City Health Challenge

The first City Health conference, held in London, set the scene for planting drug and alcohol treatment at the heart of the new public health agenda. DDN reports. Photos by Gill Bradbury

The formation of Public Health England (PHE) will herald a new era for delivering drug and alcohol treatment, Hugh Morris, chair of the London Drug and Alcohol Policy Forum, told delegates at the first City Health conference in London. There would be a real opportunity to work with individuals within their social context to address all of their needs, and the emphasis would be on partnership working across all areas of health that boost a client’s wellbeing.

‘Drug and alcohol problems are a symptom rather than the cause, and we need to treat the individual, not the symptom,’ he said. To achieve this in the current culture of budget tightening and cost cutting would mean being innovative and learning from examples of good practice around the world.

This was echoed by Duncan Selbie, chief executive of newly formed PHE, who said it was ‘a stroke of genius’ to bring public health back into local government by giving them a legal duty to improve health, as historically this had always been the case.

‘We are all in this together – no one owns health,’ he said, before emphasising the importance of making improvements to people’s access to employment, housing, and local community infrastructure. He promised to concentrate efforts on the poorest groups in society and to address current health inequalities that have created a 15-year gap in life expectancy, depending on postcode.

In common with all public services, ‘cost savings across back office functions must be pursued’, he said, but pledged that budgets for next year would be kept at current PCT levels. He told delegates that it was up to them to show that what they did worked and make the case for maintaining their budgets, and also stressed that ‘the biggest savings will be made by early health interventions’.

How would drug and alcohol treatment fare as part of the new public health approach, delegates wanted to know.

‘Can you give us a guarantee that we won’t be forced off maintenance scripts?’ asked Eliot Albers from the International Network of People who Use Drugs (INPUD). ‘We have been worried about the rampant moralism of recovery – can you give us reassurance?’

Selbie stressed that PHE would be professionally led and would make sure treatment was evidence based. ‘There’s nothing moralistic about that,’ he said. He left the conference promising ‘a much deeper conversation’ in six months time, when PHE was fully staffed.

In the following session on urban health dynamics, Professor Phil Hanlon of Glasgow University looked at ‘what’s next for the health of society’. The UK’s ‘trivial’ drug problems of the 1970s were now comparable to Afghanistan, ‘because we’ve taken the benefits of modernity and pushed them too far,’ he said. ‘We’ve created consumerism and more people feel stressed, overwhelmed and unhappy.’ Public health was on the brink of transformation, he suggested, and we were in for ‘a bumpy ride, but not a continuation of the same’.

Senator Larry Campbell brought his perspective on ‘changing the status quo’ from Vancouver, where, as mayor, he had been involved in dynamic harm reduction efforts including the first safe injection site in North America.

Forming a coalition to look at crime prevention and tackling addiction had been the way forward, he said, including neighbourhood groups, NGOs and businesses. They had involved VANDU, the local network of drug users, from the start, and had welcomed homeless people to the free meetings by offering refreshments. One of the many tangible outcomes was Insight, the registered injection site, which offered healthcare in all its forms.

‘You can change the status quo but it takes a single group of like-minded people who are prepared to go down a voyage of discovery,’ said Campbell. ‘You can go all over the world and find programmes and what works, but it takes effort on the part of citizens to get involved.

‘You have to be in it for the long run,’ he added. ‘You have to fight people and know that you’re in it to save lives.’

Professor Mark Bellis brought the focus back to the UK with a sobering look at drinking habits, likening the picture to Hogarth’s Gin Lane.

‘Around 50 per cent of all violence in England and Wales is alcohol related and around 50 per cent of adults avoid city centres at night because of alcohol,’ he said. Cheap alcohol and longer opening hours shaped the way we drink, with people drinking more in a single night out than government recommendations for a whole week.

‘It’s illegal to sell alcohol to a drunk person but just three people were prosecuted in 2010,’ he said. Furthermore, city centre statistics did not reflect the wider damage to families and from incidents and regular drinking habits in private environments: ‘People are dying in part due to a toxigenic approach.’

The range of options for tackling this included environmental management, earlier support, limiting alcohol sale times and increasing prices.
‘We need to let the public know about the real dangers, rather than just saying “drink responsibly”,’ he added.

Speakers considered the ‘traditional’ public health challenges, such as infectious diseases, alongside emerging issues, such as new drugs and evolving social behaviours.

A very modern public health problem was presented by Dr Owen Bowden-Jones of Central North West London NHS Trust, who looked at the continuing rise of club drugs. At this year’s Glastonbury Festival, benzylpiperazine (BZP) overtook cannabis as the drug most confiscated by police. In an anonymised survey in Soho by drug intervention database Tictac, urine samples showed a high concentration of new psychoactives – so-called ‘legal highs’. A further sign of their popularity was in the growth of online sales outlets, from 314 sites in 2010 to 690 a year later.

Given evidence of usage, the small numbers of people presenting for drug treatment indicated that users of new psychoactives either did not encounter problems, or if they did, they did not want to be associated with traditional drug services or consider them appropriate for their needs, said Bowden-Jones. Through setting up the Club Drug Clinic in Chelsea and Westminster Hospital, it was established that there was a definite need for the service. By making self-referral easy, by email and by mobile phones via QR codes, they had attracted clients with an average age of early 30s from across London and beyond.

Reminding delegates of some of public health’s toughest challenges, professor of hepatology, Graham Foster, warned that the situation with hepatitis C was ‘going to get grimmer’, with many older patients now needing palliative care.

‘The virus is spreading and the epidemic is getting bigger,’ he said, adding that the Health Protection Agency’s figure of 6,000 infections a year was a ‘gross underestimate’ and that the problem would get much bigger in the next  ten years.

‘We need a new treatment model that deals with patients where they want to be treated,’ he said. The population of active drug users had shown a good success rate for cure and for disease-free survival – ‘therapy can be given, people can be treated, they can be cured’. A study in Bristol had shown that by treating just a small proportion of injectors, the spread of hep C could be halted and the disease eliminated.

To eradicate hep C would need political support, funding – which wouldn’t be cheap, but a viable alternative to expensive deaths or homeless people dying on the streets – and staying power for a concerted effort over the next ten years.

‘If we do nothing it’s going to get worse on our watch – it’s going to be us stepping over bodies on our way to work,’ he said. ‘We can eliminate this and we should.’