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We all know there are many factors involved in any individual’s health, there are environmental factors, the physical circumstances in which they live, their behaviours and genetics. Access to good medical services, for both prevention and treatment are also recognised as being important. But the processes by which it is decided which services are provided where, be that at a national, regional or local level are, perhaps, less frequently considered. Yet we all know there are significant variations in everything from cancer survival rates (good to be in the USA, Canada, Australia, Finland or Iceland) to access to good quality ante-natal and early years care, where Western Europe general does well as do Japan, Singapore, Hong Kong and Macau but the USA does relatively badly.

Then of course there is the issue of how health services are paid for and equity of access. Is it generally available free at the point of access? Do you have to pay a fee? Is there a social or private insurance system? To what extent is there a private market? How regulated is it? Now all this dizzying array of variations is enough to make you feel that health is a lottery, even when considering mainstream need. Move toward less popular areas of health provision and things get rapidly patchier. There are many countries where access to treatment for drug use is almost non-existent. This is not limited to countries with low incomes and poor infrastructure. The Russian Federation is ideologically opposed to substitute prescribing and favours abstinence-based approaches, despite the toll in deaths and disease this creates.    

Across the globe access to sexual health services varies massively based on morality, perceptions of deserved need and, dare I suggest, electoral calculation. By which I mean the lobbying power of certain groups, such as drug users, are extremely limited.   This influences decisions in all kinds of health systems, even those with a strong national system and a commitment to providing access to all, free at the point of need.

In 2013 England devolved public health responsibilities and budgets to local authorities. In many ways this was a bold move, reflecting the important role the latter play in improving health and preventing illness. It was also intended to allow local areas to commission and shape services to best match the need to their communities. In terms of the principle behind this kind of approach I was very supportive. It is not possible to determine what services should be run across 150 local authorities from a government ministry in London. While many raised concerns about the risk of variations in services, termed a postcode lottery, I reflected that there were already differences from area to area and the benefits of being able to tailor local provision would outweigh the negatives. There remained central bodies to provide a degree of oversight and specialist input.  

Of course, this was taking place against a backdrop of reducing budgets and increasing demand for local authorities. I was also guilty of forgetting just how good some areas were at deciding “we don’t have that kind of problem”, regardless of any evidence to the contrary. When I first started in the drugs field I had to ring a London local authority to contact their Drug Action Team (DAT). Now I knew the DAT had been in existence for around two years but ended up talking to many individuals around the organisation until I ended up speaking to a senior officer there, who assured me they didn’t have a DAT “as we don’t have that kind of problem here”. Safe to say you could have deleted problem and inserted “person” and not changed the meaning or understanding, although in fact the borough had a significant drug problem.

I was reminded of this recently by two things. One was an English local authority (not in London!) being in trouble over whether it used its public health money to prop up other areas of expenditure. This seems unlikely to be the last case of its kind. There was also a recent report from Public Health England expressing concerns over reductions in sexual health services at a time when serious infections and the threat posed by antibiotic strains is increasing.

There are clearly huge benefits in having local areas involved in designing and overseeing services appropriate for their communities. But there needs to be mechanisms to prevent unpopular or marginalised services being neglected. It can be hard for local politicians and policy makers to ensure that services for drug users and other groups are not overlooked. Local areas may lack the specialist knowledge to know how to respond to complex issues or the consequences of not having certain services.

This doesn’t mean that central health ministries need to set out and determine every aspect of local delivery. What it does mean is that there needs to be strong central data, accurately reflecting local, regional and national issues. There needs to be good central advice pointing out how problems identified can be addressed in an evidence -based fashion. An overview needs to be maintained on how funding is being used. Networks to support peers can be invaluable in supporting knowledge transfer and providing confidence in tackling the less popular issues.   I will be looking at aspects of this, and its impacts on access to services, during my presentation at City Health 2018.

If local areas are not supported in the move towards devolved and local delivery the odds are firmly stacked that more and more lose out on the lottery of good health.

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!
Wednesday, December 18, 2019
It has been a little while since I managed to produce a blog. Workwise things have been especially hectic as we end the year. Not least in helping get another London Christmas alcohol campaign organised. You can see the resource produced here . Early next year I will share our experience of this year’s campaign. Looking back 2019 has been a year when the headlines relating to drugs have been consistently negative. Record drug related deaths, some worrying prevalence data, growing concerns around crime and financial pressure on service delivery. On the positive side there is some sense that drug issues are getting back on to the agenda. Hopefully this will continue. A personal highlight of 2019 was getting to hear and speak with so many fascinating people at City Health Melbourne.
Wednesday, October 30, 2019
When I hosted the first City Health conference in 2012, my hope was we might manage three or four events in different cities. I never dreamt we’d get to nine (and counting) or that City Health would reach the great city of Melbourne. Great credit must go to the Progressive Public Health Alliance for hosting a fascinating two days that provided energy, enthusiasm and challenge. Personally, I learnt a great deal and found myself questioning somehow of my own views. I met people doing amazing things in the most challenging environments. I heard of situations that made me feel a sense of despair but came away reassured that we have the knowledge, networks and commitment to positively change lives for the better.
Monday, September 23, 2019
Sometimes things just work out. Last Monday, I was involved in three separate events which each highlighted the potential of urban areas to effectively tackle health issues when there is political leadership to do so. The day also provided a timely reminder of the importance of harm reduction, and how this needs to be at the heart of health approaches in our cities. With so many countries and agencies forgetting the lessons of harm reduction, or actively turning their back on them for narrow ideological reasons, it was uplifting to hear examples which delivered quantifiable gains in terms of lives, better health, and human rights.

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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.