Public Health at a crossroads again: meeting the challenge of a reformed system in England

Posted by David Hunter, Newcastle University, Peter Littlejohns, King’s College London, and Albert Weale, University College London



With health policy understandably preoccupied with the pressures on, and changes occurring in, the NHS arising from the impact of COVID-19, implementation of the Health and Care Act 2022, and various strikes among the workforce, it is imperative not to overlook the public health system reforms in England.

Public Health England’s (PHE) sudden demise in August 2020 followed mounting criticisms of its performance during the early stages of the pandemic and general unpreparedness.1 Rather than consider how PHE might be reformed, the government rushed to replace it with two new bodies: UK Health Security Agency (UKHSA), and Office for Health Improvement and Disparities (OHID). Like PHE, the UKHSA is an executive agency with close ministerial oversight while still permitting ‘independence in the delivery of policy advice’. It will act as a ‘system leader’ for health security with responsibility for pandemic preparedness and external threats across the UK while bearing in mind that health is a devolved responsibility.

PHE’s remaining functions in respect of the wider public health, including health improvement and population health, lie with OHID. Located within the Department of Health and Social Care (DHSC) and jointly accountable to the Secretary of State for Health and Social Care and the Chief Medical Officer for England, it enjoys even less independence than the UKHSA. Building on the work of PHE, OHID’s priorities include tackling obesity, improving mental health, promoting physical activity and other population health issues, notably inequalities.

There is merit in taking stock to identify any lessons which might be gleaned from the mixed life of PHE and whether the new bodies offer hope to do things better.2

Learning the lessons

The findings from a research project to explore the circumstances surrounding the rise and fall of PHE may assist with the learning process.3 Five broad underlying issues were identified in the research which contributed to PHE’s demise.

• 

  PHE did not possess the capacity to undertake a testing regime
   of the size and complexity required by the pandemic

  Severe funding cuts in public health spending, nationally and locally, since 2010 meant that PHE functioned with reduced capacity when the pandemic struck
• PHE did not possess the capacity to undertake a testing regime of the size and complexity required by the pandemic, the absence of which was the basis of the case against the organisation
• The governance of PHE as an executive agency meant it lacked independence
• While decisions made by PHE at the start of the pandemic were later considered mistakes (and judged outside the law by a judicial review) at the time there was little information about the nature and possible effects of the virus and limited capacity in the health system which required tough prioritisation decision to be made
• The sudden closure of PHE without any consultation was widely reported to be due to blame-avoidance behaviour on the part of key actors, principally Dominic Cummins (as former Chief Advisor to the Prime Minister, Boris Johnson) and Matt Hancock (as former Secretary of State for Health and Social Care). There was also a view that the decision was based on policy favouring use of the private sector and contracting out functions like test and trace.

Key lessons from these findings centre on two major areas of concern: the respective remits of the new bodies, and their governance.

Remits

The respective remits of UKHSA and OHID need to be clearer and more transparent if the risk of fragmentation is to be avoided. A welcome feature of PHE was its attempt to bring together the key public health functions that had previously operated in separate silos. As things now stand, separating communicable diseases (CDs) from non-communicable diseases (NCDs) is a retrograde move since, as the pandemic highlighted in stark terms, close links exist between them when it comes to those groups and communities which suffered most in terms of illness and death. A syndemic understanding of diseases and their underlying social factors is pivotal in preventing disease in the future and avoiding fragmentation.4

Governance

Governance of the new public health bodies requires careful attention. As an executive agency, PHE was criticised for its lack of independence from government which restricted its ability to ‘speak truth to power’. Given UKHSA enjoys the same status, it remains unclear how it intends to avoid a similar fate. The problem is a deep-seated and pervasive one within government. The idea that OHID being housed in the DHSC will allow it to exercise greater influence and have a closer collaboration with ministers could be a good move, or, more likely if history is any guide, it may be overly optimistic. There is a risk that OHID may disappear into Whitehall and become invisible, lacking even the limited degree of independence PHE had. To succeed, OHID has to be visible and have allies inside government.

A further issue concerning the governance and working style of both agencies, especially OHID, centres on their ability to operate effectively across government. Public health comprises numerous ‘wicked issues’, that is, multi-faceted problems that are complex and for which there are no simple or single solutions. Confronting them will be especially challenging for a government which, for all its rhetoric about ‘levelling up‘, remains topic- and department-focused, operating in silos rather than concerned with cross-government issues.5

OHID has a steep hill to climb if it wants to lead a transformational agenda across the wider determinants of health which demands a whole-of-government approach. The hill just got steeper following government delays in tackling child obesity and its failure to implement a national food strategy. In keeping with the prevailing political ethos, there is a renewed focus on individual behaviour change and lifestyle choices rather than tackling the influence on health of commercial interests via taxation and regulation.6,7 If significant inroads into the population health agenda are to be made, then confronting powerful vested interests in, and lobbying from, the food and drinks industry and their ’friends’ in government engaged in what has been termed ’institutional corruption’ cannot be avoided.8 Whether OHID has either the backing from government or competences for such a struggle remains doubtful in the extreme.

Conclusion

Public health once again finds itself at a crossroads. It can either continue to ‘muddle through’ with a broken political and public policy system that is not fit for purpose.9 Or there is an opportunity to construct a strong and confident public health system that is well-placed to confront the challenges facing it. The aftermath of COVID-19 should make the choice of options self-evident. However, as things stand, it is unlikely that the UK’s broken political system with its focus on short-term fixes is up to the challenge. Without major systemic change aimed at overhauling the UK’s political system, a risk of further deterioration in the state of the public’s health may be unavoidable.

References:

1. Calvert J, Arbuthnott G. Failures of state: the inside story of Britain’s battle with coronavirus. London: Mudlark, 2021. https://harpercollins.co.uk/products/failures-of-state-the-inside-story-of-britains-battle-with-coronavirus-jonathan-calvertgeorge-arbuthnott?variant=39528280391758
2. Vize R. Controversial from creation to disbanding, via e-cigarettes and alcohol: an obituary of Public Health England. British Medical Journal 2020; 371:m4476 http://dx.doi.org/10.1136/bmj.m4476
3. Littlejohns P, Khatun T, Knight A, Hunter DJ, Markham S, Coultas C, Kelly MP, Ahuja S. (2022) Lessons from the demise of Public Health England: where next for UK public health? London: NIHR ARC South London. https://arc-sl.nihr.ac.uk/sites/default/files/uploads/files/public-health-report-sept-2022-final.pdf
4. Horton R. Offline: COVID-19 is not a pandemic. The Lancet 2020; 396: 874. https://doi.org/10.1016/S0140-6736(20)32000-6
5. Pope T, Shearer E, Hourston P. What levelling up policies will drive economic change? The need for a long-term focus on skills and cities. London: Institute for Government, 2022. https://www.instituteforgovernment.org.uk/publications/levelling-up-policies?
6. British Broadcasting Corporation (BBC). Junk food: obesity strategy falling apart, Jamie Oliver says. 15 May 2022 https://www.bbc.co.uk/news/uk-61449921
7. Ralston R, Smith K, O’Connor CH, Brown A. Levelling up the UK: is the government serious about reducing regional inequalities in health? British Medical Journal 2022; 377:e070589 https://doi.org/10.1136/bmj-2022-070589
8. Draca M. Institutional corruption? The revolving door in American and British politics. SMF-CAGE global perspectives series: 1. 2014. http://www.smf.co.uk/wp-content/uploads/2014/10/Social-Market-FoundationInstitutional-Corruption-the-revolving-door-in-American-and-British-politics.pdf
9. Ricketts P. Hard choices: the making and unmaking of global Britain. London: Atlantic Books, 2022. https://atlantic-books.co.uk/book/hard-choices

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 Science, Institute for Psychiatry, Psychology and Neurosciences, King’s College London

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

The views and opinions expressed by the authors are those of the authors and do not necessarily reflect those of Newcastle University, King’s College London, University College London, or Fuse, the Centre for Translational Research in Public Health.

Intersectionality: buzzword or key to tackling health inequalities?

Posted by Dr Daniel Holman, Professor Sarah Salway, Dr Andrew Bell, University of Sheffield

Intersectionality – the idea that multiple axes of inequality overlap and interact – arguably holds great potential to understand and tackle health inequalities. But what do researchers and those working in policy and practice in this area actually think about the approach? What do they see as the key challenges and opportunities? We held a professional stakeholder workshop and consultation survey to find out. Our findings indicated a ‘cautiously optimistic’ view of an intersectional health perspective.

A growing interest in intersectionality and health

Intersectionality is currently something of a buzzword. A search of the scientific literature reveals an explosion in interest, with an eight-fold increase in papers mentioning the term in the last ten years, and a twenty-fold increase for those mentioning both ‘intersectionality’ and ‘health’:

Figure 1 - SCOPUS documents mentioning both 'intersectionality' and 'health' in title, abstract or keywords

The interest in applying intersectionality to health research, and specifically health inequalities research, has now also been fuelled by the pandemic. Ethnicity, deprivation, and age strongly influence Covid-19 outcomes. Calls for intersectional analysis of Covid-19 have now been published in BMJ Global Health and The Lancet.

Yet recent events have indicated significant political barriers. The Sewell Report essentially explained away ethnic health inequalities with reference to socioeconomic factors – anathema to intersectionality – and last year the UK Government declared itself ‘unequivocally against’ Critical Race Theory (within which intersectionality is rooted).

Further, policy-making is a process of dialogue, negotiation and ‘knowledge interaction’, with power relationships, varied sources of ‘evidence’ and competing drivers clearly at play. So, we should not expect the concept to straightforwardly impact how health inequalities are understood and addressed.

Theory vs. practice

In theory, intersectionality offers a critical, innovative approach for understanding and tackling diverse health inequalities. It essentially concerns the power structures and processes that drive these inequalities, and seeks to highlight how unjust systems of discrimination such as racism, sexism and classism operate in tandem to result in unequal, unfair life chances. The animation video below gives an overview of the approach:

 

Putting intersectionality to work entails a number of practical challenges. Many of our participants thought the term sounded like just another buzzword, questioning what it adds. Concerns were raised about the complexity of intersectionality both as a conceptual and methodological framework. For resource-strapped public health teams this was felt to be a particular barrier. Complexity can sometimes inhibit action because policy making processes support simplicity and certainty.

Methodologically, intersectionality includes a danger of over-disaggregation. Working with finer and finer categories to produce a granular picture of inequalities risks losing sight of the processes of disadvantage that impact across groups of people. Questions were also raised over how we can reveal mechanisms including discrimination, use mixed methods and participatory approaches, include marginalised populations, and access large, high quality datasets that intersectional analyses might require.

How might intersectionality actually be implemented? We asked respondents to consider two suggestions

First was the idea of using intersectionality to target and tailor interventions and policies. This raised numerous concerns that it potentially takes focus away from structural changes; assumes that all those in a particular intersection are the same; excludes those who do not fall into the targeted category, and; reinforces deficit and stigmatising narratives. Nonetheless, respondents thought that targeting could have value if marginalised groups were included in the process. They also suggested that geography should be considered when targeting as it is a key aspect of social context.

Second was the idea of monitoring and evaluating the impact of policies and programmes on different sub-groups. This approach was more popular, with participants keen to be able to demonstrate differential and unanticipated outcomes of initiatives. Again, the importance of meaningful engagement of marginalised groups and careful attention to understanding mechanisms, were highlighted.

What is the way forward? Our participants emphasised some key principles and points of action:

• Ensure a clear focus on systems of social discrimination and how they structure access to power, resources and life chances, especially via social institutions (such as schools).
• Wherever appropriate, participatory and co-productive approaches - entailing more equitable knowledge-production – should be used.
• Carefully consider complexity; arguably intersectionality’s biggest asset and challenge. What constitutes the right level of complexity and in which context? Trade-offs are inevitable.
• Develop clear methodological guidelines, possibly in the form of a toolkit, to help with implementing intersectionality, especially for non-academics with limited research resources.
• Big datasets with well measured social variables are essential.

Intersectionality holds much promise. It has the potential to help ensure that those experiencing multiple discrimination are not further disadvantaged by the Covid recovery phase. Acknowledging and addressing potential pitfalls and limitations of the approach is therefore crucial. Marginalised populations, researchers, policy and practice professionals all need to be part of the conversation.

To read more about the project from which this research originated, please take a look at the project website: http://intersectionalhealth.org

Feeling like an imposter? Learn to get comfortable with ambiguity

Peter van der Graaf, Fuse Knowledge Exchange Broker, Teesside University and Travis Sztainert, Knowledge Mobilization Specialist, Frayme

Do you ever feel like your lack of ability or knowledge is going to be exposed? In that case, you might suffer from Imposter Syndrome! Knowledge Mobilisers work across boundaries and are asked to perform tasks that they don’t feel “qualified” for, triggering feelings of anxiety and failure. What causes these feelings and how can we overcome them? In an attempt to answer these questions, we compared experiences across the pond by reflecting on our roles as Knowledge Mobilisers in Canada and in the UK. We argue that these feelings should not be avoided but harnessed by turning imposter syndrome into a useful repertoire for the role.

"Piled Higher and Deeper" by Jorge Cham www.phdcomics.com

In March the annual UK Knowledge Mobilisation Forum took place, which brings together practitioners, researchers, students, administrators and public representatives who are engaged in the art and science of sharing knowledge and ensuring that it can be used. This year, the Forum was held online for the first time, and one of the sessions was dedicated to interactive posters. Participants could preview posters in GoogleDocs and leave comments and questions for the presenters, who were later interviewed to respond to the feedback left on their posters.

In our poster, we explored why Knowledge Mobilisers are particularly prone to feelings of being an imposter. They work in a competitive specialist profession; everyone strives to be a guru, but at the same time their work occurs in the background. It often goes unrecognised if done well (and shows up particularly bad if it fails!) but is time-intensive with work often being unclear, making it feel like you’re not moving forward.

Our poster - see the full version here

Developing trusting relationships between knowledge producers and users often requires complex and lengthy conversations, which only increase the risk of being exposed as an imposter. At the same, there are limits to collaboration (not everybody wants to work together or share their knowledge), which can add to feelings of failing at your job as a knowledge broker.

Moreover, the role requires you to be a neo-generalist with varied expertise and, therefore, there is always more to learn. Organisational change and consequently personal change (the one certainty of working in the health and care sector) are always on the horizon, meaning that you have to continuously adapt your role. In addition, system changes often change the knowledge and evidence that is required by users and this increases transaction costs (time and resources spent on adapting knowledge) for boundary workers.

However, there is a lack of ‘professionalisation’ of the field and training is scattered: this can make you feel like you’re missing essential skills and knowledge. During the poster session we conducted a quick poll to ask how many participants had received formal training in knowledge mobilisation: 83% had not. Or as one of the participants summarised: Knowledge Mobilisation is a Cinderella service. Being undervalued by funders, universities and professional organisations means you are often faced with a lack of resources and unable to do your job. In fact, it is often expected that Knowledge Mobilisation can be done “off the side of the desk” or in addition to work as a researcher or policy maker. Thus, a paucity of time and space is set aside to adequately tackle complex issues.

To overcome these challenges, the first rule of Knowledge Mobilisation is that you need to be comfortable with ambiguity. Feeling like an imposter is not (in itself) bad, is a normal part of the learning process, and can be harnessed. Skills are most often developed on-the-job, and feelings of imposter syndrome can help drive you to learn more, do better, and be open to new concepts and experiences. Overconfidence can lead to a lack of insight into your weaknesses, which in turn can lead to actually becoming an imposter. Accept that you have shortcomings and areas for improvement. It’s okay not to know what you’re doing, or not to have all the answers. Think of yourself as an enthusiastic learner who is gaining experience and expertise - imposter syndrome will help you to stay humble.

Being open and honest about not having all the answers can actually be seen as a strength. As one participant pointed out in response to the poster: it helps to level power differences between partners by showing that you don't hold all the power (and are human like everyone else) and therefore empowers those working with you. It's ok for them not to know it all too and therefore may prompt questions that people may otherwise have been afraid to ask, leading to more open conversations, and strengthening relationships and trust. It can also mean that, when you are sure of answers, others know that they can trust you because you have previously shown that you would not say you knew something when you did not.

What skills do you need to be a good knowledge mobiliser? @AnnetteBoaz reckons connectivity, charm, inclusivity, empathy, creativity, integrity, curiosity, diplomacy and humility. Sounds very familar! #KMb2021 #ukkmbf2021

— Vicky Ward (@VLWard) March 22, 2021

Participants described this as a cyclical process, where feelings of imposter syndrome drive new learning, which increases your confidence to go into new situations that lead to fresh experiences of imposter syndrome, starting the cycle again. Forum members also emphasised the importance of operating as a team: the vast amount of skills required as a Knowledge Mobiliser (keynote speaker Annette Boaz mentioned connectivity, charm, inclusivity, empathy, creativity, integrity, curiosity, diplomacy and humility for starters), means it is almost impossible to develop these skills as an individual. Teams of Knowledge Mobilisers can bring these skills together and use different skills at the same time.

Moreover, acting like an imposter can be a valuable role: by communicating out of character a knowledge broker can help to make sense of differences in knowledge use. Adapting to the audience and stage required helps knowledge brokers to translate differences in performances between policymakers, practitioners and academics. Knowledge Mobilisers should not fear being an imposter but instead learn to embrace imposter syndrome!

If you are interested in learning more about imposter syndrome in knowledge mobilisation, take a look at:

• Travis’s PowerPoint presentation at the Canadian Knowledge Mobilization Forum sharing experiences, reflections and potential antecedents and consequences of imposter syndrome, as well as exploring ways to address this feeling (https://www.dropbox.com/s/x73adly7m3c1bid/Feeling%20Like%20and%20Imposter%2C%20and%20How%20to%20Overcome%20it.pptx?dl=0)
• Peter’s upcoming book chapter in Palgrave Handbook of ‘Imposter Syndrome’ in Higher Education (in print), reflecting on challenges in knowledge brokering through AskFuse, a rapid response and evaluation service run by Fuse, the Centre for Translational Research in Public Health, which caused feelings of being an imposter.
• Their joint poster can be accessed here: https://www.linkedin.com/posts/travis-szt_imposter-syndrome-in-knowledge-mobilisation-activity-6782473994651217920-XUud

Working together to tackle inequalities and inactivity

Posted by Sophie Phillips, Fuse & NIHR School for Public health Research (SPHR) funded PhD Researcher, Department of Sport and Exercise Sciences, Durham University, and Dr Rachel Mowbray, Insight Coordinator, County Durham Sport, Active Partnership.

In today's Fuse blog post, Sophie and Rachel tell us about collaborating during Sophie's secondment at County Durham Sport between January and March 2021.

It seems obvious that we would work together, right?

I conduct research in an academic institution and Rachel promotes evidence-based working in an Active Partnership which collaborates closely with Durham County Council. Our day-to-day roles are quite different. But, we have a shared goal: to tackle inequalities that stand in the way of physical activity engagement and support children and adults to be more active. By working together, combining knowledge, skills, and connections, we think we can make even greater progress towards improving people’s health and wellbeing.

How is academic research positioned within the physical activity landscape?

Physical activity policy and practice is a large and complex system made up of many different organisations, approaches, and settings. Academia is often positioned as external to the system, trying to create impact from the outside through activities referred to as ‘pathways to impact’. But in reality, academic research could be a crucially important element of the system in its own right (but often doesn’t have that position). Can positioning academic research as part of the system (as opposed to outside the system) make creating impact less of a hurdle and more of an opportunity?

Through my secondment to County Durham Sport, academic research has been embedded into the local Active Partnership. This gave me a huge opportunity to make an impact (on a daily basis!) by simply talking to others in different parts of the system. By sharing my knowledge and passion through conversations, I felt like I could make a real difference. Sharing information and ideas can challenge and influence thinking. This can (and does) influence the way things are done.

What are the benefits of an embedded researcher in policy or practice?

Rachel: Non-academic audiences often cannot access academic publications in meaningful ways because of financial barriers and/or because of the academic format. Having Sophie embedded in our organisation brought academic research to life and into the conversations happening between practitioners, policy makers, and non-academic researchers. These conversations allowed us to access the most up-to-date and robust information about physical activity. In the same way, County Durham Sport were able to offer extensive knowledge of the local physical activity system and inequalities. Working together, we created a stronger evidence-base on which to tackle the challenge of inactivity.

Sophie: I was able to communicate knowledge from academic research papers on physical activity into meaningful insight for County Durham Sport. One of the pieces of work I conducted during the secondment was a report on early years physical activity and movement. This included translating evidence from academic research papers into meaningful and accessible outputs (including reports, overviews in tables, and presentations). I was also able to engage with different stakeholders and physical activity providers across multiple settings, who are involved with local early years provision. This helped to bring together both the research evidence and the current local landscape, to make evidence-based and actionable recommendations about future early years provision.

Take-home messages from our collaborative experience…

Our day-to-day roles are very different, as are the expectations and outcomes of our work. Although this presents some challenges (such as differing timescales and required outputs), ultimately, we share a goal - to tackle inequalities that stand in the way of physical activity engagement, support everyone to be more active, and help to improve people’s health and wellbeing. Finding this common ground can foster true collaborative thinking and drive connections between academic and non-academic players in the physical activity system. Integrating our different perspectives and approaches is beneficial and necessary to create meaningful system change.

Rachel: Tackling big issues (like inequalities in physical activity) requires a collaborative and evidence-based approach. I would encourage other third sector organisations to engage directly with academic researchers - both to learn from their expertise, and to share your own experience of practice or policy. We can achieve more working together than we can alone!

Sophie: My experience of collaboration with County Durham Sport has been invaluable. It has influenced the way I think about conducting and communicating research. I would encourage other public health research PhD students to explore the opportunities of engaging in a short time with policy and practice partners in their field, to help view their work from different angles.

Sophie’s academic research is about measuring the physical activity and movement behaviours of pre-school aged children. Her secondment at County Durham Sport was funded by UK Research and Innovation (UKRI) QR Strategic Priorities Fund awarded through Durham University.

Rachel promotes evidence-based partnership working to tackle inequalities in physical activity through her role with County Durham Sport, Active Partnership funded by Sport England.

Images:

1. Jonathan Greenaway on Unsplash

2 & 3. Photo of Rachel (https://www.countydurhamsport.com/about-us/meet-the-team) and Sophie (https://www.countydurhamsport.com/homepage/news/) with thanks to County Durham Sport.

Uniting planning and health to tackle obesity

Public Heath England (PHE) has just published practical guidance, informed by Fuse research, for local authorities wanting to use the planning system to improve public health. In this blog post Andy Netherton and Michael Chang, from PHE's Healthy Places Team, tell us how they hope the guidance will be used to tackle obesity.

---

Obesity is a modern day public health challenge that cannot be met by a traditional scientific approach alone. Tackling obesity levels in England requires action by national and local government, health and social care, non-governmental agencies, communities and individuals – a whole system approach.

Traditionally the vast majority of public discussion and state campaigns target individual level behaviour change and treatment. This does not address the environment in which we live, that influences the decisions and actions that we make; things such as what we eat, whether we exercise, how we travel to work, how we interact within the community and if we have access to and use open spaces.

These physical environmental factors can be influenced by national and local policy and action. State led interventions are difficult to put into place due to the need for evidence within complex social and environmental determinants. The difficulty to isolate evidence related to these interventions and local government capacity to balance competing demands results in an inconsistent approach to policy adoption.

The use of planning policy and development management is a clear example of an intervention to tackle obesity which is not yet consistently applied across the country. Practice across the country has shown a diverse range of approaches in local plans and planning appeal decisions which has taken over 10 years to develop, but is now accelerating.

Figure 1 – Charting the use of planning for healthy weight environments

This policy to implementation lag has to be seen in the context of an increasing obesity challenge, both in terms of prevalence and health inequalities.

Figure 2 – key obesity data and trends

Statistics on Obesity, Physical Activity and Diet, England, May 2019 - NHS Digital, Government Statistical Service

Is the reason down to the nature of local evidence provided or the knowledge of the individual local authority teams, planning inspectors or the wider planning regime?

This was recognised within the Childhood Obesity: a plan for action, Chapter 2. The challenges it identified, included the proliferation of fast food outlets, less active travel, limited access to green spaces and physical activity; and these factors create an environment that makes it harder for children and their families to make healthy choices, particularly in some of our most deprived areas.

The Childhood Obesity plan confirmed that local authorities have a key role in tackling this challenge and pledged support:

• to make sure that all local authorities are empowered and confident in finding what works for them, and;
• to develop resources that support local authorities who want to use their powers and provide up to date guidance and training for planning inspectors. 

In response Public Health England (PHE) has released guidance on using the planning system to promote healthy weight environments.

Previous research by PHE (Spatial Planning and Health: Getting Research into Practice (GRIP) study report) identified that local authorities would benefit from support that reduced the need for resource input, for example reduced duplication to create policy and practice. This publication is aimed at getting knowledge into action by providing guidance and a template supplementary planning document (SPD), one of many planning levers available to local authorities, that can be used by local authority planning and public health teams. It answers the following questions:

• What is the current evidence base linking the built and natural environment and healthy weight? Specifically, can the local food environment influence diet and obesity?
• How can the planning regime be used to promote healthy weight environments?

The publication identifies the background work necessary in order to comply with planning policy development, where the key is the use of local evidence and consultation. It specifically provides guidance on the use of the 400m exclusion zone for hot food takeaways, features of the built environment and building design that promotes physical activity, use of green space, allotments and neighbourhood design.

The provided supplementary planning document (SPD) is a starting point that requires local content and policy to be added. It can be used as a whole or parts selected on local need or to dovetail to existing local policies. Clearly this intervention is one intervention that must be used within a wider national and local obesity strategy.

There remain challenges to promoting a healthy food environment, for example the impact from the rise of industrial kitchens for food delivery must be monitored. Work must continue to influence the energy and compositional content of other food options and build our homes and neighbourhood to allow people to more active.

This publication provides guidance on a practical evidence based intervention that draws together several professional groups within a local authority. Gateshead Council have successfully adopted and defended on appeal, controls on hot food takeaways as part of a wider approach to tackling obesity and promoting healthy weight environments. It is hoped that for many areas working together to tackle obesity will provide confidence to further unite planning and health. It moves the debate from a deficit model of obesity to an asset based (salutatogenic*) approach to promoting healthy weight.


*Israeli-American sociologist Aaron Antonovsky coined the term "salutogenesis" to describe an approach which focuses on a positive view of wellbeing rather than a negative view of disease.

Perseverance and Public Health: creating a cultural shift takes time

Guest post by Susan Jones, Research Associate, Teesside University

I spoke to a young woman the other day who had moved to North East England recently. She already had a little boy, just coming up 2 years old, and was now well on in her next pregnancy. Because I had been involved in evaluating babyClear© - an intervention to help support expectant mothers to stop smoking - I asked her whether the midwives had enquired if she smoked, (she doesn’t). “Oh yes”, she said, “they’re much more into keeping a close eye on you here”, as compared with the region where she lived before.

This buy-in by maternity staff, and the change to practice, is reflected in our paper, recently published in BMC Health Services Research (Jones et al., 2019)[1], in those Trusts that facilitated the intervention most successfully.

It is crucial, yet difficult, to answer questions about the effectiveness of initiatives like these. It takes time and perseverance t
o identify the questions, conduct the research and bring in the system and practice changes, which in turn support behaviour change in patients.

How do we go about answering questions about effectiveness of interventions designed to support people to change their behaviour and to become healthier?

It was in 2012, that the findings from interviews with midwives were first published (Beenstock et al., 2012)[2] and the search for new ways of embedding National Institute for Health and Clinical Excellence (NICE) Public Health Guidance 26 (2010)[3] more thoroughly, began. As a result, babyClear© was initially implemented across North East England from 2013 to 2015.

Fundamentally, interventions like babyClear© can be shown to be effective in certain circumstances (NICE, 2010; Bell et al., 2018)[4] but our latest paper found that these changes required specific contexts and cultures in the implementing organisation to maximise their effectiveness and potentially their sustainability and transferability.

These changes in staff practice and patient behaviour do not happen in isolation; the external context is important too and, in this case, the national context has become increasingly supportive.

For example, there have been a number of new pieces of legislation, guidance and reports during this time, all pushing in the same direction:

• Saving babies’ lives: reducing stillbirth and neonatal death: a care bundle (NHS England, O'Connor and Gould, 2014)[5]
• Tobacco Control Plan: Delivery Plan 2017 - 2022 (Department of Health and Social Care, 2018)[6]
• Hiding in Plain Sight; treating tobacco dependency in the NHS (Royal College of Physicians and Tobacco Advisory Group, 2018)[7]
• Not to mention ongoing lobbying from the Challenge Group (2018)[8], a coalition of likeminded, stop smoking, activist organisations, with their ‘Review of the Challenge’.

Clearly, there is an appetite to find solutions to the health problems that smoking causes; however, imposing regulation, without understanding and dealing with the causes, is never going to be hugely effective in a democracy like ours.

So what we see is a lot of different ‘scatter gun’ approaches all dedicated to the same aim – typical of lots of health and social interventions – but is this the best approach?

It is being recognised more and more that intervening in complex systems, such as the NHS, is both necessary and – at the same time – problematic. Largely, the problems come from a lack of understanding of the multiple complexities of the contexts and the effect of cultures upon outcomes. New ways of combining research methods are required to investigate these complex systems and find appropriate answers (Moore et al., 2014)[9]. Updated guidance from the Medical Research Council on evaluating complex interventions is being drafted as I write.

Fuse Complex Systems research programme

Only when the links – or active ingredients – between the different elements of an intervention are identified, and proper attention is given to the contexts and cultures surrounding it, will we be able to understand the necessary environment and resources for it to thrive, ensure its sustainability and maximise outcomes.

Our paper is one step in this direction but there is much more to do. Fuse has a Complex Systems research programme, because the researchers know how important it is. They will soon be publishing their plans for the future direction of their research on this topic.

This is an area where research and evaluation are moving fast, as they attempt to get to grips with the way health and public health are changing in the lives of staff and patients.

References: 

1. Jones, S. et al. (2019) What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory. BMC Health Services Research. Available at: https://rdcu.be/bA4fK (Accessed: 20th May 2019).
2. Beenstock, J. et al. (2012) 'What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England', Implementation Science, 7(1), p 1. 
3. National Institute for Health and Care Excellence (2010) Public health guidance 26: Quitting smoking in pregnancy and following childbirth. London: NICE. 
4. Bell, R. et al. (2018) Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tobacco Control. Available at: http://tobaccocontrol.bmj.com/content/early/2017/02/10/tobaccocontrol-2016-053476 (Accessed: 20th May 2019). 
5. NHS England, O'Connor, D. and Gould, D. (2014) Saving Babies Lives: reducing stillbirth and neonatal death: a care bundle. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf (Accessed: 10th April 2019). 
6. Department of Health and Social Care (2018) Tobacco Control Plan: Delivery Plan 2017 - 2022. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/714365/tobacco-control-delivery-plan-2017-to-2022.pdf (Accessed: 20th May 2019). 
7. Royal College of Physicians and Tobacco Advisory Group (2018) Hiding in plain sight: Treating tobacco dependency in the NHS. Available at: https://www.rcplondon.ac.uk/projects/outputs/hiding-plain-sight-treating-tobacco-dependency-nhs (Accessed: 11th April 2019). 
8. Challenge Group (2018) Review of the challenge 2018. Available at: http://ash.org.uk/information-and-resources/reports-submissions/reports/smoking-in-pregnancy-challenge-group-review-of-the-challenge-2018/ (Accessed: 10th April 2019). 
9. Moore, G. et al. (2014) Process evaluation of complex interventions: UK Medical Research Council. Available at: https://mrc.ukri.org/documents/pdf/mrc-phsrn-process-evaluation-guidance-final/ (Accessed: 10th April 2019).

Image:

1. 'Smoking when pregnant' by johndavison883 via Flickr. Public Domain Mark 1.0.

Merry Christmas from everyone at Fuse