A new social contract for Public Health

By David Hunter, Newcastle University; Peter Littlejohns, King’s College London; Albert Weale, University College London; Jacqueline Johnson, public health and management consultant; and Toslima Khatun, King’s College London

Air pollution is widely recognised as a serious health hazard while Covid-19 shone a spotlight on the weaknesses of the UK’s public health system

The UK is in the grip of a public health crisis. With depressing regularity, new research shows the growing deterioration of the public’s health. Improvements in life expectancy have stalled, health inequalities have widened, obesity and alcohol misuse are placing an increasing strain on health services, and air pollution is now widely recognised as a serious health hazard. While Covid-19 shone a spotlight on the weaknesses of the UK’s public health system, they had existed for some time. Indeed, as Michael Marmot has argued, most of the deterioration in health stems from 2010 and the Coalition government’s austerity policy. This resulted in cuts to public spending with local government, which is responsible for public health, suffering some of the deepest.

Despite the wealth of evidence testifying to the parlous state of public health and with many studies offering solutions that are both cost-effective and for which there is robust evidence, there remain significant political and organisational barriers to the realisation of an effective public health system. Unless these are confronted, the chances of progress are slim.

A new social contract for public health

We support the case for a new social contract in which health policy is truly public. Public health policies are often criticised by those of a neoliberal persuasion for restricting individual choice and for ‘nanny statism’. We refer to this form of liberalism as ‘vulgar individualism’. Big government and state overreach are viewed as problems which stifle personal freedom and hinder private sector growth on which the economy depends.

In fact, a much bigger problem is state underreach and a failure to take up and apply policies and policy instruments that are known to be effective in order to improve health. But as long as governments continue to subscribe to the view that the health of individuals is a matter of personal responsibility then action of the kind needed will not be forthcoming. Over the past 13 years or so, successive governments have subscribed to this view ignoring all the evidence which demonstrates the flaw at the heart of such thinking, namely, a belief that that government is best which governs least.

In place of such a stunted political ideology we propose a new social contract for public health incorporating the principles of what might be termed ‘social individualism’, that is, a commitment to using the instruments of collective political authority to create the conditions for individual choice and fulfilment.

What are the elements of the new social contract for public health?

First, and importantly, a social contract for public health would focus on prevention, reflecting the significant body of evidence demonstrating how a wide range of public health measures would prevent more serious conditions developing. But while it is easy to state all this, as indeed numerous academics and analysts have done over many years, unless political leadership is in place to confront the challenges the prospect of change happening is slim.

A particular challenge is the tension arising from the urgent driving out the important. With an NHS under extreme pressure in respect of growing waiting lists and staff shortages, for electoral and other reasons, politicians are most likely to prioritise addressing these to the exclusion of longer-term public health measures. Yet, as the Hewitt Review of Integrated Care Systems points out, ‘we have mistaken NHS policy for healthcare policy’.

Second, a new social contract requires a precautionary state, paying attention not only to known hazards but also to remote and uncertain ones. If the pandemic taught us anything, it was the need to be prepared and have sufficient resources in place to enable swift and effective action to be taken. Sadly, for a government emerging from the debacle over Brexit and trapped in a mindset of short-termism with a focus on campaigning rather than governing, adopting a policy of precaution does not come naturally.

Third, social solidarity is required in the face of health inequalities. Social individualism recognises that policies for the most vulnerable are not policies for a particular group in society, but policies for all of us when in need. What is required from public policy is the support to resilience over the life cycle.

Fourth, a new social contract requires a different approach to government and governance. In particular, addressing the short-termism that pervades our politics has to be challenged and replaced by a more sober acknowledgement of how governments need to function. A populist politics that wishes away the need for planning and relies on easy, facile slogans to attain and retain office – ‘the unbearable lightness of politics’ as the historian, Tony Judt, put it – undercuts the seriousness that is needed for effective government.

Above all, a new social contract sees a central role for an active state. To this end, we set out a manifesto to frame the approach to public health that is needed in the hope that it might inform the political debate as preparations get underway for a general election due over the next year.

A manifesto

Much that needs to be done already exists and is supported by a sound evidence base as well as by the main UK public health bodies. The Hewitt Review’s plea for priority to be given to population health matched by new investment is also worth acting on. Some measures could be swiftly adopted by a new government if it so chose. Others will take longer but making a start by implementing what be done quickly would make most sense in tackling the crisis facing public health.

Above all, regardless of the particular topic demanding attention, at the heart of public health policy is the need to work in a cross-organisational and cross-sectoral way. This will not happen without strong political leadership, but to embed a cross-government commitment to public health requires new legislation to place a duty on all government departments to respect in their policies the claims of public health. To monitor how policy is taken forward and implemented, there is a strong case for making the publication of health impact statements obligatory.

If the winds of change blowing through the country offer a turning point in the public’s health, then the incoming government has no time to lose in seizing the opportunity.

For an extended discussion of the issues raised go to our new book: Littlejohns P, Hunter DJ, Weale A, Johnson J and Khatun T (2024) Making Health Public: A Manifesto for a New Social Contract. Bristol: Policy Press

Bristol University Press | Making Health Public - A Manifesto for a New Social Contract, By Peter Littlejohns, David J. Hunter, Albert Weale, Jacqueline Johnson and Toslima Khatun

Authors

David J Hunter, Emeritus Professor of Health Policy and Management, Population Health Sciences Institute, Newcastle University

Peter Littlejohns, Emeritus Professor of Public Health, Centre for Implementation Sciences, Institute for Psychiatry, Psychology and Neurosciences, King’s College London

Albert Weale, Emeritus Professor of Political Theory and Public Policy, University College London

Jacqueline Johnson, pubic health and management consultant

Toslima Khatun, teaching fellow, King’s College London



References

The answer starts with austerity, The Guardian, 10 August

https://www.theguardian.com/commentisfree/2020/aug/10/england-worst-covid-figures-austerity-inequality

Hewitt P (2023) The Hewitt Review: An independent review of integrated care systems, GOV.UK https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1148568/the-hewitt-review.pdf

Judt T (2010) Ill Fares the Land. Harmondsworth: Penguin Books 

https://www.penguin.co.uk/books/178939/ill-fares-the-land-by-judt-tony/9780718191412 

The views and opinions expressed by the authors are those of the authors and do not necessarily reflect those of Fuse, the Centre for Translational Research in Public Health.

Image:

Image by Jacques GAIMARD from Pixabay.

Media representations of disabled people

Posted by Laura Navin, Health and Social Care student, Northumbria University

Picture by Laura Navin

Negative media representations of disabled people still exist in society and this needs to be addressed. I have dyspraxia which is a learning difficulty, and I sometimes struggle with my co-ordination, communication, processing and speed but it has not stopped me from achieving my goals!

In the media, disability tends to be portrayed through a medical or deficit model, with disabled people often treated as pathetic.^1,2,3 TV charity shows such as Children in Need encourage pity for disabled people² and people with disabilities are still seen as “the heavy burden of care”; “the helpless victim”.³ Yet even when well-meaning, encouraging pity is discriminatory as it creates stereotypical and negative assumptions about disabled people². These negative representations can decrease a disabled person’s self-esteem and make them feel like they are not part of society.^1,4

The issue is heightened by the absence of disabled people and their voices within mainstream media which might help to reclaim the narrative and counter negative stereotypes. As Caroline Casey, founder of The Valuable 500, a global movement putting disability on the business leadership agenda, has suggested “from daytime TV to adverts on social media, to the articles which publications run, representation and visibility of persons with disabilities simply does not reflect our society”. This was brought to light recently for example, when Sia’s decision to cast a neurotypical actress in the role of an autistic female protagonist in her upcoming film was widely criticised.

There are more positive portrayals of disability in the media however. Harry Potter star, Daniel Radcliffe has dyspraxia and acted as an inspiration to many when saying, “do not let it stop you. It has never held me back.”. In 2018, Lee Ridley from the North East won Britain’s Got Talent and in 2021, EastEnders star Rose Ayling-Ellis became the first deaf contestant on Strictly Come Dancing. Even these more positive representations are emblematic of the failure to represent disabled people as everyday, ordinary citizens however. As Lee Ridley claims, “Our government has a very weird relationship with disabled people. We are either seen as superhuman or as some sort of burden”.

Portrayals of disabled people as a burden on society have been shown throughout both austerity and the Coronavirus pandemic. Disabled people have been mocked as ‘scroungers’ in television shows and newspapers, with arguments that incapacity benefit had become a ‘lifestyle choice’ for the lazy, and that a disability benefit crisis was responsible for the UK economic crash resulting in the disproportionate targeting of disabled people within austerity measures.^5,6 Covid has been argued to be one of the biggest media outbreaks medicalising disabled people.^1,7 During the pandemic, disabled people were seen as ‘vulnerable’ and had to isolate from society.^5,8 ‘Vulnerable’ is a label that is often rejected by people with disabilities and its adoption does not portray the importance of disabled people’s rights and viewpoints.⁹ Labels such as ‘vulnerable’ or ‘immunocompromised’ when used to explain differential susceptibility to illness have also been argued to result in an unreasonable, unpleasant message about the value of disabled people’s lives. The sunflower lanyard which could be worn by disabled people to show they were exempt from wearing face masks helped in some ways to increase disability awareness and create more understanding, support and respect towards disabled people. However, this is another form of labelling, and not all disabled people want to identify their disability to the world. Greater understanding and training on disability ethics is urgently needed to avoid this sort of discrimination and support disabled rights more systemically.^9,10

 

It is also important that disabled voices are heard in society and that the media represents disabled people in a more positive light. Sometimes when I tell people about my dyspraxia they feel pity for me, but this is not what I want. I am telling my story to inspire others, not create sympathy, so please do not feel sad for me, feel happy for me! I have succeeded in my academic studies and graduated from university with second-class honours as a student with dyspraxia. I have been involved in podcasts and dissertation writing to raise my voice as a disabled person and in doing so I hope to give others the confidence to do the same. I am now studying for a postgraduate certificate in education (PGCE) to teach health and social care. I hope to continue to raise my voice and to inspire others.

Part of our Fuse blog Student Series

The Fuse blog Student Series showcases posts by students who have been challenged to write a blog as part of their studies at one of the universities in the Fuse collaboration, the NIHR School for Public Health Research, or perhaps further afield. The authors may be new to blogging and we hope to provide a 'safe space' for the students to explore their subject and find their voice in the world of public health research.

The views and opinions expressed by the author are those of the author and do not necessarily reflect those of Northumbria University or Fuse, the Centre for Translational Research in Public Health.

References

1) Cameron, C. (2014) Disability Studies: A student’s guide. London: SAGE Publications Ltd.

2) Barnes, C. (1992) Disabling imagery and the media: an exploration of the principles for media representations of disabled people. Halifax, England: The British Council of Organisations and Disabled People and Ryburn Publishing Limited.

3) Goethals, T. et al. (2020) ‘I am not your metaphor: frames and counter-frames in the representation of disability’, Disability & Society, 12 (1), pp.1-19. DOI: https://doi.org/10.1080/09687599.2020.1836478.

4) Casey, C. (2020) ‘Where all the disabled people on screen? We must increase representation or risk reinforcing damaging stereotypes’, Independent, 1 December. Available at: Where are all the disabled people on screen? We must increase representation or risk reinforcing damaging stereotypes | The Independent (Accessed: 22 March 2022).

5) Ryan, F. (2019) Crippled: austerity and the demonization of disabled people. London: Verso.

6) Briant, E. et al. (2013) ‘Reporting disability in the age of austerity: the changing face of media representation of disability and disabled people in the United Kingdom and the creation of new ‘folk devils’, Disability & Society, 28 (6), pp.874-889. DOI: 10.1080/09687599.2013.813837.

7) Shakespeare, T. et al. (2021) ‘Triple jeopardy: disabled people and the COVID-19 pandemic’, The Lancet, 397(10282), pp.1331-1333. DOI: https://doi.org/10.1016/S0140-6736(21)00625-5.

8) Courtenay, K. and Perera, B. (2020) ‘COVID-19 and people with intellectual disability: impacts of a pandemic’, Irish Journal of Psychological Medicine, 37, pp.231-236. DOI: 10.1017/ipm.2020.45.

9) Singh, S. (2020) ‘Disability ethics in the coronavirus crisis’, Journal of Family Medicine and Primary Care, 9 (5), pp.2167-2171. DOI: 10.4103/jfmpc.jfmpc_588_20.

10) McLean, S. and Williamson, L. (2007) Impairment and disability: Law and ethics at the beginning and end of life. Oxon: Routledge-Cavendish.

The toxic mix of Universal Credit, austerity and widening inequalities

Concerns about the mental health impact of government reforms under austerity are growing and emerged in Universal Credit research commissioned by Gateshead Council which is soon to be published in BMJ Open[1].

 

Mandy Cheetham, Research Associate at Teesside University, posts on Mental Health Awareness Week.

The invitation to present the findings at Newcastle University’s recent conference on human rights, health and welfare made me reflect on the multiple ways in which Universal Credit drives inequalities and undermines claimants’ rights.

Panel members (Mandy, pictured furthest right)

Want, Disease, Ignorance, Squalor & Idleness: Beveridge’s 5 giants

As part of a panel discussion, I was struck by the powerful comments of my fellow panel members who framed the rising need for food banks as a failure of social security. They described the “uncomfortable truth” of food poverty, the “violence of austerity” and the need to start from a position of love and care, offering people dignified, not demeaning responses to crises.

The sense of exclusion, shame, embarrassment and stigma surrounding food insecurity and the use of foodbanks was clearly articulated by the Universal Credit claimants in the study we did in Gateshead and Newcastle. One participant with a long term health condition commented:

"I think the most degrading thing about Universal Credit was that I had to go to foodbanks. I couldn’t afford to eat" (Claimant interview)

Universal Credit claimants and staff supporting them recognised the political choices which undermine people’s basic rights to food and social security, which are fundamental to health and wellbeing.

"It seems to be government policy at the moment to punish people for being poor" (Staff interview)

It is hard to see these choices as accidental when Amber Rudd, the Secretary of State for Work and Pensions, acknowledges that the rise in food banks is at least in part due to the roll out of Universal Credit. It is brutal and unrelenting in its effects.

Last week, I attended a thought provoking seminar by Guy Standing (co-founder of the Basic Income Earth Network), who reflected on the benefits of securing a basic income for all and described his view of the modern giants blocking transformative progress, including precarity: creating ‘supplicants’ with no rights, asking for favours from friends, family and bureaucrats, reliant on charity with no sense of agency or freedom. 

Digital exclusion, delays, deductions, intensified work related requirements, arbitrary risk of sanctions and maladministration by the Department for Work and Pensions associated with Universal Credit, all combine to maintain the precarious existence of claimants, undermining their rights to financial and material security, and social inclusion required for health and wellbeing.

This is not new. In a paper entitled ‘First do no harm’, Barr et al (2016)[2], found the programme of reassessing people on disability benefits using the Work Capability Assessment was independently associated with an increase in suicides, self-reported mental health problems and antidepressant prescribing. The authors suggest that the policy may have had serious adverse consequences for mental health in England, which could outweigh any benefits that arise from moving people off disability benefits.

The four year welfare benefits freeze, austerity and implementation of Universal Credit is a toxic combination that has truly terrible consequences for those reliant on the state leaving people without enough money to fund the basics essential to participate in society. 

Piecemeal changes announced by government to phase out “unnecessarily long” three year sanctions under Universal Credit, for example, are welcome but do little to address the wider concerns raised about the continuing hardship which people experience on Universal Credit (Dwyer P. 2019)[3]. 

There are increasing calls for public health to respond in the face of mounting evidence of the harm to people’s physical and mental health which Universal Credit is causing. If government Ministers and policy makers were guided by the principles of “First Do No Harm”, it would be hard to see how the continued roll out of Universal Credit could be justified in the name of ‘welfare reform’. Public health needs to be at the forefront of efforts to address concerns about rising inequalities in different dimensions – income, work, mental and physical health, families and relationships, which were highlighted this week by the Institute for Fiscal Studies (Joyce and Xu 2019).

References:

1. Cheetham M, Wiseman A, Moffatt S, Addison M. (2019) The impact of Universal Credit in North East England: a qualitative study of claimants and support staff BMJ Open (in press).
2. Barr B, Taylor-Robinson D, Stuckler D, Loopstra R, Reeves A, Whitehead M. ‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study Journal of Epidemiology and Community Health, 70:339–345 http://dx.doi.org/10.1136/jech-2015-206209.
3. Dwyer P. [editor] (2019) Dealing with welfare conditionality, Bristol, The Policy Press. 
4. Joyce R. and Xu X. (2019) Inequalities in the twenty-first century: Introducing the Deaton Review, Institute for Fiscal Studies and Nuffield Foundation, London, UK https://www.ifs.org.uk/inequality/wp-content/uploads/2019/05/The-IFS-Deaton-Review-launch.pdf

Images:

1. Courtesy of Newcastle University Law School: https://twitter.com/NCLLawSchool/status/1121333821121671169
2. Courtesy of Ruth Norris (@ruthpnorris): https://twitter.com/ruthpnorris/status/1121512102437453830 
3. Courtesy of the Institute For Fiscal Studies: https://www.ifs.org.uk/inequality/chapter/briefing-note/

Universal Credit and the perspectives of ex-Jobcentre Plus staff

In last week's blog post, Mandy Cheetham wrote about the impact that Universal Credit is having on health and wellbeing in Gateshead.  In today's guest post, Kayleigh Garthwaite, Jo Ingold, and Mark Monaghan present their findings from preliminary research with former personnel from Jobcentre Plus.

Universal Credit has attracted considerable criticism from experts and politicians. Yet could it be that it has also caused civil servants associated with the policy to leave their jobs?

Throughout 2018, Universal Credit (UC) has been a prominent feature of political discussion, second only to Brexit. UC is an attempt to simplify the benefits system through the introduction of one single working age benefit and to improve incentives to work through the radical restructuring of the benefits and Tax Credits systems. The design and implementation of UC have been defined by austerity and large-scale expenditure cuts to central government departments and drives for greater efficiency following the (2007-8) financial crash. Consequently, the roll out of the policy has been beset with difficulties, magnified by a turbulent political environment (two General Elections, the Brexit Referendum and changes in Ministerial Portfolios).

Since the introduction of UC, which has consolidated both conditionality and punitive benefit sanctioning, there has been an accruing evidence base highlighting the detrimental impact of UC and social security reform more broadly, particularly for those living on low incomes and in poverty. Unfortunately, there is no clear sign of this research being incorporated into policy and so far, no sign that UC will be amended or abandoned.

Between us we have spent the last few years looking at various aspects and impacts of changes to social security policy in the UK, ranging from accounts of the social consequences of austerity, exacerbated by UC, which has led to rising levels of foodbank use; the role of evidence in the policy discussions within the Department for Work and Pensions (DWP) at the time of UC design; and the role of employers in active labour market policies. It became apparent that little work had been conducted with practitioners responsible for the rollout of the policy. This seems a significant gap bearing in mind the amount of negative publicity that has accompanied the rollout of UC, which sat alongside public statements that despite the difficulties, staff morale within the DWP remains the highest in Whitehall.

Despite a slight increase from 2017 to 2018, from around 2010 there has been a significant reduction in the number of civil servants which coincides with the design and development of UC. Little is known of the reasons for staff departures and whether the demands of working on a controversial policy such as UC played a role. Over the summer of 2018 we conducted preliminary research in the form of in-depth interviews (n=8) with former personnel from Jobcentre Plus in the North of England. We initially hypothesised that reasons for departure would include: financial packages on offer; timing; age; ill health; other opportunities in the labour market or career change; dissatisfaction with current role or manager; and a lack of opportunities in the Department or wider civil service. We were particularly interested in whether objections to policy were also part of the equation.

Amongst our respondents, dissatisfaction with their current role was perhaps the clearest theme to emerge as to why they departed the DWP. This wasn’t always linked to UC per se, but was part of the broader austerity landscape in which UC emerged and was linked to longer term ideological developments within both social policy and public administration, which coalesced around increasing use of managerialist forms of governance and austerity. As has been documented, the movements towards activation in welfare policies foregrounded as a means of reducing the deficit has required specific forms of governance to the extent that welfare-to-work organisations find themselves in almost permanent processes of reorganisation. For our respondents, it was this experience that produced the most consternation.

In terms of top down management targets, our respondents told us of the impact of initiatives within the DWP and how targets and objectives were impossible to hit as meetings with clients had become so truncated, but also because of inconsistency in targets:

… they changed the goalposts all the time. One Monday when I went in it would be all about getting so many people into work experience that week. The next Monday morning it would be getting so many people into sector based work academies.

This impacted most of the vulnerable who would fall through the system when the initiatives didn’t match their needs. This frequently ended in a sanction, leaving the staff feeling bereft and stressed from the predicament of their clients, but also their own working environment:

I just thought “this is awful”. I went home and I was really stressed, my jaw was stressed. And I just thought, “oh my god”. I just felt terrible. And I was annoyed with myself for letting her get to me like that. But it was just an unnatural situation really.

These issues were confounded by a key development in DWP: ‘digital by default’ service delivery. The target culture not only fed into individual appraisal where managers would closely, physically monitor the working practices of front-line staff; staff performance was also measured through digital monitoring. This contributed to staff feelings of dehumanisation. Our respondents reported that the move towards a fully digitized service not only led to feelings of de-skilling and autonomy, but also took away the public service motivation and ethos that drew our respondents into working in the civil service in the first instance. Staff described being permanently on the ‘back foot’, in that digital services were rolled out without staff being given the relevant training. There was also a profound shift in their own views of the public service ethos, which had changed to such an extent that staff reported to us that it was now ‘embarrassing’ to be associated with Jobcentre Plus and that their actions were making ‘vulnerable people more vulnerable’.

I wanted to do a good job, but at the same time my heart wasn’t in it, I was part of something that didn’t sit very comfortably with me. It was becoming embarrassing to say where I worked.

We are not suggesting that UC was solely or directly responsible for the findings we report here. Many of these issues reported to us predated the rollout of UC. But what we found seems to be a product of the direction of policy travel, as well as continuous reorganisation of the delivery of social security and public employment services are in the UK. What was apparent from our discussions with ex-Jobcentre Plus personnel is that under UC these factors were only getting worse. Time will tell whether this continues to be the case.

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

About the authors:

Kayleigh Garthwaite is a Birmingham Fellow in the Department of Social Policy, Sociology and Criminology at the University of Birmingham.

Jo Ingold is Associate Professor of Human Resource Management and Public Policy at the University of Leeds.

Mark Monaghan is Lecturer in Criminology and Sociology at the University of Birmingham. 

With thanks to LSE British Politics and Policy, and the London School of Economics and Political Science.

All articles posted on this blog give the views of the author(s), and not the position of Fuse, the Centre for Translational Research in Public Health; the five North East Universites in the Fuse collaboration, or funders.

Featured image: J J Ellison [CC BY-SA 3.0], from Wikimedia Commons

Universally discredited?

Posted by Mandy Cheetham, Research Associate, Teesside University and colleagues.

I listened to the budget in October 2018 in anticipation of an announcement about Universal Credit. We had just completed a study commissioned by Gateshead Council about the impact of the roll out of Universal Credit. I had been profoundly moved by the accounts of Universal Credit claimants with health conditions and disabilities who participated in the research. In a budget for “strivers, grafters and carers”, Philip Hammond announced that the “period of austerity was coming to an end”. He promised an additional £1 billion over five years to ‘smooth the transition’ to Universal Credit. Despite acknowledging “genuine concerns” about implementation of the programme, “Universal Credit is here to stay” Hammond asserted.

 

Two weeks after the budget announcement, I had the pleasure of meeting Philip Alston, the UN Special Rapporteur for Extreme Poverty and Human Rights, who was visiting the North East as part of his UK tour. We presented the findings of the Universal Credit research and he asked probing questions about the implications. We were not alone in drawing attention to concerns about the adverse effects of Universal Credit on people with disabilities. A statement of Alston’s conclusions can be found here.

Our research report was published on 15 November and the findings covered by the Guardian and Independent newspapers, local radio and television news.  Doctors’ concerns about Universal Credit were also highlighted in a British Medical Journal feature which cites our research.

The research team and Gateshead's Director of Public Health have received emails from people sharing their experiences and thanking us for raising this important subject. It has been highlighted by the Association of Directors of Public Health. I have met with local MPs, elected members, and senior managers in the Council and voluntary sector in Gateshead where I work as an embedded researcher. The findings have been shared with Department for Work and Pensions staff and we have been invited to the House of Lords. This kind of (inter)national interest is rare and a bit overwhelming! The research was made possible, because Gateshead Council commissioned it. Independent academic research of this kind is essential if we are to understand the impact of government policy on North East communities.

The findings raise questions (again) about public health advocacy and research. What is our role if not to work with communities whose voices are often unheard or ignored in policy to enable their views and experiences to contribute to debates (Smith and Stewart 2017[1]). This research demonstrates the power those voices can have when assembled using robust qualitative research methods and in the absence of any other data. The policy changes taking place under the guise of welfare ‘reform’ present huge challenges to public health and wider efforts to address health inequalities. If Universal Credit continues to be rolled out, vulnerable claimants will continue to endure hardship and destitution. Suicide rates will rise and the human and financial costs to the health and social care system will increase. As public health researchers, we have a duty to raise awareness of the effects of a policy which is undermining the health and wellbeing, employment prospects, food, financial and housing security of the most vulnerable people in society. It remains to be seen whether the government is listening to a growing body of evidence (Arie 2018[2], Cheetham et al 2018[3], Walton 2018[4]) about the impact of Universal Credit or whether, as Philip Alston (2018: 1) observed, ministers will continue to dismiss concerns and doggedly resist change in response to the many problems highlighted.

Mandy will present her research at the Fuse Quarterly Research Meeting: The impact of Universal Credit on health & wellbeing in Gateshead.  Find out more on the Fuse website.

About the authors:

Dr Mandy Cheetham Research Associate, Teesside University

Dr Suzanne Moffatt Reader in Social Gerontology, Newcastle University 

Dr Michelle Addison Research Associate, Newcastle University 

Alice Wiseman, FFPH, Director of Public Health Gateshead Council

The views expressed here are those of the authors and do not necessarily reflect those of the author's employer or organisation.

References:

1. Smith and Stewart (2017) Academic advocacy in public health: Disciplinary 'duty' or political 'propaganda'? Social Science and Medicine Sep;189:35-43. doi: 10.1016/j.socscimed.2017.07.014. Epub 2017 Jul 21.
2. Arie, S. (2018) Doctors concerns over universal credit are mounting BMJ 363: doi: 10.1136/bmj.k5131 5th December 
3. Cheetham, M. Moffatt, S. Addison M. (2018) “It’s hitting the people that can least afford it the hardest” The impact of the roll out of Universal Credit in two North East localities: a qualitative study. Gateshead Council, Teesside university and Newcastle university and Fuse, the Centre for Translational research in Public Health https://www.gateshead.gov.uk/media/10665/The-impact-of-the-roll-out-of-Universal-Credit-in-two-North-East-England-localities-a-qualitative-study-November-2018/pdf/Universal_Credit_Report_2018pdf.pdf
4. Walton, E. (2018) Life and Times A truth universally acknowledged: moving to Universal Credit leads to large debt and poor mental health British Journal of General Practice 68 (677): 577. doi: https://doi.org/10.3399/bjgp18X699977. 

Public health isn’t good politics (part 2)

Knowledge exchange lessons from the spotlight event at the University of Sunderland

Posted by Peter van der Graaf, AskFuse Research Manager, Teesside University and John Mooney, Senior Lecturer, University of Sunderland

In our last blog, we reported on the 4th Fuse international conference on knowledge exchange in Vancouver, B.C. Provocative speakers explained that public health is, at best a hard sell to policy makers and at worst impossible to influence decision making. Luckily, they also presented short cuts for making it more likely that public health evidence would be heard by policy makers.

Sharon Hodgson, Shadow Minister for Public Health, speaking
at the Spotlight on Public Health event in Sunderland

These challenges and the potential short cuts were clearly present at the University of Sunderland spotlight event that we attended, which aimed to increase the visibility of public health research at the university.

Sharon Hodgson, the Shadow Minister for Public Health, opened the afternoon session with a passionate plea for introducing a minimum unit price for alcohol in England, following the example of Scotland. However, she made it clear that the Scottish choice for a 50p unit price would be a hard sell to both her voters and the Labour party. Labour colleagues simply dismissed the policy as a ‘tax on the poor’ and voters would feel the pinch on their already austerity squeezed household budget.

This ignited a lively debate with researchers in the room, who highlighted the research evidence that is available in favour of a 50p unit price. While statistical models consistently demonstrate that this would have the biggest impact on reducing alcohol related harm, such as liver disease, the Shadow Minister was concerned with how the price selected might impact on her voters. Specifically, she felt it was more important that increased costs to people living in more deprived communities were not dismissed, but instead presented as a health improvement incentive.

Having visited various supermarkets in her constituency to check the prices of different types of alcohol in order to work out the impact of different MUP limits, her conclusions sided with the views of the voters and Labour peers: 50p would hit all the different types of alcohol and not just the cheap ciders and therefore penalised not just the heavy drinkers but also the moderate drinkers in deprived communities. Instead, she argued for a 40p unit price, which would mostly affect the price of cheap ciders, and therefore target only the problem drinkers and not the other drinkers in her constituency. What counted as the most important evidence for the Shadow Minister was quite different from what the researchers in the room perceived as the best evidence to inform policy.

When an audience participant also tried to make the economic case by suggesting that the 50p tax would generate a better return for the Government that could be used to finance alcohol addiction services, the Shadow Minister remained unconvinced.

What did start to sway her was another suggestion to change the narrative from a ‘tax on the poor’ (which might be used as a stick by Conservative party members to beat their Labour colleagues), to a ‘tax for the wellbeing of all’. This narrative framed the 50p MUP as a policy that would affect all walks of life and could encourage a change in drinking cultures among all ages and classes, with the money raised being reinvested across a range of policy areas.

Shanon Hodgson agreed that this might make for an ‘easier sell’ and perhaps more importantly serve as the basis of a future health legacy that she could leave for her voters. By reframing the narrative from a small group problem (problem drinkers in deprived communities) to an emotive public issue of damaging drinking cultures, better policy and voter engagement might be secured.

Paul Cairney presenting at the 4th Fuse International
Conference on Knowledge Exchange in Public Health  

The evidence that she really needed were stories to demonstrate meaningful (personal) health gains and cultural change across different sectors of society. This requires a new type of evidence. It does not mean dismissing academic research and all the rigorous evidence it generates, but it does require a careful consideration of the policy system and process in which it is used and a willingness to adapt the messages and narrative to that context and the other types of evidence that are prevalent in that context. This is neatly summarised in the top tips from political science offered by Paul Cairney in his presentation at the 4th international Fuse conference:

1. Find out where the action is (‘actors’) 
2. Learn the rules (‘institutions’) 
3. Learn the language/ currency (‘ideas’) 
4. Build trust and form alliances (‘networks’) 
5. Be entrepreneurs, exploit ‘windows of opportunity’

Public health researchers operating as political entrepreneurs might be a hard sell to academic institutions but they have a world to win when trying to get evidence into decision making where it matters and creates impact.

Getting physical activity research moving

Posted by Louise Hayes, Research Methodologist, Newcastle University and the Fuse Physical Activity Group

So, we all know we should be more physically active – the evidence is out there. People who are more active are less likely to suffer from many chronic diseases, have more energy, better mental health, sleep better…… But how do we get people to be more active?

We knew researchers across North East England were working on physical activity related research and we knew that practitioners were delivering physical activity interventions, with the aim of getting more people active. What we didn’t know was who was doing what and whether or not the evidence from the researchers was getting to the practitioners or if the practitioners were delivering evidence-based intervention or evaluating their interventions. So, a little over five years ago, Martin White, the then Director of Fuse, Laura Basterfield and I (two physical activity researchers at Newcastle University), set about getting physical activity researchers from across the region together. We wanted to provide a forum for researchers to share information on current and future research and to identify opportunities for collaborations across individuals and teams conducting PA research in the Fuse partner universities. The inaugural Fuse Physical Activity Workshop (#FusePAW) was held at Newcastle University in May 2013.

It quickly became apparent that there was an appetite for a Fuse Physical Activity Group to be formed to build upon the enthusiasm for collaborative working and developing a shared physical activity research agenda that was in evidence at this first PAW. Several people also made it clear (and yes, we do mean you, @Scottylloyd1979!) that there was a need to widen the base of the group to include our practitioner partners involved in delivering physical activity interventions on the front line and to build relationships across sector boundaries. And so the Fuse physical activity group was born!

Liane Azevedo and I took on the role of leading the group, along with a team including Scott Lloyd, Caroline Dodd-Reynolds, Alison Innerd and Natalie Connor representing the North East Universities and public health partners. Since then we have had twice yearly Fuse PAWs, hosted by each of the five Fuse Universities and covering a range of topics from inequalities in physical activity to measurement of physical activity and physical activity during pregnancy. We’re proud to say that we’ve achieved an equal balance of academics and practitioners attending the events.

From the outside it might look like it’s been plain sailing – we’ve attracted an amazing cast of physical activity researcher royalty to present at our events, (see the list below - to name but a few!). On the inside there has been blood, sweat and occasional tears! Will the speakers agree to come? Will anyone sign up to attend? Will there be enough parking spaces/coffee? Will we be able to afford fruit during the breaks or just (unhealthy, but delicious) biscuits? (The latter has often been uppermost in the minds of some of our delegates if the feedback we receive in our, now infamous, shiny blue feedback box* is anything to go by!)

We were nervous that attendance might suffer when austerity measures cut into our budget meaning we were no longer able to provide lunch – but happily attendance has steadily increased and we have begun to attract individuals from outside the North East and sometimes even from outside the UK!

It was great to celebrate our tenth PAW on 20th April 2018, following #Fuse10 on 19th April, and to think about our previous events. All the hard work definitely felt worthwhile as we reflected on the many interesting presentations, workshops and discussions that have come out of the FusePAWs as well as collaborations, including a joint evaluation of the Redcar school pedometer intervention by Northumbria and Leeds Beckett Universities.

As #FusePAW, we have a responsibility to ‘do

’ physical activity research better and try to capture how FusePAWs inform physical activity within the region and further afield. To this end we discussed how we can work together more effectively as academics and public health practitioners to challenge traditional methods for delivering and evaluating physical activity interventions to nudge the field forwards at this event.  If you have any suggestions on how we can do this please contact me at louise.hayes@ncl.ac.uk

Watch this space for findings!


The Fuse Physical Activity Group is Louise Hayes, Liane Azevedo, Scott Lloyd, Caroline Dodd- Reynolds, Alison Innerd and Natalie Connor


Just a few of our amazing cast of presenters

Professor Ashley Cooper (University of Bristol), Dr Esther Van Sluijs (University of Cambridge), Dr Paul Kelly (University of Edinburgh), Dr Nick Cavill (Public Health England), Bob Laventure (Loughborough University), Prof Charles Foster (University of Oxford) Dr Mark Tully (Queens University), Prof Tess Kay (Brunel University), Prof Adrian Taylor (University of Plymouth) and Prof John Saxton (Northumbria University).

* Look out for our next event to see it for yourself!

Public health, social justice, and the role of embedded research

Posted by Mandy Cheetham, Fuse Post doctoral Research Associate and embedded researcher with Gateshead Council Public Health Team

On this date (13 November) in 1967, Martin Luther King was awarded an Honorary Doctorate in Civil Law from the University of Newcastle upon Tyne. The speech he gave at the award ceremony is both powerful and moving. It was the last public speech he made outside the US before his assassination in April 1968. You can read it for yourself here or watch it here.

Newcastle was the only UK University to award an honorary degree to Dr King in his lifetime. In accepting the honour, he said “you give me renewed courage and vigour to carry on in the struggle to make peace and justice a reality for all men and women all over the world”. As I listened to the speech, it struck me that the three “urgent and indeed great problems” of racism, poverty and war, which Dr King described in his speech, are just as relevant today as they were then. It made me reflect on our role in universities now and on my role as an embedded researcher in Gateshead Council.

That's me on the left

On Sunday 29 October, I had the privilege of being part of the Freedom City 2017 celebrations held on the Tyne Bridge to mark this significant anniversary, inspire people, and stimulate academic debate about potential solutions. Performances across Newcastle and Gateshead came together to mark different civil rights struggles across the globe, including Selma, Alabama 1965, Amritsar, India 1919, Sharpeville, South Africa 1960, Peterloo, Manchester 1819, and the Jarrow March, Tyneside 1936.

The celebrations were timely, as I am just finishing an embedded research project in Gateshead, undertaken less than a mile from where we stood on the Tyne Bridge. It has been an inspiring year. I’ve learnt a lot, but I have also seen the devastating effects of austerity and poverty on North East families and communities. The research findings demonstrate all too clearly the continuing impact of the social injustices which Martin Luther King talked about fifty years ago.

I believe our role as writers and researchers in public health is not just to highlight the effects of these grave injustices, but to be part of the solutions, developed with the communities affected. If we accept that we are all caught up in what Dr King described as “an inescapable network of mutuality”, then universities have an important part to play in changing attitudes, working with others, facilitating connections, and inspiring efforts to “speed up the day when all over the world justice will roll down like waters and righteousness like a mighty stream”. (Dr Martin Luther King Jr. Speech on Receipt of the Honorary Degree, November 13, 1967).

I believe embedded research affords us valuable opportunities, to work alongside local communities with colleagues in public health and voluntary sector organisations, to challenge injustices and push for the kinds of social and political change advocated by Dr King.


Photo credits:

1. Martin Luther King Honorary Degree Ceremony: http://www.ncl.ac.uk/congregations/honorary/martinlutherking/. Courtesy of Newcastle University.
2. Photo by Bernadette Hobby of "the judge", representing the establishment, about to receive the Jarrow Marchers petition. The judge was made by Richard Broderick sculptor.
3. Freedom on the Tyne, The Pageant: http://freedomcity2017.com/freedom-city-2017/freedom-city-tyne/. Courtesy of Newcastle University.

‘First, do no harm’: How to think about austerity and public health

Posted by Ted Schrecker, Fuse Associate and Professor of Global Health Policy, Durham University

The current ‘neoliberal epidemic’ of (selective) austerity directs our attention to public health impacts of choices about public finance in several ways. Most fundamentally, anticipated post-2015 public expenditure cuts in the UK will reduce public expenditure as a proportion of Gross Domestic Product (GDP) to the levels of the 1930s, ‘taking the size of the state to its smallest in many generations’, in the words of a 2014 Institute for Fiscal Studies briefing. In fact, on recent projections by 2020 public spending in the UK as a proportion of GDP will be below the figure for the US, despite the latter country’s bloated defence budget. It is implausible that a National Health Service that is free at the point of use can be maintained with pre-World War II levels of public spending. Even a brief conversation with anyone familiar with US health care reminds us just how much that matters.

Meanwhile, the health consequences of social spending cuts that fall disproportionately on the poorest people and regions are beginning to be manifest in rising food insecurity and increased use of food banks – the latter trend probably related to the rising rates at which benefit recipients are sanctioned. Further health impacts, more difficult to isolate epidemiologically but probably at least as significant, are associated with the stresses of chronic insecurity, powerlessness, and lack of ‘control over destiny’.

There is a basic ethical and political point here about the politics of evidence. Sir Michael Marmot and colleagues wrote in 2010 that ‘It is hard to see how even ideologically driven commentators could think that having insufficient money to live on is irrelevant to health inequalities’. Good point.

In a previous blog with Clare Bambra, we demonstrated that politics can make us sick; Clare recently wrote a similar blog highlighting large health divides across Europe, showing that where you live (and the health policies implemented there) strongly affects how long you live. Against the background of austerity and the rising costs of healthy diets, it is indefensible to ask public health professionals and advocates to demonstrate, over and over again, that (for example) inadequate incomes lead to unhealthy diets and poor health. Rather, the burden of proof should be shifted: we must insist on clear and convincing evidence that national governments’ choices about the level and composition of public expenditure first, do no harm to health, except in extraordinary and clearly justified circumstances. This is an important part of the case for (independent, third party, adequately resourced) health impact assessments, especially of policies and programmes outside the health sector. Such a shift in the burden of proof is also congruent with the strong presumption in international law against retrogression (backsliding) with respect to human rights such as the right to health – a presumption that assumes special importance in an era of austerity.

Is corporate tax avoidance a public health issue?

Public finance, then, is a public health issue. This point applies to the revenue side, as well. The publication of the ‘Panama papers’ reminds us of the extent to which cross-border tax avoidance, whether legal or questionably legal, represents one of the ‘fiscal termites’ that can undermine states’ ability to provide everyone with the prerequisites for a healthy life. (Interestingly, the phrase ‘fiscal termites’ was coined by the former director of the International Monetary Fund’s Fiscal Affairs Department.) The question of how maintaining health services free at the point of use and investing effectively in prevention could be financed should be asked as a routine element of public health practice and advocacy – part of a broader strategy of interrogating scarcity. One answer could be using revenues from clamping down on UK corporate taxes avoided by major transnational corporations. In the real world, resources can almost always be found for the purposes of the powerful: think HS2, Trident renewal, and so on.

Choices about public finance are political choices with consequences for health and health inequalities; academics and practitioners must not be shy about pointing out those consequences.


A more extensive list of references is available from the author.  All views expressed are exclusively those of the author.

Photo: Servizi Mediali.  Reproduced under a Creative commons 2.0 licence. 

Back to the Future: health and housing working together

Guest post by Patrick Vernon, Health Lead, National Housing Federation

The launch of the Due North report in September 2014 was a rallying cry for greater priority around tackling health inequalities with a manifesto in how all stakeholders and system players can recycle effectively the £136 billion in public spend for transforming services. Since May 2015 we have a new Government with a clear agenda on austerity, public sector reform and the revitalisation of the devolution agenda with the mantra of the "Northern Powerhouse". In the middle of this maelstrom has been the Government's approach to tackling the housing crisis with the immediate reduction of 1 per cent in rents over the next four years, the extension of the Right to Buy and the ongoing impact of welfare reforms. These changes have become a major turning point in the history of the social housing sector along with the changes in supported housing.

Although there is an emotional, political, moral and (increasing) evidence base for the links between poor housing and health, the gap between fact and reality still feels light years away. There is a clear role for the social housing sector to work with the NHS, social care and employers in transforming services and care pathways to meet demographic, lifestyle and morbidity changes in the population. A step in the right direction is the Memorandum of Understanding (MoU) to support joint action on improving health through the home which was signed by all stakeholders in the health and housing sector in Autumn 2014. The document highlights at a strategic and national level the key principles and actions around a collective approach around delivery. However, what is currently missing is a regional approach that is embedded in the devolution agenda. This is already happening in Greater Manchester as part of DevoManc (giving greater powers to the combined authority working in partnership with a directly-elected Mayor). In the North East we need to ensure that housing and health are part of the devolution plans.

Thus the Fuse Quarterly Research Meeting (QRM) ‘Creating Healthy Places in the North East: the Role of Housing’ on Tuesday (20 October) in Darlington is the start of another important chapter in the health and housing trilogy (or may be pre-sequel) on how health, social care and housing can work together in meeting the needs of local communities in a period of austerity. All the speakers at the event had - in essence - the same message: a need for strengthening partnerships and system leadership along with collating, translating and communicating the evidence for cost-effective interventions.

The event not only had international examples from the Netherlands and New Zealand but also local case studies from a number of housing associations such as Thirteen Group (Middlesbrough Recovering Together project), Gentoo Housing (Boilers on Prescription), Home Group (social prescribing), Tyne Housing (working with homeless people in the community) and South Tyne side Homes (sheltered accommodation for residents with dementia). The case studies illustrated how better commissioning and service integration can make a difference to the lives of people.

The challenge in a period of reduced budgets and further potential cuts in the forthcoming Comprehensive Spending Review is how we make the business case and get the right people in the room to transform services, building on the spirit and vision of the Due North report in tackling health inequalities and achieving greater health equity.

I think one of the key outcomes of the QRM is for Fuse to act as broker between service providers, commissioners and service users in creating a strong North East dialogue between the health, social care and the housing sector. This can be achieved by networking, sharing good practice, supporting development of the evidence and, finally, an advocacy role in influencing the devolution agenda.

Thus, if Marty McFly and Doc Brown pop out of their DeLorean DMC-12 again in the future, we can share with them the successful journey that we have undertaken in ensuring that the housing sector is a valued, respected and key partner in delivering better health and social care services and an integral agent in tackling the public health agenda.

For more information visit the National Housing Federation website or read the Fuse research brief accompanying this event: Creating healthy places in the North East - the role of housing.


Photograph 'Back to the Future DeLorean Time Machine' by AdamL212 via Flickr.com © 2007: https://www.flickr.com/photos/lautenbach/1393032429

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