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Last week I met with someone who, having just completed a Masters in Epidemiology, is keen to work in the health field. Over a hot chocolate I outlined my perception of the current big issues relating to substance misuse, our most vulnerable populations and the policies and structures we have in place to address these issues.

Unsurprisingly, given current circumstances, it was not a wholly positive picture. Progress in some areas, for example TB, are matched by record drug related deaths and, for the first time in many years, worrying drug prevalence data around the use of opiates and crack cocaine. Despite my naturally cheery character (honestly) I could have ended up quite depressed if it wasn’t for the fact that I was talking to someone brimming with enthusiasm and energy to see what they could contribute to tackling some of our most glaring health inequalities. And certainly, enthusiasm and optimism, coupled with knowledge and understanding, are essential requirements when seeking to navigate the current landscape where financial resources are increasingly hard to find, and structures can often seem to hinder rather than help.

One of the subjects we discussed was the problems faced when people are seeking to access various health services. Many of us who are, allegedly, relatively organised, with some knowledge of the health system and considerable resources in terms of access to the internet, telephones or a secure postal address, have stories about the problems we or loved ones have experienced when trying to get treatment and services, being passed from clinic to clinic, with different consultants and specialists dropping in and out. Tests, scans and medication are often determined within a silo, continuity of care is hard to ensure. Appointments are cancelled at short notice, administration is often poor (this applies as much to the private sector as the NHS, the only difference often seeming to be more comfortable seats and a water cooler in the waiting rooms of the former). How much harder for those with less personal resources and social capital?

Healthwatch, the independent champion for those who use health and social care services, produced a report last December which highlighted the additional problems faced by those who are experiencing homelessness. These included being unable to register with a General Practitioner because they didn’t have proof of address. Accessing any service was difficult, this could be again be linked to identification issues, but also ringing up to make appointments or being contactable could prove impossible. Homeless people often felt that their situation was poorly understood and that there is a reluctance to invest time and resources in their needs. They experienced significant problems in getting the range of help needed and often felt that they were penalised for struggling to comply with health advice or treatment regimes.

While a depressing tale, it is, in many ways, hardly surprising. But given the community as well as the individual consequences this situation is clearly of concern. Also, if we have a genuine commitment to addressing health inequalities, we surely need to focus on a group whose health out comes and life expectancy are so poor, with homeless men in England dying on average at 47, for women its even worse at 43.

Some great work has been undertaken. The Kings Fund are undertaking a major piece of work looking at access to health services for rough sleepers and the impact of ill health in preventing people getting off the streets, this is due to report in the autumn. At a practical level Pathway have developed models of care for the homeless and rough sleepers. Over the last decade they have brought together a network of professionals who are involved in the health care of excluded groups, including vulnerable migrants and sex workers. Their work combines compassion with the highest professional standards. I have met some of those who have benefited from the work of Pathway and the results have been truly transformative. In 11 hospitals they have established homeless healthcare teams. These help those in need deal with the whole range of problems they are coping with, be it physical ailments, mental health issues, substance misuse etc. It’s a system that seems to work. So, what are the magic ingredients?

Of course it is essential to have highly trained specialist doctors and nurses, the Pathway teams include a specialist GP, links to community services, someone who can help access accommodation and the immediate basics of fresh clothes and shoes can be provided, they have also established Pathway Care Navigators, someone with lived experience who can not only relate to the individual but guide them through the maze of officialdom and service structures.

The idea of a care navigator has utility way beyond dealing with the well-recognised marginalised groups. Parts of the NHS are exploring how it may not only help patients but also reduce demand on GPs. Let’s hope that the great work of Pathway, Find and Treat and other services leads to wholesale improvements that help people experiencing homelessness live significantly longer, healthier and happier lives. It may well be the case that this is an example of approaches developed to help the most marginalised benefits the mainstream. Many of us when we experience ill health will have other problems and issues in tow. When we are ill our ability to cope with even the most benign bureaucracy is reduced. We are not one dimensional, we cannot be reduced to a single pathology. We could all benefit from a good navigator.

Proceed till apprehended

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.