The Troubled families Programme: what's health got to do with it?

Guest post by Stephen Crossley, PhD student in the School of Applied Social Sciences at Durham University

A couple of weeks ago, the expansion of the Troubled Families Programme was formally announced during the Queen’s Speech. This formality came two years after the government itself announced their plans to expand it, around 10 months after they announced further details such as the criteria to be called a ‘troubled family’ under Phase 2 of the programme, and around six months after some local authorities started working with ‘troubled families’ as part of the expanded programme.

Another troubled family?

There have been numerous criticisms of different elements of the Troubled Families Programme since the programme was announced in the wake of the riots in England in 2011, with David Cameron promising to ‘turn around’ the lives of the most troubled and troublesome families in England by the end of the Parliament that finished in May 2015. Ruth Levitas and Jonathan Portes highlighted that the figure of 120,000 ‘troubled families’ used by the government (characterised as ‘neighbours from hell’ in the prime Minister’s launch speech), actually referred to research published four years earlier on families thought to be experiencing multiple disadvantages such as maternal mental health, poverty, material deprivation, poor quality or overcrowded housing. Levitas argued it was a discursive strategy which succeeded in feeding vindictive attitudes towards the poor.

A report carrying a series of interviews with families, written by Louise Casey, the senior civil servant in charge of the programme, was criticised for its lack of ethical process and the government admitted it was a ‘dipstick’ process which didn’t meet the government criteria for research and therefore didn’t require ethical approval. My own investigations revealed that a ‘survey’ used by Casey to highlight the need for ‘radical reform’ didn’t actually exist. In a series of speeches during 2013, Casey told audiences of a survey which showed that, in one deprived area in the North East, not one out of 3000 children had attended a dentist for a routine check-up, but that 300 had presented at A&E for emergency dental care. The survey was, in fact, an anecdote shared during a meeting about a different government programme, which Casey never thought to check before sharing with audiences, preferring instead to tell them it ‘encapsulates the problem’ of ‘troubled families’ in a single example. Casey also told the 2013 RCGP conference that these 120,000 families ‘dominated NHS budgets. That’s the long and the short of it’, which isn’t exactly true either.

To date, however, health has played a relatively minor part in the Troubled Families Programme (TFP) and health issues were not mentioned in either the criteria for families in Phase 1, or the outcomes expected in order for their lives to be considered ‘turned around’. But this is starting to change. The government published a report in July 2014 entitled: ‘Understanding Troubled Families’ which included information on the characteristics of families entering the programme in its early stages (my brief (Mis)understanding Troubled Families is available here). The data showed that the majority of the families being worked with under the banner of the TFP were not particularly anti-social, weren’t serial offenders and most of the children were in education, albeit not all of the time. In fact, the only characteristics that could be applied to a majority of families included in the report were that they were white, they lived in social housing, they had an adult on out-of-work benefits (although we don’t know why) and they had a family member with a serious health issue or a disability. In short, and if any personal characteristic can adequately explain unemployment, these families were probably more likely to be out of work because of health, disability or caring issues than because of any intergenerational culture of worklessness.

In the expanded second phase of the programme, ‘parents and children with a range of health problems’ is included as one of the six criteria for families, who have to hit two of the criteria to be labelled ‘troubled’. Other criteria include ‘children who need help’ and ‘children who have not been attending school regularly’. These vague criteria are open to interpretation and councils will be encouraged to go out and find ‘troubled families’ in order to ‘turn them around’ (or make ‘significant and sustained progress’ in phase 2) and claim the cash bonus, via the Payment By Results process, for doing so. A health bulletin on ‘troubled families’ was also published when the new criteria were announced, highlighting the health related issues some ‘troubled families’ faced, and a ‘leadership statement’ followed shortly after, accompanied by information on skills and training and interim guidance on data sharing amongst partner agencies. With health visitors and school nurses now under the remit of local authorities in England, it is likely that many will become involved with the TFP.

All of these developments should concern health professionals. The TFP assumes that the answer to the families problems lie firmly within the four walls of the family home, with a strong rhetorical focus on ‘getting in through the front door’ and working with the family ‘from the inside out’. In short, there is no room in the narrative for wider determinants of people’s circumstances. Its alleged success has never been proven. There is scant evidence to justify such an approach and it is unlikely that having a determined, non-specialist key worker will make much difference to many of the health problems ‘troubled families’ experience. The programme is a good example of what David Hunter and Jenny Popay and others have called ‘lifestyle drift’, where the focus of interventions drifts towards attempting to change individual behaviour, despite the wealth of evidence pointing to other solutions. But this ‘responsibilization’ strategy is also a punitive, stigmatising discourse which is targeting some of the poorest and most vulnerable families in England, telling them that they are the architects of their own misfortune and that they just need to try harder and follow a routine. A simultaneously fascinating and alarming article in the BMJ recently, exploring the role of psychology in government workfare programmes highlights that this approach is not a unique aspect of the government’s welfare ‘reforms’. Health professionals should tread carefully.

Stephen Crossley's first peer-reviewed article on ‘troubled families’ can be found here.

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Complexity in health organisations: setting ourselves up for chaos or enjoying the simple things in life?

Posted by Peter van der Graaf

Can applying a complexity lens to health organisations be more than an academic exercise with practical applications for service delivery? This question was central to a two-day meeting last week in London at the Health Foundation between researchers, policy makers and health practitioners. The event was organised by The Knowledge to Action Group (KTAG), an international team of senior academics and coordinated by two leading members of Fuse’s Complex Systems research programme, Prof David Hunter and Dr Emily Henderson. The group brought together the crème de la crème of health research and knowledge mobilisation, with about 40 handpicked participants from across the UK to debate a green paper on the topic (which is a tentative government report and consultation document of policy proposals for debate and discussion).

The essence of this meeting was about getting to grips with the consequences of doing research and developing interventions in a world that is inherently complex (which is not to be confused with just being complicated!). The green paper (Knowledge-to-Action: Addressing Complex Problems in Health Systems, May 28/29 2015) described complex systems as non-linear; dynamic; and having no single point of control.  Because of these characteristics, outcomes in a complex system are unpredictable and resistant to interventions. So are health systems really complex? Anyone trying to get research evidence into practice will quickly discover that knowledge mobilisation is prone to all the characteristics outlined above for complex systems.

In one of the breakout sessions during the event the difference between complicated and complex was illustrated with the example of building a rocket versus raising a child.  Building a rocket is complicated but will lead to a predictable outcome (successful launch) if all the different pieces are correctly assembled according to the guidebook. However, raising a child is complex (as many parents will testify) and often leads to chaos in many academic households. This is bad news for academic parents and health service managers: you cannot steer the thing (but you are still accountable for it) and even if you find the solution to a problem in the system it is likely not to work when you try it again. The dynamic nature of systems means that what works in one context or at one point in time may not work the same as the system changes.

How do you work within such a system? Fortunately, the event provided four case studies of research projects where the academics had managed to work within a complex health system to produce change across different areas, often in co-production with policy makers and health practitioners. The authors of the green paper distilled four themes from these case studies to inform future research and interventions:

1. the balance of central and distributed authority in organisations and systems; 
2. the importance of emergence (continuous learning and adaptation); 
3. the need for co-produced knowledge; and 
4. a range of leadership positions and styles.

These four themes were discussed in more detail in various breakout sessions over the two days.

Participants embraced the spirit of the event and discussed a wide range of topics (from the need for a critical discourse department to finding positive deviants), whose relationships with the four themes were sometimes unclear and mostly unpredictable. Nevertheless, some key messages emerged from the event that will soothe the nerves of academics and service managers. By visualising complex organisations as “patterns of conversations between interdependent individuals” (as quoted in a presentation from Allan Best on the first day), working in complex systems becomes conversation management and engagement. According to the researchers involved in the successful case studies, this works all the better outside the normal context of everyday work by taking commissioners to the pub or baking a cake for a meeting with service managers to get the conversation really going. Isn’t it ironic that to work inside complex systems, one needs to go back to basics in a more simple system?

52 weeks in public health research – the (very) rough guide

Guest post by Avril Rhodes

Remember the natty idea to take photographs representing a year of working in public health research? Well, how about a quick analysis of what we saw, snapped and submitted? Here are the exciting and indeed revealing results.

After looking at 198, or was it 200, images a portrait of researchers concerns emerges – not exactly Maslow’s hierarchy of needs, so much as the Rhodes' hierarchy of academic obsessions.

Bottom or is it top of the pile comes food. It’s official – no less than 42 pictures, close up and distance shots, ranging from individual snacks, drinks and meals to full size conference spreads and displays. I felt slightly queasy after looking at them all. Feed those academics!

The next most important thing is to feed the mind. Any passing course, lecture, symposium and the like weighing in with 20 pictures. But there’s lots more that get close to the mind-feeding category although making more cameo-esque appearances, such as degree ceremonies, IT, stands and posters, books, theses, work in progress and journal covers. Publication definitely counts. Completing work even more.

The office – no not the TV series, comes next, with 16 images, inflated perhaps with opportunities created by moving office and the delights of standing desks and desks tied to exercise apparatus. I would not have dreamed that taking a picture of the immediate work environment was so important. 

Travel ranks highly but possible to count in different ways. Railway stations are significant at 11 pictures, especially Newcastle Central – of world significance as stations go, but that’s just me. Car travel featured just slightly with a nod to cycling. Active travel (good and bad) is clearly a source both of delight, when stairs get favoured, and frustration, when lifts are promoted. Exercise equipment got a decent look in too. 

Signs and marketing really played on the collective academic mind. Labelling, the impact of shop placements and advertising, spelling mistakes, unintended humour, public health messaging, came in with around 12 images. Some of this felt a bit judgemental, when it came to cheap unhealthy food signs. Not too many wider determinants of health, it has to be said.

 

Field work related images scored a fairly respectable 9.

 

Culture kept creeping in. Museum visits, architecture, music, sculpture were all there. Nature played a relatively small part, but researchers did appreciate the cute, the beautiful, office plants and the changing seasons.

 

Then a whole rag bag of one-offs. Some were clearly novelty items or personal reminiscences, and some seemed like stream of consciousness, or pet concerns.

Curiously, the academic world was quite short of pictures of people, except in crowd shots doing serious lecture type stuff. It looked a camera shy world. So what do we have? A hard working, semi-office bound, nomadic community that likes writing, learning, unable to switch off form public health even when undertaking a leisure activity or just walking around the town, that enjoys high art and longs to sniff a flower. Is this what we are? The camera apparently doesn’t lie.

Public Health Post-election: What is its future?

Posted by David J Hunter, Professor of Health Policy and Management, Durham University and Fuse Deputy Director

The Conservatives’ election victory has brought both old and new faces into the ministerial team at the Department of Health. Jane Ellison returns as a junior minister and will retain the public health brief thereby bringing a degree of continuity to the post. She was growing into the post in the run-up to the election and public health insiders speak well of her.

Public Health Minister Jane Ellison

The fact there has been extensive coverage of the other ministerial appointments in health excluding hers might say a great deal not only about the place of public health in the government’s health priorities but about the level of importance the media attaches to the subject.

Clearly the funding difficulties plaguing the NHS will be uppermost in Jeremy Hunt’s (back as Secretary of State for Health) in-tray with the integrated health and social care agenda not far behind. But the new government is also committed to implementing the Five Year Forward View (5YFV) produced by the NHS Chief Executive, Simon Stevens, last October. Herein lies the hope for public health and surely the near certainty that it will occupy a high place on the government’s list of priorities.

Public health did not feature prominently in the Conservative Party’s manifesto and no major new initiatives were promised. None of the parties had much to say about public health during the campaign. And yet the new government is going to come under significant pressure to up its game over the next five years with the call for ‘a radical upgrade in prevention and public health’ featuring prominently in the 5YFV.

Not only that, but Simon Stevens rarely misses an opportunity in public to stress the importance of public health, admonishing successive governments for their failure to implement the Wanless ‘fully engaged scenario’.  Since the NHS failed to heed the warning, it ‘is on the hook for the consequences’. Wanless wanted a transformed NHS that put health and not illness first.

The 5YFV urges the NHS to redeem itself over the wasted years by becoming an advocate for ‘hard hitting action’ on avoidable lifestyle-related illnesses. Because these put added pressure on health care services, tackling them at source has to be a high priority if a universal service free to all at the point of use is to be sustained.

The latest projections from WHO published a week ago show that Europe faces an obesity crisis by 2030 and that urgent action is needed by governments. In the UK, 33% of women are forecast to be obese by 2030 compared with 26% in 2010. For men, the figures are 36% and 26% respectively. The figures are worse in some other WHO member states with only The Netherlands doing better and remaining stable.

As we know, although there is no silver bullet for tackling obesity restricting unhealthy food marketing is regarded as a key policy lever available to governments. Where this leaves the government’s responsibility deal approach to addressing key public health challenges is uncertain. Even if its critics are persuaded that it is working, the key question in the light of the WHO projections is whether it is working fast enough given the urgency of the crisis looming in under 15 years’ time.

Another key development concerns devolution within England and the Northern Powerhouse initiative. Local MP for Stockton South, James Wharton, has been made the first minister for the project. It builds on the DevoManc announcement earlier this year which put local government in charge of the NHS budget for the Greater Manchester region. Chancellor George Osborne, the architect of this experiment, in his first speech since the election will announce today similar devolved arrangements for the City regions, including Newcastle.

The move to devolve power and responsibility could have major implications for public health as local government will be able to pool budgets and adopt place-shaping policies to improve health and wellbeing and tackle the social determinants of health.

But the catch must be that these developments are occurring at a time when local government is on its knees. With no let up to austerity in sight and with further public spending cuts to come which will fall heavily on local government, the question has to be asked: is local government being set up to fail? Whatever the outcome, there will be significant implications for public health which cannot be predicted. Watch this space.

How active are pregnant women? Measuring the methods

Posted by Louise Hayes and Cath McParlin 

Louise and Cath are presenting on the subject of physical activity in pregnancy at the Fuse Phyical Activity Workshop tomorrow (15 May) at Sunderland University.

So we all know we should move a bit more to be more healthy and reduce our risk of getting diseases like diabetes. For a long time pregnancy was seen as a time when a woman could put her feet up, take it easy and ‘eat for two’. But not any longer! Guidance published over the last few years recommends no ‘pregnant pause’, but rather that pregnant women should aim to achieve at least 30 minutes of activity of at least moderate intensity activity on most days of the week - just like the rest of us.

Part of the justification for this is that physical activity might help to reduce the risk of gestational diabetes (GDM) – that’s a type of diabetes that is diagnosed in pregnancy and (usually) resolves after the pregnancy. However, to some extent, the jury’s still out on whether or not being active when you’re pregnant really does reduce GDM.

Partly this is because we don’t really know how to measure physical activity accurately in pregnant women. The more precisely we can measure physical activity, the more accurately we can establish the relationship between it and GDM and other health outcomes.

Physical activity measurement is fraught with difficulty in any circumstances – it’s a challenge to measure such a complex and multi-faceted behaviour. Pregnancy brings additional challenges. With the development (and increasing affordability) of numerous objective methods for measuring physical activity – pedometers, heart rate monitors, accelerometers - objective measurement of physical activity in epidemiology is increasingly common. For pregnant women, however, the validity and acceptability of these methods remains unclear.

We have agonised over how best to measure physical activity in a pregnant population. What effect does the increasing size of the ‘bump’ have on the validity of waist-worn monitors? How good are monitors at recording low-level activity, common in pregnant women? What are appropriate cut-offs for different activity intensities in pregnant women?

The choice of measurement method has a huge influence on conclusions we draw about how active women are during pregnancy. We have compared questionnaire methods and accelerometry using different criteria to define activity intensity and found that, depending on the method used, we identify anything from 12% to 65% of pregnant women to be meeting the current guideline (30 minutes of at least moderate activity per day) in the first half of pregnancy.

We’re looking forward to discussing the whys and wherefores of different methods of assessing physical activity with the experts attending the Fuse PA Group Workshop at Sunderland University tomorrow (Friday 15 May).

Party manifestoes, part 2: A war on junk food?

Guest post by Avril Rhodes

The Fuse blog has seen pieces on the marketing of junk food near supermarket checkouts in recent weeks. Interestingly, whilst all the political Parties profess many policies related to children and young people, this is a specific topic where they are silent. Perhaps it’s too micro an issue or maybe involves dealing with too many big business interests. Who knows? However, I wouldn’t wish to be called cynical and neither would our potential political masters, who are working hard on the junk food agenda…to varying degrees.

Conservatives will:

• Act to reduce childhood obesity (how?) 
• Continue to promote clear food information (not all that clear an aim, on reflection) 
• Introduce a national evidence based diabetes prevention programme (sounds interesting) 
• Invest more in primary care to prevent health problems (needs more detail)

Labour will:

• Set a new national ambition to improve the uptake of physical activity (and this means…?) 
• Set maximum permitted levels of sugar, salt and fat in foods marketed substantially to children (assuming we know what these foods are, and can get over the qualifier “substantially” without disappearing in a legislative quagmire, this, could, in the end improve the offer at the proverbial check out)

Liberal Democrats will:

• Restrict marketing of junk food to children, including restricting advertising before 9.00pm, and maintain the ‘5 A DAY’ policy (more specific, but perhaps would have the unintended consequence of driving the advertising onto the internet, and what about the argument that the 9.00pm watershed is an anachronism in light of current TV viewing technology?)
• Encourage traffic light labelling of food and publication of information on calorie, fat, sugar and salt content in restaurants and takeaways (and would this be better than dealing with the check-out offer? Or are people going out already committed to a more unhealthy option in the interests of convenience?)

Greens will:

• Extend VAT at the standard rate to less healthy foods, including sugar, and spend the money raised on subsidising a third of the cost of fresh fruit and vegetables. This, it is stated, could prevent 5,000 premature deaths a year. (A bold one this. Could the money raised be tracked to ensure this happened? What about ensuring the quality of the subsidised produce? Who provided the calculations on lives saved?)

Before you despair and think that there are more questions than answers, there is some good news here. All the parties (well except perhaps UKIP, who don’t discuss junk food, though are loud on backing British farming and fishing) have got the message that action needs to be taken about what our food contains. This should encourage the world of public health research. 

All views expressed are exclusively those of the author.

Party manifestoes, part 1: Four lessons to untangle the public health policies

Guest post by Avril Rhodes

Hung over by the election talk? Worn down by the TV debates? Well how about reading the manifestoes? Be honest with yourself, when did you last read a manifesto? The Liberal Democrats’ manifesto is 158 pages, but the remaining largest national parties (Conservative, Labour, Green and UKIP) make do with around 70 to 80ish pages. And the public health policies are all over the place, under welfare, housing, transport, the environment, education, the economy and, occasionally, under health – so need some real work to find. However, that’s good, even if the party seems untroubled by, or hasn’t heard of, the wider determinants of health, at least they’re there…or somewhere. So, first lesson, be prepared to find a public health policy just about anywhere. 

Second lesson, be ready to make comparisons and choose your topic. Take the broad sweep and you will find the whole thing indigestible, and it may turn you into a floating voter after you’ve agreed and disagreed in about equal measure with all you’ve read.

So, here’s one of the easier examples: booze and fags.

• Conservatives will end open display of tobacco in shops, introduce plain packaging and support people “struggling with addictions”. The latter is swept up in a review in how best to treat long term yet treatable conditions, which include alcohol addictions. 
• Labour come in with a levy on tobacco firms to pay for NHS staff and they will target high strength, low cost alcohol products, their argument being that this fuels problem drinking. 
• The Liberal Democrats want to reduce smoking rates, complete the introduction of plain packaging and also make a tax levy on tobacco companies, in their case to contribute to the costs of health care and smoking cessation services. They will also monitor evidence on e-cigarettes and “ensure restrictions on marketing and use are proportionate and evidence based”. Finally they will introduce a minimum unit price (MUP) for alcohol. 
• The Greens will increase alcohol and tobacco taxes to help fund NHS spending increases and set a MUP of 50p. In a big section on road safety they will reduce the alcohol limit for drivers “to as close to zero as possible”. 
• UKIP under their “Save the Pub” campaign will provide tax breaks for micro-breweries, amend the smoking ban to give pubs the chance to open smoking rooms, “properly ventilated and separated”, oppose minimum unit pricing and reverse the plain packaging rules. All of this, which you will have guessed, is in a chapter on “Heritage and Tourism”.

Third lesson, consider what’s not been said. Reading between the lines I think it’s probable, for example that Labour and the Greens would favour plain packaging, the Liberal Democrats might consider 50p for their MUP, and Labour might be amenable to, say, reducing the blood alcohol limits. But we can’t be sure.

Fourth lesson, if you’re going to have a debate with your friends about what’s on offer, anticipate the arguments they might offer, like, for example, that good local pubs, will combat loneliness, provide employment, and maintain community cohesion. Does that end justify the means? Or is UKIP’s claim that 6,000 pubs closed due to the smoking ban and ending the alcohol duty escalator worth bringing in the smokers from the cold?

All views expressed are exclusively those of the author. 

A blether with Scotland’s fast food vendors

Guest post by Michelle Estrade, Scottish Collaboration for Public Health Research and Policy (SCPHRP)

In June 2014 the Scottish Government published a voluntary framework, entitled Supporting Healthy Choices, which encourages the food industry to take action towards offering healthier food choices to consumers. The recommendations include guidance on promotional activities, healthier cooking practices, and types and portion sizes of foods offered. Just after the recommendations were drafted, I sat down with owners of independent fast food shops in lower-income neighbourhoods across Scotland to discuss how they felt about offering healthier menu options. They shared many thoughts on tradition, customer demand, and the deprived neighbourhood context, suggesting that food vendors in disadvantaged areas would need additional incentives and assistance in order to implement healthy menu guidelines and ensure that their customers don’t miss out on the potential benefits.

The shop owners I talked to took pride in their menus, using words like “traditional” and “proper” to describe the foods they sold. Because they felt food was being prepared the proper way, there was a sense of reluctance to change cooking methods. One example was the use of traditional beef dripping for frying, rather than healthier oil alternatives. During our conversation, the food vendor I was interviewing looked at me quizzically and asked: “I mean, how can we say we’re traditional if we’re cooking in palm oil or rapeseed oil?”

Most places I visited had a well-developed sense of niche, which was a common reason for offering only certain types of foods and not others. When I asked about the possibility of adding other [healthier] options, a fish and chip shop manager gave me a cheeky smile and quipped: “…they’re not coming here because they want fruit.” Again and again, the food vendors I talked to explained that they needed to respond to customer demand in order to keep their clients; competition was described as “cut-throat”, and the fear of losing business was palpable.

Indeed, price was viewed as a major barrier to offering healthier options to current clientele. The owner of a sandwich shop shared a personal example of the dilemma: “I don’t allow my kids to have fizzy juice, so I dinnae really like having it. I’d like to buy fresh juice, but it’s so expensive, you wouldn’t make any money. With the price you would have to charge, they wouldnae want to buy it.” Another told me: “We’re barely making a profit just now. If we were anywhere else we’d be able to charge more, but in [this neighbourhood], most of our customers are on a limited budget...”

I went into this project assuming that the major problem I would uncover would be a lack of awareness and knowledge about healthy eating. All we would need to do is help food vendors realise how important it is to get people to make healthier food choices, and they would be eager to jump on board with guidelines like Supporting Healthy Choices. What I found though was a much more complex set of circumstances at play – a constant struggle to cope with economic pressures, intertwined with the enduring characteristics of the neighbourhoods in which these people did business. Reflection on this has helped me realise that perhaps what needed uncovering was my own lack of awareness about the pivotal role of environment and context. Too often, I think, researchers are eager to jump into intervention mode and change what is happening without first thoroughly understanding why it’s happening.

Michelle is presenting at the Fuse Quarterly Research Meeting - More than enough on our plates: tackling the takeaway food diet at source tomorrow (Thursday 30 April).

Whipping town planners into shape

Guest post by Michael Chang, Town & Country Planning Association

Obesity is climbing up the national and local government agenda, and following two previous seminal publications – the Foresight Report on reducing obesity in 2007 and the Marmot Review of health inequalities in 2010 – one of the many spotlights has now firmly fixed on town planners and the planning system.

So all eyes will be on town planners at the Fuse event – More than enough on our plates: tackling the takeaway food diet at source – on Thursday (30 April).

This blog will attempt to shed some light on what planning can, must, should and could do. Coming from a non-academic background and admittedly a town planner, I take a pragmatic but liberal view of the planning system. This is not surprising as I work for a charitable organisation which essentially championed good planning for healthy outcomes for people in the Victorian times through the building of two garden cities in Letchworth and Welwyn.

Planning is a legal mechanism tasked with a land use function and exists to ensure the sustainable use of a scarce resource that is the land and the natural environment. What we do is grounded in what planning law, dating back to the 1990s, allows us to do and what national policy in the National Planning Policy Framework (NPPF) published in 2012 requires us to do. Why do I emphasise these dates? Simple. Laws change and policies evolve. Of all the planning laws and policies we have had, there has never been an explicit reference or requirement to consider access to fresh healthy food. That is, until 2014 with the online Planning Practice Guidance which the government hailed as a triumph in condensing thousands of guidance into an accessible and evolving online guidance, and which supports the NPPF. In addition to having a section on health and wellbeing, it states:

The range of issues that could be considered through the plan-making and decision-making processes, in respect of health and healthcare infrastructure, include how: opportunities for healthy lifestyles have been considered (e.g. planning for an environment that …promotes access to healthier food).

Healthier food is of course not defined but at least planners are now strongly encouraged to consider food in planning.

Laws and policy frameworks haven’t stopped some enlightened local planning authorities in doing what they think is right for their local areas to use current planning powers to improve access to healthy food or rather, to restrict the proliferation of unhealthy land uses. We know there are dozens of councils now pursuing planning policies to prevent burgeoning shops serving unhealthy foods, albeit meeting increasing resistance from the food industry and also from within different sections of the planning profession. Actions in planning also take time: five years between the publication of Foresight (2007) to the first Supplementary Planning Document (SPD) on takeaways in 2009 and the Greater London Authority’s takeaways toolkit in 2012. Also there are more than 350 local planning authorities across England, so we still have a long way to go.

The Town and Country Planning Association (TCPA) published the Planning Healthy Weight Environments resource in 2014 which highlighted the following considerations regarding food in planning:

• Development avoids overconcentration of hot-food takeaways (A5 class use for the sale of hot food for consumption off the premises) in existing town centres or high streets, and restricts their proximity to schools or other facilities for children and young people and families.
• Shops/markets that sell a diverse offer of food choices are easy to get to by walking, cycling or public transport.
• Leisure centres, workplaces, schools and hospitals with catering facilities have a healthier food offer for staff, students, and/or customers.
• Opportunities for supporting innovative approaches to healthy eating through temporary changes of use have been explored.
• Development maintains or enhances existing opportunities for food-growing, and prevents the loss of food-growing spaces.
• Opportunities are provided for households to own or have access to space to grow food – for example roof or communal gardens, or allotments.

So the key message of this blog is: there is actually no legal, or professional, basis that stops town planners from taking appropriate policy actions to promote healthier communities through the provision and access to fresh healthy food. Much of what is needed is a cultural change within the profession, more active support of colleagues in public health in the planning process, continuing advocacy by national organisations, and last but not least (especially where Fuse is concerned), translating valuable evidence from academia to a format planners can use.

Have we been had?

Guest post by Jean Adams, Centre for Diet and Activity Research (CEDAR)

Parents don’t like sweets at supermarket checkouts. The ‘guilt lane’, as it’s been called, seems designed to attract children in a place where they are a captive audience – you can’t just move away from the checkout when you have a trolley full of shopping that you need to pay for.

This consumer concern is what seems to have prompted many supermarkets to impose total, or partial, bans on checkout confectionary.

It was certainly a healthy dose of parental curiosity that prompted our recent study on food at checkouts in non-food stores. The lead author was in Primark with her pre-schoolers, noticed a LOT of sweets by the till, and started to wonder how pervasive a phenomenon this was.

We felt food at checkouts in non-food stores was a worthwhile thing to study for two reasons. Firstly, these are places where we assumed most people aren’t naturally thinking about food. Buying confectionary at a supermarket is, perhaps, appropriate. But at a clothes shop? Presumably most people don’t go into Primark to buy some energy-dense, nutrient-poor snacks. So any purchases they do make are unplanned and prompted entirely by the display, rather than, say, hunger. Secondly, a lot of campaigning attention has been devoted to #junkfreecheckouts in supermarkets. To some good effect. But if the problem has just shifted to other types of shops, then any war is not yet won.

So we enlisted the help of two medical students, who were keen to get some hands-on experience of public health research, and did a survey of all the non-food stores in the MetroCentre - which has the dubious accolade of being the second largest shopping centre in the UK (I’m sure it was the largest in Europe at some point).

Of 205 non-food stores in the MetroCentre, 32 of them, or 16%, had food within arm’s reach of the checkout queuing area. All these stores stocked less healthy checkout food, although about half of them also had foods that were not specifically identified as less healthy. This was mostly bottled water or chewing gum – so not exactly healthful! Overall more than four-fifths of checkout food was less healthy and would not be allowed to be advertised on children’s TV in the UK.

As well as making life easier for the parents of young children, there may well be health benefits of #junkfreecheckouts. Around the world, most checkout food really is ‘junk’ – soft drinks, and foods high in energy and salt, and low in vitamins and minerals. Checkout food may prompt impulse purchases and purchasing requests from children, which parents find hard to resist.

But, importantly, I’m not aware of any research that shows that people who see more checkout junk food eat more junk food, or that removing checkout junk food leads to changes in what people buy or eat. This is one of those absence of evidence, rather than evidence of absence situations – we just don’t know what effect checkout confectionary has on what kids eat.

There was an interesting discussion on the Food Programme recently suggesting that sales of confectionary from UK supermarkets were steady, or rising, despite many stores removing it from checkouts. Checkouts aren’t the only way to prompt impulse purchases in supermarkets. Prominent, end-aisle displays, and price promotions seem to be keeping sweets sales buoyant. At least for now.

This wasn’t what we meant: a prominent confectionary display opposite a #junkfreecheckout at my local supermarket (that pizza wasn’t mine!)

Which makes me wonder…have we been had? Have supermarkets taken confectionary off tills because it makes them look responsible and ‘part of the solution’, knowing full well it will have no effect on sales? And what might the consequences of that be for public health? Well, no change on the diet front. But what if supermarkets voluntarily choosing to remove checkout junk food, means that it also closes down a conversation on unhealthy food environments? Could the supermarkets keep referring to this non-change as a way of trumpeting how importantly they take health, and silencing any requests for further, serious, meaningful change?

I find this a bit scary. Some well-intentioned public health campaigning might have made things worse? I don’t know that it has. Maybe it hasn’t. Probably it hasn’t? Hopefully it hasn’t. Probably it’s just made no difference. At the very least, it makes life a bit easier for stressed out parents trying to get the shopping done and their kids to eat a healthy diet?

How hard can it be? Flying over the gap between research and policy

Posted by Peter van der Graaf

A man in a hot air balloon realised he was lost. He reduced altitude and spotted a woman below. He came lower and shouted: “Excuse me, can you help? I promised a friend I would meet him, but I don’t know where I am”. The woman below replied: “You’re in a hot air balloon hovering approximately 30 feet above the ground. You’re between 40 and 41 degrees north latitude and between 59 and 60 degrees west longitude”.

“You must be a researcher,” said the balloonist. “I am,” replied the woman, “how did you know?” "Well,” answered the balloonist, “everything you told me is technically correct, but I’ve no idea what to make of your information, and the fact is I’m still lost. Frankly, you’ve not been much help at all. If anything, you’ve delayed my trip.”

The woman below responded: “You must be a policy maker”. “I am,” replied the balloonist, “but how did you know?” “Well,” said the woman, “you don’t know where you are or where you’re going. You made a promise, which you’ve no idea how to keep, and you expect people beneath you to solve your problems. The fact is you are in exactly the same position you were in before we met, but now, somehow, it’s my fault.”

This story was presented by Professor Roland Bal from Erasmus University in Rotterdam, the Netherlands in his recent Knowledge Exchange Seminar titled: ‘Hybrid management in science-policy practice relations’. You might have heard the story before, as it is adapted from an article by Locock & Boaz in 2004 in Social Policy and Society and also quoted in the PhD thesis of one his students, Rik Wehrens (2013), who studied the Dutch Academic Collaborative Centres for Public Health and how they shaped the co-production of research, policy and practice within this field in the low lands.

 

In his seminar Roland used the above story to explain that we often fall into the trap of thinking of two communities (ivory tower scientists on the one hand and policy makers at the coalface on the other) with completely different perspectives on the use of research and evidence. He did not deny there were differences between both professions, and gaps to bridge but suggested that we should use these gaps more strategically. By starting from a recognition that all science is a social practice quoting Jasanoff (2004) (“Scientific knowledge [..] both embeds and is embedded in social practices, identities, norms, conventions, discourses, instruments and institutions” (p. 2-3)) he showed how the Dutch Centres have been able to blur the boundaries between the two communities by distinguishing between a front and back stage for their partnerships and performing on these stages at different times in the collaboration process.

At front stage the academics took the limelight and made all the right noises about scientific rigour by presenting their advisory report to public and policy audiences, complete with imposing lecture theatres. They deliberately emphasised the difference between academics and health professionals to create the impression of ‘science speaking truth to power’. However, the content of the reports and the research behind were intensely debated behind the scenes on various back stages between academics, health professionals and policy makers to ensure that the research objectives and findings were embedded in the wider political context. In other words, collaboration and distinction were highlighted at different times in the process to enable each community to explain and sell their work to their peers: policy makers needed to account for their compromises and shared decisions, and academics needed to manage the expectation around their research.

Two key mechanisms provided crucial in this staging: firstly, dual appointments that enabled health practitioners to take up part-time roles in academia (but surprisingly not the other way round!) and, secondly, scenario approaches that clustered specific interventions into modelled scenarios connected to relevant policy programmes.

What lessons does this hold for Fuse? Are we still trying to bridge the two communities or should we spend more time developing different stages? AskFuse (our responsive research and evaluation service) might be a step in the right direction to create the back stage for initial conversations between policy makers, health professionals and academics but where is our front stage? Are we making enough noise? And how serious are we about dual appointments (researchers in residence?) and linking research on interventions to specific policy programmes?

Hunting down the seasonal calories: an Easter eggs-ercise

Posted by Avril Rhodes

Will you be looking forward to an Easter egg hunt soon? Well, beware, those Easter treats are really loaded with calories, fat, and bizarrely, a little fibre. I’d love to say I’ve spent hours researching this, but I haven’t - just one trip to this weight loss website and I was overwhelmed with results. So, I picked a few favourites.

No Easter eggs were harmed in the writing of this blog (although some may have been consumed)

 Let’s go for some at the top end, weighing in at 1,250.2 calories, 67.7g fat and 4.0g fibre was the Kit Kat Chunky Easter egg from Nestle. Chunky indeed. Another in the heavyweight division for possibly more sophisticated palates, is the After 8 Giant (clue here) Chocolate egg also from Nestle which has 1,072 calories, per shell (possibly the calorie measuring people couldn’t bring themselves to estimate the whole egg). It has 64.6g fat and 16g fibre, which is a consolation but not as good as, say, porridge. How about the dark chocolate Easter egg from Green & Black’s, sneaking in at under 1,000 calories with 960, but 69.5g fat (ouch!) and strangely, 16.6g fibre? I know that Garfield, the cartoon cat, once said he’s never met a calorie he didn’t like, but there are limits to how you might increase your fibre intake. However, with Green & Black’s you are buying Fairtrade chocolate, which can’t be bad, and this also applies to Divine Chocolate.

Ding-ding! Round one goes to this heavyweight contender

And what about the children I hear you cry. The Buttons Easter egg by Cadburys is 858.6 calories per medium egg, (who said medium?) with 48.6g fat and 1.1g fibre. The Cadbury Caramel egg, per 38g egg (so a snack really), is 195 calories; with a mere 10.2g fat and 0.2g fibre. Parents might be tempted by the pack of two (to keep each other company, presumably) Cadbury Caramel bunnies, which come in at 200 calories, 10.8g fat and 0.2g fibre. And I couldn’t write this blog without paying homage to the Cadbury’s Crème egg which is 180 calories per egg with a fat rating of 6.3g. Although, I have overheard gossip about the Crème egg being downsized, bearing in mind that you seem to be able to buy these from December 26th onwards.

And what about the office snacking? More bad news. A single Lindt chocolate mini-egg, a mere 5g, is 30calories, a Malteaster bunny (ahhh) by Maltesers is 157 calories; and each Cadbury’s mini egg is 16 calories.

However, you can earn your calories. The same website that calorie counted the eggs, makes some suggestions that seem blatantly sexist…for example a 40 year old female weighing 12st 7lb who is moderately sedentary, can use 100 calories spending 30 minutes hovering/dusting/mopping floors, or, if you prefer, 20 minutes weeding the garden. What a way to earn about half of a Crème egg! I have no idea what you do with the other half.

Well, have a Happy Easter anyway from all at Fuse. That's all yolks!