Strengthening partnerships to improve primary care in the Deep End

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

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

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

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

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

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

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

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

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

What we’re hearing from Deep End communities

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

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

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

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

What communities say needs to change

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

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

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

Moving forward together

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

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

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

New one‑page resources for practices

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

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

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

Why this matters

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

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

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

Find out more about the Deep End Network

About the author

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

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

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

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

The context: why this service mattered

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

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

Our approach: mixed methods and lived experience

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

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

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

What we found: complexity at every level

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

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

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

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

For service users, the benefits were clear: 

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

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

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

The challenge and value of qualitative work

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

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

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

Why it worked: partnership and collaboration

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

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

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

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

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About the authors:

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

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

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

Does antibiotic prescribing penalise communities in most need?

Posted by Adam Todd, Reader in Pharmaceutical Public Health in the School of Pharmacy, Newcastle University

Since the discovery of penicillin by Alexander Fleming in the 1920s, there have been over 150 antibacterial drugs developed and marketed for human or veterinary use. The effect these drugs have had on infectious diseases and population health is remarkable. A once considered serious bacterial infection can now be successfully managed using antibiotics prescribed from the doctor. This was not always the case, as our grandparents may testify: bacterial infections were often fatal and the choices available to manage such infections were limited. Bloodletting for pneumonia, mercury for syphilis, and honey for wound infections were all commonly used approaches before the discovery of antibiotics.

This "golden age" of discovery may, however, soon come to an end, as more and more bacteria are becoming resistant to the antibiotics available to us. It is for this reason that healthcare organisations across the world have been focusing on developing 'stewardship policies' to promote the appropriate use of antibiotics. In England, the situation is no different, and the Department of Health and Social Care has developed an antimicrobial resistance strategy. As part of the plan, doctors have been urged to reduce the amount of antibiotics they prescribe when it is safe and appropriate to do so. As the majority of antibiotic prescribing occurs in primary care settings, such as GP surgeries, healthcare providers working in this setting are set specific prescribing targets.

It is important to establish if the polices are working from an antibiotic stewardship perspective, but also that these polices are fair, and do not penalise communities in the most need of care. Our work aimed to address these questions. To do this, we used antibiotic prescribing data from the NHS, as well as working out the characteristics of the local areas in England using nationally available data sources.

Overall, we found that, in England, the plan to reduce antibiotic prescribing appears to be working: since 2014, antibiotic prescribing has reduced by around 14 per cent. We also found that the prescribing of 'broad spectrum' antibiotics, used to treat a wide range of infections, have also reduced.

When we considered local factors in our analysis, we showed that the most deprived areas of England had the highest levels of antibiotic prescribing. And even when we factored in two long-term conditions – diabetes and Chronic Obstructive Pulmonary Disease – both of which are associated with increased antibiotic use, we still found higher levels of prescribing in the most deprived areas of the country. We also showed that geography was an important factor too: compared to London, all other areas of England had higher levels of antibiotic prescribing – with the East of England, and the North East of England having the highest levels.

You might ask why this is important? Well, that's a good question. Our work shows that in addition to a national strategy to reduce antibiotic prescribing, it is important to consider local needs too. People living in more deprived areas might, for example, have greater health need for antibiotics compared to people living in more affluent areas. National one-sized-fits all targets might not necessarily account for this. If there is greater antibiotic need in deprived areas, doctors working in these areas might be unfairly penalised for prescribing them. This is not fair on the doctors working in primary care, but may also impact on patients too.

The antibiotic stewardship polices appear to be reducing overall antibiotic prescribing, which is a positive thing, although there is still significant variation in prescribing across England. It would be appropriate for future prescribing targets to account for local factors to ensure the most deprived communities are not inappropriately penalised.

The bottom line is if someone is in medical need of an antibiotic, they should be prescribed it, regardless of the characteristics of their local area or where they live.

Adam leads a programme of research that explores how pharmaceutical interventions, including medication, immunisation and screening approaches, can be used safely, appropriately and equitably at a population level.

Image: 

"England Map silhouette" by Natasha Sinegina through Creazilla: https://creazilla.com/nodes/2538-england-map-silhouette. You may obtain a copy of the License at https://creativecommons.org/licenses/by/4.0/ (CC BY 4.0).

Is Exercise Referral fit for a new decade?

Posted by Coral Hanson, Emily Oliver, Caroline Dodd-Reynolds and Paul Kelly

“Exercise referral doesn’t work”. We have heard this said time and time again, particularly by those who are peripherally aware of the field, but perhaps most worryingly by commissioners and those involved in public health policy. We’ve argued that this is simply not true. A different interpretation is that the exercise referral evidence-base, and the way it is used, hasn’t been working.

The term ‘exercise’ conjures images of Mr Motivator-style aerobics in eye-searing 1990’s lycra

Exercise referral is a decades-old process where professionals in primary care (GP/practice nurse) or secondary care (specialist doctor/physiotherapist) refer patients to a community-based physical activity scheme - often delivered by a leisure provider. National policy guidance (NICE, 2014) recommends that referrals are made where a patient is otherwise inactive or sedentary (both different parameters and not simple to classify in a primary care setting such as a GP surgery) and additionally has an existing health condition, or is at risk of having one.

Traditional evidence-generation for exercise referral has tended to be single-site studies that are then condensed using systematic-review-based methods. Given the considerable variation in how schemes are designed, delivered and evaluated at local level, this is problematic. Vague policy guidance and limited evaluation funding means that most scheme iterations are unsuitable for inclusion and interpretation in this outcome-driven way (Oliver et al., 2016). Collectively, the findings of such overviews are rather underwhelming.

Consequently, during times of tightened public health spending and commissioning, many UK exercise referral schemes have been de-commissioned. This seems misguided, given evidence that some schemes work, for some individuals, in some contexts. Understanding these nuances is at odds with the ‘best practice’ and ‘scaling-up’ that is so often seen as desirable within physical activity policy. Evidence must (and thankfully is starting to) account for consideration of local tailoring and best fit for a given community. Incorporating such evidence into policy is a different matter, of course.

To assist with collating evidence that can meaningfully inform policy and commissioning decisions in this area, our recent editorial in the British Journal of Sports Medicine proposes a sea change in how exercise referral is considered, categorised and reported. The term ‘exercise referral’ is outdated in 2020. ‘Physical activity referral schemes’ more appropriately describes the innovative and extensive range of programmes being delivered, and allows for other types of referral including self-referral, social prescribing and group-based needs assessments, to potentially contribute to the evidence base.

Personally, we’re not keen on the term ‘exercise’; it conjures images of Mr Motivator-style aerobics in eye-searing 1990’s Lycra. It sounds so imposed and constrained

You may have noticed we have replaced ‘exercise’ with ‘physical activity’ – surely a more inclusive term for what is ultimately a behaviour – and one which we are trying to change. Traditionally exercise referral schemes were mainly gym-based and we think that this image probably persists when we think of exercise referral today. Personally, we’re not keen on the term ‘exercise’; it conjures images of Mr Motivator-style aerobics in eye-searing 1990’s lycra. It sounds so imposed and constrained. Even a simple phrasing change can have far-reaching implications, and hopefully for the better in this case.

In the editorial, we propose a simple way of identifying, classifying, and recording key information about physical activity referral schemes that will enable better understanding of what exists and what is working. Our new reporting checklist (or taxonomy) encompasses all physical activity schemes that:

1. have the primary aim of increasing physical activity,
2. have a formalised referral process, 
3. are provided for individuals who are inactive/sedentary, and/or have or are at risk of a health condition. 

The classification framework can be seen in figure 1 (below). The full reporting checklist can be found in the editorial. We propose that this be used by commissioners, practitioners and researchers alike: for auditing and monitoring, to capture service delivery and in generation of evidence reviews.

Figure 1

We are very keen to hear from anyone working in exercise/physical activity referral of any kind as we move forward with refining this idea. The model was proposed to policy-makers, practitioners and academics at a consensus event in late 2019, and we are currently refining it by undertaking a Delphi Survey. We are inviting further comment, critique and engagement to make the final version as accessible and ‘fit for purpose’ as it possibly can be, so please get in touch with Coral, Caroline, Paul, or Emily via twitter or email - details below.

Coral Hanson, Research Fellow, Edinburgh Napier University @HansonCoral / C.Hanson@napier.ac.uk

Emily Oliver, Associate Professor, Director of Research in the Department of Sport and Exercise Sciences, Durham University @_EJOliver

Caroline Dodd-Reynolds, Associate Professor, Department of Sport and Exercise Sciences, Durham University @carolinedod / caroline.dodd-reynolds@durham.ac.uk  

Paul Kelly, Lecturer in Physical Activity for Health, The University of Edinburgh @narrowboat_paul 

References:

• Hanson, CL, Oliver, EJ, Dodd-Reynolds, CJ & Kelly, P (2019). We are failing to improve the evidence base for “Exercise Referral” How a Physical Activity Referral Scheme Taxonomy can help. [CR14] British Journal of Sports Medicine Published Online First: 17 December 2019. doi: 10.1136/bjsports-2019-101485
• National Institute for Health and Care Excellence. Physical activity: exercise referral schemes. National Institute for Health and Care Excellence, 2014. https://www.nice.org.uk/guidance/ph54/resources/physical-activity-exercisereferral-schemes-pdf-1996418406085 (Accessed 06 Jan 2020).
• Oliver EJ, Hanson CL, Lindsey IA, Dodd-Reynolds CJ. Exercise on referral: evidence and complexity at the nexus of public health and sport policy. International Journal of Sport Policy and Politics 2016;8:731–6.

Images: 

1. ‘Mr Motivator 2’ by Dave Tett via Flickr. Attribution-NonCommercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0): https://www.flickr.com/photos/66551670@N00/388434590 © 2007.
2. 'Figure 1' reproduced from Hanson, CL, Oliver, EJ, Dodd-Reynolds, CJ & Kelly, P (2019). We are failing to improve the evidence base for “Exercise Referral” How a PhysicalActivity Referral Scheme Taxonomy can help. British Journal of Sports Medicine Published Online First: 17 December 2019. doi: 10.1136/bjsports-2019-101485 with permission from BMJ Publishing Group Ltd.

Making the rural a bit more idyllic

Guest post by Christina Dobson, Research Associate, Institute of Health and Society, Newcastle University

Ah, the countryside. The home of all that is natural and healthy, the epitome of the ‘good life’. Where you can stroll down the lane to collect fresh eggs or veggies from your neighbour, simply dropping your money in the honesty box left at the end of their drive. I grew up in a rural area, and still live in one now. I love that I only have to walk (more like dawdle - I have a very curious and distractible three year old!) for 10 minutes (five minutes without said three year old) from my front door and I am in the North Yorkshire Moors National Park.

And it seems that living in a rural area could actually be good for you in a number of ways. You are likely to be more satisfied with your life, experience better health overall, and live an average of two years longer than people in urban areas. Maybe it’s the un-polluted air, the connection between land and food, the sense of belonging and community? Or maybe that is just a myth, sold to us all through Postman Pat?

Because, actually, living amidst the beautiful rolling hills may not be so good for you if you develop cancer. In fact, it may even put you at greater risk of developing certain cancers and make you less likely to survive your cancer. With roughly 20% of the population of England living in a rural area, this poses a serious public health problem.

However, we don’t really know why rural patients are facing poorer survival rates than urban patients. One of the strongest factors is that cancer is often diagnosed at a more advanced stage in rural patients, limiting the treatment options available to them. We know that delays in diagnosis are strongly linked to advanced stage cancers, and, as such, encouraging early diagnosis has been central to UK cancer policy for over a decade.

When we begin to think about where diagnostic delays may be occurring for rural patients, it seems that they are investigated and diagnosed just as quickly as urban patients, after referral to hospital for specialist assessment. It follows then that there may be problems prior to referral to hospital that are slowing down rural cancer patients’ diagnoses, either in the way patients respond to symptoms, or the way they are managed in primary care.

Thanks to funding from Yorkshire Cancer Research, and alongside colleagues from Aberdeen and Glasgow, we are starting to look for answers to some of these questions. This study will involve interviewing people in rural Yorkshire to understand their experiences of bowel cancer symptoms and decisions around if, how, and when to seek help about them. The findings from these interviews will be used to work with local communities to think about what interventions we may be able to design to encourage people in rural areas to present to their GP and, hopefully, increase the likelihood that their cancer is diagnosed at an earlier stage and that they will survive.

It is an exciting study, as there is so little known about symptom experiences in rural populations, with lots of issues to explore. For instance, availability and regularity of public transport, provision of health care services in rural areas, hidden poverty, cultural beliefs and experiences of ill health and employment, to name but a few. And then there’s the messy complexity of defining the ‘rural’, or maybe we should be looking to instead describe the multitudes of ‘rurals’? Plenty to keep me busy!

With the arrival of National Bowel Cancer Awareness Month it’s been valuable to reflect on the importance of this study and the opportunities and challenges that lie ahead. Understanding some of the barriers to timely presentation that exist for rural populations, and devising ways to overcome them is our challenge for the next two years, and beyond. Maybe, longer term, we can help to make the ‘rural’ a bit more idyllic.

Prevention by any other name would smell as sweet

Guest post by Tom Embury, Public Affairs Officer, British Dietetic Association

Next week, June 4th - 8th is Dietitians Week 2018, where the British Dietetic Association and its members and allies celebrate the work of dietitians. This year’s theme is “Dietitians Do Prevention”, which intends to highlight the important role that dietitians have to play in prevention and public health. We know nutrition and hydration underpin so much of our health and getting it right can reduce the impact of illness, aid recovery, or prevent some diseases and conditions altogether.

NHS England’s Five Year Forward View, in the most recent frameworks from NHS Scotland and the Northern Irish Health and Social Care Service and is embodied in the principles of the Wellbeing of Future Generations (Wales) Act.

It has been made clear by everyone from Marmot to the NHS Confederation that we need to strengthen prevention and that it should be everybody’s business. Despite this, many dietitians (and indeed healthcare staff in general) still don’t think of themselves as doing prevention or public health, especially as so many work in hospital settings, delivering acute care. Our recent 2018 member survey has shown that 40% of our members don’t feel that they do prevention or public health activity. This may be because they don’t have the time or resources, despite wishing to do so, but in some cases, it is because they don’t see public health as part of their remit.

Of course, we believe all our members “do prevention” and public health, but not everyone will call it by that name. Indeed, the term public health often seems to have quite a narrow definition, associated with the work of local government public health teams. This is important work, but by no means is that everything public health entails.

This is why, in preparation for Dietitians Week this year, we asked all our specialist groups for their view on how they do prevention. Our specialist groups cover pretty much all of the areas of dietetics - from paediatrics to older people, public health to critical care. What we found is that there are dozens of words and terms used to describe activity that is essentially a form of prevention.

Some were variations, like primary, secondary or tertiary prevention depending on where you work and what types of illnesses your patients have. Others, such as Making Every Contact Count or Healthy Conversations, relate to specific campaigns or initiatives. In areas like Mental Health or Paediatrics, a whole different language can exist. Even rehabilitation or recovery after acute illness is a form of prevention - preventing future episodes, further hospital visits or complications. One great example comes from Fuse itself – the research carried out into the impact of energy drink intake amongst young people has had an impact on national level policy making.

This is why we are trying to celebrate prevention in all its forms and with all its various names. Dietitians are and should to a greater extent be a core part of the public health workforce.

Our incoming Chairman, Caroline Bovey, highlighted this issue with terminology and understanding at our recent Annual General Meeting. She asked the crowd of over 100 dietitians to raise their hands if they were involved in public health. Some hands went up but they were definitely in the minority. She then asked who had a twitter account where they talked about diet and nutrition – far more hands shot up. “You are all”, she said, “doing public health dietetics”.

So, whether you’re having a healthy conversation or making every contact count, supporting rehabilitation or reducing hospital admissions, celebrate the way that you do prevention. We can’t let the terminology get in the way of sharing best practice or spreading good ideas. We’d love you to tell us about it as part of Dietitians Week! Get in touch via dietitiansweek@bda.uk.com

A prescription for tackling riskier drinking?

Guest post by John Mooney, Fuse associate and Senior Lecturer in Public Health, University of Sunderland.

In keeping with the ‘Dry-January’ season, John Mooney reflects on a current initiative to assess the feasibility of alcohol brief interventions in high street pharmacies…

“A man walks into a high street chemist – and asks for a paracetamol and an Alka-Seltzer…” could be the start of a very unpromising joke or sketch outline… Thankfully, it’s neither, as it more accurately depicts a very common scenario, which might represent the basis of a potentially effective setting (namely pharmacy / high street chemist shops) for health promotion messages around the health risks from alcohol misuse and / or overconsumption.

AUDIT score card collection box, with prize incentive to participate

Alcohol unit indicator diagram

Unsurprisingly perhaps, it is by now fairly well established that “alcohol brief interventions” (ABIs) - in which short well-validated questionnaires about habitual drinking patterns and consequences are linked to tailored advice and feedback - can be an effective intervention in primary care based consultations / GP practices as evidenced in the SIPS trial. Evidence for the effectiveness of such interventions however is less convincing in other settings, even those where, as in a GP consultation, health is the primary focus of the interaction. Pharmacy outlets for example might be considered an obvious parallel candidate ‘setting’ where, as in the scenario above, there may clearly have been an alcohol related context surrounding the primary reason for the person’s visit.

Indeed, in addition to over-the-counter ‘remedies’ which might be sought out after alcohol over-indulgence, there are a number of ‘indicator-prescriptions’ which could be suggestive of a more chronic / long-term damaging level of alcohol consumption (such as stomach acid suppressants or high blood pressure medications). High street chemists therefore, by virtue of their community embedded location, specialist knowledge and windows of opportunity for engagement, could theoretically present a very promising setting for ABIs. The lack of evidence of effectiveness in studies where this has been rigorously evaluated, has prompted questions as to why this might be the case. Investigators have speculated on the explanation being attributable to anything from the variable attitudes of pharmacy staff to the additional time and resource constraints associated with modern pharmacy practice. A recent Master of Pharmacy dissertation at the University of Sunderland(1) – which explored possible reasons in interviews with pharmacy staff, provided some local corroboration for these potential explanations. Interviews with participating pilot sites had also however noted the value of the awareness raising aspect of the process:

“Some patients had been drinking a bottle of wine a night and didn’t realise that it could contain 9-10 units and they were really shocked when they realised”

Other potential strengths of pharmacies as a setting for ABIs might be the now well established practice of providing support to pharmacies looking to embrace a wider health promotion role. As part of NHS England’s current ‘Promotion of Healthy Lifestyles’ programme, pharmacies are now required to participate in up to six health promotion campaigns per year(2). This generally involves the display and distribution of leaflets provided by NHS England or other collaborating institutions or stakeholders. As a result, there are usually highly visible and engaging ‘health promoting and awareness raising materials’ adorning the display areas of high street pharmacies and messages around alcohol health risks and reducing them are often a focus of such displays.

Given that the brief questionnaires and tailored advice of alcohol brief interventions is a more pro-active approach than the passive display of information, a current UK pilot feasibility study for pharmacies in several UK regions funded by Drinkaware UK, involves participants self-completing a score card that is the basis of most ABI interventions. Abbreviated as AUDIT, the Alcohol Use Disorder Identification Test, developed by the World Health Organisation(3), involves a series of questions about drinking habits and the extent to which drinking might have impacted on daily activities. Not quite ‘shock tactics’, the revelation of a score that flags up concern – can give respondents some cause for reflection – especially after the season of excess! Of course the score cards themselves have information on where respondents can seek further help and participating outlets receive training in responding to questions that might arise. Essentially the pilot aims to examine how best to integrate ABIs, as unobtrusively as possible into the day-to-day working of the pharmacy.

Not a programme lacking in ambition, the same score cards are also being distributed by trained advisors in selected participating supermarkets and other community settings across the UK, the evaluation of which is set to be complex and challenging. Ultimately the organisers hope to be able to make best practice recommendations about the most effective way to implement ABIs in pharmacies and other settings, where traditionally ‘hard to reach groups’ including working age men (a key high risk group for developing alcohol related health problems) can be more easily targeted.

AUDIT score cards with information leaflets

Indeed the current Drinkaware national campaign (‘Have a little less’) of which the above initiative is a part, will be run to coincide with 'Dry-January'. With a particular focus on working age men aged between 45-60, the message is that ‘Having a little less’ alcohol can have significant health benefits. This is in line with an emerging expert consensus around some of the potential drawbacks of an over-emphasis on one month of the year(4) and that it would be more beneficial for example to achieve three drinking free days for every week of the year. With long term trends in UK consumption still on the rise and a 44 per cent increase since 2009 in those aged 50 and over accessing alcohol treatment, all initiatives exploring innovative ways of getting the message across are to be welcomed. Don’t be too surprised therefore if you are asked about alcohol consumption the next time you collect a prescription!


Note: The Sunderland University Team who are evaluating the Drinkaware community ABI pilot comprises: Prof Jonathan Ling, Mr John Mooney (PI), Dr Zeibeda Sattar and Dr Nicola Hall. Please address any correspondence to john.mooney@sunderland.ac.uk

References:

1. Asghar S. Assessing the Feasibility and Practicality of delivering Alcohol Brief Interventions in Pharmacy Settings. MPharm Dissertation, University of Sunderland 2015/16.
2. PSNC page on promoting healthy lifestyles: http://psnc.org.uk/services-commissioning/essential-services/public-health/ 
3. PHE Guide to WHO AUDIT: https://www.alcohollearningcentre.org.uk/Topics/Latest/AUDIT-Alcohol-Use-Disorders-Identification-Test/ 
4. http://theconversation.com/dry-january-is-it-worth-giving-up-alcohol-for-a-month-51956

Photography by Eileen Robinson Art ©

Mapping collaboration and constructing a compass

Guest post by Lindy Turnbull, Senior Lecturer, Faculty of Health and Life Sciences, Northumbria University

Collaboration is promoted as a key aspect of commissioning and delivery in public health (NHS England, 2016) and health care (NHS England and NHS Improvement, 2016). Joint working and integration of services are seen as the way forward for the future NHS with new integrated models of care at the forefront of service redesign, and collaboration core to managing increased demands with diminishing resources. Although collaboration is a familiar concept and has been the subject of research and discussion it is still an area of practice which is poorly understood. It is striking that existing definitions of collaboration identify professional sharing with the focus on patient care, yet there is little representation of patients in most studies and the role of patients in collaboration seems to be missing from the existing theory.

I began my research after leading the development of Outpatient Parenteral Antimicrobial Therapy (OPAT) a new model of care which required collaborative working across secondary and primary care to deliver treatment in patient homes. The development of this service was challenging and required strong collaborative relationships to overcome the organisational barriers to integration. Having experienced the challenges of collaborating to develop an integrated service I wondered if these difficulties continue into the delivery of the service in practice, and how collaboration takes place within the challenging environment of the constantly reorganised NHS.

The aim of my research was to develop substantive theory about what collaboration means in the delivery of integrated care, the way it is manifested in day-to-day practice and how it is shaped by the situation in which it takes place. I viewed patients and professionals as participants in collaboration and interviewed three patients and 21 professionals. I have used a social constructionist approach to grounded theory (Charmaz, 2008) and a range of situational mapping techniques (Clarke, 2005)1 to map collaboration within the situation of integrated care delivery. Analysis was a fascinating and absorbing experience as I used mind mapping software to analyse and compare the perspectives of those involved in collaboration and then to combine perspectives to map and analyse the complexity of the situation.

Participants expressed a number of interactive mechanisms (trusting, communicating, co-ordinating and rehearsing) which were influenced by a range of situational co-ordinates (goals, limits, certainty, uncertainty and power) and these were used together to navigate the complexity of the healthcare situation and direct the process and outcomes of collaboration. The capability of individuals to act, or interact was informed by their interpretation of the situation and this directed the capacity for collaboration within the care situation. Positional mapping techniques identified four directions of collaboration: developing, maintaining, limited and disrupted, and I found that limiting factors were significant in changing the direction of collaboration. The communication of some social limitations such as terminal illness, professional roles or work requirements altered an individual’s capability to collaborate and the capacity for collaboration within the situation.

My analysis has constructed a collaboration compass which is used to navigate the situation and direct the collaboration experienced by patients and professionals. I am in the process of writing up and still fighting my enthusiasm to write about everything I found and learned during my study; there simply aren’t enough words!

Reference:

1. Clarke, A. (2005). Situational analysis: Grounded theory after the postmodern turn. Thousand Oaks, CA: Sage.

Health Research Authority summary: The Meaning and Manifestation of Collaboration in Domiciliary Outpatient Parenteral Antibiotic Therapy: A Grounded Theory Situational Analysis.

Mind over matter in Fuse?

Posted by Peter van der Graaf, AskFuse Research Manager

Mental health is a rising star on national and local agendas. At national level, mental health was for the first time ever included in all of the main political party election manifestos and features significantly in the NHS Five Year Forward View. At local level, Public Health teams across the North East are reviewing their mental health services and upskilling themselves in the best ways to reduce self-harm and suicide. You may ask what all the fuss is about?

Various reports have pointed out that poor mental health is costing the UK economy £105bn per year, including £8bn annually in sickness absence, and a further £15bn in lost productivity absenteeism (where people are at work, but under-perform due to mental health issues). The Care Quality Commission (CQC) recently sounded the alarm over the state of mental health services in England. In its first ever review of mental health crisis care, the regulator found that 42% of patients did not get the help they needed.

The picture is particularly bleak in the North East, which has the highest suicide rates in the UK and rates have been going up steadily since the economic recession and public sector cuts (after a long period of stabilisation) and are likely to increase further with additional cutbacks planned in recent spending reviews. Not surprisingly, mental health issues are higher in deprived areas, among men, those who are unemployed, and related to alcohol problems, all of which the North East is leading on in national league tables. Mental health services, described by one of our practice partners as “the Cinderella of Public Health”, are bearing the brunt of these cuts, in times when you could argue that their service users need them most.

To make the most of existing intelligence and services, the Public Health Intelligence Northern England (PHINE) network recently organised a dedicated event on self-harm and suicide, offering participants access to various interactive data sets (e.g. Community Mental Health Profiles) to help local authorities make sense of national data for their own patch. Where are the suicide hotspots in different localities? Who are most at risk and what services can they access? The data profiles were well received by the audience but were also met with some criticism around lack of integration with local data, such as counselling data collected by GPs in the North East. Moreover, although this data helps to identify what is happening where, it does not allow for answers to the question why? Public health commissioners need help to interpret this data and understand why suicide and risks are going up in one area or user group but not in another.

What can Fuse do to support this? Are we making our research on mental health issues available to decision makers and professionals? For instance, where can Public Health practitioners find information about the lessons learned in the award winning Change UR Mind about Young People project (evaluated by our Translational Research programme); or about the literature review on self-harm produced by the Knowledge to Action Group within our Complex Systems programme? Moreover, is our research responding to local concerns and needs? Do we help them in interpreting national data and matching this with their own data? And do we support them in developing interventions to address hot spots? How can Fuse work more effectively with partners in the region that are working on suicide prevention strategies, post-event services and mental health research?

Partners are closer than you might think. For instance, The Westgate Unit at HMP Frankland is a therapeutic, personality disorder treatment service based in a high security prison setting.  The Unit helps prisoners diagnosed with Borderline Personality Disorder who are most at risk of self-harm and suicide. The unit has developed its own research on why different prisoners self-harm but is struggling with budget cuts and would welcome support from academics in developing and conducting further research. You might counter that this is not public health, but given the significant impact of mental health on the UK economy, the NHS and, last but not least, the impact on families and communities, I would argue that this is a unique opportunity for Fuse to get involved.

Our region already has a wealth of clinical expertise available on mental health: the Mental Health Research Group (MHRG) is a joint initiative of the Tees Esk Wear Valleys (TEWV) NHS Foundation Trust and Durham University, in which clinicians, academics and service users, including young people, collaborate to improve local health services. The group recently showcased their research during their annual conference. Unfortunately, Fuse is not a partner in this network. However, clinical staff in the Trust are keen to develop their research skills and contribute to a better understanding of mental health issues and interventions in the North East and would welcome collaborative research with Fuse.

This might be a good time to ask: should Fuse put mind over matter when it comes to mental health?

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

Guest post by Avril Rhodes

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

Conservatives will:

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

Labour will:

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

Liberal Democrats will:

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

Greens will:

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

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

All views expressed are exclusively those of the author.

The Stevens Factor – our man from Consett

Posted by Avril Rhodes and David J Hunter

Simon Stevens, the Chief Executive of NHS England is not as he seems. Behind the urbane witty manner, the man who likes, apparently, to speak without visual aids, is a man of real steel. Well, Consett steel actually, as at home speaking about his early experiences of working at the then Shotley Bridge General Hospital, as defending the NHS before the Public Accounts Committee and leading five year forward views. We have two gems here, someone who knows north-east England and relishes speaking almost exclusively about public health, despite the enormity of the operational responsibilities he carries, and definitely a force to be reckoned with, as his vertical rise from junior manager to CEO, via advising the Blair government at No 10, testifies.

Simon Stevens: a man of Consett steel

We shall soon be entering manifesto season. At his recent Centre for Public Policy and Health lecture at Durham University Queen’s Campus, whilst it wasn’t called a manifesto the audience were given an insight into six key priorities on Mr Stevens' mind, some of which built on the five year forward view released in October. Not in any kind of order these were:

1. Re-conceptualising what we mean by the NHS – the NHS is now a pensioner, in organisational terms but is still revolving around dealing with problems as they arise, with too little spent on underlying prevention. It seems to be hard enough to co-ordinate the different services currently provided, let alone stepping up to a new level where there is no difference in health and social care, and any aspect of policy that affects life chances, and health and wellness, is integrated both in planning and delivery. But this is a goal that means a fundamental re-orientation of what’s provided, how and where.
2. What about the unexploited advantages of primary care? The division between primary and secondary care in the UK, which has deep historical roots that pre-date the NHS is both a barrier, in terms of setting up a division that wouldn’t be recognised in some other countries, and also a positive, in providing personalised care, close to home. But what about the areas where primary care is all too thin on the ground, the unpopular parts of the country where GPs don’t want to work – the so-called ‘inverse care law’ which Stevens invoked. Can this be fixed through the development of a population-oriented primary care system?
3. The NHS is a major buyer and employer and has a sizeable economic footprint in local communities. Back in his Consett days, the steel works had recently closed and the NHS took up some of the fall out as the local and large employer of alternative resort. This lesson has not been lost on Stevens. The NHS should be able to influence poverty and health through its own economic position in each locality.
4. Work needs to be done on ensuring people get and stay in high quality jobs. The NHS can support this (partly linking back to the third point) through what it does as an employer but also could have a much stronger role in health interventions whilst people are at work. Unsaid at the time, but the workplace is somewhere people spend a lot of time, so why not? The NHS needs to set an example in being a good employer itself, but to its shame falls short, for example in the management of shift systems, or provision of healthy eating options at work. This was definitely a ‘can do better’ on the report card.
5. Local Authorities have come back in from the cold with their new (or is it re-gained?) responsibilities in public health. There is an awakening to the scope local government could have, arising from the debate about devolution in England, set off by the Scottish referendum, and even within their existing powers, local authorities can reach the parts the NHS can’t reach in affecting population health and well-being. 
6. And finally, what about the planning of new cities and towns? These could provide a test bed for working out new ways of place-shaping and designing health and wellness into the built environment and also new ways of delivering the NHS, given the blank sheet these major developments offer.

Let’s see how many party political manifestoes pay attention to these ideas in the Spring of 2015.