Strengthening partnerships to improve primary care in the Deep End

Posted by Dr Angela Wearn, Associate Member of Fuse and Advocacy and Engagement Lead for the Deep End Network North East and North Cumbria

In this blog, Angela reflects on what people living in some of the region’s most disadvantaged communities have told the Deep End Network about challenges they face when it comes to accessing primary care, including attending appointments, and what we can do to improve this.

The Deep End Network is a growing GP-led international movement that began in Glasgow in 2009 as a response to the ‘inverse care law’, which is that those who need care the most often struggle the most to access it.

The North East and North Cumbria Deep End Network was established in 2020, with support from Fuse, the Centre for Translational Research in Public Health, and the NIHR Applied Research Collaboration North East and North Cumbria, creating a space for practitioners working in areas of severe socioeconomic disadvantage to share experience, shape solutions, and influence how primary care can better meet the needs of the people it serves.

Funded by the North East and North Cumbria Integrated Care Board, the Deep End Network focuses on four core priorities:

• Workforce: Building and retaining a well‑supported workforce in high‑need communities.
• Education: Strengthening training at all levels so current and future health professionals understand health inequalities and access to opportunities
• Advocacy: Ensuring Deep End practices and communities shape local and regional decisions on funding, access and service design.
• Research: Evaluating Deep End initiatives to understand what works, why it works, and how effective approaches can be scaled to improve outcomes.

Since 2023, I’ve been working as Advocacy and Engagement Lead to build and strengthen partnerships between Deep End communities, practitioners and researchers, ensuring the experiences and perspectives of underserved patients and communities inform both our research portfolio and the wider support and initiatives we offer practices.

Over this time, additional funding and support from across NIHR infrastructure, including the NIHR Applied Research Collaboration North East and North Cumbria, NIHR Three Schools and NIHR Research Delivery Network, has further supported targeted involvement and engagement work with those living in Deep End neighbourhoods, the majority of whom have had no previous experience of involvement in research or service development.

Support through the NIHR Three Schools collaboration was made possible through membership of Fuse, which is part of the NIHR School for Public Health Research, one of the three NIHR schools within the collaboration.

What we’re hearing from Deep End communities

Many Deep End patients face multiple, overlapping challenges including low income, insecure housing, poor mental or physical health, caring responsibilities, trauma, or homelessness. These pressures make it harder to engage with primary care, even when people want to.

Through conversations, workshops, and community-led sessions, people have shared why engagement can feel difficult:

• Personal pressures: the emotional and practical effort of attending can feel overwhelming and ‘too much’ on the day of the appointment.
• Feeling unheard or stigmatised: which makes reaching out feel pointless.
• Time and capacity: life can be busy, chaotic, and demanding, with health often taking a backseat.
• Overwhelming contact routes: getting through to the practice or accessing a suitable appointment can feel impossible.
• Negative past experiences: GP practices don’t always feel welcoming or safe.

Overall, I regularly hear that disengagement is rarely about disinterest, it’s about the collective barriers that build up and make staying connected to care difficult.

What communities say needs to change

Improving patient engagement in Deep End areas is complex. There is no single fix, and practices are working under significant resource constraints. But through our involvement work, communities have highlighted three priorities for investment and change that they feel would make a meaningful difference:

• Improve connection and communication
• Strengthen co‑design approaches
• Build sustainable, community‑based partnerships

These priorities align strongly with national ambitions around personalised care, prevention, and reducing inequalities, and they reflect what people say would help them feel more able to engage with primary care as the wider system shifts towards more integrated neighbourhood-level working.

Moving forward together

The NHS encourages practices to work closely with Patient Participation Groups (PPGs), but Deep End practices face additional challenges: limited resources, diverse patient needs, and complex barriers to involvement. From the community perspective, awareness of PPGs is low, confidence is often limited, and many people are unsure whether their voice will genuinely matter. To support better partnership working, the Deep End Public Advisory Group identified three simple involvement principles that are easy to remember and act upon, and clear enough to come back to when things get busy or complex:

• Make it easy
• Make it worthwhile
• Value patient experience

These principles are practical, community-informed and can be applied across a range of contexts to guide diverse involvement.

New one‑page resources for practices

To help bring these messages to life, we’ve co‑developed two infographics with Deep End patients, communities, and Nifty Fox. They distil community insights into quick, usable one-page resources that GP practices and other decision-makers can draw on to strengthen engagement and build more inclusive partnerships.

Supporting Patient Engagement in the Deep End: insights from the community
Working Better Together in the Deep End: patients and GP practices as partners

These resources will sit alongside a wider collection of materials, including a public‑facing animation and an illustrated impact report, which will be shared over the coming months. A celebration event is planned for early next year.

Why this matters

The Deep End Network exists because tackling health inequalities requires more than goodwill, it requires meaningful partnerships and system‑level commitment. These new resources are an important step in supporting practices and others to work alongside communities in ways that feel respectful, realistic, and rooted in the experiences of people who face the greatest barriers to accessing and influencing the care they receive.

We hope they support teams across the North East and North Cumbria and beyond to strengthen relationships, reduce barriers, and create primary care environments that are more responsive to the needs of communities most affected by health inequalities.

If you would like to know more about partnership working, co-production or our involvement work in the Deep End please contact Dr Angela Wearn (angela.wearn@newcastle.ac.uk)

Find out more about the Deep End Network

About the author

Dr Angela Wearn is Advocacy and Engagement Lead for the Deep End Network North East and North Cumbria and a Research Fellow with the NIHR Applied Research Collaboration North East and North Cumbria. She is also an Associate Member of Fuse, the Centre for Translational Research in Public Health.

Training tomorrow’s Public Health leaders: impact, innovation and prevention

Posted by Liz Morgan, Head of School for Public Health North East, NHS England

The North East Public Health Postgraduate Specialty Training Programme holds an event annually to showcase the work that has been done by trainees over the previous year. This annual showcase highlights how public health trainees in the North East are delivering practical, high‑impact work across the health and care system, demonstrating the value of prevention-led leadership at a time of increasing system pressure. It not only celebrates the tremendous work our trainees have been doing but also provides an opportunity to share that work with public health colleagues in multiple settings During this time, our trainees will have been immersed in communities, health and health-related systems and research environments, identifying challenges, designing solutions and implementing projects that demonstrate innovation and impact. The projects presented at our last meeting ranged from heath protection and health improvement to policy development and healthcare public health. Each one reflected the commitment, curiosity and compassion that defines our public health workforce.

Tackling air pollution through NHS leadership

Most NHS Trusts in the North East employ at least one public health consultant, valuing the broad benefits that this can bring, but also providing greater capacity for public health training. Dr Laura Keast had been undertaking a placement in Northumbria NHS Trust, implementing the Clean Air Hospital Framework and demonstrated the value of collaboration between public health and sustainability teams. Air pollution remains the single greatest environmental threat to public health in the UK, contributing to an estimated 30,000 deaths annually and worsening health inequalities. By making air pollution a tangible and locally relevant issue through accessible monitoring of nitrogen dioxide levels and clear health messaging, the initiative has generated engagement and momentum for action. Importantly, the project highlighted that public health leadership, data expertise, powerful health messaging and alignment with national policy levers are critical in overcoming uncertainty and organisational resistance to change.

Reducing missed outpatient appointments for children

Dr Mark Riley presented a service evaluation undertaken at South Tees NHS Trust exploring why children are not brought to outpatient appointments, an issue with significant implications for health outcomes and system efficiency. Using surveys and follow-up telephone calls, the evaluation identified five key themes:

• appointment timing
• forgotten appointments and reminders
• administrative barriers
• health literacy
• cost of attendance.

Forgotten appointments were the most common reason for non-attendance, with parents strongly favouring clearer and more frequent text reminders. Difficulties rearranging appointments, confusing letters and limited awareness of travel cost reimbursement schemes further contributed to missed care. The findings underscore how relatively small, system-level changes, such as health-literate communications in multiple languages and flexible appointment scheduling to include evenings, can reduce inequalities and improve service use. Finding a champion in the organisation to enable change was also critical.

How leaders make difficult priority-setting decisions

As pressures on the NHS intensify, difficult decisions about how to allocate limited resources are unavoidable. Dr Tom Seasman explored how senior health leaders justified priority-setting decisions. Qualitative in‑depth interviews with leaders across the English health system show broad support for prevention and reducing health inequalities. However, when faced with real-world trade-offs, decisions often favour short-term frontline clinical care over long-term preventative investment and leaders differ in their responses. Clinical leaders often prioritise immediate need and the “rule of rescue”, while those approaching the same problem from a public health perspective place greater emphasis on maximising population health gains through prevention. Political constraints, emotional proximity to patients and fragmented funding structures frequently limit leaders’ ability to shift resources from acute care to prevention, despite widespread recognition that long-term sustainability depends on doing so. These findings raise important questions about how the health system can better support leaders to make transparent and ethical trade-offs.

Policing and public health: prevention in action

Prevention also featured strongly in work exploring collaboration between policing and public health. This is important because of shared commitments to improve lives, reduce harm, reduce unnecessary demand on services, reduce vulnerability, improve equity and maintain public trust. Since the publication of a national consensus statement in 2018, prevention has become more explicitly embedded within policing policy and inspection frameworks. A 2025 review concluded that, while the original vision remained relevant, a refreshed consensus was needed to reflect current challenges and language. Kylie Murrell led on this national project, chairing the policing and public health collaborative, leading on the re-drafting of the document and sign off and associated ministerial briefing. The work highlights both the appetite within policing to engage more fully in prevention and the ongoing need for public health professionals to support cross-sector partners to identify upstream opportunities to reduce harm, vulnerability and demand. It's also an excellent example of how our trainees have led on national initiatives.

Supporting wellbeing within the public health workforce

Alongside the ongoing system-level challenges, attention to the wellbeing of the public health workforce itself is increasingly recognised as essential. Vineeta O’Key reflected on the work the trainees had been doing to support their own wellbeing and on how a Wellbeing Away Day could demonstrate how evidence-based wellbeing approaches could be embedded within training and professional development. Grounded in the “Five Ways to Wellbeing”, the day prioritised connection, learning, physical activity and engagement with nature through volunteering with Durham Wildlife Trust. Feedback highlighted the value of protected time for relationship-building, reflection and compassionate leadership, reinforcing the role of wellbeing as both a personal and professional competency in public health practice.

Julie Lowe presented her experience of travelling to Canada and the Netherlands on a Churchill Foundation fellowship. The Foundation funds approximately 100 Fellows each year to travel overseas to explore an issue of societal importance. This project focused on community interventions to improve the health and wellbeing of unpaid caregivers, who, as a population, experience poorer mental and physical health outcomes known informally as the ‘carer burden’. She shared reflections from her own experience as a young carer and motivation for choosing a career in public health. Findings from her experience included the importance of listening to diverse groups of carers to understand their needs and preferences, and the need for interventions that reduce carer burden rather than responding to health needs as they arise.

Taken together, these projects reflect a common theme: public health impact is maximised through leadership, collaboration and a commitment to prevention, even in constrained systems. Our trainees are already having an impact in their placements and communities by shaping national priorities, supporting workforce wellbeing and building partnerships beyond health. Creating spaces like this conference where recent projects and ideas can be shared, and challenges are explored are vital and demonstrates how public health continues to be pivotal in navigating complexity and working towards more equitable and sustainable futures. I would strongly encourage all of our public educators and senior public health colleagues to attend this event. As Public Health influencers, the task of considering, adapting and altering these ideas and interventions for the benefit of the populations we serve rests with us.

Sparking curiosity with Twinkle, Twinkle Arti

Posted by Nicola Aldridge, Research Associate, and Cassey Muir, Research Associate / Co-lead of the Fuse Early Life and Adolescence Research Cluster, both from Newcastle University

We were recently given the exciting opportunity to showcase the Twinkle, Twinkle Arti project at Discover Festival, a free, one-day festival organised by Newcastle University that brings together families, communities, and researchers through interactive activities and inspiring ideas.

Nicola and Cassey

Discover Festival is designed to spark curiosity, build connections, and encourage people of all ages to explore new ideas. Each year, the university creates a packed programme of family-friendly events, and this year, we were delighted to be part of it as members of the Twinkle, Twinkle Arti research team.

Bringing Arti's story to life

Throughout the day, we invited families to step into Arti’s world through the Twinkle, Twinkle Arti storybook. Developed by Fuse researchers at Newcastle University, with funding from the NIHR School for Public Health Research, the book was created and co-produced with families to support the wellbeing of children experiencing challenging family circumstances, such as drug and alcohol use. While these experiences inspired the story, its themes of feelings, belonging, resilience, and hope resonate with all children.

Visitors to our stall in the Great North Museum had the chance to watch a CBeebies Bedtime Stories style video of it being read aloud by the author. They could also explore puppets and original illustrations from the book, and view artwork created by primary school-aged children who had participated in a pilot study of classroom lessons based on the story.

Families were also able to take home a free copy of the storybook, along with a link to the online read-aloud video and a set of simple conversation prompts designed to encourage creativity, emotional expression, and meaningful family time at home. We handed out nearly 80 copies on the day!

Conversations that matter

Beyond engaging with families, it was equally exciting to see the conversations that the project sparked among professionals attending the festival. We spoke with people from a range of sectors, including teaching, school governance, clinical psychology, and general practice with social prescribing links. Their curiosity about the project and enthusiasm for its potential applications highlighted the broad relevance of Twinkle, Twinkle Arti and the importance of creating accessible resources that support children's emotional and social wellbeing.

One particularly rewarding conversation was with a family who shared their personal experience of the impact of alcohol on family life and how they might be able to use the book. Hearing their reflections was both moving and affirming. It served as a powerful reminder of why the project began in the first place and reinforced the continued need for resources that help children navigate difficult experiences. Moments like these bring the research to life, reminding us that behind every study, storybook, and activity are real families whose experiences matter and whose voices continue to shape our work.

Creating a community star mural

Another highlight of the day was our evolving community star mural. We invited children to create their own star by drawing, colouring, or writing ideas about what they or Arti could do when they felt sad or worried, with 114 stars being created on the day. It was wonderful to see children enthusiastically embracing the activity, and even more special to watch parents, carers and grandparents join in too, talking to their children about the messages in the book. The excitement on their faces as they added their stars to the mural was a lovely reminder of the power of creativity to bring people together.

A colourful celebration of hope and resilience

By the end of the day, the mural had grown into a colourful display of hope, kindness, and imagination. It was a privilege to share the Twinkle, Twinkle Arti project with so many families and to see first-hand how children connected with Arti’s story and messages of hope, resilience and belonging. Events like Discover Festival provide a fantastic opportunity to bring research into the community, and we were grateful to be part of such an inspiring day.

Find out more about Twinkle, Twinkle Arti

• Read this Fuse blog about the development of Twinkle, Twinkle Arti
• Read about Twinkle, Twinkle Arti as a NIHR School for Public Health Research (SPHR) case study
• Read about piloting Twinkle, Twinkle Arti in primary schools
• Listen to this Fuse podcast to hear Cassey discussing her research on social and emotional resilience in children and young people affected by parental substance use.
• Download the book for free.
• Watch a video of the book being read aloud.

Sun safety this summer: from UV apps to sun protection tips that actually work

Posted by Angela Rodrigues, Associate Professor in Psychology, Northumbria University and co-lead of the Fuse Behaviour Change Cluster

The UK has already seen unusually hot weather this year, with temperatures high enough to make sun safety a live issue well before many people have packed for their summer holidays.

For many of us, the instinctive response to good weather is to get outside while it lasts. But sudden bursts of hot, bright weather are also a reminder that sun protection needs to start before we are already on the beach.

UV exposure is not only a problem on foreign holidays or during peak summer. In the UK, UV levels can reach 3 or above from as early as April – this is the point at which many public health bodies advise taking sun protection seriously, especially for people who burn easily.

Abroad, particularly in southern Europe or long-haul destinations, levels commonly reach 8, 9 or 10 in summer. That is a significant jump from what most people living in the UK are used to at home, and one reason holidays are often when their skin is most at risk.

My research with holidaymakers suggests that people want to manage sun exposure better – especially when they are given clear, location-specific information about UV levels, plus practical reminders about when to protect themselves.

Staying safe in the sun works best as a combination of habits: seeking shade, wearing a hat, covering up, limiting time in strong midday sun, and using sunscreen properly.

Not just sunscreen

One of the most effective things you can do is seek shade during the middle of the day, when UV levels are at their highest – typically 11am-3pm in the UK and during similar peak hours abroad. A wide-brimmed hat, a long-sleeved layer for the hottest part of the day, and sunglasses that offer UV protection all add meaningful protection that sunscreen alone cannot provide.

Planning ahead makes this much easier. Before you head out, check the UV index for your destination. Most weather apps now include this. Then plan the highest-exposure parts of your day around it.

Think of sun protection as part of your morning routine: apply sunscreen before leaving the house, just as you would brush your teeth, and pack a hat, sunglasses and sunscreen in your day bag. It is also worth taking a light cover-up such as a T-shirt, kaftan or sarong to protect your shoulders and chest.

When you stop for lunch, that is your natural cue to reapply sunscreen. Many people on holiday take a midday break anyway. A shaded lunch, and even a short siesta during peak UV hours, is not just a pleasant holiday habit. It is good sun safety.

By the time you head back out later in the afternoon, you’ll have rested, cooled down and reapplied sunscreen, and you are making better use of the lower-UV part of the day.

Simple “if-then” plans can help too. If the UV index is forecast to be 3 or above, then I will cover up and seek shade. If I am heading to the beach, then I will reapply sunscreen as soon as I arrive and again after swimming.

One thing our research consistently shows is that most people underestimate how quickly their skin can burn, particularly in strong sun. Rather than trying to calculate a safe window, treat the UV index as your guide. If it is 3 or above, cover up and seek shade during the strongest part of the day.

Sunscreen works best when applied generously and reapplied regularly, but guidance on how much to use can feel vague. Our research suggests a helpful rule of thumb: for your face, neck and ears, aim for around a teaspoon’s worth. For a full body application, you need considerably more than most people use, roughly the equivalent of a golf ball.

Applying more than you think you need, and reapplying every two hours when you are outdoors, makes a real difference to the protection your skin gets. You should also reapply after swimming, sweating or towelling off, even if the product is labelled water resistant.

Apps are useful – if they change what you do

Studies of sun protection apps suggest these digital tools can help when they give people specific, usable information rather than vague warnings. In my research into holidaymakers’ views of these apps, participants valued UV index information and location-based reminders because these helped them to plan their day, rather than simply reacting once already in strong sun.

Personalised guidance can make sun protection feel less like guesswork by taking account of your skin type, where you are and how strong the UV is at that moment.

If you use a sun protection app, look for one that provides real-time, location-specific UV forecasting and concrete, practical advice, rather than general reminders. Even a basic UV index tracker can help you decide when to cover up, when to seek shade and when UV levels are lower.

The SunSmart Global UV app (supported by the World Health Organization, the World Meteorological Organization, the UN Environment Programme and the International Labour Organization) shows what this can look like. It gives users location-specific UV information and indicates when sun protection is needed.

That is the kind of practical guidance holidaymakers in my research said they wanted: advice that helps them make decisions in the moment, not just general messages about staying safe in the sun.

Enjoy the good weather

Sun protection does not mean staying indoors. It means making the sun easier to enjoy: checking the UV index, packing a hat and sunscreen, seeking shade when UV is strongest, and reapplying before your skin reminds you.

Skin cancer is largely preventable, and small habits add up. The aim is to make sun protection part of the day – not an afterthought once you are already hot, tired and turning pink.



Image: Photo by Kampus Production from Pexels

Adapted with thanks to The Conversation

Why safer spaces matter for young people’s physical activity

Posted by Caroline Dodd-Reynolds, Professor of Physical Activity, Durham University

Fuse Associate Professor Caroline Dodd-Reynolds explores what can be done to create environments in which LGBTQ+ young people feel safe to enjoy physical activity. Fuse blog in Pride Month.

This work forms part of the Joyful and Safe Physical Activity (JASPA) project, funded by the National Institute for Health and Care Research (NIHR). This project, and the funding that supports it, are only possible through Fuse, the Centre for Translational Research in Public Health, and its membership of the NIHR School for Public Health Research (SPHR).

The 2026 Commonwealth Games come to Scotland this summer, showcasing elite athletes at the top of their game. But for most of us, physical activity looks much more ordinary: walking to school, joining a PE lesson, dancing in the kitchen or going to the gym.

Now think about how that kind of movement feels. Easy? Enjoyable? Safe?

For many LGBTQ+ young people living in disadvantaged areas, the answer to those questions is no.

In our creative joyful and safe physical activity project, young people aged 14-21 showed us how adults can make physical activity feel more fun, safe and inclusive. They did this by reimagining what it means to be active, and by bringing colour, creativity and vibrancy into traditional sport and exercise spaces.

Around 80% of adolescents globally do not do enough physical activity, and global physical inactivity has remained largely unchanged for the past two decades. This affects growth, development, mental health and physical health. We also know that some young people face greater barriers than others, including those living in poorer areas, disabled and neurodivergent young people, and those with questions around their gender or sexuality.

Every child and young person should be able to take part in movement and physical activity without feeling disengaged, excluded or unsafe. Physical activity can, and should, bring joy. But this is not only about competitive sport, PE or joining a gym. Movement can also mean walking, dancing, playing active games, skating in the park, or simply feeling able to move through a space without fear.

In our earlier research, young people often knew exactly where they could be active: outdoors, at school or college, or in a local leisure centre if one was available. But knowing where to go was not the same as feeling able to take part. They described feeling harassed, worried, unsafe or excluded from physical activity.

We call this “physical activity insecurity”: when a young person’s ability to be active is limited because a space feels uncomfortable, exposing or unsafe. This can be especially acute for young people whose experiences of poverty, disability, neurodiversity, gender or sexuality overlap. Some transgender and non-binary young people in our research described harassment, exclusion and gender discrimination that made ordinary movement feel difficult or risky.

We worked with young people to explore what safer, more joyful physical activity spaces could look like.

Creating inclusive spaces

So what can adults, schools, youth workers, leisure centres and other community organisations do?

First, the language we use matters. Terms such as sport, gym or exercise can be immediately off-putting for some young people, especially if they already associate these words with embarrassment, exclusion or previous bad experiences.

Thinking about physical activity more holistically and using the term “movement” instead can help. Physical activity can be something as simple as walking.

Second, adults need to have honest conversations with young people about how they relate to physical activity. This might include talking about stereotypes around sport, PE or exercise, and how these make young people feel. It might also mean recognising that some young people have many other pressures in their lives, making physical activity feel like one more difficult or exposing thing.

Young people are most likely to engage with someone they already know and trust, in a calm and welcoming space. From there, adults can help reimagine physical activity as movement that might be enjoyable, informal and part of everyday life. This could mean dancing in the kitchen, roller-skating in the park, going for a walk, or simply feeling able to enter a room without bracing for judgement. More traditional sporting examples may work too, but they should not be the only starting point.

Third, adults can ask what might help organised and formal physical activity spaces feel more like the spaces young people imagine for themselves. That means listening to young people’s ideas, being open to challenge and rethinking what counts as a good physical activity space. For example, a good space may not be the one with the best equipment. It may be the one where young people can choose whether to join in, wear clothes they feel comfortable in, see signs that they are welcome, and leave for a quieter area if they need to.

Welcoming and safe

On a practical level, most physical activity spaces, whether indoor or outdoor, can be made to feel more inclusive and safe. Small changes can make a big difference. These might include using more vibrant colours, displaying friendly messages and avoiding long lists of rules and instructions.

It can also help to make participation optional rather than compulsory, provide a quiet space where young people can step away when needed, and reconsider clothing rules, which can be a major barrier for some.

The point is not to make every young person love sport. It is to ask why some spaces make movement feel exposing, difficult or risky. If adults want young people to be more active, the first step is not another rule, target or campaign. It is creating places where they do not have to brace themselves before joining in.

Find out more

• Access practical guidance for adults working with children and young people disengaged from physical activity.
• Find out more about this work, including a Moving Spaces 'zine' co-produced with young people.

Adapted with thanks to The Conversation

Moving from blame to support: rethinking food insecurity in diabetes

Posted by Ruth Boocock, Associate Professor and Dietitian, Teesside University, in Nutrition and Hydration Week.

This work started with a deceptively simple question: ‘How do clinicians identify food insecurity in people living with type 2 diabetes, and what actually helps once they do?’

By clinicians, I mean the people working directly with patients, for example GPs, nurses, dietitians, and others working in busy, often stretched diabetes services.

To explore this, I reviewed published research from across the world. Over many coffees, I read and debated papers, regularly asking other colleagues: ‘Is this really a pattern, or am I reading too much into it?’

What came through very clearly were the human stories beneath the data. Clinicians wanting to help, but constrained by time and systems. People with diabetes trying to manage blood glucose, while also worrying about whether there is enough food at home.

Asking about food only works if there’s something to offer next

Many clinicians want to ask patients about access to food and some already do, but the evidence shows that screening alone is not enough.

Without time, clear processes, or obvious referral routes, screening often stalls. I repeatedly came across similar experiences: ‘I asked the question. They said yes. And then I didn’t know what to do’. That moment matters. It can leave clinicians feeling stuck and distressed, and patients feeling exposed and unsupported.

One of the key messages from the evidence is that this isn’t about individual clinicians doing more. Food insecurity needs to be part of everyday systems, with prompts, shared responsibility across teams, and links to support that actually exists. Without that organisational backing, raising the issue of food tends to fall down the priority list, especially on busy clinic days.

Trust makes disclosure possible

You can’t script disclosure about food insecurity. People tend to talk when they feel listened to and not judged.

Shifts in practice, even just small changes in language came up repeatedly. A nurse replacing ‘Why aren’t you following the diet?’ with ‘What gets in the way?’ or a GP explaining ‘We ask everyone about access to food, because it can affect diabetes management.’

These shifts matter, they help move conversations away from blame and towards problem‑solving.

There was also a consistent tension between dietary advice and financial reality. Guidance may be clinically sound but still impossible to follow when money is tight. Recommended foods and ideal meal plans don’t always match what someone can afford or access.

Across the evidence, one message stood out, ‘Starting where people are really matters’. Advice framed around better, not perfect is far more likely to support engagement than aiming for an ideal that feels unreachable.

This isn’t something clinicians can fix alone

Many clinicians described feeling unsure where to send people for help. Knowledge of local food support was often limited or quickly out of date. Some avoided the conversation altogether, worried about raising an issue they couldn’t help with.

Where things seemed to work better was in areas with strong links between health services and community organisations such as food banks, pantries, community kitchens, and social prescribers. Not just signposting, but relationships and connection.

Another common theme was confidence and skills. Here, even when people accessed food support, they didn’t always feel able to turn unfamiliar ingredients into meals that worked for diabetes. Practical, community‑based support, including cooking sessions or simple recipe swaps helped bridge that gap.

What did I learn?

One of the biggest surprises was how rarely food insecurity appeared on its own. Transport costs, prepayment meters, missed appointments, and medication routines were often part of the same picture.

Stigma also ran throughout the existing research. Many people felt blamed for their diabetes and ashamed of needing help with food. Seen in that light, it becomes easier to understand why disclosure feels risky.

Perhaps most surprising was the impact of small system changes. Adding two evidence-based questions to patient records and a clear referral route doesn’t sound transformative. In practice, it can change conversations and access to support in very real ways.

Where I’ve landed

I started with the academic literature. I ended with a clearer sense that while food insecurity shows up in clinical settings, it isn’t something clinicians can or should be expected to solve alone.

If we want better diabetes outcomes, we need systems that make it:

• easier to ask about food
• realistic to respond to what we hear, and
• normal to work alongside community organisations beyond clinic walls.

My review is now published and available here.

If you’ve tried something that worked, or something that didn’t, I’d really like to hear about it. Being open about the messy space between screening and support feels like a good place to start.

More than quit rates - our smoking research was about complexity, trust, and real voices

Posted by Angela Rodrigues, Associate Professor at Northumbria University, and co-lead of the Fuse Behaviour Change Cluster, and Team

By the time we wrapped up our final interviews, we felt a mix of pride, exhaustion, and curiosity. Pride because we’d managed to complete a complex mixed-methods evaluation across four pilot sites. Exhaustion because, well, public health research never seems to run smoothly, and we had a few recruitment bumps along the way. And curiosity because we still weren’t sure how all the pieces would fit together. This was a mixed-methods evaluation of a 20-week smoking cessation service in the North East & North Cumbria.

The context: why this service mattered

When we first got involved, the idea was simple: evaluate an enhanced stop smoking service designed specifically for people living with severe mental illness (SMI). People with SMI experience stark health inequalities. On average, they die 15-20 years earlier than the general population, largely due to chronic physical health conditions rather than psychiatric causes. Smoking is a major reason for this health gap, and it is something that can be changed. Yet many tobacco dependence services do not adequately meet their needs.

The service offered more support than the standard provided by the local council, combining behavioural support with medication-assisted treatment over 20 weeks. It followed a ‘cut down to quit’ model, and aimed to be person-centred, flexible, and responsive.

Our approach: mixed methods and lived experience

We used a mixed-methods approach, including quantitative analysis of recruitment and outcomes, surveys with service providers, qualitative interviews with both staff and service users, and a review of Smokefree Taskforce documents. We started with a well-defined plan, but the process taught us to embrace flexibility. Recruitment was slow. Referral pathways shifted. Data systems didn’t always talk to each other. And finding service users willing to be interviewed was harder than we expected.

One of the most rewarding aspects was working with our Lived Experience Advisory Panel (LEAP). They helped shape our protocol, refine our interview questions, and interpret findings. Their input reminded us why we do this work. It’s easy to get lost in methodological frameworks, but the real insight often comes from lived experience. One LEAP member words stuck with us:

“You need to understand what it’s like to be told to quit smoking when smoking is the only thing that gets you through the day.”

What we found: complexity at every level

The Behaviour Change Wheel framework (figure 1) helped us make sense of what was happening on the ground. Service providers used a range of strategies, including medication, leaflets, nicotine e-cigarettes, planning, and social support. Most felt capable and motivated to deliver the service, but some found it more harder than expected. Complexity was a recurring theme, as illustrated in one advisor words:

“It’s not just about smoking, it’s about everything else going on in their lives.”

Figure 1: Visual map of key themes identified in our study

We also saw how broader systems shaped delivery. Some sites had strong links with primary care; others struggled. Data recording was patchy. Staff wanted more training, not just in smoking cessation, but in understanding mental health complexity more broadly. And while the service was designed to be flexible, that flexibility sometimes created confusion. Who was eligible? How long should support last? What counted as a successful quit?

For service users, the benefits were clear: 

• better physical and mental health
• financial savings
• fewer unpleasant smells
• and fewer side effects than expected.

But staying engaged was tough. Motivation fluctuated. Life got in the way. Participants reminded us regularly that behaviour change doesn’t happen in a vacuum:

“I wanted to quit, but then my meds changed and everything fell apart.”

The challenge and value of qualitative work

Personally, we found the qualitative interviews both the most challenging and the most illuminating part of the process. Some participants were open and reflective; others were more reserved and required extra support and reassurance to feel comfortable speaking openly, particularly service users. We learned to be flexible in our approach, arranging a casual phone call with service users to build a rapport prior to the interview.

Despite the difficulties recruiting service users, once they were engaged in the interviews, all were eager and willing to share their experiences. We learned that it is important to develop a level of trust with service users, and that patience and empathy can encourage openness and in-depth understanding.

There were challenges too. We had hoped for more interviews with service users, more consistent data, and deeper engagement with those delivering the service. In particular, connecting with service deliverers proved difficult, largely due to the time lag between service implementation and the research evaluation. By the time we began our research, staff had moved on, memories had faded, and priorities had shifted, making it harder to capture a full and accurate picture of delivery. But public health research rarely hands you a neatly packaged story. What it does offer is insight into systems, into people, and into the messy, unpredictable reality of trying to improve lives.

Why it worked: partnership and collaboration

Looking back, we think the study worked because it was grounded in genuine partnership. The Smokefree NHS strategic team were incredible, collaborative, responsive, and deeply committed to making the service work.

We built relationships with service providers who shared their experiences openly, with LEAP members who challenged our assumptions, and with service users who trusted us enough to talk. Within our research team, we supported each other through the inevitable ups and downs. That collective effort, across roles, organisations, and lived experiences, is what made the project feel meaningful.

This experience has already shaped how we’re approaching future projects. Next time, we’ll go in with clearer expectations, more flexible timelines, and a deeper appreciation for the emotional labour involved, not just for us as researchers, but for the people we’re working with.

Researching smoking cessation in people living with severe mental illness isn’t just about measuring quit rates or evaluating service models. It’s about recognising the complexity of their lives, earning trust, and ensuring their voices shape the research process. More than anything, this project reminded us that we, as researchers, must be more attuned, more patient, and more willing to adapt.

---

About the authors:

Dr Angela Rodrigues, Associate Professor, Northumbria University, and co-lead of the Fuse Behaviour Change Cluster

Dr Lauren Hoult, Associate Lecturer, Researcher in Behaviour Change & Public Health, Northumbria University

Prof Katie Haighton, Professor in Public Health and Wellbeing, Northumbria University