suspect in unlocking the door to good health, but it’s clear that they do play a role. As such, we need to scope what aspects can change to help provide customers and communities with healthier options.

When it comes to food, there is no universally accepted metric for ‘health’. The term is open to interpretation and keenly fought over, see the fat Vs carbs debate. However, such considerations are rendered obsolete when considering the nutritional profile of independent takeaway food, where meals were found to be “excessive for portion size, energy, macronutrients and salt”. It is the sheer volume of food provided that is the intimidating/wondrous [delete as personally appropriate] factor.

Pizzas are the chart toppers when it comes to portion size, delivering a medium value over 1,800 calories, though fish & chips are not far behind on an excess of 1,600 calories. This is a hefty dollop of energy, given that an adult women is advised to consume 2,000 calories per day. Of course, just because a portion contains this amount of food, it doesn’t mean that one will consume it all. But the evidence is clear “people consistently consume more food and drink when offered larger-sized portions, packages or tableware than when offered smaller-sized versions”.

It was not our assertion that any particular cuisine type is to blame, but to find potential solutions to what has likely been an arms race by traders in response to their most vocal customers to provide the most calorific-kick per quid, as highlighted in this quote from a Scottish fast-food trader.
“They just want chips… they'll have a look and then go along have a look at their deals and then come back and they'll order… they like the value for money. The competition here is unbelievable.”
In our NIHR School of Public Health Research funded study based at Fuse in collaboration with The Centre for Diet and Activity Research at the University of Cambridge, we wanted to challenge the notion that quantity rules above all, to see if traders and their customers were accepting of promotion of smaller meals.

Louis throwing himself into the research
Fish & chips offered the ideal starting template. Their taste is as beholden to us, as espresso is to the Italians, therefore reformulation has limited potential. Despite their volume, they’re presented as a one-person meal, with smaller sizes mainly limited to children, pensioners or as lunchtime specials.

Engaging with traders is a huge challenge. Therefore, we asked Henry Colbeck Limited, an independent specialist fish & chip shops wholesaler, to give the project that foot-in-the-door via a trusted voice. We co-designed the intervention, but crucially, they led on delivery and we retained our independence as a research team for analysis and interpretation of the evaluation data.

We were operating in an intervention landscape reliant on traders’ voluntary participation. This meant an emphasis on the potential financial rewards of provision of smaller meals to traders’ businesses, through articulating the power of customers’ awareness and demand for healthier options.

Henry Colbeck were key to creating a meaningful dialog with and between traders and getting them on-board with the trial. We found both owners and their customers were broadly accepting of the prominent promotion of the lighter meals, with a reported increase in the proportion of smaller meals sales, however our sample size was too small to derive statistical inference.

Lite-BITE box developed by Henry Colbeck Ltd
Interestingly, during interviews with traders, one big question remained, ‘what constitutes a smaller meal?’ During the trial, it was left to traders to define and package accordingly. Concurrent to our independent evaluation, Henry Colbeck sensed an opportunity and developed a new product specific packaging, the ‘Lite-BITE’. They have subsequently sold, along with their partner suppliers across the UK, 12 million boxes in 2018, highlighting that there is the customer demand for a more modest and manageable portion.

Despite this success of raising the profile of smaller meals, how much of them we consume is still unknown and more work is required to better understand the health implications. Also, like the traders in our study, we the consumer, would also benefit from clearer, potentially standardised, portion sizes that could help support nutritionally informed choices.

Our study was formative in nature, but the Lite-BITE box sales show an appetite for smaller takeaway meals and the access to traders that Henry Colbeck provided far out numbers those we could have obtained through door-stepping as academic researchers. We should put all potential tools on the dinner table that could help create healthier environments, including harnessing customer power. So next time you’re in your favourite fish fryer, if it’s not on the menu, ask for a smaller meal and hopefully the owner will soon start to sniff out that saline scent of profit to be made from healthier options.

Louis stars in our video about the research

Image: 'Beamish offers Edwardian-style fish and chips' from BBC Wear 2011:

Friday, 8 March 2019

Igniting my future career with a SPARC

Guest post by Naoimh McMahon, Postgraduate student, University of Central Lancashire

Naoimh recently passed her viva and won Research Student of the Year at the North West Coast Research and Innovation Awards 2019.

Around about now the National Institute for Health Research (NIHR) will be letting early career researchers know if their applications to Round 5 of the Short Placement Awards for Research Collaboration (SPARC) scheme have been successful.

These awards provide funding to allow trainees within the NIHR infrastructure to spend time in other parts of the NIHR to network, acquire new skills and expertise, and establish collaborations with experts in their field. To be eligible for this round of the SPARC scheme, applicants have to be undertaking a formal research training programme, such as a PhD, and be funded by an NIHR award. Additionally, applicants needed to be based in part of the NIHR infrastructure that has a specific remit to build research capacity, such as the NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). In 2017 I applied for Round 4 and while I met both of these criteria, I was also facing the final year of my PhD with a lot of writing still left to do! However, this would be my last chance to apply for the SPARC award and so it seemed like too good an opportunity to pass up.

For my PhD, I was based at the University of Central Lancashire in Preston, and my research was funded through an NIHR CLAHRC North West Coast doctoral studentship. This work was looking at how people negotiate different discourses within the field of health inequalities and how such discourses work to shape thinking and action. With this interest, and a new-found penchant for the North of England, I knew exactly where I wanted to spend my time during a SPARC placement – it had to be in the North East with Fuse! And so towards the end of October, I emailed Professor Clare Bambra (@ProfBambra) to make my case and see if she might be happy to act as my host and supervisor for a placement. After what I can only assume was a glowing reference from one of my PhD supervisors, Clare was on board and we booked in a call to discuss plans for the SPARC proposal.

The requirements for a SPARC award are that you provide a training programme for the placement and you justify the proposed benefit of the programme for your own research and the potential impact for your future career development. After talking through different ideas and options, and considering the short time frame of the placement, Clare and I settled on a training programme oriented around evidence synthesis on the topic of gambling and health inequalities. At the time, gambling was becoming increasingly topical but there was little written about the effects of interventions on social and health inequalities. This focus for the placement was seen as a good fit as Clare had a strong interest in this topic and it would allow me to apply insights from my PhD research to a new body of literature. A co-authored peer-reviewed publication was to be the main output from the placement and we stressed the opportunities provided by the wider Fuse infrastructure for networking during the placement. In March 2018, I found out that my application had been successful and in April I started my six-week stint at Newcastle University.

Slot machine True to our word, we did exactly what we promised in the proposal! During our scoping searches of the gambling literature we identified a number of recent systematic reviews which synthesised evidence on different types of interventions for reducing gambling behaviour and gambling related harm, and so we felt it would be of value to collate the findings from across these reviews into a single umbrella review. The resulting paper has now been published in Addictive Behaviours. Reflective of the wider health inequalities literature this review has highlighted the lack of consideration of equity effects of intervention strategies in both primary research and evidence syntheses in the field of gambling. Additionally, it has illustrated that there is likely to exist an ‘inverse evidence law’ in this field where there is the least amount of research and evidence for interventions that are most likely to be effective. A big thank you to Katie Thomson (@katiehthomson) and Eileen Kaner (@EileenKaner) for all of their help and input with this review.

 Along with completing this work during my SPARC placement I had the chance to meet people from the Fuse health inequalities programme; get to know some lovely new office mates; attend Fuse’s 10th birthday event and meet people working in local authorities and third sector organisations; meet Fuse Director Ashley Adamson; and attend a Quarterly Research Meeting on eating and drinking patterns in young adults. Last, but certainly not least, I attended and presented my PhD research at the 4th International Fuse Conference which was held in Vancouver in May of last year (see here for a related post on the conference).

In October 2019, the NIHR will launch Round 6 of the scheme and for anybody who may be thinking of applying, here are some things to keep in mind when preparing an application:
  • Be ambitious about where you want to spend your time – if you don’t ask you don’t get!
  • Develop a training programme that works for both you and your host supervisor
  • Try and co-ordinate dates to fit in training or conferences at your host institution
  • Detail specific outputs in your application and allow yourself time to get these finished after the placement has finished.
Taking on this type of placement was going to be demanding at any point during a PhD but from my experience it is definitely worth the time and energy. Thank you especially to Clare and Katie, and to everyone at Fuse that made the placement such a positive and worthwhile experience.

  1. Image by Pexels on Pixabay
  2. Jeff Kubina from the milky way galaxy [CC BY-SA 2.0 (]

Friday, 1 March 2019

Is public health ready for complexity?

Guest post by Brian Castellani, Professor of Sociology at Durham University

Public health, presently, is at a difficult crossroads. Its massive success in making the world a healthier place has led to a global embrace of its incredible insights; but still, the challenges currently faced have not given in so easily, as they are deeply entrenched complex problems - or, alternatively, what are more generally referred to as wicked problems!  The global spread of infectious disease; an exponentially growing (or, alternatively, greying) population throughout many parts of the world; the negative impact ecological upset is having on climate and health; urbanisation and the development of mega cities and metropolitan regions; the increasing costs of health and healthcare; air pollution; the opioid epidemic; and so forth.

Still, despite this increasing complexity, public health has been rather resistant to making the shift, falling back on tried-and-true ways of thinking about and modelling public health issues. This is particularly true when it comes to the harsh realities of getting funded or published!  This needs to change! The challenge, however, is how?

Here are, in my mind, six things that public health researchers and practitioners can do to make more effective use of the complexity sciences and advance the use of these ideas across the field:

Six ways to advance the study of complexity in public health

1. Public health is in a difficult position: it realises its work is more complex, but it is struggling to embrace the tools and concepts of complexity science and computational modelling, as it means doing things differently.
  • This is particularly problematic in terms of funding streams and publishing in journals.
  • The only way forward, then, is to get on with it and actually start funding and publishing such work. High risk can lead to high reward! 
2. Related, the best way forward is for public health to employ a mixed-methods approach, as most public health issues require more than one method, including computational modelling.
  • This includes embracing the old and the new, particularly in terms of complex networks, machine intelligence, participatory systems mapping, qualitative comparative analysis (QCA), and agent-based modelling.
3. Public health needs to adopt a critical approach to complexity, as not all methods or theories are equally useful. In other words, the advance of complexity thinking in public health has to be more than the simple application of hard science methods.
  • For example, while complex network analysis is powerful, it has significant limits.
4. Public health also needs to develop its theoretical and conceptual understanding of public health topics as complex. This is also true in terms of policy evaluation.
5. Public health needs to recognise the important role it plays - both in terms of theory and practical experience - in the development of the complexity sciences, as most of these scholars are trained in other fields. Practitioner expertise, combined with the latest advances in computational methods, will go a long way to improving health. It cannot, however, just be one or the other.

6. Finally, public health needs to adopt a case-based approach to modelling its various complex topics, as health (be it an individual or population) is about cases.
  • In turn, it needs to move away from the strict study of variables and variable-based statistics.
  • Statistics remains very important for complexity modelling; but variables need to be attached to context and cases and their various path-dependent trajectories.
  • Related, the field needs to shift to modelling multiple case-based trajectories, rather than designing a single model.

I want to thank Fuse for the opportunity to present a brief overview of the value of the complexity sciences for public health (and, in turn the value of public health for complexity science!) on 14 February 2019 at Newcastle University.  For those interested, here is a link to the presentation.

Friday, 22 February 2019

What old crisp packets dig up

Posted by Duika Burges Watson, Lecturer at Newcastle University based in the Institute of Health and Society

It appears that I’m an academic litter picker. I like to have hands on experience of topics I write and teach about. Inspired by the new module I’m leading on Global Health in the Anthropocene, and in particular a lecture on plastic pollution and health, I went litter picking. The Anthropocene is a new (ish) term to public health - considered to mark a turning point where “changes to the structure and function of the Earth's natural systems represent a growing threat to human health”[1].

I certainly found a good site for it. In less than 10 minutes from a 2 metre square area, I collected 69 crisp packets amongst the plastic bags and other items. I was intrigued, so I took them home and washed, sorted and ‘analysed’ them. Some use by dates were no longer visible, but of those I could read, 49 of 69 were Walkers crisp packets (parent company Pepsico) with use by dates from between 1996 to 2014. I went back the following weekend to the same site, dug a little deeper, and collected a further 89 crisp packets of which 51 were Walkers. The oldest packet was a Geordie company, Tudor (more on them later), with the use by date 10th January 1992.

Walkers bought out Newcastle
based company Tudor in 1987
There is a lot to be explored on crisp packets including use by dates, ingredients, health labelling and advertising.  Many even listed the time of production, often very late at night. For example, a Walkers smokey bacon use by 23rd June 2012 was made at 10.48pm. The irony of time was not lost on me in terms of the Anthopocene: we can know the exact minute the crisps were made (but not the date), they take about 2 minutes to eat and result in decades of rubbish.

Walkers began using foil bags in 1993 with plastic coatings. Yet people have been finding perfectly preserved plastic Walkers bags from the 80s in litter picking efforts. In September 2018, no doubt inspired by David Attenborough’s shocking profile of marine plastics in the series ‘Blue Planet’, the public started sending their bags back to Walkers. Royal Mail protested that people had to put them in envelopes first.

Walkers took up the challenge created by public protests. They have promised to find alternative solutions to the pesky bags by 2025, and until then have set up a recycling deal with company terracycle across the UK. There are collection points all over the UK.

But it wasn’t just the plastic pollution that concerned me. Crisp consumption is one of those things that people in public health worry about because these are classic examples of the high fat, salt, sugar foods where over-consumption can play havoc with our health. But we’ve been eating crisps for a long time, long before epidemics of obesity, and they have a cultural history to boot. A Brief History of Crisps (2012), suggests they were a British invention that turned up in the English edition of The Housekeeper’s Manual in 1829. The ‘modern’ industrial crisp really found its crunch after the first World War when the Smith’s company enrolled grocers and butchers across the UK to offer crudely made crisps (made in house with lots of fatty smells apparently). In the 1950s it all changed, technologies were imported from the USA and production scaled up. The first company to employ this technology was the previously mentioned Tudor. In 1967 they introduced the first ‘salt and vinegar’ chips to the UK market from their base in Sandyford, Newcastle. Tudor’s 1970s-80s commercials have a distinctly Geordie feel (note the ‘Dunstan Rocket’ in the first ad below – an iconic piece of architecture!). As a more recent immigrant to Newcastle, I had always wondered why every time I got served a sandwich it was with crisps – now I know – they have a proud Northern heritage. Walkers bought out the Tudor company in 1987.

In my ‘analysis’ of crisps, I have been wondering about their continued value as ‘food’. Is there a way we can still enjoy them as cultural icon without creating so much waste and without damaging our health? The one thing I’ve learned about food is that preferences change, tastes change – is the solution to learn to like something else? Last year the Walker’s crisp factory in Peterlee was bought by Heather Mills for her vegan food empire VBites. She is now looking to take over an abandoned factory in Northumberland. If successful, this would be the largest vegan food producing factory in the UK.

One of the sessions I’ll be leading in the Anthropocene module is on food – from source to senses. There is growing international concern about what kind of diet we ‘can’ eat if we want to protect and preserve the planet in the face of the Anthropocene and global climate change. The Eat Lancet Commission produced some rather controversial findings in January that offers their vision of what a ‘sustainable’ diet might involve[2]. Not unexpectedly, it involves cutting back on meat and eating more veg. Most agree that urgent change is required to farming systems and diet, but getting exactly the right mix of dietary components has created tensions. The Sustainable Food Trust, for example, points out that some land is not suitable for vegetable production and that grazing is the best option in some places. So, no simple solutions, and more debate to be had.

Another area of interest that will be covered in the course is new understanding of what it is that makes food ‘delicious’, how we ‘sense’ food, and what promotes ‘satiety’ or feelings of fullness. The ‘flavour’ of food involves a fusion of sensory inputs: smell, taste, colour, sound, trigeminal nerve stimulation[3], and our enjoyment of it is mediated by our culture, our history, our environment. Crisps are not difficult to figure out from a sensory perspective, like many other ‘fast’ foods, they are particularly heavy on salt, fat and sugar: what I would call ‘tongue’ foods. More complex ‘flavours’, particularly those involving smell, have been found to better trigger satiety – that’s why you can keep eating crisps without feeling full. But why do we like these ‘tongue foods’ so much? It’s complex; you’d have to join the course to explore this question.

So what about crisps then? Can we as public health researchers do more with ‘flavour’ to inspire different kinds of food choices? Could we encourage archaeological litter picking to engage the younger folk given so many foods are in single use plastics? People seem willing to give up plastic bags - could we encourage people to stop eating crisps until 2025 when they are in recyclable bags?  I don’t know the answer to these questions, but it will require more than litter picking to know. Food choice is academically interesting from a flavour point of view.  The crisp example throws up other challenges for public health - the Anthropocene creates interesting ethical questions about how we eat ‘beyond’ questions of the food itself. In March we will be running flavour masterclasses for the public where we get hands on to unpack the mystery of the humble crisp, why we like them, and what we should do about it! These questions are also being addressed by the Altered Eating Research Network (AERN) at Newcastle University, a new interdisciplinary collaboration that considers how our relationships with food are diverse, sometimes problematic, and how they intersect with the changing environments we live in and co-create. Keep an eye on the AERN website for details of flavour masterclasses and other upcoming events.

  1. Whitmee, S., Haines, A., Beyrer, C., Boltz, F., Capon, A.G., de Souza Dias, B.F., Ezeh, A., Frumkin, H., Gong, P., Head, P. and Horton, R., 2015. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health. The Lancet, 386(10007), pp.1973-2028.
  2. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems (Walter Willett et al.).
  3. The trigeminal nerve is responsible for sensations in the face and for motor control of biting and chewing. It is how we experience the ‘spiciness’ of food, the ‘coolness’ of mint or the ‘fizziness’ of carbonated drinks. Spence, C., Smith, B. and Auvray, M., 2015. Confusing tastes and flavours. Perception and its modalities, pp.247-274.

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.