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Around the world, cities are increasingly concerned with not only protecting, but also improving the health of their citizens. This is driven by many factors, the link between a healthy population and economic success being one of the most politically compelling. Closely linked to this, health inequalities/inequities are recognised as barriers to cities achieving their potential. This concept has gained traction with a broad range of politicians and policy makers, even if the breadth of factors and levers to achieve these goals are perhaps less well understood. What is clear is that the delivery of a healthy city requires the involvement of agencies beyond the traditional, narrow, understanding of those which deliver medical services. We all regularly hear and chant the mantra of needing to end silo working and the virtue of adopting holistic approaches. 

Since 2012 City Health International has provided a space where a broad range of agencies and cities can showcase and discuss innovative projects. This has provided a rich environment to allow for consideration of the diverse issues facing our urban centres. Many participants have clearly valued the opportunity to hear views of those with differing specialisms and perspectives. Some have found it challenging to have the norms of their own disciplines or professional cultures questioned. On occasion there has been visible discomfort, but I strongly believe that this level of challenge is necessary if we are going to develop the ability to look at problems and their potential solutions in the round, to develop the horizontal, cross cutting approaches that are essential in maximising available assets and resources to deliver the best possible outcome for our cities.

Professional and philosophical silos are comfortable places to inhabit. They provide structure, certainty and security. This links to peer support, increasingly narrow specialism, hierarchy and career structure. Let me pause a moment and make clear that I am not criticizing specialists or experts- they are vital. Especially, for example, if I am going to be the beneficiary of their hard- won expertise. But all this can make it hard to look at broad, big picture issues. We don’t want to diminish expertise; we need to think of ways to mix it up, to potentiate it. Easier said than done when structures and funding often encourage silo-based approaches.

Yet there are many good examples of experts knocking holes in the walls of their silos, reaching out to collaborate and identifying new approaches that meet the needs of people and areas. An example of this kind has been produced by the Guy’s and St Thomas Charity which works closely with the hospital of that name in South London. I apologise for being London centric again but it’s where I work, and I think the example is applicable elsewhere.

Their recent report From one to many looks at the experience of people with multiple long-term conditions in two London boroughs (Lambeth and Southwark).   It is, to the best of my knowledge, the first report of its kind. From the beginning it challenges common preconceptions, not least in that long-term conditions are not just an issue for older age. It raises the issue that a narrow focus on a specific condition or disease may not provide a good understanding of an individual’s experience. It provides further, in-depth evidence of the impact of social context, ethnicity and economic background. It is presented in a manner which combines expertise and accessibility (the interweaving of personal stories with population level data is very effective), sound research and impactful graphics.

A chart that illustrates the average age of diagnosis for a range of conditions highlights the importance of mental health issues and their interrelation with physical conditions. It highlights co-morbidity in a highly effective manner, placing diabetes very much at the centre of health concerns as regards long term conditions. It does a great job of corralling risk factors. 96 % of people with long-term conditions in Lambeth have more than one associated risk factor (e.g. hypertension, alcohol consumption, obesity, high cholesterol). Not that surprising, I grant you, but do we reflect this in how we commission and deliver services? The report highlights the amount of medication prescribed and the benefits of social action. It also raises the potential of learning more from examples of positive deviancy. What are the factors that allow certain groups and individuals to overcome challenging situations or thrive better than their peers?

The report ends with questions, it doesn’t pretend to provide a menu of answers. Those seem most likely to be found when we escape the comfort of our silos and engage with colleagues from other spheres in the communities we work with. It may not always be comfortable, but it is likely to be rewarding. City Health International provides a valuable forum to develop this thinking.

If you have examples of research or experience from other cities, please do send me links or an outline via City Health International.

Wednesday, April 01, 2020
Everything is changed. COVID-19 and responses to it have seen dramatic and fundamental changes to how life is lived around the globe. International travel has come to a near complete halt, much of the world is under some form of lock down with businesses, schools, shops, pubs and cafes shut. Our economic and social reality is now unrecognisable from that of only weeks ago.
Tuesday, March 10, 2020
Clearly the current health focus is strongly centred on Covid- 19 and related issues, as it has been for the past few weeks. It is a demanding situation for politicians, officials, and indeed all of us, especially those working in our healthcare system. One of the major challenges we face is increasing understanding and encouraging changes in behaviour, while also avoiding panic and overreaction. Trusted and accurate information is clearly essential, both for those who have a key role and for the general public. We are certainly seeing more of England’s Chief Medical Officer and Chief Scientific Adviser in the media than usual. In the current situation, politicians are not only keen to hear from experts, but also happy to let them step into the spotlight. While we still see sensationalist headlines, there are also visible benefits of this approach, with more measured and informed elements within the media coverage- though this is less evident on the outer reaches of the online universe. Before I move on to other topics, let us reflect on the significant additional pressures being placed on our frontline health providers. They deserve our gratitude and, in many instances, much improved terms and conditions. Let’s hope that when this coronavirus issue passes the staff that so many rely on are not overlooked.
Monday, February 10, 2020
Public health is front and centre of the media currently, with concerns about the coronavirus outbreak, which was first identified in the Chinese city of Wuhan, splashed across almost every front page. With confirmed cases now reported in numerous countries across the world, we face the possibility of a pandemic. As several experts and commentators have pointed out, in our modern, highly interconnected world no epidemic remains a local concern. This, of course, makes for frightening headlines- which, in turn, calls for calm and informed responses.
Wednesday, January 15, 2020
So here we are: 2020. Let me start by wishing all of you the very best for the year ahead. I have, occasionally, been accused of an inclination toward cynicism and a failure to look on the bright side of things. So, for my first blog of the year, at least, I am going to be determinedly upbeat. You can judge for yourself how long it lasts. This sense of optimism is influenced by the fact that the end of 2019 saw some positive signs in the world of substance misuse. While it was something of a mad scramble against time, we managed to pull together a high quality and well-supported pan-London Christmas alcohol campaign. I am very grateful to colleagues who delivered the key elements of this work and to everyone who supported it. Some, in fact, went well beyond the call of duty to engage with our colleagues in the blue light services. Although we will not have any data in terms of its reach and impact for some months (I will update you), what I can confidently say is that many individuals and organisations liked the messaging and tone. I like to think it is helping contribute to Londoners having a more considered and healthier relationship with alcohol, though there is a way to go yet!

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CITY HEALTH INTERNATIONAL EVENTS

CHI Melbourne 2019

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CHI Liverpool 2019

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CHI Odessa 2018

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CHI Basel 2017

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CHI London 2016

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CHI Barcelona 2015

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CHI Amsterdam 2014

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CHI Glasgow 2013

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CHI London 2012

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City Health International
Founded in 2012 City Health International is a network of individuals and organisations engaged in the study of and response to structural health issues and health behaviours in the urban environment. For the first time in history the majority of the world’s population now live in urban environments and the proportion continues to grow. As national governments struggle to deal with the pressures and demands of growing urban populations against a backdrop of financial deficits and uncertainty, it is increasingly left to those working at a city level to provide the leadership and support needed to tackle key health issues.