How can A&E units improve their performance?

The first point that I must make is that I do not wish to appear unappreciative or condescending. Hospital A&E work is amongst the most important that any person can undertake and many of us would find the strain unbearable. I have nothing but admiration for the doctors and nurses who work unsocial, long shifts, take life and death decisions and have to put up with stressed patients and carers as well as people who should not really be in A&E at all.

I have never worked in A&E or for the NHS and am not medically qualified. My interest derives from having been an investment analyst specialising in healthcare for thirty years and more latterly from my role as an elected Councillor. Opinions in this blog are entirely my own and are intended to stimulate constructive debate and study, not to offer final solutions. I certainly would not to be so arrogant as to think that I know better than medical professionals working at the coal face. Where I am wrong I hope readers will tell me by posting a comment on this blog or tweeting @barbararesearch .

International data on the performance of A&E is difficult to compare because the systems, categories and data collected vary considerably around the world. The UK does, however, rate relatively highly. All counties are experiencing financial pressure over healthcare spending. Life expectancy is rising more rapidly than the typical retirement age. As a result the proportion of elderly people in the population is rising, leading to healthcare costs growing in relation to the economy. Medical advances intensify the pressure since improved healthcare is usually more expensive than what went before and is also an important driving force behind increased longevity.

The financial pressures on A&E departments reflect partly the demographic trends behind healthcare, partly the need to fund medical advances along with R&D and partly the limited alternatives especially out of hours. Pressures on the NHS outside A&E are also a factor and largely result from the same underlying trends.

Improving the performance of A&E units is certainly a major challenge. The issues are complex. Many ideas about the deficiencies of A&E departments are either mistaken or overly simplistic. For example, conventional wisdom is that money would be saved if more people who attend A&E without urgent medical needs went to their GP instead. This belief is based on figures suggesting that an A&E assessment costs around £110, roughly three times higher than the GP equivalent. However, common sense suggests that this analysis is wrong. Why should it cost more for a junior hospital doctor to give an opinion in an A&E unit than for a more highly paid GP to do so instead? The likely explanation is that on average cases in A&E really are more complicated and more urgent, pushing up average costs. Patients who should not really have come to A&E ought not to need to see anyone more senior than a junior hospital doctor.

Another suggestion that does not fully fit the facts is that the main cause of pressure on A&E departments is growing difficulty in seeing a GP at short notice or out of hours. The time for which patients have to wait before an available appointment with a GP has recently been moving roughly in line with the normal seasonal pattern. A&E on the other hand has recently seen demand grow by much more than normal. In addition, the hourly pattern of A&E attendance over the course of a day has not changed significantly. A change in hourly attendances in A&E would be expected if the problem was caused mainly by a reduction in the out-of-hours services of GPs.

Yet another myth is that NHS 111, the official NHS medical telephone helpline, is increasing the workload on A&E departments. In fact, only around 8% of calls handled by NHS 111 result in advice to attend A&E. Moreover, 30% of callers say that they would have gone to A&E if NHS 111 had not existed. The truth is that NHS 111 helps to divert patients from A&E rather than adding to those attending.

What can be done to help A&E?

  1. Improve Management. Progress has been made over increased cooperation between hospital staff and teams. However, every A&E unit is different as illustrated by the fact that CQC criticisms of A&E vary considerably between hospitals. Meeting the main Government-imposed targets does not in itself mean that all is well. Every A&E unit would benefit from having one person in overall charge with wide ranging powers, just as a country usually has one prime minister (or equivalent) and a company normally has one chief executive. The person selected should have strong leadership qualities and knowledge of A&E. He or she may have other duties apart from managing A&E and might usually work normal office hours. The person chosen should simply be the best for the job and could be a doctor, professional manager or someone from another medical profession.
  2. Eliminate bottle-necks. In my experience the longest wait in A&E is usually before seeing a doctor but after a nurse has obtained brief details. One extra junior doctor on duty at all times would have a significant effect on the performances of some A&E departments. Whilst A&E units vary considerably, on average they see about 270 patients per day. The total running costs of all A&E departments in England add up to around £2.6 bn per annum, which corresponds to the attendance of 21.7 m patients at a total of 218 providers. The average number of doctors employed by an A&E department is around 25, of whom about 10 are on duty at any one time. The 25 doctors would typically include about 5 consultants, although sometimes there may be none present at night or weekends. At least one consultant is always on call.The extra cost of having one more junior doctor on duty at all times in an A&E department would on average add about 1% to the department’s total A&E costs. An extra consultant at all times would increase costs by about 3%. With good management and appropriate recruitment the way forward for A&E departments would look much less problematical. The key hurdle is that recruitment is easier said than done.
  3. Recruiting staff. Every A&E unit should carry out a detailed analysis of the movement of patients through the facility in order to determine the optimum staffing level for doctors of different levels of seniority and likewise for nurses. The analysis needs to take into account unexpected peaks in numbers of patients, the fact that patients do not arrive at regular intervals and the unexpected absence of staff (e.g. due to illness). The NHS could have a small central team available to help A&E units on request with their statistical analysis and to provide appropriate software. Any bottlenecks that do not relate to staff numbers should also be studied thoroughly. The biggest obstacle standing in the way of major improvements in A&E departments is not money but rather real difficulty in recruiting and retaining doctors. A&E has amongst the least attractive shift working arrangements, the highest workplace stress levels and the least opportunity for private practice. The NHS has tried various approaches aimed at attempting to overcome the A&E labour shortage. Steps have been taken to recruit foreign doctors. Many GPs in England have accepted positions in A&E units and this trend could be reinforced by allowing GPs to establish surgeries in hospitals close to A&E units and with shared facilities. The problems of some GPs in finding affordable accommodation for their practices could thereby be lessened. A new GP contract could allow the GP practices located in hospitals to take some of the load off A&E departments whilst allowing the GPs to continue their own unrelated practices. The difficulty in recruiting A&E doctors has resulted in total A&E expenditure on locum doctors reaching around £80m per annum in England. Locums cost much more than permanent staff. If the money spent on locums were used instead for permanent staff each A&E department could have both a permanent extra junior doctor and an extra consultant on duty at all times.The official Government target is for 95% of A&E attendees to be admitted to hospital, transferred or discharged within four hours of arrival. The worst A&E waiting times for England as a whole in recent years occurred in the week to 4th January 2015, when only 86.7% of attendees had a wait of less than four hours. This failure is not as bad as it might appear. In a typical A&E department seeing 270 patients per day the Government’s target would have been met even in this very bad week if just 22 more people had experienced a wait of under 4 hours. One extra junior doctor and one extra consultant on duty at all times would have been more than sufficient to enable the unit to achieve the Government target providing that the 22 patients did not arrive too closely together.
  1. Size of A&E Departments. There are many powerful arguments for having fewer, larger A&E units and only one against doing so. The case against having fewer units is that on average it will take longer to get to the nearest. However, the time taken to get to hospital is less critical than seems intuitively right. There can be no denying that for some patients every minute counts and delays will be fatal. However, for most critically ill patients quality of care affects the outcome more than speed. Most very urgent treatment can be given in ambulances (e.g. stopping severe haemorrhages, resuscitation). Journey time to hospital is only one factor in determining how quickly treatment can begin. Other factors may include, for example, diagnostic tests, x-rays, getting the opinion of a suitable consultant, getting an operating theatre ready, getting necessary drugs from the hospital pharmacy, securing a hospital bed in an appropriate ward and obtaining a medical history (especially if the patient is unconscious or delirious). Valuable time to offset longer ambulance journeys could be saved partly by educating the Public about when to call for an ambulance. Undesirable delays in summoning an ambulance and requesting one unnecessarily should ideally both be addressed. Ways can be explored to help speed the journeys of patients not arriving by ambulance. For example, special 15-minute parking bays for use by drivers offloading patients could be made available near to A&E units.

The advantages of large A&E facilities are:

  • More specialist teams will be possible within A&E or at the same hospital e.g. for strokes, heart attacks, trauma, asthma, diabetes.
  • Peaks and troughs in patient attendance and staff availability will be more predictable.
  • More flexibility will exist to direct medical attention where it is needed and to call on other hospital departments especially when understaffed.
  • A greater range of equipment may be available.A&E closures should be avoided unless it can be clearly demonstrated that the overall effect is to improve medical services and help patients.
  1. The Long-term future. The long-term pressures on A&E are inevitable, given the long-term demographic trends and medical advances. The problems are global. All we can do is to strive to become ever more efficient and to allocate adequate resources. Attracting more doctors and nurses into A&E without paying them more is not going to be easy but a review and consultation about improving working conditions could only help.
Posted in A&E, Department of Health, Elderly, GPs, Hospitals, NHS, Patients | Tagged , , , , , , , , , , , , , ,

Reflections on Andy Burnham’s speech

Before I give you the complete low down, there were some exceptional comments that came midway and at the end of Andy Burnham’s speech on Labour’s ten year plan for health and social care today. Midway through, he spoke about a ‘national entitlement’ to end the postcode lottery of care. If a service was available in one area, it would be available in every area. This is a significant promise which repudiates the current direction of travel: no more local decision making on what is provided, only on how. We called last year for a National Service Guarantee that would give that same certainty to everyone. The challenge is deciding what is left out.

The second comment of note was at the end and built on the one above: “The NHS can’t do everything”, he said, “we have to do more for ourselves, our families, our neighbours. Taking out of the NHS only what we need” and “reset our expectations”. “We need a national debate over which direction the NHS takes”. I do believe that this is a political first. For all else that was said, and what was omitted (IT infrastructure; the effect of rapidly growing digital health and diagnostic technologies; research, innovation & growth; personal healthcare records under our control, how to integrate a means tested service with a free-at-the-point-of-use service), this is the conversation we have been calling for. Anyone who looks at the predicted growth in funding that the NHS will need – driven by more people living longer with long-term conditions, a higher prevalence of complex needs, exponential growth in medical and digital technology capabilities & personalised genomic medicine – and takes the bigger economic picture into account (falling earner to over 70s ratio, balance of payments deficit etc), will know that the NHS cannot go on promising everything to everyone.

Andy Burnham is to be commended for being so frank. The sooner we can begin to review the growing demands against realistic budgets, the sooner the public will be able to partake in an informed discussion on what the NHS in the 21st century is for, how it can be fair, what we must do for ourselves, and what the choices are before us. The NHS is too precious for us not to be having these discussions.

The low down as I heard it….

Sir John Oldham kicked off Labour’s 10 year plan for health and social care this morning, but not before King’s Fund chief Chris Ham had said all (three?) political parties had been invited to set out their stalls – and implied only Labour had taken up the offer so far.

Joint commissioning is essential for integrated care Sir John said, and joint leadership development too. He asked (rhetorically) why there were no local authority representatives on the NHS England Board, and why there were umpteen different national clinical directors for different body parts…NCDs take note!

Fiona Philips introduced Andy Burnham who immediately quoted our by-line as his ambition: Making Health Personal, which was very kind of him, although he didn’t credit us. Andy talked about what he has learned, both from Sir John’s and other reports, but also while listening to the front-line over the past two years citing four themes:

  • Clarity – hence his emphasis on person centred care facilitated by one team
  • Stability – so he has set the path to integration as a ten year journey with no new structural reorganisation
  • Flexibility – he knows integration can’t be mandated from on high but relationships need to be built at the coal face
  • Consensus – getting the right values at the centre and a focus on whole person care is essential

He then went on to give more detail in five areas: Competition, National vs local health, Money, Organisations and Empowering professionals and people, although there were the recurrent themes throughout of integration, personalisation and bringing mental, social and physical care together.

On Competition, Andy said he would call time on the market experiment “market forces will break the NHS apart” and that NHS as “preferred provider” would provide stability during a time of substantial service delivery change. The private sector has a role he conceded, and he would want to see long term contracts where given, with a distinction drawn between the not-for-profit and for-profit organisations and the same standards expected of all. This would include the private sector being subject to FOIs and being charged a ‘training’ levy.

A “national health entitlement” would be set out so it’s clear what people are eligible for (this is the first time I have heard this articulated) and this would include re-establishing the authority of NICE to get rid of the postcode lottery. We called for something similar in our ‘National Health Guarantee’ in our Going with the Flow report (see above). He emphasised that the National focus should be on what is delivered, and local should be the ‘how’. The health and wellbeing board with the local authority would increase their focus on public health and the wellbeing of their population achieving Sir Michael Marmot’s ‘health equity every policy‘ goal.

The existing financial framework rewards the treatment of illness with no incentive for prevention. Although Andy talked about money and that the Year of Care payment programme for e.g. frail elderly would be the new system for payment, with care in the home incentivised, there was little other detail and nothing on the projected NHS budget deficit.

The whole person care approach would only work if there is an accountable organisation, he said. All local health economies need to create an integrated care organisation. Alongside this there would be a new role for Monitor, they wouldn’t focus on competition but on financial viability of whole health economies. Andy said he wanted to see shared loyalty to local population rather than to the employer’s organisation. There should be a new role for the ambulance service too – less about emergency journeys and more about out-of-hours care. NHS 111 would be re-visioned and beefed up.

Empowering those who give and receive care was the last subject. With fewer providers, bringing social, mental and physical care together, he espoused new rights: a single point of care, single care plan, the right to counselling and therapy and to respite care. The NHS would be involved in training social care staff, with common standards for them and NHS staff.

There was a lot of detail covered, with as much missing, particularly on the financing, even for a transition period during which new models of care are put in place. As with all policy announcements, there is always much detail still to be worked through. No Party can claim the moral high ground on NHS reforms of the past, but at least Andy Burnham seems to be asking the right questions for the future.

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British Heart Foundation and 2020health on the same page

2020health welcomes the latest report published by the British Heart Foundation (BHF) ‘The 21st Century Gingerbread House’. What particularly resonated with us where the two calls to action:

  • • To protect children the UK Government should introduce consistent regulations across all forms of media, which cover all advertising techniques and distinguish between healthy and unhealthy products.
  • • All television advertisements for unhealthy products should be screened after the 9pm watershed.

In our recent report Careless Eating Costs Lives we called for the same action to be obesitythumbnailtaken, highlighting that children have become a particularly common target for junk food advertisements during prime time TV slots (Molloy 2014).  The BHF have previously reported that youngsters who watch family-orientated television shows are being bombarded with up to 11 unhealthy food advertisements every hour. If we take into account the time spent on line, using other media outlets including static advertising, a child’s life is surrounded by advertising of any number of unhealthy foods.  Healthy food messages and the ability to make healthy choices can easily become overwhelmed.

Our findings demonstrate that current legislation bans junk food advertising during children’s programmes, but for many youngsters their viewing peaks around 8pm. Crucially this legislation also does not cover the internet. Online brands can legitimately broadcast adverts to anyone who cares to watch them.  Taking steps to try and regulate online advertising is difficult to enforce and continues to prove challenging, but despite the challenges involved action must be taken.  One of our recommendations was that ‘The ban on advertising of unhealthy foods aimed at children should be extended to day-time TV, from 7am to 9pm.’

Screen Shot 2015-01-14 at 12.11.00We also recognised that just tackling advertising was clearly not enough.  We noted that in neighbourhoods with high densities of fast food outlets (Li et al, 2009 & Pruchno et al, 2014), there is a direct correlation with the increase in consumption of processed food (St Onge et al, 2003). In Tower Hamlets, one of the most deprived boroughs in England, it was found that one in five children (20 percent) was obese and a third overweight. This prompted the council to commission the development of a management framework for managing the number and location of hot-food takeaways.

Building on this and other initiatives we recommended that a licensing procedure should be introduced to control the location of fast food outlets in a local community.  As part of this a health impact and assessment should be made a core component of the development process for town planning.

If we are serious about protecting our children and preventing another generation from the risks of becoming obese we need to bite the bullet.

Blog by Matt James, Senior Researcher at 2020health


Li F, Harmer P, Cardinal BJ, Bossworth M, Johnson-Shelton D. 2009. Obesity and the built environment: does density of neighbourhood fast food outlets matter? The science of health promotion. 23(3) 203-9

Molloy, A. 2014. Children being targeted by junk food ads during family television shows, research finds. The Independent.

Pruchno R, Wilson-Genderson M, Gupta AK. 2014. Neighbourhood food environment in community-dwelling older adults individual and neighbourhood effects. American Journal of Public Health. 104(3): 924-9

St Onge M.P., Keller K.L., Heymfield S.B. 2003. Changes in childhood food consumption patterns: a cause for concern in light of increasing body weights. Am J Clin Nutr. 78: 1068-73

Posted in Childhood Obesity, Children, Health and Wellbeing, Nutrition, Obesity, Research | Tagged , , , , , , , | Leave a comment

Breakfast – the best way to start the day

With Breakfast Week taking place between 25th – 31st January 2015, award winning dietician and nutritionist Azmina Govindji explains the benefits of eating a healthy, balanced breakfast and advises on the best breakfasts to suit different lifestyles and needs.Screen Shot 2015-01-25 at 22.45.43

Azmina on breakfast: “A healthy, balanced breakfast can help set you up for the day, giving you energy, important nutrients and it can help to regulate blood sugar levels. All of which can help you to feel healthier and happier. If you want to try and avoid the temptation of a sugary snack mid-morning or that tummy rumble in the office, then having a good breakfast can really help give you the best start to your day.”

Breakfast – fuel for the day
When you wake up you have gone for at least eight hours without food or water, this means your blood sugar levels will be low. Having something to eat within two hours of waking can top up your energy stores and blood sugar levels, which can help make you feel more alert, energetic and in a better mood[i],[ii],[iii].

A healthy weight
Research suggests that breakfast eaters are more likely to be slimmer because they tend to eat less during the day and are less likely to reach for high calorie snacks[iv].

Important nutrients
Many of the foods we eat at breakfast can be good sources of nutrients such as calcium, iron and B vitamins, as well as protein and fibre, which are all important for good health. People in the UK, particularly women and children, don’t tend to get enough iron, calcium and fibre. Calcium helps to build healthy bones, iron can help keep your blood healthy and fibre keeps your digestive system working efficiently.

So what breakfast is best?
There are options to suit all tastes and lifestyles when it comes to breakfast. It’s good to mix it up a bit depending on what you fancy, what you have in the cupboard and how you are feeling. But if you identify with any of the categories below, then these breakfast ideas can help kick start your day:

No time for breakfast at home? Then grab and go. Pick up a smoothie, try one with oats for added energy or try a yogurt with some granola to enjoy Screen Shot 2015-01-25 at 22.56.32at work or on the train. Or munch through a wholemeal sandwich filled with banana. The protein in the milk will help to keep you feeling full and the banana and wholemeal bread gives you slow release energy. You really should eat something so you can get your blood sugar up, ready for the day ahead.

Office workers
If the only time you get away from your desk is to visit the coffee machine, give your brain cells a nudge by feeding them some morning fuel. Before you set off for work, tuck into a wholesome bowl of wholegrain cereal and keep some dried fruit in your desk drawer to munch on during the morning. The starch in the cereal can keep your blood sugar levels steady, and can boost your serotonin levels, helping you to feel good. Some dried apricots will give you a healthy dose of iron, known to reduce tiredness.

Busy mums
Rushing around with no time for breakfast? Give your mental energy a top-up with a bran-based cereal powered by B vitamins. These energy boosters help to release the energy from food and keep your nerves healthy – a must for busy mums. Reach for a bowl of bran based cereal with semi-skimmed milk. If possible, the best way is to eat breakfast with your child so they grow up knowing breakfast is an important part of everyone’s routine.

Active / sporty adults and children
Protein is the buzz word when it comes to sports. You need protein to build and repair muscles. The good news is that dairy foods, which can be eaten at breakfast, are rich in a special amino acid (the building blocks of protein) called leucine, which is a master at muscle mass. So, try yoghurt or milk combined with a nutty granola which will help keep your energy levels up, whilst helping to keep your blood sugar levels nice and steady. Wait a couple of hours before exercising, so your body digests all the goodness before you hit the gym.

Dieters/people trying to lose weight
Don’t make the mistake of thinking that skipping breakfast means fewer calories so you lose weight. Research[v],[vi] shows that breakfast eaters are better able to keep to a healthy weight. Dieters tend to go short on B vitamins, so make sure you get your daily dose from cereal or wholemeal bread. Not eating enough can also mean your immune system is below par, so try to get a daily supply of anti-oxidants by eating lots of fruit and vegetables. A small bowl of muesli with semi-skimmed milk and some berries is ideal.

New Year blues-buster (mood booster)
Skipping meals such as breakfast can mean your blood sugar drops, which can make you feel low. Help combat the January blues by having a good breakfast with lots of B vitamins. Vitamin B-12 and other B vitamins help produce brain chemicals that affect your mood. Low levels of the B’s may be linked to depression. Get yours from fortified breakfast cereals – most cereal packets will tell you how much vitamin B they’ve added – choose the one with the most and team it up with semi-skimmed milk. Wholegrain bread and eggs give you B vitamins, so a poached egg on toast can also do the trick.

Winter colds
Help protect yourself from catching a sniffle by boosting your immunity with a berry good breakfast (forgive me)! Try some fresh mango for vitamin A and a handful of berries for vitamin C, which will give your immune system a helping hand. Mix them into porridge, or with your favourite breakfast cereal and milk.

Constantly tired
Eating gives you calories, which is another word for energy, so eat breakfast! As for what’s in it, choose a fruity start to the day, because vitamin C is known to help reduce tiredness and fatigue. Add fresh fruit to your porridge or cereal or try a glass of fruit juice with your brekkie. Iron can also help fight tiredness and you can get iron from foods such as baked beans, fortified cereals and dried apricots.


[1] Breakfast Skipping and Health Compromising Behaviors in Adolescents and Adults, Helsinki University, published in the European Journal of Clinical Investigation July 2003

2 The Cognitive Effects of Breakfast Study, Mindlab Laboratory, Sussex Innovation Centre, Brighton (March 2012)

3 Cognitive Drug Research, in conjunction with HGCA (2004)


5 A three-month trial at San Raffaele Rome Open University where two groups of women had identical diets but one group ate 70% of their calories at breakfast, morning snack and lunch; and the second group had 55% and the rest of their calories in the afternoon and evening. Both groups lost weight but the morning eaters lost more weight than the afternoon group. Reported in the Daily Mail in June 2014


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Pound for pound: the economic case for weight loss

Guest Blog by Matt James, Senior Researcher at 2020health

Screen Shot 2014-08-19 at 16.48.42Name calling is not pleasant but sometimes behind the hurt and the pain there is a degree of truth. In 2013 the World Health Organization (WHO) called Britain the ‘Fat man of Europe’. Whilst various initiatives have sought to reduce the nation’s waistband, it is true: people are generally still consuming too much of everything.

  • A third of us eat junk food once a day
  • Those of us with a normal Body Mass Index (BMI) has decreased over the past 20 years from 41.0 per cent to 32.1 per cent among men and from 49.5 per cent to 40.6 per cent among women
  • Children on average eat 42 packets of biscuits a year

The previous blog posts in this series clearly indicate that the challenge of obesity is something that simply cannot be ignored. To adapt a familiar wartime slogan, “Careless eating cost lives”, the title of 2020health’s latest report.

To try and claim that this is something that has crept up on us is farcical. Back in 2007 Labour’s ‘Foresight Report’ set out to begin the process of finding a sustainable response to obesity over the next 40 years. The almost weekly press coverage of an obesity related story and associated rising costs mean that no one can claim ignorance, but the lack of action for what is a national crisis (as opposed to global terrorism and ebola) is astonishing. It is, according to some, the greatest threat to the nation’s health and possibly economic security

Public Health England report that in 2007 estimates of the direct NHS costs of treating NHS logooverweight and obesity, and related morbidity in England were £4.2 billion and estimated to be £6.3 billion in 2015. Projections suggest that indirect costs of obesity could be as much as £27 billion by 2015. The same experts estimated that by 2050 the NHS cost attributable to obesity and overweight would be £9.7 billion and the total costs would be £49.9 billion (at 2007 prices)

Alongside the financial impact on the NHS, there are also the wider economic implications to consider: working days lost through ill health, increased benefit payments and social care costs. Towards the end of 2014, the European Court of Justice was asked to consider the case of a male child minder in Denmark who claimed he was sacked for being too fat. The court ruled that if obesity could hinder “full and effective participation” at work then it could count as a disability, given that it is covered by anti-discrimination legislation. This not only increases the pressure on health and social care, but upon employers as well. On a case by case basis, it is likely that employers will have to make reasonable adjustments to the working environment, such as providing larger chairs or special car parking spaces, for obese employees. Providers of goods and services including shops, cinemas and restaurants may also have to make reasonable adjustments for their customers.

US studies looking at the impact of obesity and lost productivity at work found that obese or overweight workers lost productive time at work to a value of over $42 billion (compared with less than $12 billion among workers of normal weight). Employees who have medical conditions such as heart disease, hypertension, diabetes and some cancers, were found to be more likely to have higher absenteeism and greater ‘presenteeism’.

Further research needs to be undertaken to better understand the saving which could be incurred by teaching and training children and parents about living healthy lives. Overlooking this means that we end up treating and spending money ‘downstream’ on outcomes, as opposed to addressing the heart of the problem (prevention) ‘upstream’.

As highlighted by this series of blog posts, there are many questions surrounding obesity with few, ready answers available. Obesity is more than just a physical issue to be addressed by the latest recommended diet. It is much more complex because it underpins how we live our daily lives, the environment in which we live and work and how we feel about ourselves.

A culture of blame, of some people telling others to take responsibility, of demonizing business, of singling out ingredients does not lead to sustainable solutions. It is only when the bigger picture is taken into consideration and a wide range of organisations and individuals become involved, that we will really begin to address the obesity challenge. The Foresight Report recognized this and asked for a portfolio of policies to lead the charge.

FOT744272Increasing interest is being paid to how taxes and spending power can be harnessed to help promote healthier eating and drinking. Highly calorific food is often cheaper and more readily available while fresh fruit and vegetables are considered to be more expensive. This does not help to encourage any of us to pursue a healthy diet, particularly as we all look to make savings on the weekly shopping bill.

Whilst we need to ensure that freedom of choice and consumer sovereignty are not disregarded, serious consideration needs to be given to taxing foods that cause disease. There is merit in evaluating the impact of ‘soda’ taxes in countries and states that have recently introduced them, as well as reviewing whether any of these taxes have actually been hypothecated to improve public health. There is no evidence yet to show that we can simply tax our way out of public health problems, but there is a need for practical consideration around funding and a philosophical imperative to change behaviour proportionately through the tax system.

Over all this we need to invoke an obesity test on all new legislation, asking all government departments to consider the impact of proposed policy on eating behaviour and public health to ensure it does not compound the obesity crisis. Because it is a crisis, and to do nothing, or too little, will further undermine our NHS, our economy and betray those who are not highly resourced to make it through the day past the tidal wave of empty calories.


You can read 2020health’s full report, Careless Eating costs lives, here.

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Lifting the scales from our eyes

Guest Blog by Matt James, Senior Researcher at 2020health

Whatever types of interventions are introduced to address the obesity challenge, ultimately it is only the individual who can take the necessary steps to eat healthily, keep to a healthy weight or decide to lose weight. Legislation, regulation and education all have their part to play but all of us have apart to play too.

The challenge is how to engage at a personal, local and strategic level to influence positively the affordability, availability and acceptability of food, which in turn will help shape healthy choices and behaviour. What do we need to do to help people make the right choices and take the right steps to losing weight? Just bashing away about losing the pounds, weighing our food and reading confusing food labels isn’t going to cut it.   So two things need to be done without delay: Firstly adopting a health in the round approach and secondly developing effective and simple interventions at the personal level.

Adopting a ‘Health in the round’ mentality

Living a healthy lifestyle needs to become more of a priority, both individually and collectively as opposed to solely focusing on weight. There needs to be greater acceptance that people come in different body shapes and sizes and the recognition that some people will struggle with their weight. It is crucial that any interventions used to tackle obesity focus on behavioural change together with appropriate outcome measures.

Individuals need to be educated so that they have a more coherent understanding of food, diet and portion size. The focus needs to shift from a particular diet to ‘our diet’ and an improved understanding of food and what it means to eat a nutritious healthy diet.

Education needs to commence at the earliest possible opportunity and conobesitythumbnailtinue with age appropriate learning throughout life. Our health needs change depending on where we are in the life cycle so understanding our dietary needs throughout life and knowing how to make steady long term changes is paramount.   Research indicates that the rate of obesity increases with age at least up to 50 or 60 years old (Seidell 2005). That is why one of the recommendations in 2020health’s report ‘Careless eating costs lives’ calls for the commissioning of a health education and prevention strategy which covers all stages of life.

Developing effective and simple interventions
Expectant mothers, parents and children are a particular group of people to focusing on helping and supporting. As highlighted in 2020health’s report, HENRY (Health, Exercise, Nutrition for the Really Young) was first introduced to address the targets stipulated by the UK’s Department of Health’s 2009 publication: Tackling child obesity through the healthy child programme a framework for action has the strongest evidence-base currently available for any UK early intervention to prevent childhood obesity. The initiative effectively collaborates with local partners, including health trusts, local authorities, public health departments, voluntary organisations and universities. The programme was successful as a result of holistic approach, covering training in parenting; family lifestyle habits; nutrition; activity; emotional well-being

Programmes such as HENRY could be drawn out on a larger scale to give young families the best start in life. Children need to be reconnected with the food system and home economics needs to be reintroduced into the curriculum.

Getting the community involved

EPODE, originating in France, an acronym for ‘together let’s beat childhood obesity’ is the largest national obesity network. The EPODE approach endeavours to deliver programmes that create everyday norms and settings for children to eat healthily and play safely and actively. The multi-stakeholder, whole community approach facilitates the development of healthy environments including mapped walking routes, playgrounds and cycle routes.

This illustrates the fact that help needs to be given to people to be more active and enjoy physical activity, make healthy choices and act on what they already know. The advice on physical exercise needs to be clearer.

Community involvement discourages opposition and provides individuals with a value in the local environment. Local government is closely involved and a local figurehead is appointed to pioneer projects and motivate the population. Children are taught about and cooking and reconnected to the food system through farm visits and growing their own food. At risk families are offered individual counselling and the programme is specifically designed for tailoring to the individual requirements of communities.

It is possible that the use of the network framework, and nurturing a positive attitude towards effective change might reap health benefits in communities and bring about a reverse in the current trends of societal divide. This is precisely the thinking behind current Asset-Based Community Development (ABCD) initiatives which use the skills and capacities of local people (community ‘assets’) to build more sustainable communities.

There is a lot to be learned from this innovative, sustainable approach. It not least demonstrates the value of reconnecting children with the food system and food supply, by helping to instil a better understanding of what it means to live healthily.

Pharmacist first: A holistic understanding of health 

wellsthumb-1Similarly, one of the key findings from another 2020health project The Wells Family Challenge: A Pharmacist First Approach found that people do not generally understand the links between the food they are eating, exercise and illness. By forming a good trust-based relationship with the pharmacist, a mentor-type relationship was quickly established with the families, which allowed many of them to gain a holistic understanding and approach to health. This allowed for a greater understanding of how steady changes made over the mid to long term made for a greater impact than changes designed to bring about results. This highlights the value many individuals could find in a coaching relationship to help improve their health literacy.

The focus needs to become more about helping people to understand what constitutes good choice so they can take steps to change their behaviour. Government does have an important role to play in shaping food choices and the environments in which we live so that healthy options are easier to make. But it does start with us all as individuals, lifting the scales from our eyes and taking responsibility for our own health.

Similarly, one of the key closely with their local pharmacists were found to challenge imparted educational value and in so doing provided much more than a service treating coughs and colds and alleviating pressure on GPs to treat minor illnesses; they can actually

Seidell, J.C. 2005. Epidemiology — definition and classification of obesity In: Peter G. Kopelman, Ian D. Caterson, Michael J. Stock, William H. Dietz. Clinical obesity in adults and children: In Adults and Children. Blackwell Publishing. pp.3–11

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Weighing up carrots and sticks

Guest Blog by Matt James, Senior Researcher at 2020health

Overeating and poor diet. Lack of health literacy. Not enough time for exercise and a rise in sedentary lifestyles. These are just some of the reasons often cited for the rise in the obesity ‘epidemic’. It is clear from the statistics that England’s obesity issue shows no sign of abating.

* The National Health Service is spending £5 billion a year treating various consequences of obesity, including heart attacks, strokes, diabetes, cancer and hip and knee joint replacements. Estimates predict that it will reach £15 billion within a few decades.

* Worldwide obesity has nearly doubled since 1980 (European Association for the Study of Obesity 2014).

In our last blog post we saw that the ‘time bomb’ of obesity poses a significant threat on several different fronts: individual and community health as well as financial implications of days lost in work, mounting health costs and impact on society as a whole.

Research toPicture 12 date indicates levels of obesity are growing in a population who are health illiterate and unable to make healthy and nutritious choices. While messages on eating less and exercising more have been consistent, they have not been effective.

One of the main barriers to dealing with the obesity is framing the problem as relevant to the individual (Mackay 2011: 898). People are obese as a consequence of poor choices and lack of self-restraint. One approach has been to encourage the population to exercise greater personal responsibility in their food choice. Another approach has focused on giving appropriate recognition to the role of the environment in influencing and constricting individual behaviour. What often results though is a conflict between preserving individual autonomy and upholding personal responsibility on the one hand, and protecting public health through government intervention on the other. What is certain is the need for careful negotiation between personal responsibility and state intervention.

Changing people’s behaviour is a huge challenge, and realism is required rather than knee-jerk ‘banning’ responses. There is also an ongoing debate around the virtue of “pushing” rather than “nudging”. Numerous research papers have explored what constitutes a healthy diet, describing “good foods” and “bad foods” and detailing the effects they have.

Importance of norms
One way in which to try and achieve this has been to build upon the relationship between laws and norms.

What is perceived to be normal is closely associated with how people come to make decisions. There is a range of different factors which contribute to how people reach and arrive at a decision, particularly in terms of health related behaviour.

Today there is often a psychological conflict between what people want and their desire to be healthy (Government Office for Science 2007: 49). People continue to enjoy eating foods that are high in calories and find it difficult to exercise. Various factors, including habits, help to shape behaviour and decision making.

Swap it
People therefore have to Picture 14be helped to train themselves to choose the more virtuous option. The ‘Swap It Don’t Stop It’ campaign (run in the UK and Australia) builds on this kind of understanding. The campaign aims to empower the individual to make small, sustainable changes to diet and lifestyle that are easily implemented and remove feelings of deprivation. This positive approach underlying the phrase, ‘you don’t have to stop it, you just have to swap it’ takes the ‘can’t’ out of the equation.

Giving a nudge
More understanding of how the relationship between laws and norms can be applied in various policy contexts has been the focus of recent work, giving rise to Thaler and Sunstein’s ‘nudge theory’. Wiser choices are made when individuals are presented with a clear set of options that respond to various human idiosyncrasies” (Bogart 2013: 24).

However the empirical evidence shows that simply “pushing” and legislating has not worked particularly effectively to date. However it is essential that further action should be mandated in conjunction with “nudging” appropriately in a variety of ways.

Giving people a nudge in the right direction is a necessary part of a multifaceted strategy designed to elicit a specific response to a particular problem. There is a need to design policy with a twofold approach:

* Understanding why people make bad choices

* Normalise healthy choices so that they are easier to make.

Rather than actually having a direct impact on personal choice, regulation frequently helps to change the culture in which decisions are made. Understanding the mechanism by which regulation works is therefore crucial in harnessing it effectively.

An example of this can be seen with smoking and the recent smoking ban in public places. Researchers estimated a 2.4 percent reduction in heart attack emergency admissions to hospital (or 1,200 fewer admissions) in the 12 months following the ban in 2007 (NHS Choices 2010). A review assessing the impact of the law five years on indicates benefits for health, along with changes in attitudes and behaviour. People are less likely to have stopped smoking for fear of prosecution than they are to have stopped because of the environmental and cultural change which the legislation introduced. Cultural attitudes shifted so that it became less publicly acceptable to smoke in public places.

Whatever interventions are introduced, there remains a responsibility on individuals for their own health. ComRes polling conducted as part of 2020health research demonstrated that parents and individuals see themselves as most responsible for ensuring that they are well informed about how to eat and drink more healthily. Engagement at personal, local and strategic levels will help to influence positively the affordability, availability and acceptability of food, which in turn will help shape healthy choices and behaviour.

At the end of the day, it is not just about loosing weight but living a healthy lifestyle. People may decide to eat more healthily and make changes for the better which can improve lifestyles. Far from being obsolete, legislation has a role to play in helping people to make those healthy choices.

Bogart, W.A. 2013. Regulating Obesity: Government, Society and Questions of Health. Oxford: Oxford University Press.

European Association for the Study of Obesity. 2014. Obesity Facts & Figures.

Government Office for Science. 2007. Foresight – Tackling Obesities: Future Choices – Project Report. 2nd Edition.

He, F.J. et al. 2012. Reducing salt intake to prevent hypertension and cardiovascular disease. Rev panam salud publica


MacKay, S. 2011. Legislative solutions to unhealthy eating and obesity in Australia. Public Health 125 (2011), 896-904.

NHS Choices. 2010. Heart attacks fall after smoking ban, 9th June 2010.

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