ADD2510 Supporting work to eliminate Hepatitis C

1.1. The GLA Health Team leads the implementation of the Mayor’s ten-year London Health Inequalities Strategy (HIS) 2018-28 (published October 2018) with relevant partners and stakeholders, and supports his leadership role as chair of the London Health Board. The vision and aims of this approach are:
• healthy children - every London child has a healthy start in life;
• healthy minds - all Londoners share in a city with the best mental health in the world;
• healthy places - all Londoners benefit from an environment and economy that promotes good mental and physical health;
• healthy communities - all of London’s diverse communities are healthy and thriving;
• healthy living - the healthy choice is the easy choice for all Londoners; and
• supporting the Mayor’s leadership role for health.

1.2. COVID-19 has had a significant impact on London’s health inequalities, and the Health Team have been reviewing work programmes throughout the last year to ensure that work is targeting on the ongoing and emerging needs of Londoners. The HIS provides an evidence-based framework for tackling health inequalities, and as a statutory strategy will be reviewed in due course, including updating the evidence base.

1.3. In October 2019 the London health and care partnership, which includes the GLA alongside Public Health England (PHE), the NHS and London Councils, jointly published Our Vision for London: The next steps on our journey to becoming the healthiest global city (‘the Vision’). The Vision focuses on ten ambitions where partnership action is needed at a pan-London level to achieve change, and four ‘enablers’: workforce recruitment and retention, digital innovation, maximising the contribution of health and care estates, and health and care service integration.

1.4. This Decision relates to work programmes which are part of the HIS implementation as well as reflecting partnership commitments on the London Heath and Care Vision - which closely aligns with our Recovery priorities – relating to mental health and wellbeing and also to hepatitis C.

Mental Health and Wellbeing

1.5. The COVID-19 pandemic has had a huge impact on Londoners’ mental health and wellbeing. It has created new challenges and worsened existing inequalities, with some communities affected more than others. London’s recovery must include focused action to address the direct impact of the pandemic. It must also ensure that in the longer-term, those groups and communities most affected can live healthier, happier, lives.

1.6. Mental health and wellbeing is a priority of London’s response to the COVID-19 pandemic, and improving mental wellbeing is one of the nine missions overseen by the London Recovery Board.

1.7. The mental health and wellbeing mission is to have a quarter of a million wellbeing ambassadors, supporting Londoners where they live, work and play by 2025. The mission objective is to empower Londoners to act to improve their own and their communities’ wellbeing, and particularly those whose wellbeing is at greater risk. 

1.8. To achieve this we propose to engage communities whose wellbeing is at greater risk due to the pandemic, working closely with partners, and recognising and building on what works and already exists. Work towards the mission will see to work with local partners and communities to understand what would be of most value to them, and to recognise and build on the many examples of great initiatives and collaboration already happening across the capital.

1.9. Thrive LDN is helping to coordinate a collective response to the public mental health challenges which have escalated in London as a result of the pandemic. They also continue to act as a key delivery partner for the GLA on our mental health and wellbeing programme, including supporting the development of the mission. Some key pieces of work, which have influenced the development of the mission, include:

• A significant community engagement project, working with 200 different community groups and organisations to understand more about the experiences of 20 disproportionately at-risk groups. The findings illustrate a general sense of loss across all aspects of many Londoners’ lives: loss of loved ones, employment, relationships, homes, education and wider opportunities. Some suggested actions for health and care partners to consider from these have included: Strengthen community, address discrimination, targeted activities tailored to the needs of local, cultural and community groups, value family and support structures, digital inclusion, improve access to information and support and to deliver change for BAME communities.

• A series of ‘working papers’ outlining the latest evidence, research and intelligence on the mental health and wellbeing picture in London. These papers have been regularly updated throughout the pandemic with the latest evidence.
1.10. The funding proposed will align with the work outlined in MD2704. This decision supports and build on that work. The key activities for the funding outlined in that document were:
• identifying and developing targeted communications for population groups where evidence suggests they are likely to see the largest deterioration in mental health during lockdown; identifying and developing communications for non-mental health settings where we can create opportunities for mental health signposting; and

• provision of support for mental health and wellbeing community peer support initiatives – expanding programmes or upskilling people.

1.11. Improving Londoners mental health and wellbeing is a priority of the London Health Inequalities Strategy, and is reflected in two of the ten priority areas of London’s health and care vision.

Hepatitis C

1.12. Activity relating to hepatitis C is reflected in the Health Inequalities Strategy under Healthy Communities. It relates directly to objective 4.4. “People and communities are supported to tackle HIV, TB and other infectious diseases and address the stigma around them, as well as linking to the Inclusion health work programme. The Mayor is also a signatory to Our Vision for London which includes ambitions to improve the health of homeless people and to use the learning from HIV work to help diagnose and treat other blood-borne viruses including hepatitis C.

1.13. Hepatitis C is a blood borne virus that, if left untreated, can cause cirrhosis, liver cancer, liver failure and death. The most recent London-specific estimates are of 13,800 chronic infections at the end of 2018. National estimates in the most recent hepatitis C reports indicate that prevalence decreased by 11% from 2018 to 2019, so the current burden for London is likely to be lower than the 2018 figure – but still likely to be at least 10,000.

1.14. Newer curative treatments are available with shorter treatment times, better outcomes and fewer unpleasant side effects. The NHS is aiming to eliminate Hepatitis C as a public health threat by 2025 – five years earlier than the goal set by the World Health Organisation of 2030. If the NHS is to achieve this, work must continue at pace to find and treat those infected, to reduce new infections, and to increase awareness and understanding about the virus.

1.15. The GLA Health Team has been working with the LJWG since 2019 to convene partners from across the different parts of the complex health and social care landscape in London. This work has had a number of positive impacts:

• Development of a routemap to elimination of hepatitis C in London which was launched at City Hall in March 2020 and provides a focal point for elimination efforts. The routemap which has generated national and international interest, sets out five opportunity areas that require a pan London approach;

• Establishment of the London Hepatitis C Routemap Steering Group which brings together expertise from all the relevant sectors to ensure an inclusive and transparent whole city approach to the elimination efforts;

• A visit by the Mayor to a Hepatitis C Testing van outside a homeless centre in 2019 to mark World Hepatitis Day and shine a spotlight on the disease;

• Coordination and evaluation of the blood borne virus testing initiative for the homeless population housed temporarily in hotels and hostels as part of the ‘Everybody In’ policy during the COVID crisis;

• A report published by the LJWG last December, with a foreword by the Mayor’s Senior Health Advisor, setting out the outcomes and learning from that initiative.

1.16. LJWG have already received funding of £14,800 in this financial year approved via a delegated authority record for £3,600 in April 2020 and further funding of £11,200 approved under MD2688 in September 2020.

1.17. The funding of £5k will cover the costs of two consultants and just over nine days work in February and March 2021 comprising:

• £600 x 5 days = £3000
• £480 x 4 days = £1922

Mental Health and Wellbeing

2.1. Funding of £30000 will be divided over three projects as outlined below.
a) Research to improve our understanding of the current evidence on what is effective to support and improve individual and community wellbeing, specifically reflecting on the London context and the pandemic context - £10,000
b) Engagement with local partners to improve understanding of what is happening locally already, particularly in terms of community networks, and explore opportunities for how the mission might be able to build on this good work - £10,000
c) Targeted communication for London’s communities, expanding in the work programme indicated under MD2704 - £10,000
Research on wellbeing

2.2. Improving Londoners mental wellbeing, particularly those who are more vulnerable to poor wellbeing, is core to the mission. To achieve it, first we need to have a clear understanding of what wellbeing is to Londoners, and what impacts upon it.

2.3. According to What Works Wellbeing, wellbeing is about ‘how we’re doing’ as individuals, communities and as a nation, and how sustainable that is for the future . In evidence reviews by What Works Wellbeing, the determinants that are consistently associated with people experiencing the poorest wellbeing are bad health, renters, divorced or separated, poor education, long-term illness or disability, single or widowed, middle aged and men. This project will help us to understand what this looks like in a London context.

2.4. The Office for National Statistics measures national wellbeing in the UK, but there is little data to understand wellbeing on a London level and amongst different cohorts of Londoners.

2.5. To inform and support the development of the mental health and wellbeing mission, we are seeking to commission research to improve our understanding of the current evidence on what is effective to support and improve individual and community wellbeing, specifically reflecting on the London context and the pandemic context. The estimated cost is £10000.

2.6. Questions for this work might include:
• What evidence, nationally and internationally exists for improving population mental health and wellbeing?
• Horizon scanning - what new interventions are emerging?
• What do we know about wellbeing related to specific groups, e.g. Black, Asian and minority ethnic people, young people, deaf and disabled people, LGBT+ etc?

Understanding existing borough and local networks

2.7. The mission seeks to build on what is already working in terms of communities working to support each other’s health wellbeing. This has been seen throughout the pandemic, in mutual aid groups, and through programmes and networks such as Covid Health Community Champions. Many of this groups and networks involves voluntary and community sector and local authority partners. We do not currently have a London picture of this activity.

2.8. To inform and support the development of the mental health and wellbeing mission, we are seeking to: Engage with local partners to improve understanding of what is happening locally already, and explore opportunities for how the mission might be able to build on this good work. Estimated cost £10000.

Targeted communications

2.9. A further £10000 is being included as a contribution to the work outlined in MD2704, as an extension of the work on targeted communication for London’s communities. This would allow an extension of that work to develop resources for clinically extremely vulnerable; carers; and other groups at disproportionate risk of health anxiety.

Hepatitis C

2.10. Funding of £5k for LJWG will cover the following activities and objectives:

• Collaborative discussions across multi-disciplinary commissioners re multi-morbidity testing for hepatitis C and COVID19 testing in asylum seeking hotels and other opportunities where co-commissioning could be beneficial to vulnerable populations;

• Work with London laboratories to facilitate one step reflex testing in laboratories not doing automatic RNA test or not reporting results to PHE;

• Develop a plan across London to help identify reinfection and transmission of hepatitis C in vulnerable populations including scoping out a pilot peer-led advanced needle exchange with extra hepatitis C capacity;

• Facilitate a routemap to hepatitis C elimination steering group meeting to review progress in the 5 opportunity areas; and

• Liaise with stakeholders across London to facilitate collaborative engagement in the hepatitis C sector.

3.1. The mental wellbeing project recognises that different groups of Londoners experience specific inequalities and will focus on reaching the most vulnerable and marginalised. This includes socioeconomic inequalities, as well as inequalities experienced by those with single or multiple protected characteristics under the Equality Act 2010. The ambition of this project, work on wider determinants of health and health inequalities is to improve health for all through an approach of proportionate universalism: universal approaches, with additional support in proportion to need.

3.2. Hepatitis C is clearly linked with socioeconomic health inequalities: Injecting drug use remains the key driver for hepatitis C transmission. There is also a high prevalence amongst the homeless, people in prison, and men who have sex with men.

3.3. Individuals originating from regions where the prevalence of HCV is high, such as South Asia and Eastern Europe, are also at increased risk.

3.4. The general public know very little about hepatitis C, and due to the high occurrence amongst people who inject drugs the infection also bears its share of stigma and can prevent people from seeking treatment.

a) Key risks and issues

Mental Wellbeing

4.1. Delays to the commissioning of this work. There is some urgency to this piece of work as it will inform the development of the Mental Health & Wellbeing Mission and the health and wellbeing cross cutting principle underpinning the other eight recovery missions.

Hepatitis C

4.2. Risk of loss of momentum in work to tackle hepatitis C. The COVID 19 crisis resulted in pauses to blood borne virus testing in drug and alcohol services, prisons and pharmacies and made it harder for people to access needle and syringe provision services. We are therefore keen for LJWG to continue helping to coordinate and drive forward work on hepatitis C.

4.3. If LJWG cannot find funding for 21/22 some of the route map work may not continue beyond March. LJWG are in discussion with NHSE and pharma companies about funding for some areas of work but have not yet identified funding for the next financial year.

b) Links to Mayoral strategies and priorities

4.4. The Mayor’s Health Inequalities Strategy (HIS) sets out priorities to improve Londoner’s health and well-being. Mental health is a priority area and the HIS includes 5 objectives to achieve the Mayor’s aim that all Londoners share in a city with the best mental health in the world. The HIS also includes an objective that people and communities are supported to tackle HIV, TB, and other infectious diseases and address the stigma surrounding them.

4.5. Mental health and wellbeing is a priority of London’s response to the COVID-19 pandemic, and improving wellbeing is one of the London Recovery Board’s Mission.

4.6. The Mayor is also a signatory to Our Vision for London which includes ambitions to improve the emotional wellbeing of children and young people, to improve adult mental health and reduce suicides, to improve the health of homeless people and to use the learning from HIV work to help diagnose and treat other blood-borne viruses including hepatitis C.

c) Consultations and impact assessments

4.7. There has been a considerable amount of engagement to inform the development of the mental health and wellbeing mission to date. This has included:
• engagement on Talk London in summer 2020 which highlighted the importance of focussing on mental health and wellbeing in the recovery
• a series of stakeholder workshops in Autumn 2020 at which we tested and continued to develop the mission.
• Thrive LDN’s community engagement programme, through which they worked with 200 different community groups and organisations, listening to the voices of over 10,000 Londoners to understand more about the experiences of 20 disproportionately at-risk groups. The Thrive Together report published after this period provides a summary of recent experiences and ideas to support the wellbeing and resilience of all Londoners.

4.8. The above cited activities will support continuing engagement for the development of the mission.

4.9. In 2019 the Mayor convened leaders in the hepatitis C field from across NHS England and NHS Improvement, local government, PHE, the Operational Delivery Networks, local authority public health teams, outreach projects, and the community and voluntary sector. It was agreed that a coordinated and concerted approach to eliminating hepatitis C in the capital was needed. A steering group was subsequently formed with representatives from each health or care area and a broader consultative meeting was held with key sector representatives in November 2019. The steering group has identified five main opportunity areas that are a focus for progress as part of the Route map.

5.1 Approval is sought for expenditure of £30,000 to undertake research and engagement work to inform the development of the mental health and wellbeing recovery mission; and £5,000 to support the London Joint Working Group to progress work to eliminate hepatitis C (taking total expenditure to £19,800 as detailed in section 1.16).

5.2 The total cost of £35,000 will be funded from the 2020/21 Health Team’s programme budget.

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