Elimination

Today is World Hepatitis Day, with the theme of Elimination.

2016 is a crucial year for addressing hepatitis. At the World Health Assembly in May, the World Health Organisation (WHO) Member States endorsed the first ever draft Elimination Strategy for Viral Hepatitis, with the ambitious goal to eliminate hepatitis as a public health threat by 2030.


Hepatitis C is a blood-borne virus that can lead to scarring (cirrhosis) or cancer of the liver if left untreated.

The virus is a serious infectious disease, but with the right early diagnosis and treatment, hepatitis C can be curable.

Hepatitis C disproportionately affects the marginalised groups of people Blenheim works with, including intravenous drug users, prisoners and immigrant populations. Public Health England reported that in 2015 50% of injecting drug users have hepatitis C, up from 45% in 2005.

Therefore, for years, Blenheim has called on NHS England, Public Health England and the Department of Health to make the elimination of hepatitis C a clear priority. We advocate that substance misuse services, the NHS and local authorities must do more to test, treat and cure those with hepatitis C.

In 2014, Blenheim became a member of the Hepatitis C Coalition – along with a group of leading clinicians, patients, organisations and other interested parties, we are committed to the reduction of morbidity and mortality associated with hepatitis C, and its eventual elimination.

To achieve elimination of hepatitis C, we need:

  • greater awareness about the virus,
  • better prevention – including harm reduction such as injection safety,
  • increased testing and diagnosis, and

Greater Awareness, Better Prevention

Injecting drug use continues to be the most important risk factor for contracting the infection because the virus is able to directly enter the blood stream via a needle. Approximately 50% of intravenous drug users are thought to be infected with the virus. Other forms of drug use, like sharing bank notes or straws to snort powders, also pose a significant risk of transmission. More information about risk factors can be found on the Hepatitis C Trust website.

Increased Testing and Diagnosis

You can always go to your GP or GUM Clinic and ask to be tested for the virus. If you are accessing a drug or alcohol service then you should speak to your keyworker or a member of staff about having the test. Services can provide a blood-borne virus (BBV) test for you, but if this isn’t available then they will support you to arrange this with your GP, or another healthcare provider.

Hepatitis C is a ‘silent epidemic’ because it is often asymptomatic in the early stages and can be difficult to diagnose. This means that in most cases, the symptoms are absent, mild, or simply vague. It is important to get tested if you have ever shared injecting equipment, even if it was many years ago, because you may not experience any symptoms. Although there are no set symptoms, common complaints related to the disease can include:

  • Problems with concentration and memory
  • Chronic fatigue
  • Flu-like symptoms, including sweating or headaches
  • Alcohol intolerance
  • Depression or mood swings
  • Digestive problems, including nausea, loss of appetite or weight loss
  • General aches and pains, or specific discomfort in the area of the liver

These symptoms can usually be alleviated with therapy. However, the symptoms people suffer are not necessarily an indication of whether they have liver damage or not.

Better Treatment

Anti-viral therapies have advanced greatly in recent years and are now able to clear the virus, thus preventing the progression of liver disease. These NICE approved treatments cure the virus for around 70-80% of people. Treatment has been shown to reduce both inflammation of the liver and fibrosis. There is also evidence that cases of cirrhosis can sometimes be reversed through treatment.

Decisions about treatment options should be made with your doctor. You can also contact the Hepatitis C Trust’s helpline on 0845 223 4424 for more information.

Blenheim: Test, Treat, Cure

In order to address the low levels of hepatitis treatment amongst our service users, in 2014/15, we introduced a range of initiatives in partnership with PHE, Hepatitis C Trust and the London Working Party on Hepatitis C. We have trained over 100 hepatitis champions throughout the organisation to identify the levels of hepatitis amongst our service users and to support the people affected with accessing treatment.

And progress is being made. Last year, 94% of Blenheim’s new clients that inject drugs or have previously injected drugs, had a Hepatitis C test – an increase from 87% in 2014/2015.

Furthermore, we are currently supporting the I’m Worth… campaign, which has been created to support people living with hepatitis C. It aims to address the stigma that many people with hepatitis C face, encouraging and empowering people living with hepatitis C to access care and services. It emphasises that everyone living with hepatitis C is entitled to the best care.


To find out more about Hepatitis C, please take a look at the factsheet on our website.

Test, Treat, Cure.

How are funding cuts affecting drug and alcohol services?

The State of the Sector report, conducted by the Recovery Partnership, is documenting serious concerns about the declining ability of the substance misuse sector to meet the needs of those it serves.

The first survey, covering 2013, provided a snapshot of the experiences of drug and alcohol treatment services as they entered a new delivery landscape. This landscape was characterised by the closure of the National Treatment Agency (NTA) and its absorption into Public Health England (PHE), as well as the transfer of budgets and commissioning responsibilities for substance use services to local authorities.

While the first report found no evidence of deep and widespread disinvestment, in its second year (2014) the survey found that many respondents were experiencing or anticipating substantial funding reductions. This trend has continued into 2015, with a considerable proportion of both community and residential providers reporting a reduction in funding. Overall, the 2015 report finds that 38% of community drug services and 58% of residential services reported a decrease in funding. Given the announcement in the Autumn Spending Review that public health funding will be reduced by 3.9% per year for the rest of the current Parliament, challenges around resourcing safe and high quality services clearly remain.

Reductions in funding are causing significant disruption to service delivery. In London, reliable sources have indicated that over the last five years up to 50% of the funding for substance misuse services has been cut. The impact of cuts can include; larger caseloads, declining access to workforce development, limited core services, less outreach, less access to employment, training and education provision, and less capacity to respond to complex needs.

Frequent recommissioning is another disruption to service delivery. The 2015 State of the Sector report finds that 44% of services had been through tendering or contract re-negotiation in the previous year and half (49%) expected to go through one of these processes during the year ahead. Furthermore, the income volatility is putting many smaller excellent providers under significant financial strain.

Funding is not the only cause for concern. The challenge of offering effective, joined-up support to service users with multiple and complex needs, and in particular individuals with co-occurring substance use and mental health issues, is a thread which runs through the three reports.

Beyond addressing substance use, the most significant support needs of those using services are: self-esteem, physical and mental health, employment support and financial support and advice. A fifth of respondents in the 2015 State of the Sector report felt that access to mental health services and housing/housing support has worsened over the last year, indicating that better joined-up support for people with dual diagnosis and multiple and complex needs is still required. This is particularly concerning given the documented view in 2014 was that services had got worse. This reflects a worrying downward trend.

I know these concerns are shared by frontline staff, commissioners and providers, and as funds are cut further there is an increasing risk of unmet need and unsafe service models. Unless Local Authorities are careful we may find services being closed as result of serious concerns being identified by the Care Quality Commission. Another risk is Local Authorities are forced to cut substance misuse services to the extent that they can no longer provide community-based alternatives to custody for those with drug and alcohol problems, placing additional pressure on a prison service already in crisis and struggling to cope with drug-use in many establishments.

When the drugs strategy is published this year perhaps the first job should be a long hard look at its affordability.

Shocked and saddened by drug related deaths figures for 2014

At the DAAT conference in early September 2015 I heard the drug related death figures for 2014. Despite having warned people they would be worse than the previous year I was shocked and deeply saddened. I have waited to write this blog to get my thoughts together.

Last year I was shocked by the inaction of Government and many Local Authorities to the 2013 figures.

I was going to talk about the Naloxone Action Group, positive action by the Department of Health, questions in Parliament and early day motions on naloxone. I was going to talk about the fact that since the 2013 drug related death figures came out, I and so many others have worked to try and understand what is happening and the cause.

Personally I believe that increased heroin purity, poor heath and financial pressures on the drug treatment system are key factors in increasing drug related deaths. I also believe that action to increase naloxone availability in England will avert a significant proportion of these deaths. Without naloxone the figures would already have been, in my view, significantly higher.

However the 2014 figures are shocking to me, every death represents a person, perhaps a father or grandmother, certainly someone’s child, grief and the waste of a life. I picture the funerals as a silent rebuke to do more. The figures are the highest since records began.

As you read the statistics below, from the Office of National Statistics, take time to consider the people the figures represent.

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Heroin and morphine deaths rise by two-thirds in the past 2 years.

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Within England, the North East has the highest mortality rate from drug misuse, London the lowest.

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2014 registrations show drug related deaths reaching the highest level since records began.

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Majority of heroin deaths were among the 30-49 year old age groups.

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Males were over 2.5 times more likely to die from drug misuse than females.

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Two issues seemed important to understand after the 2013 figures and they remain the same after the 2014 set. Firstly what is causing the rise in deaths? And secondly what is being done to prevent them?

A naloxone summit, hosted by Blenheim, bought together a campaign for a national naloxone programme in England. Through a FOI request we discovered the true extent of under provision of naloxone with only 32% of local authorities in England saying Naloxone was available. We formed the Naloxone Action Group England to ensure the regulations were changed, to ensure effective guidance was produced, and to ensure provision of naloxone across England. We got MPs to ask a range of questions in Parliament and gained support for an early day motion, sponsored by amongst others the current leader of the opposition Jeremy Corbyn and signed by the current Shadow Chancellor, John McDonald. This was not a party political issue; the EDM was also supported by current Conservative Minister Tracey Crouch. In total 32 MPs signed up to support wider naloxone availability.

Letters to the Minister from the Drug Alcohol and Justice Parliamentary group, chaired by Lord Ramsbotham secured firm assurance that the Government would make the changes recommended by ACMD to make naloxone more widely available from October this year.

Sadly, at the Naloxone Action Group we believe around 50% of local authorities continue to fail to provide naloxone. We will do a further FOI this year.

Meetings at Chatham House with senior officials revealed clear evidence that entering and leaving drug treatment and/or prison are particularly dangerous times for overdose and death. Thus pressure to leave treatment early and failure to adequately manage transfer of those with drug problems from residential settings could seriously endanger lives.

A drug related death summit held at the beginning of this year, hosted by Drugscope, Public Health England (PHE) and the Local Government Association, examined what might be causing the rise and to look at what might be done to reduce overdose deaths in future years. The attendees included policy makers from across government, commissioners, clinical and service provider leaders, and service user representatives.

The key messages from the summit were:

  • The availability of accurate, timely and easily accessible data is important in order to make the appropriate adjustments to policy and practice in order to reduce drug-related deaths;
  • The majority of drug misuse deaths still involve opiates, in particular heroin and methadone;
  • Being in contact with a treatment service would appear to be a significant protective factor for drug-related deaths;
  • Services and practitioners should pay attention to the elevated risk for those in treatment who are regularly overdosing, are drinking excessively, live alone in temporary accommodation or are homeless, or as a result of smoking-related diseases have compromised respiratory systems;
  • Policy makers and commissioners should think about providing timely and accurate alerts to drug users who are not in the treatment system – including drug users who don’t use opiates;
  • Commissioners and services should look at how they could supply naloxone more widely in the community to ensure those vulnerable to heroin overdose (including those not in treatment), their families, peers and carers are able to access the medicine.

Over the last year we have seen PHE nationally, clearly assert the need for action to reduce drug related harm and publish significant guidance on naloxone and reducing drug related deaths. However, at a time when drug related deaths are at their highest ever level, to cut £200million from Public Heath funding to local authorities is truly outrageous.

I am still ashamed to live in a country where things like the PHE £200 million cut happen at a time of evident need and many local authorities look the other way as people die as a result of the negligent failure to follow guidelines and supply naloxone.

It’s time to stand and fight

Disinvestment in drug and alcohol treatment is putting lives at risk.

Blenheim has four strategic aims: number two is to actively and effectively campaign on behalf of people stigmatized by alcohol & drug use. So here goes…

Cuts in drugs and alcohol funding, along with the lack of political leadership, along with a lack of priority in England is having a major negative impact on some of the most vulnerable people in our communities. The moving of drugs funding into Public Health England (PHE), where illicit drug use is not a strategic priority, has given a green light to local authorities to disinvest in substance misuse services.

There has never been a more urgent need to have clear English government leadership spelling out the responsibilities of local authorities along with the levers to ensure they deliver. What we have is localism, a post code lottery, a government washing their hands of responsibility like Pontius Pilate and senior political figures actively conspiring to undermine evidenced based practice. Indeed it is not clear whether under the current Government in England will even have drug and alcohol policies.

We are witnessing the end of the best drug and alcohol treatment system in the world and the time to act to defend it is now. Its decline is being marked by lost opportunities and an increasing death toll as we fail to respond to rapidly increasing numbers of drug related deaths, health needs, and fail to tackle issues such as hepatitis C, HIV and liver disease. We are also failing to resource “harm reduction”, a phrase banished from the Government lexicon like a dirty word.

Over the next 3 years, spending on drug and alcohol services is predicted by some officials to fall between 25% and 50%.

Prior to Drugscope falling victim to Government cuts it’s recently published State of the Sector Report revealed;

  • Evidence of deep and widespread disinvestment and planned disinvestment in drug and alcohol services. (Over 70 services indicating cuts in funding with an average net reduction of 16.5%)
  • A third of local authorities indicating decisions to reduce funding in 2014/15 and 2015/16
  • The massive scale of re-commissioning and tender renegotiation leading to the widespread disruption of services. (54% of services since Sept 13 with another 49% indicating re-commissioning between Sept 14 – Sept 15)
  • Cuts in frontline drug and alcohol staff across the country and increasing caseloads
  • Worsening access to mental health services
  • Worsening provision of outreach services
  • Worsening access to housing and resettlement provision
  • Worsening access to employment support
  • Lack of provision for older clients
  • Negative impact of prison staffing cuts on access to treatment
  • Little confidence in Police and Crime plans and Joint Strategic needs Assessments/Joint Health and Wellbeing strategies reflected local needs
  • Reduction’s in harm reduction services at a time of increases in drug related deaths
  • Commissioning processes that discriminate against excellent small and medium-sized organisations delivering excellent local services

There has been a change in the focus away from the needs of vulnerable heavily addicted people with often multiple economic, social and health problems onto the needs of the wider population. The not insignificant needs of this far larger population will mean fewer resources to support those heavily dependent on drugs and alcohol with multiple and complex needs.

The provision of services to people with significant and multiple needs is being disrupted by frequent re-commissioning and system redesign. It has a hugely detrimental impact on the ability of organisations to care for people accessing services. It has had a significant negative affect on staff morale and the ability of organisations to invest their resources into the provision of services which are increasingly diverted to funding tendering capacity. Sadly at Blenheim, and I suspect other providers, staff work through the night not to help those in need but to win the right to deliver services with significant reductions in funding, challenging targets and poorly thought out PbR requirements. The costs and transfer of liabilities to the voluntary sector are driving all but the largest providers out of existence.

There is an increasing failure to address housing, complex needs, mental health and employment. There is a shocking lack of access to the employment market for people with a history of drug and alcohol misuse particularly where this is associated with criminal convictions. Specialist services addressing employment for this group were decimated in the Government commissioning of the Works Programme. Changes to welfare benefits have impacted detrimentally on housing stability and the level of homelessness experienced by those who are drug and/or alcohol dependent is rapidly increasing. The decommissioning of many NHS providers is resulting in a decline in many areas in access to specialist mental health service provision.

People with drugs and alcohol problems suffer prejudice and discrimination particularly if they commit the crime of being poor. Sadly this right to discriminate is enshrined in UK equality legislation. Yet again we see policies being suggested which focus on drug and alcohol users as being the undeserving benefit claimant if they are not in treatment. A requirement on local authorities to provide employment paying the living wage would be more constructive. It’s often not that people with drugs and alcohol problems are reluctant to work but that employers are reluctant to provide employment. We need a system of regulation that supports those experiencing problems with alcohol and drugs rather than criminalizing and stigmatizing people for being ill and vulnerable.

People who inject drugs are the group most affected by hepatitis C in the UK: around 90% of the hepatitis C infections diagnosed in the UK will have been acquired through injecting drug use. Across the UK 13,758 hepatitis C infections were diagnosed during 2013.

Around 2 in 5 people who inject psychoactive drugs such as heroin, crack and amphetamines are now living with hepatitis C, but half of these infections remain undiagnosed. PHE state “Interventions to diagnose infections earlier, reduce transmission and treat those infected need to be continued and expanded, with the goal of reducing the prevalence of hepatitis C.”

Often, hepatitis C infection remains asymptomatic and is only diagnosed after liver damage has occurred. Left untreated hepatitis C infection can result in severe liver damage, liver cancer, liver failure and death.

This year we will leave 97% of people with hepatitis C untreated. Imagine the outrage if this was breast cancer or lung cancer, particularly if the death rate was climbing year on year as it is with hepatitis C.  Now imagine if you could completely cure everyone with breast cancer or lung cancer but decided to only treat 3% a year. Outrage! This is precisely what happens to those with hepatitis C.  There is a real risk now that even this appallingly low figure will become unachievable as a result of changes in funding.

Lets move on to Naloxone: the failure of Government to roll out Naloxone in England along with a lack of emphasis on harm reduction and disinvestment in drugs services are likely factors in a 32% increase in heroin/morphine related deaths.

The ONS figures (2013) for drug related deaths show that there were 765 deaths involving heroin/morphine; a sharp rise of 32% from 579 deaths in 2012. Many of these fatalities could possibly have been prevented by the use of Naloxone as an intervention.

Naloxone is a medicine that is a safe, effective and with no dependence-forming potential. Its only action is to reverse the effects of opioid overdoses. Naloxone provision reduces rates of drug-related death particularly when combined with training in all aspects of overdose response.

The Advisory Council on the Misuse of Drugs (ACMD) undertook a review of Naloxone availability in the UK in May 2012, its report to the Government strongly recommended that Naloxone should be made more widely available, to prevent future drug-related deaths.

Scotland and Wales have national programmes to make Naloxone widely available but there has been no similar programme in England. This has led to a failure across England to supply Naloxone in over of 50% of local authorities.

Overdose remains a leading cause of death among people who use drugs, particularly those who inject. Increasing the availability and accessibility of Naloxone would reduce these deaths overnight. Perhaps we should conclude that English opiate users lives are worth less than the Welsh and Scottish ones.

There is a growing palpable sense “old school activism” in the sector. There’s no time, no money, no staff, no resource but up and down the country people, organisations and service user groups are rising to the challenge. There is a palpable sense of determination; the power of networking is gearing up, sharing ideas, inspiration and the need to stand strong in the face of cutbacks.

Unless Service User Groups and a powerful alliance of GP’s, NHS and third sector providers and charities are prepared to fight in the corridors of Whitehall and Westminster, and on the beaches of local authority cuts, I fear that the worlds best treatment system is about to be decimated in 2015/16. I fear for the people we help and I pray that I am wrong. It’s time to stand and fight.

Hepatitis C infection is a major health issue nationally and should be a PHE priority

People who inject drugs are the group most affected by hepatitis C in the UK: around 90% of the hepatitis C infections diagnosed in the UK will have been acquired through injecting drug use. Across the UK 13,758 hepatitis C infections were diagnosed during 2013.

Around half of the people living with hepatitis C infections don’t know it, according to a new publication from Public Health England (PHE) ‘Shooting up: infections among people who inject drugs in the UK 2013’ published on the 5th November 2014.

In total, 13,758 hepatitis C infections were diagnosed in 2013 in the UK, with around 90% acquired through injecting drug use. Around 2 in 5 people who inject psychoactive drugs such as heroin, crack and amphetamines are now living with hepatitis C, but half of these infections remain undiagnosed. This is why Blenheim in partnership with a wide range of organisations under the banner of the Hepatitis C Coalition is doing everything we can at a national, local and operational level to ensure more people at risk now or in the past get tested. I agree 100% with PHE when they state “Interventions to diagnose infections earlier, reduce transmission and treat those infected need to be continued and expanded, with the goal of reducing the prevalence of hepatitis C.” Current service provision needs rapid expansion.

If caught early hepatitis C can be successfully treated with antiviral medications. Often, hepatitis C infection remains asymptomatic and is only diagnosed after liver damage has occurred. Left untreated hepatitis C infection can result in severe liver damage, liver cancer, liver failure, and even death. This is why Blenheim is appalled that only a shameful 3 out of every 100 people with hepatitis C are treated each year. Treatment can completely cure most people at a fraction of the life time cost of treating HIV.

In 2013 there were 7,290 cases of tuberculosis reported in England, which is a rate of 13.5 cases per 100,000 population and TB is now one of PHE’s 7 priorities. My unscientific back of a fag packet approach suggests a rate for 21 cases per 100,000 population being diagnosed annually with hepatitis C. (Yes I adjusted for hepatitis C being UK and TB being England in relevant PHE figures).

If this is the case PHE need to prioritise hepatitis C treatment and the treatment of injecting drug users. Indeed their own experts agree.

Dr Vivian Hope, a PHE expert in infections among people who inject drugs, said: “with around half of those people living with hepatitis C still unaware of their infection, we need to do more to increase diagnosis rates. Ultimately, this will help reduce the current high level of infection we’re still seeing among people who inject drugs”.

Dr Fortune Ncube, Consultant Epidemiologist and lead for PHE on Injecting Drug Use said: to reduce transmission and decrease rates of hepatitis C infection it is imperative that we maintain adequate provision of effective interventions such as needle and syringe programmes, opiate substitution and other drug treatment.

With many services for drug and alcohol dependent people being cut back significantly across the country we are in danger of a continuing increase in the numbers infected with hepatitis C and even more people not getting the treatment they so urgently need.

HEP C SCANDAL – failure to provide treatment or baseline data

National figures suggest 49% of people who inject drugs in the UK are hep C positive, this compares to just 1% who are HIV positive. This group is more likely to have been in prison and been homeless and 47% are unaware of having hep C.

Only 3% of people with hep C get treatment annually despite existing effective treatments being available. This is a scandal.

The rate is far lower for those with drug problems and figures are not kept regularly on people’s access to treatment. This hides an appalling institutional discrimination against drug users and other minority groups. Only 52% of Health and Wellbeing Boards have given any priority to hep C despite many of them having high rates of infection. The numbers dying as a result of hep C infection are rising at an alarming rate despite it being something for which there are effective treatments. The failure to act is shameful.

Substance misuse agencies, the NHS and local authorities must do more to test, treat and cure those with hep C. A first step would be for Public Health England to add a question about whether those hep C positive are receiving treatment to data required from all service providers, to ensure an adequate baseline on which to base an improvement plan.

Public health ring fenced funding not safe in PHE and Local Authority hands

Blenheim is extremely concerned that Local Authorities are diverting ring fenced funds for public health which includes money for drug and alcohol services to fund other services. Blenheim adds its voice to that of the Faculty of Public Health which has called on Ministers and the National Audit Office to more closely scrutinise how the system is working.

Local authorities across England are diverting ring fenced funds for public health to wider council services to plug gaps caused by government budget cuts a BMJ investigation has found. The BMJ also found that public health staffing in some parts of the country is being scaled back to save money. Professional organisations have warned that public health’s voice may be drowned out in local government and that its workforce is spread too thinly.

The investigation found examples of councils reducing funding for a wide range of public health services, including those for substance misuse, sexual health, smoking cessation, obesity, and school nursing. The BMJ found that many local authorities have deployed public health funds to support wider council services that are vulnerable to cuts, such as trading standards, citizens’ advice bureaux, domestic abuse services, housing, parks and green spaces, and sport and leisure centres.

Only 45% of respondents to a recent BMA survey of public health professionals working in local authorities and at Public Health England believed that the public health grant was being used appropriately in their area, while almost half (49.6%) believed that the grant was seen “as a resource to be raided” by local government.

The BMA’s survey also highlighted fear about future staffing levels in public health, with just 12% of respondents believing that there would be enough substantive consultant posts available to serve the needs of the population in 10 years’ time.

The Association of Directors of Public Health told the BMJ that it was particularly concerned about a vacuum in public health leadership at the top of local government, with a quarter of director posts currently unfilled or filled by temporary appointments.

I am even more concerned about Public Health England’s (PHE) apparent failure to adequately ensure that the public health money is spent in line with the ring fence.

The national authority, Public Health England, has said that it supported local authorities making tough decisions and that it was right for public health grants—totalling £2.8bn across England for 2014-15 – to be used to leverage wider public health benefits across the far larger spend of local government.

Duncan Selbie the head of PHE said “The duty is to improve the public’s health, not to provide a public health service.”

At Blenheim our translation is it is about improving the health of the overall population not treating people who are ill. This is particularly unfortunate for those whose treatment is the responsibility of local authorities and PHE. PHE seems to be giving the green light to local authorities to loot and plunder the ring fenced public health grant at will.

This will then come as little comfort to those who now rely on the specialist health services to support them overcome problems with drugs and alcohol and brings into question whether these services and a relevant proportion of the funding should be transferred back to NHS England which is about providing a public health service.

As part of its investigation the BMJ issued requests under freedom of information legislation to all 152 upper tier local authorities in England (most of which are unitary, county or city councils), asking for details of all services commissioned and decommissioned since April 2013 and for details of commissioning intentions for the coming year.

Of the 143 authorities that provided information, almost a third (45) have decommissioned at least one service since April 2013, while others have cut funding to certain services, the BMJ found. Many councils are decommissioning individual contracts for services such as sexual health and substance misuse and then re-commissioning new integrated services to make efficiency savings. Other authorities have decommissioned services that they said were not having the desired outcome on public health or delivering value for money.

In total, more than half of authorities (78) have commissioned or re-commissioned at least one service since April 2013, and the pace of change is set to escalate this year as councils carry out root and branch reviews of services after the year of consolidation.