Over the past few weeks, as the local government year starts to ramp up, a number of newly elected councillors have asked me for some basic reading on Public Health. This is my suggested list for them. Perhaps you could suggest some?
Here is as promised at the induction seminar the self-reading guide to getting your head round public health. There are many more topics than those below, and I merely set out some of the more important. Perhaps the best thing is to come and talk and if you want material on specific issues like drugs, or children and young people, I will supply you with a list.
Public Health principles: the very basics
Public Health is about working with populations, out of a framework of analysis, evidence and an intention to promote and protect their health. This involves working with a range of determinants of health from education levels to health behaviours and the various threats and hazards to our health which arise from the environment (naturally occurring diseases) and from the products and progress of contemporary society (air pollution for example). Poverty and inequity lurk behind most poor health like an eminence grise et horrible. In my own mind, neither individual nor societal explanations for the burden of disease and ill-health and poor flourishing our society carries are sufficient. Both must be held in dynamic tension to elucidate what the issue is and what we can do. Equally, Public Health is not, to me, purely a science. It is an application of various sciences and art. Epidemiology and Leadership, Evidence and Influencing come together or lie ineffective. They are a blend, if you will.
We now have three out of 6 short e-learning video presentations on what public health is on Herts Health Evidence https://www.hertshealthevidence.org/ and more will be added soon. You should be able to access these free by requesting an account at the site.
If you wanted a book, then my best bet to start would be Virginia Berridge’s Public Health: A Very Short Introduction Oxford University Press, 2016. Let me know if you have difficulty finding this, I can track it down easily in London next time I’m there. There are many more choices after that from classics like Donaldson and Donaldson’s essential public health through to Geraint Lewis’ Mastering Public Health which is to my mind far more useful than Donaldson and Donaldson.
English Policy on Public Health and NHS (because Wales, Scotland and Northern Ireland all have very different systems.)
But there are many more from the LGA, and the LGA website has an invaluable series of publications for local authorities on public health. I am of course biased but the Association of Directors of Public Health blog has a series of very short pieces. http://www.adph.org.uk/category/pblog/ and it’s worth checking our updates here http://www.adph.org.uk/
In less than a month, on 11th October 2017, a new and I think ground-breaking resource will be launched which tells the story of people living with and affected by HIV.
What, another one? I hear some of you ask. Yes, and I’ll tell you why.
Why another resource?
This resource is different. Funded by Public Health England, through their HIV Prevention Innovation Fund, this new resource will feature people prepared to talk despite the stigma. It privileges the voices of people living with and affected by HIV above other voices. Multiple people living with HIV and affected by it are in the resource, have co-produced the resource and have been in workshops considering, commenting on, augmenting and amending the resource. This has been, in and of itself, a powerful experience.
This resource has a series of videos, accompanied by a website of resources, blogs and other materials. It features people with HIV prepared to share how they thrive, cope and how HIV, their health and the deepest issues of their lives come together, and the problems and the positives of that.
And I have been privileged to be the sponsor of that project, at PHE’s request.
This will be a tool to combat stigma. It will be a tool to show people the nuanced reality of living with HIV. It is a tool for people with and affected by HIV. And it is a tool for celebrating people with and affected by HIV.
The changing nature of life with HIV
We are in a time when virological suppression is a major success story (People I work with, people I love who ten years ago would have died are still alive and well and every day I cherish that and them.)
We are in a time when we could achieve the end of new HIV transmissions, and tools like PrEP are further resources in the long travail which has been the journey since the first people I knew and loved with HIV died. Today, many people with HIV are thriving , some in jobs vital to our society, others quietly living and working and relating, living out their gifts and their talents.
But, others still aren’t thriving. And it’s not just about biology. Far from it. With the success of virological suppression – where the virus is essentially regarded as undetectable – come a range of opportunities, choices and still many challenges. Stigma, ongoing challenges of living, new health threats to people with HIV, and the need to renew our efforts to cherish those with and affected by HIV while reducing new infections.
People live longer, they contribute their talents and gifts to their loved ones and our society. Great. For some, cognitive decline, however subtle, diseases of ageing in an ageing cohort of people with HIV, negotiating social support, relationships and just coping with life alongside a lifelong health condition, remain psychological, social, practical and – dare I say it – spiritual and existential challenges.
Negotiating life with HIV still takes skill. For every person who accomplishes it with panache, there is a story of sheer hard work behind it.
In a world where Pre exposure prophylaxis is becoming more available (though I notice our trial in England is still dragging its heels) and undetectable status means different issues for negotiating intimate relationships than it once did, we need more than ever to reaffirm people, reduce stigma, and most of all, learn from our friends, colleagues, loved ones, partners and residents with HIV. One of the world’s foremost HIV resources, Aidsmap has a great post on why it endorses the prevention access statement for HIV which makes you realise just how much has changed, and how much we still have to achieve.
So come on, what’s special about this, really?
Well, two things. First, the people in it. Secondly, the people in this resource, and the resource itself, will address HIV through the context of Faith. Specifically, Christian faith in this resource, but other faiths may follow suit.
I want to tell you why, and why health professionals should take notice.
But let me say this first: this resource is not an exercise in Christian exclusivism. It’s an exercise in affirming the particularity of faith and producing a model others can use and follow. A one size fits all approach to faith is an immature approach to diversity. In the same way most of us have multiple protected characteristics. Seeing people through the lens of one shows how poor the imagination of much of our diversity policy and the assumptions around it still are.
The Project will be called Positive Faith (Launches late October 2017.) The resource features people from a range of Christian churches. I’ll speak about why later.
A few thanks to the people who’ve worked hard
The project is being managed and led by Catholics for AIDS Prevention and Support. The wonderful Vicki has project managed it. CAPS are a small charity which provides direct support and care including supporting Positive Catholics. Our local Hertfordshire HIV Voluntary agency, HertsAid, has given significant support and effort to supporting this programme. And Public Health England have, of course, funded it.
Some reasons why we need this
First, we know from ever greater scientific evidence that for people of faith, their understanding of health challenges, their coping, even their health behaviour, is profoundly influenced by and mediated through their faith. People of faith – even those who feel excluded by it – greatly understand their health experience, even down to their efforts to live with HIV or stay free from it, in a way linked to their faith. We still lag behind in the UK with that understanding in many of our health services, despite it being a commonplace of Health Psychology for decades. We cannot do health without encountering faith in dialogue for people of faith. Ellen Idler’s 2016 book Religion as a social determinant of Public Health (Oxford University Press) is a lucid presentation of the evidence for this.
Second, health services sometimes still seem to remain squeamish, embarrassed or discomforted by the presence of faith. It’s the protected characteristic of the equality act many feel uncomfortable with. But over 40% of people in the UK still confess a religious faith of some kind. NICE guidance, NICE standards and more and more scientific evidence affirms that to personalise health care, we must recognise that we cannot treat faith as something totally private and separate from it. If a person of faith is in the clinical encounter, so is the issue of faith.
Churches struggle with HIV, Health services struggle with Faith
Faith is not going away. It is not dying. Even if you think it’s a minority pursuit, it’s important to that minority, which is still one of the largest in the country. And this resource is an attempt to redress an inequity in health – that of faith and HIV.
We must do better on this as a health system. This new resource speaks actively into that. If churches are sometimes uncomfortable about HIV, health services still feel uncomfortable about faith. This resource seeks to bridge that gap. To that extent this is a series of interventions about reducing stigma to build health equity for a population which still faces many challenges.
Why only a Christian resource so far?
Thirdly, this resource seeks to build inclusion of people with and affected by HIV in churches. To that extent, this clearly is a public health intervention. And this is why we haven’t produced a multi-faith resource. To understand HIV in the context of a particular faith, there needs to be dialogue in the language of that faith for people who have it. Yes, we need Islamic, Judaic, Hindu and more resources. And I hope people will use this approach as a template. But for a Christian black African woman to understand her HIV and her faith or for a gay male Christian to understand his faith and HIV prevention for himself or others, we and they need to relate that Christian faith specifically to health.
Is this really about prevention?
How will this prevent HIV? Well, by affirming and including people and pointing to them how much their health is something to be cherished and how much their faith acknowledges this. And we need to find a way to keep ourselves healthy and resilient to get the best from life. And health doesn’t mean a blissful state of freedom from any problem. It means adjustment to the realities of our physical, psychological and social challenges and limitations.
This resource sits firmly in the tradition of public health interventions to strengthen individuals and change communities.
More in-depth reflection
Nearer the time the Catholic Press are expected to cover this with some significant space. Articles have already been commissioned by The Tablet and The Catholic Universe . The Catholics in Healthcare Blog will obviously carry a post. The Pastoral Review will carry a more in-depth article on the pastoral, theological and church issues around this.
The resource will be launched on 11th October 2017 by the RC Archbishop of Southwark and the Anglican Bishop of Southwark at an event in London in which people with HIV in the Video will speak. Fr Timothy Radcliffe, OP, the Master of the Dominicans, will speak alongside people with HIV. For invitations contact Vicki Morris the Project Manager or Jim McManus the sponsor.
I apologise in advance that some of you will find this (uncharacteristically short) post irrelevant. Some of you will find it boring. I warrant, though, that just a few of you will find this salient and important.
On 13th October 2017, another one day masterclass for senior Public Health leaders on how to navigate the legal concepts they need to be effective in local government will run in London. The course is free, it explicitly intends to give public health people working in local authorities the key background to the law and practice issues affecting them, and it already filling up.
Skills for managing the system
Sounds off-putting, doesn’t it? But this course is in its fourth year and everyone I know who has been on it has found sooner or later they needed what it gave them: enough knowledge to navigate a complex issue.
People will spend a day with several senior and very experienced lawyers, getting detailed guidance, able to ask questions, and going away with a resource pack which one delegate from a previous year described as “incredibly handy: I never knew this stuff. I now know I need to know this stuff.”
The course will be delivered pro bono again this year by several amazing lawyers ; including this year Judith Barnes a senior partner at Bevan Brittan and people like Luis Andrade from Herts County Council and the Society of Local Government Lawyers. It is a joint venture with ADPH.
There are still a few places left on this, contact firstname.lastname@example.org to book.
It’s my fault, this idea
This course was my idea. I’m not going to apologise for inflicting it on people. And after several requests from people to tell them why I came up with this idea, I’m sharing with you my reasons. And they’re pretty simple.
Why on earth did you come up with this?
First, local authorities run on the law. I speak from experience of over fifteen years in local authorities. They are created by Parliament, they have many legally binding processes and a constitution, and legal issues from procuring services to making decisions are all bread and butter for senior people in local government. And these are things the public health training scheme never prepared you for.
Second, if you want to do something in local government, you need to know the legal powers and duties you have, and how to navigate them. For example, I use a particular power in the Local Government Act 1972 to fund District Councils to do public health work which saves me a significant amount of process and cost. Planning, Licensing, dealing with Anti-Social Behaviour, dealing with air pollution: they all require an understanding of the legal principles.
Third, you have to know what makes a system works if you are going to use that to the benefit of the public’s health, whether by making the system work more effectively or bypassing it.
Fourth, public health leaders need to be equipped with the same knowledge as their peers to be effective in working with them.
What use has it been?
I’ve just finished a round of telephone conversations with a small sample of people who have been through the course. The common benefits people identified from being on this programme are those below:
Knowledge – knowing enough to know when they need expert legal help
Agility – being able to identify potential solutions
Being on a level playing field with other senior managers who know this stuff
Confidence that they can promote the public health work and defend the budget and team
Ability to recognise a potential problem and deal with it early
So, if you are going on the next masterclass, enjoy. If you haven’t, get in quick.
Earlier this week I had the privilege of participating in two sessions at the Public Health England 2017 Conference. I took part in a Behavioural Sciences in public health session and in a Public Mental Health session. At both sessions the discussion, comments and questions from the audience were stimulating and deeply thoughtful. In the public mental health session I came face to face with the strong realisation that I was in a – packed – room full of people all of whom were thinking about systems approaches. I even asked if that was what we were doing and got enthusiastic nods and responses. What an experience! Seriously, it was brilliant.
Anyway, lots of conversations ensued afterwards with people asking about systems. Now I have blogged before about whole systems approaches to mental health and about some of the leadership issues in leading across systems, and some of the problem solving approaches public health can use in a systems world. You can’t do systems work on your own. And you need to be structured, purposeful but also opportunistic. We should, as Public Health types, find a natural bent to this.
Top tips for system working
For me the key thing about a system is that every system is perfectly designed to produce what it produces. So if it’s dysfunctional, in what it produces, you are going to have to disrupt it. And that takes planning, effort, and a coalition
This is an art not a science, so my top tips for systems working start with doing some reading on systems and then work with people who like working on system change. Some resources you could use for systems thinking are:
There is also an online course in Systems Thinking for Public Health from Johns Hopkins. This will give you one take on systems thinking, because there are several takes on this concept.
The thing about a system is that systems science is not a complete explanation
Recognise though, that systems approaches often come from an engineering or management paradigm (many business schools grew out of engineering schools historically) that see systems as machines. I think some of that is true, but for the most part systems are made up of humans so there are ALWAYS complex social processes and cultural issues at heart, and they explain behaviour of the system and the people AT LEAST as much as the processes in that system. So, if you don’t understand a system at least in part as a complex set of social processes, you are doomed to fail. So go beyond systems science before you go rushing in, because systems are actually not machines but complex social networks and processes.
A first key step is to try to understand the system, map it, understand it. Conceptualise it somehow. Then it’s vital to recognise that the system is made up of complex social processes, and you need to understand those to intervene, and you need to intervene in multiple places and do so purposively. Sometimes you just need to be opportunistic.
To intervene, you often need to disrupt the system, and that means getting a bunch of people to join you. Set some sensible system goals so you know how you’ll get there and when. Start somewhere, more or less anywhere, and start where you think you might get most output. No, it’s not scientific in a positivistic way. Most systems don’t work and can’t be understood like that anyway.
Changing systems is a journey, expect it to take time.
Understand the failure points
We need to understand the lessons of failure of transformation. One of the best papers I ever read is John Kotter’s “Leading Change: Why Transformation Efforts Fail” listed above. Kotter talks about eight steps to transforming an organisation, and if you don’t do these, they are very strong predictors of failure.
I seriously recommend getting hold of this paper. It was published in the Harvard Business Review, originally January 1995 then reprinted in 2007 in BEST OF HBR. This paper is so popular online that HBR doesn’t let you download or print it. I tracked down a paper copy through the British Library which is now much dog-eared and annotated. But it’s been worth every penny for me. If you only ever read one paper on transformation, read this.
Kotter gives eight golden rules of what you need to do for successful transformation. For me, these have been an excellent guide to any successful change exercise I have ever done. Not doing these are the eight reasons why transformations fail . These eight reasons are:
Establishing a sense of urgency – you must identify potential crises and opportunities
Form a powerful guiding coalition with enough power to lead change efforts and get them working together well
Create a vision and develop strategies to achieve it
Communicate the vision using every vehicle you can, use your guiding coalition to model the behaviours you want in the new world
Empower others to act – get rid of obstacles and change this that undermine your vision
Plan for , create and welcome Short-Term Wins and CELEBRATE them! They are important milestones on the journey for morale, convincing people you can do it and get there and checking you’re still heading for target
Consolidate your improvements and keep reinvigorating them. Do not declare victory too soon!
Embed the new approaches and make sure people “get” the connections between them and success
This is not an exact science. But it is a combined exercise in conceptualising, designing interventions, problem solving and leading which will stretch, challenge, dismay and reward.
One of my scientific and theological interests has, for some time, been dialoguing scientific evidence on health and medicine with faith. I believe dialogue between health and faith needs to be scientifically, theologically and epistemologically rigorous in equal measure. A growing body of robust scientific research is remembering what people of faith seem to have not quite forgotten, than people mediate their understanding of health, and their coping and living strategies, at least in part through their belief systems. That has profound implications for our health and wellbeing.
Some practical examples
Less than a month from now, in October 2017 a new series of videos, and in November a website Positive Faith will be launched as one embodiment of this. This will be series of videos and resources by, about and for people living with and affected by HIV. This exercise has been funded by Public Health England, and led by Catholics for AIDS Prevention and Support. The resource privileges the voices of People with HIV over professionals of any kind. People with HIV explicitly address these issues of health and belief.
The FaithAction health and faith portal remains, for me, one of the great things to come out of Public Health England’s partnerships with the community sector because it works at applying these lessons and collates practical examples. There are many more. I have been privileged to work with FaithAction for some time. Their report contextualising the evidence on faith and health for UK commissioners and policymakers is important reading. Their work on mental health and dementia friendly places of worship has much to offer a prevention and community engagement agenda. FaithAction have created a series of resources for commissioners, practitioners and faith communities to use together.
A series of Catholic mental health demonstration projects has been delivered. A mental health access pack for Churches – written by professionals and experts by experience – has been created by a charity whose values commit them to work on disability and health. You can read my invited blog on why I endorse the pack, here.
The University of Leeds with Leeds Public Health team has explored the links and barriers between religion and public health in some really exciting work on mental health.
I don’t claim any of what I say here makes people of faith better or more special than those of no faith in the world of health and care. I merely say that we have legitimate and understandable motivations and values to be in that world, and we have a contribution to make every bit as valuable as anyone else. And our values inform that. We can no more leave our values or identity at the door that anyone else.
Faith cannot be the one “protected characteristic” that is private when every other one is recognised to be part and parcel of the person. But that’s for another blog.
The scientific evidence behind this
Most of you who know me well know this is an area of interest. I do my job because of my value base. Early next year my review article on some of the best recent publications in health and faith will make its appearance in Reviews in Religion and Theology.
In the process of entertaining this interest I have amassed a smallish library of 200 volumes in several languages, including volumes which stand out like Ellen Idler’s (the polymath Epidemiologist and Sociologist) recent and rather excellent Public Health volume on Religion as a social determinant of public health , the brilliant theological/philosophical work Flourishing by one of my theological heroes Neil Messer and a range of materials on psychology, psychopathology and religion. I’m preparing this collection (well the stuff in English anyway) for donation to a library where people will get easier access to it.
Faith still relevant to our population
Some of you may think Faith – especially explicitly religious faith – is a minority interest. Well you may be right, but that minority is still between 37% and 43% of the population depending on who you speak to. We wouldn’t now be so discriminatory as to dismiss LGBT populations because they’re 2% – 3% of the population depending on who you read, would we? So let’s recognise that our value bases inform who we are, and most of us are part of some minority. It’s inclusion of every minority’s best offerings which makes social life vibrant.
Prof Stephen Bullivant a sociologist at St Mary’s University has undertaken analysis of ONS data (I believe as yet unpublished) which suggests that, for example, Catholics are present in the health and care field in numbers around eight times more than they would be if they were just present in the same proportion as their presence in the general population. Incidentally, Stephen Bullivant’s recent report on the “No Religion” population is a good read for anyone in public policy.
People still understand and filter their health experiences, beliefs, behaviours and life choices (including the choice to serve) through their religious belief. NICE guidance recognises that and has stated there is a strong evidential case for its salience in care. It is folly not to engage with this. My invited paper to the Equality and Human Rights Commission on what this means for healthcare employers in terms of workforce strategy, service quality and equality and diversity law explores the practical and organisational implications of this further. The growth of non-religious spiritual and pastoral care in our hospitals, recognising that humanists and others who describe themselves as non-theist and non religious, have spiritual needs too, is welcome and valuable alongside care for those who do have religious faith.
The Guild of Health and St Raphael
A short while ago, I was approached by the Guild of Health and St Raphael to become their president, a role which I shortly take on, after a bit of reflection and dithering on my part. I look forward to this immensely. It came, to me at any rate, as something of a shock. I did the “why on earth would they want me, couldn’t they find anyone better?” And “why on earth would they want a Catholic? ” thing. I then thought of suggesting Archbishop Justin Welby before realising he’s a patron already. And then I thought of Lord Rowan Williams, who’s a patron of something else they do already. Whoops!
In discussing this with a good colleague , she reminded me that she calls me “the health and faith babel fish”. By which she means I seem to be good at translating the field of health to the field of faith. She asked me “do you think the Guild does important things?” “Yes”, I answered. “Does it have a sound theology?” “Yes”. Have they got people who are scientifically credible?” Again, “yes”. Just for starters, the Director, Gillian Straine is a PhD qualified Scientist and an ordained Anglican priest. “Does it resonate with your desire to make clear the links between health and faith?” “Yes, vey much so.” “Well, then in your own words -get on with it.” And so, with that kick up the motivations, here begins a journey.
Formed in 1904 to bring together members of the clergy and medical professions to study and promote the healing ministry of the Church, it claims to be the oldest organisation in the UK working in the field of Christian health. Anglican in heritage it is now ecumenical in outlook. The two Anglican Archbishops of York and Canterbury are Patrons along with the Methodist Church’s President, and now the Guild has let in a – rather stumbling – Catholic President! (What were they thinking, I hear you ask?) An academic journal is coming. And practical resources. We have plans!
Academic community of interest
The academic community interested in the crossover between health and faith in the UK is growing. From Professor Chris Cook (psychiatry and psychology) at Durham, to the Guild’s newly launched Raphael Institute collaboration with epidemiologists, scientists, medics and psychologists, through to the work of Professor Michael King at UCL and many others I could mention, a body of work is beginning to be pumped out in a UK context examining the links between health and faith. Similar communities in German medical schools, Swiss Universities, Italy and, of course, the United States are creating work of use and value to the public health community.
Putting effort where my mouth is
There are a number of reasons why I am delighted to take on the role of President. First, Health and Faith, and the links between it, are an enduring interest. My paid professional role as a Director of Public Health seeks to improve and protect the health of a population, something to me which resonates deeply with the call I believe all faiths – including the humanists I am lucky to know and learn from – have to improve human life and hold in good stewardship our earth. I have written elsewhere, in The Universe about the vocational aspect of this. And I guess as part of that I need to play my part in dialoguing the health and faith world constructively and rigorously to help us find what mitigates for maximum human flourishing – for those of all faiths and none. That doesn’t mean those of us of faith leave our values at the door of the office, by the way.
The second is that participation in the work of ensuring people are as healthy as possible, in all dimensions, is a direct participation in one of the ultimate purposes of what most people of faiths do – the cherishing of and service to the human. Visit a Sikh or Jewish social service centre if you haven’t ever done so. You’ll be amazed.
The third is that because of this insight, people of faith have much to offer from “all our best traditions” as the hymn goes to the world of healthcare, and to the whole issue of what health means. In fact, we were here first. Long before the NHS, before organised health care, we were there. And people like the Historian of Science Gary Ferngren and others are writing the history of that engagement.
Christian Social Teaching as a Health Inequalities Manifesto
A further reason is that this provides a much needed opportunity toexplicitly link Catholic Social Teaching (sometimes called the Catholic Church’s best kept secret) and its seven principles embodying Justice, dignity of the person and so on to issues of health. Read any book on inequalities in health and a book catholic social teaching side by side and they say very similar things. People have a right to health, and the means to health including good , healthcare, education and so much else and this is part of doing justice to our world. Good quality healthcare is framed as an exercise in justice and love in such teaching. I can find that link implicitly or explicitly everywhere I look. The founder of the Science of Healthcare Quality and Healthcare Improvement, who was not a Catholic, explicitly defined Quality Improvement in Healthcare as an exercise in love. The links are significant. For more on the seven principles of Catholic Social Teaching, read here. Recent changes over the past fifteen years in US health care policy have generated a significant body of Catholic thought on Just Health Care policy including a whole body of thought on access. I’ll be discussing my take on what Public Health and Catholic Social Teaching agree on with regard to access, equity, justice and commissioning policy at an International conference on mental health in Oxford in summer 2018.
The fourth reason is that now, explicitly in the policy frameworks of all of the four devolved administrations of the UK, there is the recognition that health has many social dimensions, and needs social actors. This is a Kairos moment – an auspicious time when we can speak into the agenda of what it means to be healthy, and what health and social care is about. We have things to say. And that means re-energising communities about what they can do on their health. Faith communities can be a part of this. And examples of good practice here abound, from dementia friendly places of worship to social inclusion programmes and projects for people with long term conditions.
The riches of tradition informs the progress of today
The fifth reason is that while each of us can offer things from our own tradition – I have a particular tradition which feeds my commitment to improve and protect the heath of the population. I don’t claim it’s better, I just claim it has enduring relevance. Catholics founded religious orders dedicated to health and healing, for example. Countless people we call saints have been engaged in health. The St Vincent de Paul Society is a Catholic charity providing help from white goods to holiday breaks to clothing to utility crisis payments and has a bigger volunteer workforce than CAB last time I looked. Entirely funded by Catholics. Mary Aikenhead, founded the order which created the hospice of which I am a trustee. Her values of advocacy for and inclusion of the most excluded (and said in those words) are a constant reminder to me not to become complacent in a public health system where it would be easy just not to try to find a way through the cuts being imposed on us.
Those Catholic religious orders still run health and care services across the World and the UK (and over 150 centres from hospices to refuges for victims of human trafficking in England today). One of those orders is the biggest non-governmental emergency aid agency in the world, among whose volunteers I am proud to count myself. My tradition is supposed to roll up its sleeves, include and serve. (and it often needs a good kick to remind it of that.) Moreover, my tradition attests to the fact that health is social as much as it is individual. These must go together. No human being is anything other than precious. Justice, Love and Hope are the hinges on which we embody that insight.
Institutions sometimes get decadent and fail people. That happens in the NHS and public sector as much as it happens in the churches. The point is that continual renewing of our purpose – maximum human flourishing. Every faith which has a sense of the divine is at its best committed to human flourish and justice – even if at its worst we shamefully can and do at times betray and sully that commitment – because we believe that’s what God wants for God’s world.
The whole person
The sixth reason I am keen to do this is because the scientific evidence supports these insights as much as it informs them. We are becoming increasingly aware that health includes the whole person, and especially for those who cannot be cured, health is about making a good response to the realities we face. Like the Guild’s Director, Gillian, I am a cancer survivor, lucky to be alive after a Grade IVB lymphoma. Like Gillian, that experience has shaped how I am rediscovering the riches of the Christian tradition to speak to today’s world on health. Her book Cancer: a pilgrim companion is a brilliant read.
For those with long term conditions or disabilities, those with long term mental health challenges, those who are dying, the World Health Organization’s definition of health as a complete state of psychological, physical, spiritual wellbeing is hopelessly optimistic, and unreal. It implies they are less than fully human, and with that comes the risk they become devalued. That is not a Christian view. Suffering, limitations and disabilities are not valueless. It is also not a view that sits with the science of health inequalities, otherwise why bother with the discourse of tertiary prevention?
The World Health Organisation’s vision is valuable, but its valuable because of where it points us. It is future rather than present, a hope for the future. That means we have to revisit what health means here and now. And I would argue that the science and our theology are mutually affirming on this, and the Guild is ideally placed to do that work from the academic work at one end of the spectrum to the work of caring, praying and doing at the other.
Called to serve
Earlier this year, The RC Diocese of Westminster led a season of events entitled Called to Serve the Sick. I hate the term “the sick” but that’s for another time. The series was intended to be a practical continuation of Catholics being recalled by Pope Francis in 2016 to serve and welcome, when we sometimes exclude too easily. A series of roadshows, which I was privileged to present at, discussed a Catholic Understanding of Health and Social Care, why Catholics should feel a particular importance of committing to health, social justice and social care, and what local communities can do about it. We had an audience of health and care workers, and people struggling with health issues. And people of all faiths and none. We’ve been asked to do more. There is a demand for this work.
The Bishop who led this season, Bishop Paul McAleenan said that “It is fitting that this season comes as a continuation of the Year of Mercy, giving us the opportunity to practice that most important act of Christian love, care for our neighbour. Good health, poor health, disability and ultimately our death, are integral aspects of what it means to be humans precious to God, and so they are of huge importance to us as people of faith.
On this, I hope, people of all faiths and none can make common cause.
This week the Advisory Council on the Misuse of Drugs published its report on the Drug and Alcohol Commissioning system in England. Government hasn’t responded yet, and to be honest much of the trade press and media gave it very little coverage. A good and thoughtful blog piece on this report and some of the issues it raises by Will Haydock rewards reading.
This report is a mixed bag but we shouldn’t ignore it
I’ve heard a number of policymakers and thought leaders be frankly dismissive of this report. And I think that’s a shame.
There are some real mixed aspects of this report. First what I think are the downsides:
It feels like an approach of suspicion towards local authorities. They more or less ignore the joint Public Health England, Local Government Association and Association of Directors of Public Health report on drugs commissioning. Were the findings of that report, that actually a number of things which needed to change were being changed, just inconvenient to their narrative, one wonders? Picking one set of what’s gone before (back to pre-2012) while ignoring the other (the ADPH/PHE/LGA Report) just makes it easier to dismiss your report, without looking to see if there’s anything salvagable of value in it.
The report doesn’t engage with the substance of the Government’s new strategy other than demanding that it does several things they want. It doesn’t welcome what’s good in the Strategy and doesn’t really critique what’s problematic. How can we take seriously a report about commissioning which doesn’t engage with a strategy whose impact on that commissioning system will be wide-ranging? On any view, that’s a mistake. And it makes it even easier to dismiss this report.
The report doesn’t engage really with the financial climate for the public sector, preferring to take an uncritical and somewhat rose-tinted view that everything will be better if we just hand drugs back to the NHS. This is naïve in the extreme given where NHS finances are now.
A nostalgia for the pre-2013 days which is not only unrealistic but shows some convenient amnesia of some of the things before 2013 which were not good. Putting drugs services back into the NHS is not going to protect them, that is a completely false hope in my view. The report feels like it wants to hark back to a presumed Golden age when the National Treatment Agency (remember them) ran things, and the NHS had control of drug and alcohol commission. Oh it was so much better, then. Except it wasn’t
In addition, there are two things in particular I regret about this report. The first is it’s a pity they don’t mention any of the cuts to Local Authority budgets really, except some mention of the Public Health Budget and I think they take an overly selective reading of their own 2015 survey.
The second is that this is yet another report, giving yet another – sometimes overly partial – narrative. Some have said this is really a narrative on behalf of the provider sector. Writing reports feels like a rather dated tactic these days. Getting together and discussing constructively issues between commissioners, providers and researchers is the approach that’s needed. Writing disgruntled reports back and forth seems to slightly miss the point in a system that needs us, more than ever, to work together.
Finally, I think they don’t sufficiently factor in the significant changes in demographics, use and epidemiology since 2012. The drug and alcohol world is a different one in terms of trends, users, evidence and policy. Going back to 2012 is not the answer. Arguing for the best funding and best commissioning and provision we can get now, is.
The report more or less lacks the nuanced and balanced understanding we have a right to expect from an organisation which should know better, and which should have done its job better.
So, we have a report which, given what I’ve said above, would be easy to dismiss, lends itself in the way it has been put together to not being taken seriously, and looks to some people as naive and partial. I think we need to look beyond all that and really think through this report.
The signals in the noise: Some good points
In the midst of what feels like a great deal of noise and lament, there are some good things and some sensible points. They do point out some areas where the system needs to work better.
They acknowledge some good things about the changes since 2013 – but spend little time telling us what they are before proceeding almost straight away to say everything else has more or less gone downhill. I can’t help thinking they’re making a selective and overly rose-tinted reading of recent history.
My own view of where we are is rather more nuanced than this report. Some things are better, some things are more challenging, and some challenges endure – we didn’t have research right in 2012, for example, We still don’t have it right now. The idea that the drug treatment system was ideal or even “really great” before 2013 is an unsupportably revisionist view of history.
Worth looking at the key conclusions and recommendations
It’s worth looking at their key conclusions and recommendations because while there are some things in here I find really problematic, there are some areas where they have a point and we need to listen. It’s just a shame that rather than talk to commissioners, they feel it’s more appropriate to shout at them.
ACMD Report Conclusions and Recommendations
My take on these
Despite the continuation of the ring-fenced Public Health Grant to local authorities until April 2019, reductions in local funding are the single biggest threat to drug misuse treatment recovery outcomes being achieved in local areas.
This is the only point where they really acknowledge reductions in funding, but their point is reductions by commissioners, not reductions by government.
More and more people are saying that the government needs to reverse the cuts to public health, and these cuts are increasingly damaging. It would be good is ACMD felt able to join that call. They didn’t. I think that’s a mistake.
National and local government should give serious consideration to how current levels of investment can be protected, including mandating drug and alcohol misuse services within local authority budgets and/or placing the commissioning of drug and alcohol treatment within NHS commissioning structures.
Mandation of services seems to be everyone’s knee-jerk solution to this, so we mandate more and more of a smaller and smaller pot of money. All that does is make the job of running a public health system undoable.
Mandation is not the answer to this, reversing the cuts is the answer. Government has decided to impose cuts across the public sector, the drugs sector is no more special than any other part and cannot be exempt. Are drugs services more important than safeguarding children? The more you mandate, frankly the more you pass the problem elsewhere to the rest of the system. More and more mandation is an appealing, but ultimately false, solution.
National government’s commitment to develop a range of measures which will deliver greater transparency on local performance, outcomes and spend should include a review of key performance indicators for drug misuse treatment, particularly those in the Public Health Outcomes Framework (PHOF), to provide levers to maintain drug treatment penetration and the quality of treatment and achieve reductions in drug-related deaths.
This recommendation doesn’t feel well thought through, which suggests the authors don’t understand the reporting which exists.
Reporting is already transparent with lines explicitly on drug misuse within the reporting on the ring fenced grant. The Public Health grant already has 26 lines of reporting, including substance misuse, for around £50m in my Authority’s grant. By comparison social care reporting lines are less than 10 for £300m . Benchmarking service costs is already done by CIPFA and can be publicly gained from government data on the Public Health grant. This recommendation completely misses the point.
The local health and wellbeing board or local drugs board and local authority are the places to consider and address “falls in treatment penetration”. This recommendation seems to want to re-instate the performance management of the old National Treatment agency.
There is enough transparency in the PHOF and other indicators, combined with the new strategy and guidance. We don’t need yet another additional range of measurements.
The quality and effectiveness of drug misuse treatment is being compromised by under-resourcing.
This is too sweeping, even if they have a point. Resourcing is not the only issue, even though it is an issue. Models of care, changes in demographic patterns and population need get very simplistic analysis in this report in some places.
The PHE and LGA report identified that commissioners have said in a number of places services needed reconfiguration to meet changed need and changed models of service. This conclusion just ignores the joint PHE, LGA and ADPH work on drugs commissioning.
There is another opportunity for ACMD to argue that the public health cuts need to be reversed here.
National bodies should develop clear standards, setting out benchmarks for service costs and staffing to prevent a ‘drive to the bottom’ and potentially under-resourced and ineffective services.
What do they actually mean by this? I don’t know. I’m not sure they do either.
This isn’t benchmarking, this feels like an attempt to set a national tariff or a minimum payment or go back to the market management arrangements of the old National Treatment Agency. That could have some merit, or it might not. But this recommendation should have been clearer and more focused about what mechanisms and structures they feel will help.
The Government’s new Drug Strategy Implementation Board should ask PHE and the Care Quality Commission to lead or commission a national review of the drug misuse treatment workforce. This should establish the optimal balance of qualified staff (including nurses, doctors and psychologists) and unqualified staff and volunteers required for effective drug misuse treatment services. This review should also benchmark the situation in England against other comparable EU countries.
This is a helpful recommendation. Most commissioners I know would welcome a workforce review of skills and workforce needed for the future including workforce redesign. Simply basing workforce on models of workforce pre-2013 is not the answer to the changed epidemiology, policy and financial climate
There is an increasing disconnection between drug misuse treatment and other health structures, resulting in fragmentation of drug treatment pathways (particularly for those with more complex needs).
This is nothing new, and was recognised long before the new system came into place. We need to do something about it though, and they do us a service by reminding us.
The new drugs strategy, The 2017 revision of the Orange book clinical guidelines and the recent PHE guidance on co-existing morbidities actually provides opportunity to advance this agenda, as does the mental health crisis care concordat. Much of this disconnection is because the system as a whole is fragmented. Putting treatment services back in the NHS won’t solve that.
Local and national government should consider strengthening links between local health systems and drug misuse treatment. In particular, drug misuse treatment should be included in clinical commissioning group commissioning and planning initiatives, such as local Sustainability and Transformation Plans (STPs).
This is a mostly sensible and welcome recommendation. Inclusion in STPs and strengthening links good, and making links with CCG and other plans. But has ACMD forgotten we have Health and Wellbeing Boards? (Ok, they’re not always wonderful either, but please, don’t just ignore an entire sector.
Frequent re-procurement of drug misuse treatment is costly, disruptive and mitigates drug treatment recovery outcomes.
Procurement can be a two-edged sword, if not done well and purposively. It can be a great tool for developing quality, and it can be a disrupter. The key thing here is to do it well and sensitively.
This conclusion could have been more nuanced, and identify in much better detail some of the ideas and suggestions for making this happen. There are numerous reports of places where re-procurement has been necessary to secure service improvement.
Commissioners should ensure that recommissioning drug misuse treatment services is normally undertaken in cycles of five to ten years, with longer contracts (longer than three years) and careful consideration of the unintended consequences of recommissioning. PHE and the Local Government Association (LGA) should consider the mechanisms by which they can enable local authorities to avoid re-procurement before contracts end in systems that are meeting quality and performance indicators.
In and of itself this isn’t the answer. Long contracts with a complacent provider don’t help anyone. I think the report though is calling for some kind of stability and relationship, and that makes sense. A key issue for us as commissioners is how we work well with the rest of the system to do that. To my mind this is a call for better system leadership and commissioning, and seen in that light we should give it serious thought.
Procurement is part and parcel of the legal framework of commissioning and providing services, many other areas have used it to improve outcomes and there is evidence that this has happened since 2013 on a range of public health services.
Procurement conducted well can remove unintended consequences and be a tool for improving quality, cost and outcomes. Done badly it can have the effects the report laments.
Systematically seeking to avoid re-procurement is both unlawful and seeks to thwart the intentions of value for money and effectiveness that procurement can, used well, address.
The ACMD is concerned that the current commissioning practice is having a negative impact on clinical research into drug misuse treatment across NHS and third (voluntary) sector providers. Many treatment providers are third sector and current research structures are not designed to recognise them. System churn due to recommissioning and reduced resources mitigates the stability and infrastructure required for research.
This is not new. Drug treatment services in many places have long been outside the NHS, and issues of research capacity, research structures and even things like provision and management of Specialist Registrars and Speciaist Trainees have been issues. We do need to ensure these issues are addressed constructively.
The Government’s new Drug Strategy Implementation Board should address research infrastructure and capacity within the drugs misuse field. Any group set up to work on this should include:
· government departments;
· research bodies such as the Medical Research Council (MRC) and the National Institute for Health Research (NIHR); and
· other stakeholders.
A sensible recommendation which we should support , but it should also include commissioners. The lack of mention of local authority commissioners, once again, feels sadly like distrust.
I don’t know about anybody else, but I can’t help thinking that the issue of chemsex is one we are still not really getting our act together on. I claim no specific expertise here, but what I do know is this issue is impacting on the health of our population, and an already vulnerable one at that, so we need to act. And I have several friends and colleagues from across the country -the youngest 24 and a student, the oldest 50 and a professional in the City, whose processes of getting out of the harm they’ve come to I have helped with.
We seem to have depressingly little in the way of national leadership or action on this from the Public Health community, with the work of some dedicated individual clinicians and community activist -step forward David Stuart and 56 Dean Street, Greg Owen, Matthew Hodson, GMFA , James Wharton, MenRUs, Burrell Street Clinic for their Safer Chemsex Kit and a few others being most visible. I have provided links to several pieces of this work in the footnotes, but let me also direct you to London Friend’s work on LGBT drug use and recommendations for treatment services . I hope anyone I have missed off will forgive me.
It is simply unacceptable for the skills and resources of the Public Health profession to be absent from this issue.
I was discussing this today at another meeting. I said to a colleague from another agency “people say we don’t have a problem locally” and before I could continue to say “and they’re wrong” he interjected, “they should just open grindr, it’s everywhere.”
The use of some kind of substance to enhance sex is known and common throughout history (drinks while dating?) And if people are fine about that and use without harm, then I don’t feel it’s my business. But recently the phenomenon of chemsex has become a bit better known than it was. A search of MEDLINE and PSYCARTICLES when I was doing a quick review to inform this blog, after removing duplicates, found in 2014 3 papers, a search for 2017 found 48 papers so far in the health and psychological literature.
Chemsex is a term for a complex of behaviours – use of dating apps to have parties where sustained group use of drugs happens, particularly drugs like cocaine, crack, GHB (gamma hydroxybutyrate) and crystal methamphetamine. Sex is often but not always a given at some of these parties. Slamming – injection of drugs for quicker highs, sometimes happens, and with it sometimes sharing needles.
While it may be more of a scene for gay men, bisexual men and heterosexuals do it too. What will that pattern will be in two years time? We know that trends started by gay men sooner or later get picked up by the wider heterosexual world, or am I just remembering disco through rose tinted (glitter encrusted) spectacles? (Showing my age there.)
Increasingly, use of chems or drugs is reported by men using dating apps for 1-1 encounters too. Recent work has shed more light on the multiple motivations and issues at play. From the many paper available, I have a few which I think resonate. Weatherburn et al identify a range of motivations linked to “enhancing the qualities valued in sex” including enhancing attraction, heightening sensation, intensifying intimacy and connection and, for some men, overcoming lack of libido. Media attention and the interest of the scientific press seems to have been somewhat limited to date.
The increasing intelligence from reporting by clinicians and community groups of problems presenting from chemsex is concerning. From understandable motives – socialising, feeling good, enjoying sex and coping with life pressures are reported as factors, certainly in GHB use for some time , the drug use is primarily intended as a facilitator of these. But clinicians are reporting a range of harms including addiction and other sequelae.
Dedicated professionals like David Stuart and others working on this issue, have brought greater light on chemsex. The publication by James Wharton of his chemsex experiences in Something for the Weekend and the associated meda reporting,have gone some way to cast some light on this as an issue which needs addressing.
Parties are not the only places, however, where chemsex is becoming an issue. Increasing use of chems with sexual hook ups means some men may rarely have sex sober. It’s not just physical risk, but psychological. Intimacy may become associated with being high, and for some, dependent on it.
A 2014 BMJ editorial suggested a minority of men engage in chemsex but community reports suggest this is growing and becoming more prevalent. There are as yet no robust epidemiological estimates. Weatherburn et al report up to 18% of men from three London Boroughs uses cocaine and 10.5% GHB compared to 4.8% and 1.6% respectively of men elsewhere in England.
Wharton quotes estimates that a gay man dies in London from GHB overdose every 12 days but very few have been high profile. Estimates of prevalence vary in recent reports but what is clear is that this is becoming an increasingly prevalent presenting problem in sexual health clinics, and few services as yet seem prepared to address it effectively.
There are also some people who seem to be able to use drugs regularly without seeming to come to harm. If people genuinely can do that safely, and we can help them successfully avoid harm, then my interest ends there. But many do come to harm, and it’s those who experience harm in any form I’m interested in here. And the harms from chemsex can be wide.
Whether or not this is a minority phenomenon in terms of the population, the harms to some users are significant and the barriers to accessing services also important disablers of helping men deal with harms arising from chemsex.
What we don’t know reliably is how many men engage in chemsex without coming to some form of harm. Most data from clinics and the small amount of research to date identifies some kind of harm. A spectrum of harms across physical, psychological and social health is possible. Some of the documented and reported harms are shown in Table 1 below. But this isn’t exhaustive.
Table 1: Harms from chemsex
· STIs, HIV and other Blood borne viruses
· Physical effects of comedowns
· Risks to circulatory system from injection
· Respiratory risk from frequent use
· Risk of death from overdose
· Disrupted sleep patterns, anorexia, weight loss
· Impaired immune function
· Use of chemsex to facilitate social contact and overcome loneliness, isolation
· Coping mechanism for stigma and homophobia
· Impact on coping skills, sleep, employment, cognitive functioning
· Impact on relationships of becoming habituated on having sex while using drugs
· Psychological impact of financial problems from financing habit
· Impact on identity integration and acceptance
· Bereavement from people in social networks dying as a result of G
· Group identification
· Coping with stigma
· Holding down a job and responsibilities
· Risk of debt and homelessness
· Criminalisation for possession of drugs and sometimes dealing
Public Health Issues
Chemsex is not just a drugs or an HIV or a sexual health issue. For most men it seems to be linked to a complex manifold of issues. From the physical risks to health, to the psychological risks and impact on lifecourse development, there are significant issues which impact on the populations and individuals who use it.
I have spoken, written and presented elsewhere on how the need to ensure LGBT populations are able to live happily and successfully across the lifecourse must be a public health issue,. So I won’t repeat that here. One of my worries is that chemsex for some can hamper or impair that process.
The mental health impact of being unable to have sex or be intimate unless high presents a number of challenges. But there is another set of issues. If some gay men use chemsex to cope with stigma or feelings about being gay, that must be seen as potentially problematic. It is a commonplace in psychology of LGBT populations that a key task is identity integration and acceptance. Theory and evidence assumes that identity integration and assimilation is crucial to health and wellbeing outcomes for gay men across the lifecourse,,. It is assumed to be especially important to ensure inclusion for LGBT people in education and employment. If chemsex disrupts such processes, or means a population or sub-population of gay men can only feel good enough about themselves where mediated through drug use (either individual or in groups), there may be significant avoidable psychological morbidity as a result. If what Wharton says about younger gay men finding it easy to get into this scene is true, then that has worrying implications about the ability of those men to form attachments and integrate their identity as they grow, with potential maladaptation and poor coping and mental health across the lifecourse.
Policy frameworks and action
While chemsex is mentioned in the new UK Drugs Strategy, there has been much criticism of the lack of commitment on what to do about it. There remains no coherent public health response. Community harm reduction approaches including safer injecting kits are most visible interventions with the best available frameworks for clinical response being those developed by David Stuart There is as yet no clear national policy framework or consensus guideline on what can or should be done. Community intelligence is still crucial to developing action on this, and we need to find ways of making sure we capture and factor that into response planning, on a more agile basis than we sometimes do.
What can be done?
A range of action is needed, and this needs to be revised as we know more. I group suggested actions under domains here.
Domain 1: Establishing prevalence and incidence
We need as clear a picture of prevalence, service use, harm, morbidity and mortality as can be compiled, nationally and locally
Including and using community intelligence in this development will be crucial
Asking about chemsex use should become a routine question in sexual health services on the electronic patient record
Domain 2 : Harm Reduction strategies
We need to work with providers of dating and sex hook-up apps to target information on harm reduction to users engaging in chemsex
The current good practice (chemsex care plan and harm reduction information and kits) should be rolled out to those areas who identify they have a developing issue
Support harm reduction including continued information and kits to reduce harm
Agencies could consider safer chemsex courses as a way of helping reduce harm including teaching people skills of what to do about GHB overdoses
Agencies should combine efforts to make available a single reliable source of information on reducing harm from chemsex and where to get help
Sex venues should consider placing information on chemsex and where users can get help.
Domain 3: Service response and readiness
Most chemsex users don’t find drugs services resonate with them on the whole. We need to identify what drugs services and sexual health services can to do address this and roll it out
Sexual health and drugs services should identify what they can to do ask gay men about, identify and respond to chemsex issues, and develop collaborative approaches to sharing skills
Those services should become skilled in particular identity and lifecourse issues facing gay men
Services should consider whether they can recruit people recovering from chemsex harm to work with those seeking support
Agencies working on this should convene with experts on drug use, sexual health and LGBT development to develop some consensus guidelines on harms and issues, and intervention strategies, and keep this under review.
LGBT community groups who provide social groups or counselling facilities should consider what they can do to continue to support gay men with lifecourse identity development
Employers with large numbers of gay men in population centres likely to be affected should consider what resilience and support packages they can put in place for employees with performance issues arising from chemsex