ADD2523 Hepatitis C London Elimination Work

1.1 Hepatitis C is a blood-borne virus that, if left untreated, can cause cirrhosis, liver cancer, liver failure and death. However, hepatitis C is now curable. Newer 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 2030 goal set by the World Health Organization (WHO). According to the WHO, elimination is defined as an 80 per cent reduction in new infections from 2015 levels; 80 per cent of those eligible being treated; and a 65 per cent reduction in mortality from hepatitis compared with 2015 levels.

1.2 In 2018 London accounted for nearly a third (31 per cent) of new hepatitis C antibody-positive laboratory reports in England. 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 per cent 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.

1.3 The GLA has been supporting the work of the LJWG since 2019. Over the period 2019 to 2021, the LJWG was commissioned to provide services, with a value of £30,000, relating to hepatitis C elimination work. This was approved under cover of MD2439 in 2019-20, MD2688 in 2020-21, and delegated authority records.

1.4 Further services have been necessitated by the COVID-19 crisis, which has resulted in delays to hepatitis C testing and some of the work that had been planned for 2020-21. The work also falls within the Mayor’s manifesto commitment to support this work and progress it within the first 100 days of his 2021-2024 mayoralty. The value of the additional services required in 2021-22 is £21,000. It is proposed that the services be commissioned by varying the GLA’s current contract with the LJWG.

1.5 Officers acknowledge that section 9 of the GLA’s Contracts and Funding Code requires, where the expected value of a contract for services is between £10,000 and £150,000, that the services required should be procured competitively. However, section 10 provides that an exemption from this requirement may be approved where a supplier has had previous involvement in a specific current project; or the where the work proposed is a continuation of existing work that cannot be separated from the new work. As the current provider of hepatitis C elimination-related services, the LJWG – because of the work undertaken to date – has unique experience of the work required and the GLA’s particular needs in this regard. As a result it is highly unlikely that we could identify an alternative organisation to the LJWG that offers similar expertise and level of stakeholder engagement; that is able to provide the services in the timescale required; and that would provide comparable value for money.

1.6 The LJWG has the expertise and relationships with stakeholders that makes them ideally placed to work on the pan-London elimination efforts. Established in 2009, the LJWG is a group of expert clinicians, and patient advocacy and voluntary-sector leads, working in collaboration with a wide group of stakeholders. Their mission is to eliminate hepatitis C in drug users and those engaged in drug services in London. The LJWG works across three main areas:

• running pilot projects – for example, testing for hepatitis C in needle-exchange pharmacies

• coordinating research reports to understand the challenges around, and overcome barriers to, addressing hepatitis C in London

• creating resources for substance misuse services and people at risk of hepatitis C.

1.7 The LJWG has undertaken a broad range of work, including: consultation across the London system, to identify the areas where coordination and synergies are needed; and development of a Routemap to Elimination, which was launched at City Hall in March 2020. The Routemap sets out five opportunity areas that are a focus for progress:

• Promoting the conversation: reducing stigma around, and raising awareness of, hepatitis C, and the highly effective treatments that are now available.

• Engaging people who are under-served by traditional health systems. The groups of people most at risk from hepatitis C are likely to have complex health needs and are unlikely to be diagnosed and treated in a hospital setting.

• Working with GPs to find the undiagnosed. This includes updating GPs on availability of new treatments, spreading good practice and encouraging a proactive approach to case-finding.

• Reducing pathway attrition, by making sure pathways from testing into treatment are as simple and short as possible. This workstream looks at care pathways across London to identify how pathways can be simplified and made more patient centred.

• Aligning hepatitis C and HIV public-health efforts. Four key areas have been identified for potential future partnership work. These are promoting and scaling up testing; addressing stigma; reducing co-infection; and defining and maintaining elimination.

1.8 A London elimination steering group has also been established that combines expertise from the organisations and communities involved in, and affected by, the prevention, diagnosis, treatment and support of people living with and at risk of hepatitis C. This ensures an inclusive and transparent whole-city approach to the delivery of the Routemap.

1.9 The COVID-19 crisis resulted in reduced hepatitis C testing and treatment for injecting drug users. However, the steering group continued to meet; and the services commissioned from the LJWG have supported the coordination and evaluation of blood-borne virus tests for homeless people housed in hotels. Between May and August 2020 a total of 1,082 people were tested: 72 identified with an active hepatitis C infection; 22 were found to have HIV; and five people tested positive for hepatitis B. These conditions would have been missed and remained untreated without this testing. An evaluation report was published in December 2020 with a foreword by the Mayor’s Health Adviser.

1.10 The Mayor has also raised awareness of hepatitis C through a visit to a testing van outside a homeless centre; this was to mark World Hepatitis Day in 2019. One of the Mayor’s manifesto commitments is to bring a new focus on hepatitis C, and to work with the NHS to end all new hepatitis C infections in London by 2025.

1.11 Approval is now sought for expenditure of £21,000 from the 2021-2022 Health team budget to the LJWG to continue the elimination work. The objectives for this are set out below, at section 2. The funding will cover:

• 23 days of a project manager’s time, with a daily fee of £600 per day = £13,800

• 18 days of a support team at £400 a day = £7,200.

2.1 The LJWG will be working with London’s hepatitis C sector, enabling collaboration and joint work to achieve elimination as a public health threat by 2025. The objectives for this work are:

• the development of plans for the five opportunity areas in the Routemap

• development of a social media and communications plan for the Routemap – this will support action to raise the profile of hepatitis C via regional communications, thus reducing stigma; and encourage people to recognise the risk factors, and ask for a test if they think they may have been exposed

• reporting on and encouraging one-step reflex hepatitis C testing.

2.2 The LJWG will also manage the steering group and engage with stakeholders, identifying the gaps and identifying new opportunities to test and treat post-COVID-19. This will include:

• planning four steering group meetings in July and October 2021, and January and March 2022, and liaising with steering group members to maintain engagement

• supporting communications to raise awareness of organisations involved in scoping a needle-exchange provision, to reduce transmission, on World Hepatitis Day (28 July 2021); this is in line with scoping an advanced peer-led needle exchange to reduce transmission of hepatitis C with extra hepatitis C capacity (funded by Hackney council)

• liaising with the London operational delivery networks, and the London testing-laboratory network.

3.1 The London Health Inequalities Strategy sets out the Mayor’s vision to create a healthier, fairer city where nobody’s health suffers because of who they are or where they live. It has a strong focus on supporting some of London’s most vulnerable groups, who suffer some of the greatest health inequalities. The people hepatitis C affects are among the most vulnerable in society, who often have to overcome additional barriers to access healthcare – for example, because of a lack of permanent address or a negative perception of public services.

3.2 Intravenous drug use remains the most important risk factor for hepatitis C infection. In 2016 it was estimated that almost two-thirds of people in London who inject drugs had hepatitis C. There is also a high prevalence among the homeless; people in prison; and men who have sex with men. Individuals originating from regions where the prevalence of hepatitis C is high, such as South Asia and Eastern Europe, are also at increased risk.

3.3 The general public know very little about hepatitis C. Due to the high occurrence of the virus among people who inject drugs, the infection also bears its share of stigma – which can prevent people from seeking treatment.

a) Key risks and issues

4.1 A key risk is that the funding is not approved quickly. Due to the elimination target of 2025 set by NHSE, and the manifesto commitment to support this, there is some urgency to this work. So as not to lose momentum, the LJWG undertook some work without confirmation that funding had been approved.

4.2 Another risk is that the work does not lead to a reduction in cases of hepatitis C. In order to mitigate this risk, some analysis will take place on the trajectory of the data and how the work of the Routemap will contribute to elimination efforts. The Mayor has limited powers to eliminate hepatitis C, so there will need to be clarity about his role and powers.

b) Links to Mayoral strategies and priorities

4.3 One of the pledges in the Mayor’s manifesto was to bring a new focus on the target of ending new hepatitis C infections by 2025. The Mayor supported this work in his first administration, including a visit to a testing van to mark World Hepatitis Day in July 2019; launching the London Routemap to Elimination in 2020; and issuing a video message to support the LJWG conference in 2021.

4.4 One of the objectives in the health inequalities strategy (HIS) is that people and communities are supported to tackle HIV, TB and other infectious diseases, and to address the stigma surrounding them. The HIS also includes a focus on supporting some of London’s most vulnerable groups, who suffer some of the greatest health inequalities.

4.5 Our Vision for London, to which the Mayor is a signatory – along with NHSE, Public Health England (PHE) and London Councils – includes a commitment to using the learning from work on HIV to help diagnose and treat other blood-borne viruses, including hepatitis C and sexually transmitted infections.

c) Consultations and impact assessments

4.6 The London Routemap to Elimination was developed in 2019 in consultation (delivered by the GLA and the LJWG) with leaders in the hepatitis C field from across NHSE and NHS Improvement, local government, PHE, the Operational Delivery Networks, local authority public health teams, outreach projects, pharma companies, and the third sector. There was unanimous agreement that a coordinated approach to eliminating hepatitis C in the capital was needed.

4.7 There are no conflicts of interest to declare from those involved in the drafting or clearance of this form.

5.1 Approval is sought for expenditure of £21,000 in grant funding to the London Joint Working Group on Hepatitis C and Substance Use (LJWG), to support the work to eliminate hepatitis C in London in 2021/22.

5.2 The cost will be funded from the Health Team’s Programme budget for 2021/22 (specifically the Health Inequalities Strategy workstream budget) under the ‘Public Health and Health & Care Partnerships’ recovery foundation.

6.1 The foregoing sections of this report indicate that: the decisions requested of the Assistant Director concern the exercise of the GLA’s general powers, falling within the GLA’s statutory powers to do such things considered to further or which are facilitative of, conducive or incidental to the promotion of economic development and wealth creation, social development or the promotion of the improvement of the environment in Greater London. In formulating the proposals in respect of which a decision is sought officers have complied with the GLA’s related statutory duties to:

• pay due regard to the principle that there should be equality of opportunity for all people

• consider how the proposals will promote the improvement of health of persons, health inequalities between persons and to contribute towards the achievement of sustainable development in the United Kingdom

• consult with appropriate bodies.

6.2 In taking the decisions requested, the Assistant Director must have due regard to the Public Sector Equality Duty – namely, the need to eliminate discrimination, harassment, victimisation and any other conduct prohibited by the Equality Act 2010, and to advance equality of opportunity and foster good relations between persons who share a relevant protected characteristic (race, disability, gender, age, sexual orientation, religion or belief, pregnancy and maternity, and gender reassignment) and persons who do not share it (section 149 of the Equality Act 2010). To this end, the Assistant Director should have particular regard to section 3 (above) of this report.

6.3 Section 9.1 of the Contracts and Funding Code (the Code) requires the GLA to call off services with a value of that concerned here from a suitable framework, where possible; or if not, to undertake a competitive process managed by TfL Commercial in respect of the services required. However, the Assistant Director may approve an exemption from this requirement under section 10 of the Code upon certain specified grounds. One of those grounds is that a contract may let without competition where a supplier has had previous involvement in a specific current project, or where the services concerned are a continuation of existing work that cannot be separated from the new project/work. Officers have indicated that this ground applies, and that the proposed contract affords value for money. On this basis the Assistant Director may approve the proposed exemption if satisfied with the content of this report.

6.4 In the event that the Assistant Director makes the decisions sought, officers must ensure that the GLA’s contract with the LJWG is varied before the commencement of the additional services.

7.1 This work will be led by the LJWG with the support of the London Hepatitis C Elimination Group. A working group is in place, comprising the LJWG, the GLA and PHE.