Thursday 26 March 2015

The 'C' Word VII: Caring (for carers)

Posted by Jenni Remnant

Last month I attended ‘Caring for carers: developing good practice for carers in Newcastle’. Over 130 people were in attendance -  a mixed bag of commissioners, health and social care providers, third sector and voluntary organisations, and student representatives from both Newcastle and Northumbria University. 

The day began with acknowledging the scale of the ‘problem’. Guy Pilkington, Clinical Chair of NHS Newcastle West Clinical Commissioning Group described the issue as ‘under recognised, under supported, and under resourced’ in his opening talk. 

We went on to learn from Ewen Weir, director of wellbeing, care and learning at Newcastle City Council, that a recent study from Leeds estimated the national value of the free labour of informal carers per year is £119 billion. He asked us to imagine if informal carers around the country went on strike, and suggested to us that if informal care ceased, the system - which is already ‘creaking’ - would fail.

Throughout his talk Ewen drew on his own experiences of caring, and described sometimes emotionally, how despite his expertise, he struggled to navigate the system when attempting to access care for a family member. He told the audience that the issue of informal care is ‘ignored at our peril’ and explained that it is expected that by 2017 we’ll reach a tipping point, where demand will outweigh supply.

Atendees were introduced to the numbers in Newcastle according to the 2011 census. We were informed that of our population (279,100), 27,644 reported that they provide unpaid care: 6822 of these for upwards of fifty hours per week. As might be expected the emotional wellbeing and mental health of carers was considered a public health concern, and in the group work the physical dangers of some carers’ situations were highlighted as risky.

Open Clasp’, a local theatre company, gave us a further reality check. In two brief scenes they portrayed the story of a carer who ends up putting her mother into a care home. Two actresses showed with painful clarity the difficulties faced by unpaid informal carers and paid care assistants. It was difficult to watch and - judging from my experiences, and the experiences of people close to me of both caring roles - totally accurate.  

Your Person Centred Plan
We discussed throughout the day the introduction of the Care Act (2014), that is said to be ‘built around the carer’, provide more clarity and put carers on an ‘equal footing’ with the ‘cared for’. A diagram was used to illustrate this, which for those who know, looks very similar to illustrations of person-centred planning (see diagram above). This is where the person in receipt of service provision is placed in the middle and a plan of support is created to surround them. It was interesting in this respect to visualise this model, whereby someone with a person centred plan might be being cared for by someone else with a similar service plan. Could all this ‘planning’ actually get in the way of the caring?

Another interesting feature was the lack of discussion about the ‘cared for’. I have been inclined to argue (evidenced in past blogs) that while disabled, ill and older people are chronically undervalued by society, it doesn’t seem beyond the realms of imagination that the people that care for them might be undervalued. That said though, feedback was given to us that the top three issues for carers, as identified by carers, were: their mental health and wellbeing, their emotional health, being able to have a break, and accessing information.

I looked forward to when the audience had the opportunity to put questions to a panel which included commissioning representatives, a carer’s champion GP, Council representatives and Katie Dodd, the Chief Executive of Newcastle Carers. The questions were kind and focused on shared/combined budgets between clinical commissioning groups (CCGs) and local authorities and information sharing, in essence, the nitty gritty application of rhetoric to reality. Although, following these questions, all parties seemed to work on the assumption that the energy in the room would be maintained and turned into action. The inappropriate care responsibilities placed on young carers was a hot topic throughout the day, and one attendee asked: ‘what is an appropriate caring responsibility for a young person?’ to which the answer was that being a carer is always an inappropriate role for a young person. The time they spend caring should be the time for their education, learning and growing. Something we could all agree on.

The day held some ideological issues for me. I struggled with discussion of carers, without the voice of the ‘cared for’ (although I find this descriptor in itself uncomfortable). We also very infrequently visited societal and systemic issues beyond just care, such as the undervaluing of the ‘cared for’ that I mentioned above, as well as issues around class and gender.

The day scared me, despite my previous experiences and reading around the subject, I had not understood the pressing public health concern that the care of carers represents. I am genuinely terrified by the implications of this. People are devastated by the strains of informal caring and a seemingly impossible system - it can be agony - and this is before demand outstrips supply.

The day motivated me, the use of the theatre company was inspired, and their agreement to be involved suggested a world of potential in terms of research and participant engagement and knowledge exchange.

There’s not much conclusion to this other than to acknowledge that a health crisis looms, in a context of cuts, closing third sector and voluntary organisations, and shrinking resources. Research will have a role, and probably more than ever we will have to think intuitively to keep up with developments. Certainly the practical application of the Care Act from April 1st and its impact will be one to watch.

Tuesday 17 March 2015

A new cocktail – the McGonigles – gin and public health anyone?

Posted by Avril Rhodes

I went to Stockton High Street last Saturday (bear with me, this gets more exciting) and a vision opened before my eyes. A new business has opened (only to be applauded in the High Street which has been struggling for years despite the Herculean efforts of the Council) which is called Dr M’Gonigle’s Emporium. Now, Dr M’Gonigle (or more commonly McGonigle depending on where you look) is becoming an increasingly well- known Medical Officer of Health of Stockton, during the inter-war years, who tirelessly championed population health for local people, especially those who were feeling the effects of low income in general. He made compelling links between poverty and ill health. Despite this his name has been used for the branding of a pub – yes, a pub! Am I the only one who sees this as incongruous?

What Pub? Website, which operates for CAMRA (the Campaign for Real Ale) proudly declares…..

“About the Pub

Opened Dec 2014 and named after Dr George Cuthbert Mura M'Gonigle who fought hard to maintain the health of the poor people of Stockton. A pleasant open plan bar offering big screen TV and serving up to four real ales and a cider.”

The external d├ęcor made it absolutely clear that customers and passers-by alike were to see a link between the naming of the pub and the image of the great man himself, adapting an image of the good doctor that is frequently used in tributes to his work, see picture left, as a motif.

When I next down four pints of real ale and a cider, I shall of course be thinking about my health and my disposable income to enable me to cruise along the bar taps instead of settling down to a plate of healthy food.

This new development is sad to the point of being tear-jerking. Stockton High Street is at the end of a major refurbishment, one of many over the years to try and breathe new life into what was once a proud shopping centre of choice and indeed, branded the widest High Street in the UK. The latest work is impressive, but still can’t disguise that there are far too many voids, leaving too few shops attracting too few customers. I hope I’m proved wrong and that the current refurbishment will have the desired effect. At a time when there is much debate about licensing and public health, and the effect on drinking patterns, how, on top of the controversy did this strange name slip through the Local Authority’s scrutiny?

This, dear audience, is like opening a tobacconists named after Sir Richard Doll, who discovered the link between smoking and (ill) health. It really is, but then Dr McGonigle smoked and died young, but at least this was before the work of Doll was completed and published. Amber Taverns who own the establishment cannot claim ignorance.

Thursday 12 March 2015

Who’s opting out of responsibility? Battle of the checkouts

Posted by Mel Wakeman

Let's make Britain healthier. Please remove all junk from all tills and make EVERY store take responsibility

This was the message that was shared by all the supporters of our Thunderclap campaign on Monday 9th March. The Children’s Food Trust, British Dental Association, British Dietetic Association, Action on Sugar and Faculty for Public Health signed up alongside more than 100 other advocates asking stores to get rid of the junk food they display and promote at their checkouts. Our social reach exceeded 94,500 which is hugely encouraging and supports the idea that much of the public would welcome and benefit from such a move.

Courtesy of
I am not ignoring the fact that when it comes to the power of pestering from children, parents have a responsibility to set boundaries and deal with whining requests for sweets and treats. I also appreciate that the public are entitled to choice but my point is that if we want to make healthier choices, they should be the easiest of choices. Why not promote fresh fruit and low fat, salt and sugar options at the tills? In my mind if you want to buy junk, then walk to the dedicated aisle; that is your decision and your responsibility. We have been advised to reduce our sugar intake (the WHO released new guidelines last week) and many will need support to do this; we must have an enabling environment that promotes positive health behaviour change rather than be constantly tempted and encouraged to pick up sugar rich and energy dense foods.

In our first blog we named and shamed the leading stores that have yet to step up to the plate: Marks and Spencer, Morrisons, Asda, Sainsbury's Local, Iceland Foods and WHSmith. I have since written to all these stores asking them to adopt a blanket policy to remove all junk from all their tills. In each letter I stated that not doing this undermined any company values and intentions to be responsible for the products they sell. They are essentially sending out mixed messages concerning their company priorities (i.e. profits vs health) and most importantly they are undermining customer efforts to make healthier choices. I mentioned that evidence now suggests we are more likely to choose unhealthy products when impulse buying and that highly processed foods may be linked to addictive eating. These factors all exacerbate the negative impact junk food has on our health.

The fact that Tesco, Lidl and Aldi have most recently committed to junk free checkouts is evidence enough that it can be done. Implying healthier checkouts can't be done and that customers don’t want them says these stores haven't tried hard enough! Many may want to have their cake and eat it but this is really not the way forward to better health. Tesco for example only display food items that contribute one of our five a day, have no ‘red’ traffic light ratings, and are deemed by the Department of Health to be a ‘healthier snack’. This approach makes a lot of sense to me, they still offer choice so what’s the problem?!

So let’s go store by store and examine what I learnt about their company values and marketing policies. I checked out what they are currently doing in terms of in-store health initiatives and questioned why they did not acknowledge their role in supporting customers in making healthier choices.

1. My first letter went to the CEO of Marks and Spencer.

I commended their 22 pledges on the Government’s responsibility deal; they provide calorie controlled options as part of their ‘Calorie Reduction Plan’ and they have developed a ‘Well-being Week’ and ‘Veg Pledge’ but they could do so much more as part of their ‘Plan A’ initiative to promote healthy living.

Their initial response to my letter was read with some amusement. It contained this statement:

“From May 2012 we removed all sweets that might appeal (to children) from our belted till points. Belted tills are the most common type of tills we use in our food sections and are where we believe customers are most likely to be distracted by their display.”

My reply went like this:

With all due respect, how can you determine which sweets might and might not appeal to children at your belted till points? The colourful, character sweets may certainly appeal to younger children (and adults!) but how can you assume that in the absence of these, children will not go for the next best thing? You are also assuming that parents and families tend only to use the belted till points? Children are certainly not just the vulnerable party here either; as stated in our letter, health problems attributed to diet significantly affect both adults and children.

With the continued roll out of your self-serve checkouts, surely it would be wise to review your current policy on all sweets at all till points. A blanket policy certainly sends out a much stronger message concerning your health agenda. The range and quantity of sweets on display at the self-service points are often vast and as we said previously, the accumulative impact of impulse buys (of high calorie foods) can be extremely detrimental. Our suggestion is simply to swap these items that are of low nutritional value with those that are healthier and more nutritious.

Their reply came back as follows:

M&S have “made a note of and will pass on my comments about having more healthier and more nutritious items to their Service and Policy team for their consideration.” Of course they “can’t confirm that any changes will be made” and following my request, would not provide a contact name for the person that leads this team (so that I could continue discussions). It was interesting to read that M&S are so “focused on engaging with millions of customers” yet they were very reluctant to commit to or continue conversations with me.

2. My second letter went to Sainsbury’s

Sainsbury Company Values acknowledge they have a key role to play in promoting healthy eating and (apparently) set out to make healthy choices easy for their customers. They state they are encouraging good health and helping people change their behaviour. Their 2014 marketing code of practice is very explicit regarding the protection of children; that they will aim to support the role of parents, uphold responsible consumption and nutrition. This all sounds great as they implement these values and policies in their large supermarkets but they fail to do so in their smaller, local stores. My request was to continue to roll out their Company Values and codes of practice to ALL Sainsbury’s stores.

I have yet to receive a proper response other than being allocated a case manager with assurances that a full investigation will be conducted on behalf of the CEO. This was over a week ago....

3. My third letter went to Asda

Asda have reformulated products and cut the costs of healthier produce but other than that I found it very difficult to find any mention of specific healthy marketing policies. They have 22 pledges on the Government responsibility deal but the majority are related purely to alcohol. They have pledged to lower salt and saturated fat but, in my experience, on entering an Asda store you often hit a wall of doughnuts, muffins and biscuits before you get to the fruit and veg sections.

The response I received from Asda was the most positive and promising:

Their new Vice President of customer relations responded on behalf of their CEO. She indicated that following some recent changes to their structure, she was taking on Asda’s health agenda. She said she appreciated some of the significant issues that we face as a nation, and is keen to quickly determine how they as a business can help. She explained how she was currently recruiting a team to help first define their role in people’s lives from a health perspective (their customers, colleagues and communities they serve) and then prioritise the areas where they can make most material impact. To that end, she assured that her new Senior Director, once appointed, would contact me to discuss this subject further. I was quite happy with this and will certainly look at following this up.

4. Next was WHSmith

As a leading non-food retailer, I reminded WHSmith that they still have a key role to play in promoting healthy eating and enabling their customers to make healthier choices from the food that they offer. In their Corporate Responsibility document they acknowledge WHSmith “take the responsibility for the products we sell seriously”. Their Marketing Code of Practice states WHSmith “aim to offer customer’s choice but it is also essential that we accept and act responsibly concerning the food and drink products we offer”. The volume and variety of junk food displayed next to their tills is vast. WHSmith also use a particularly strong upselling strategy which further encourages the purchase and consumption of junk food. Buy a book or magazine and be asked to buy a massive bar of chocolate is entirely irresponsible.

I read with interest that WHSmith “always take into account the level of knowledge, sophistication and maturity of the people we are marketing to, particularly children”. In light of this statement, I thought they would be interested to know that research suggests our nutrition knowledge is not sophisticated and adults often make food choices based on taste preferences without considering the health ‘value’. Adults often act impulsively too so it is a very large assumption that we can expect children to make sophisticated informed choices when it comes to food!

Coincidentally a paper was published in the journal Public Health Nutrition around the time that I wrote to WHSmith and reported that almost one-sixth of non-food stores displayed checkout food and the majority of this was ‘less healthy’ and displayed at child height. Less healthy food was also more likely to be subject to a written price promotion than healthier food. Surely this has to change?

I have had no response from WHSmith.*

5. Next was Morrisons

Their corporate responsibility review clearly outlines the commitments they have made and it is reassuring to see continuation of the 27 pledges made as part of the Governments’ responsibility deal. They have reformulated products and are promoting healthier options, fruit and vegetables but as yet there are no signs that they plan to remove the junk. When questioned on this matter via Twitter they reported that they were responding to customer demand for choice.

I was intrigued by this and asked them if they had completed any customer surveys. Tesco and Lidl for example reported that over two-thirds of their customers prefer healthy checkouts and that adopting junk free tills had received overwhelmingly positive responses.

I have had no response from Morrisons

6. Last but not least was Iceland Foods

Iceland’s corporate responsibility document outlines the commitments that they have made as far back as the 1980s. They have 10 pledges on the Government’s responsibility deal. Like Asda, they have reformulated products and are actively promoting fruit and vegetables. Again, they seem reluctant to take responsibility for the products they promote.

I have had no response from Iceland Foods.

If we are to see improvements in the levels of overweight and obesity in the UK, we must change our social and food environment. Without doubt they (amongst other factors) influence our food preferences. The responsibility simply cannot be put on the consumer alone; the responsibility also lands firmly on the shoulders of our stores too.

*UPDATE 13/03/15

Posted simultaneously, through the power of the internet, here and on Mel's personal blog The Grub Hub.

Yesterday I received a reply from WHSmith (pictured right), so I felt it only fair to share this and my response to it, as I have for Marks and Spencer, Asda, Sainsbury’s, Morrisons and Iceland Foods.

My reply was addressed to WHSmith Group Communications Director Mr Mark Sabin:

Thank you for your letter in response to my request to stop the display and promotion of confectionery at WHSmith till points. I have read with interest your 2014 corporate responsibility report and would now like to raise some issues and questions concerning this report and some of WHSmith’s responsible retailing policies:

1. In your letter you explained that: “WHSmith are a very small player in the UK confectionery market”. I strongly believe this is not valid justification to ‘opt out’ and pass on your responsibility to the major supermarkets. As a seller of confectionery, sweets and soft drinks, no matter how small your contribution to the market, you are obligated to consider the full impact your products may have on consumer health.

2. Your report states: “you have extended your healthy food range”. Whilst products such as granola pots, smoothies and health food bars may be marketed as and appear ‘healthy’ they often contain high amounts of added sugar. These items are generally no better than sweets or chocolate and mean that we exceed our recommended sugar intake when consumed in excess. Have you consulted a registered nutritionist or dietitian when determining your product range? Do you have a specific threshold using traffic light labels or set a maximum sugar or fat content (that I mentioned in my previous letter) to help identify healthier products? Reviewing portion sizes of the products you provide is certainly a valuable step you have made but simply looking at the total calorie content is not always entirely helpful. As a nation that is in the midst of a health crisis attributed to diet, it is very important to consider the added sugar, saturated fat and salt content too.

3. You state that: “where your stores are in travel locations and you offer a more extensive range of food, drinks and snacking products, you have been increasing the range of healthy alternatives”. If you are assuming we are more likely to snack whilst travelling, it would be useful to have an evidence base here and if you are stocking more ‘healthy’ items, are you actively promoting them instead of the confectionery? You must also be confident your healthy alternatives meet the appropriate legislation if they are to be labelled as such. Please can I point you towards this rather large faux pas in one of your stores:

4. You state that: “your staff are trained to never offer promotions repeatedly to regular customers”. Are you assuming your customers are more likely to be regular if they purchase from stores in travel locations i.e. commuters making repeated journeys? How would WHSmith staff know if a customer is regular or not? Surely staff rotations and altering customer habits would make this impossible to determine with confidence and is a large assumption to make?

5. You explain that: “when chocolate or confectionery is included as part of a promotion, it is often designed for sharing or as a gift”. This clearly passes on the responsibility to your customer, rather than accepting it yourselves. Again, how can you possibly assume that the confectionery you sell will be shared or gifted?

6. You explain that WHSmith staff are: “trained on how to offer promotions so that staff never offer confectionery products to parents with children and never offer promotions repeatedly to anyone who has made it known they do not wish to be advised about such promotions”. How can your staff make a judgement that an adult has or does not have children? Children are not the only vulnerable party here either and unless your staff manage your till points throughout every working day, how can they determine if a customer has already been previously asked? You are also putting the onus on the customer to state if and why they don’t want your product. This could potentially be awkward for the customer in making unnecessary justifications.

Overall I am concerned about the assumptions made about WHSmith customers and from the explanations you have provided, I am not convinced your methods and criteria for selling products is sufficiently robust. I would be very happy however to discuss the nutritional contents and values of the products you offer and help establish a range that is clearly healthy and varied for your customers. I look forward to hearing from you again.
Yours sincerely,

Mel Wakeman

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Tuesday 3 March 2015

No time to run: is role overload contributing to physical inactivity in parents?

Posted by Caroline Dodd-Reynolds

Last night during a Twitter exchange, it somehow came about that I would write a #fuseblog on barriers to physical activity and a healthy diet in working mums. Interestingly, my one-year-old daughter had just gone nicely to bed at this point and so my husband and I treated ourselves to a healthy(ish) home-cooked dinner, albeit at 9pm. Normal service was resumed however at 12.30am when we were woken by the sound of the one-year-old vigorously banging on her cot and shouting, ‘Is DARK!’ (yes, it’s the middle of the night). So here I am typing this blog with two hours of sleep under my belt. Primarily this is why I no longer do very much exercise-based physical activity, or indeed eat as healthily as I used to. I am sure there are many who can relate to this sleep-deprived existence. Certainly the transition to parenthood can be an experience of life-changing proportion. For me, the transition back to work after months of no sleep and complete displacement from my previous identity was interesting.

There is guilt at leaving my little one at nursery and then there is the race through the day so that I can leave early enough for us to have an hour of (potentially active) play before bedtime. There is guilt at not being able to attend the evening functions at work, the interesting lectures that I know would be pure luxury to immerse myself in. There is pressure to succeed at work, not so much to prove that I can be both a parent and an academic, but more that if I don’t, then there is little point in having endured the guilt. And what of physical activity? Well, please see my previous points as to why this takes a seat so far back that I can barely see it.

The Chief Medical officers recommend 2hr 30min moderate-vigorous physical activity (MVPA) per week for adults; an individual is classed as inactive if achieving less than 30min moderate physical activity per week. Time spent engaged in MVPA declines with age and in 2012, 67% of men and 55% of women aged 16 years and over were meeting recommendations. These data were self-reported and objective monitoring methods suggest these figures are inflated. Guidelines for reducing sedentary behaviour are less clear but should involve avoiding prolonged periods of sitting. I am a full-time Lecturer in Physical Activity and Nutrition and so the irony of spending hours (sitting) writing lectures on the perils of sedentary behaviour and energy-dense snacks, is not lost on me. I did a quick PubMed search including physical activity and working mums as key terms and found a lonely but slightly reassuring 10 articles.

One article describes succinctly and astutely the fact that much is known about motherhood as a transitional influence on the physical activity habits of new parents, but actually very little about those new parents (or indeed any parents) who work. Emily Mailey and her colleagues, from the Dept of Kinesiology at Kansas State University, talk about ‘role overload’ and how this is associated with negative health outcomes such as elevated stress, depression and anxiety. I am starting to feel better here. The 25 mothers and fathers who participated in focus groups for this study reported barriers such as ‘scheduling constraints’ which I think many working parents may identify with – for me it is the Outlook calendar that keeps me on track and I know that if I schedule 30min into it on a Tuesday, I do have time to nip out for a run and I am more productive for it. But then what if someone requests a meeting or tutorial? Interestingly, ‘prioritising’ is noted as a facilitator. One mother comments that she had to get up at 5am to fit her physical activity into her day. Indeed this is a thought that often crosses my mind. Another, is that working parents may well comprise a special population in terms of physical (in)activity habits and sedentary behaviour; when I was on maternity leave I was certainly more active than I am now.

Anyway, I’m writing this on a Friday (thank goodness for the weekend). I really must clean the bathroom tomorrow, and the car needs a good wash, these will get my activity counts up, great. Oh but then there is that paper I need to write, and next week’s lecture I have yet to prepare. I know realistically what I will be doing this weekend – and it may not comprise any minutes of MVPA, nor help my preparation for next week at work, but I know it is the finest choice and that my little girl will laugh out loud with delight when she sees the animals on the farm.

Feeling slightly more awake after some strong coffee, I have just read this blog back and am sad that it sounds rather negative. It isn’t meant to, but it has made me think a little more about how I spend my days (and the potential to ask for a standing desk at work). And in case you were wondering, I would not swap my little girl for any amount of physical activity. Mailey and co. talk about being a role model and being active with your children. In a good week with no illness, sleepless nights or marking, we probably do manage to achieve this to an extent. And my little girl is happy, active and eats a healthy but balanced diet (vegetables and chocolate included) so perhaps we are doing things right after all?