Monday, 19 June 2017

Who can buy an alcohol service?

This is a slightly longer post than usual, as it’s (almost) the words I spoke at the recent New Directions conference in Weston-super-Mare.  For those who haven’t been to New Directions before, I strongly recommend it.  There’s always an excellent line up of speakers, this year including Marc Lewis, Nick Heather and Lucy Rocca to name just a few.  One of my favourites, who I hadn't seen before, was Marcantonio Spada, from London South Bank University, talking about how our beliefs about how we think and how our brains work actually affect the reality of how we think and what we do: metacognition.

I was asked to speak in a session called ‘Can we have traditional alcohol services?’, under the title ‘Who can buy an alcohol service?’  So here goes…

Morning everyone.  I feel like I should start this talk with something of a disclaimer, maybe get my apology in first. In fact, three apologies. First, I'm going to talk to this title of ‘Who can buy an alcohol service’, but I’m not entirely sure what it means, so I'm going to use it an opportunity to present some kind of ‘state of the nation’ reflections from my job as a commissioner of substance misuse services in Dorset

Second, I'm worried about the length of this. But I shouldn't be much more than 20 minutes.

Finally, I don't explain too much of the nuts and bolts of commissioning, or who does what - it's part of my shtick that it's complicated, so maybe I don't want to destroy the mystique. But equally, please stick your hand up or shout out if I'm talking about something you'd like explaining. In my job, it's an extremely unfunny running joke that we talk in acronyms we can't actually spell, left alone explain. Fundamentally, I'm a commissioner, which means my employer - Dorset County Council or Public Health Dorset - pays the NHS or charities to provide treatment for what, despite Wulf's powerful and persuasive points yesterday*, I'm going to simply call 'substance misuse'. And that should really be a fourth apology, before I've really started.

Oh, and a fifth: I'm talking only about my experience, which I'm aware is very English. It's not even British. The systems in Wales and Scotland - not to mention Northern Ireland - are notably different.

But back to that title. The simple answer to this title question is: loads of people.  I think it’s a truth universally acknowledged that at the moment commissioning responsibilities are hugely fractured within the public sector.

This diagram, which I showed when I spoke at New Directions last year, is meant to be a helpful explanation of the NHS in light of the Coalition Government’s reforms – which included the transfer of all commissioning funds for substance misuse treatment to local authorities.  I don’t find this helpful – apart from to illustrate the mind-boggling complexity of the current arrangements.  And it doesn’t even cover some crucial elements that potentially relate to substance misuse, such as housing, or employment.

And this is where we might think we could run into problems.

I’ve written and spoken before about how the shift of responsibilities for drug and alcohol treatment from the National Treatment Agency to Public Health England wasn’t just semantic; there is potentially a genuinely different worldview associated with these different organisations.  And the different commissioners might have very different ideas of what the ‘problem’ with alcohol is, who the relevant potential ‘clients’ are, and what a positive ‘outcome’ would be.

But my comment last year was that we shouldn’t see this chaos or complexity as necessarily a bad thing.  Perhaps it would be neater and easier for commissioners and providers if we had straightforward, simple structures for ‘alcohol’ services, but of course life – including addiction, or dependence, or problematic use – is more complicated than that.  I’m going to stick my neck out and say that it doesn’t make much sense to look at alcohol use, or addiction, as separate from other elements of a person’s life.

Once we’re thinking about a person’s life as a whole, are the problems, the clients, or outcomes really that different for different organisations?

And I’m not going to deny that this is an issue, particularly when resources feel scarce.  There are arguments about who should be funding alcohol liaison nurses in hospitals, for example.  The acute trust or CCG might state that this is surely about public health, but the local authority Public Health team is likely to reply by saying that it’s the hospital that will save money by having fewer admissions, so shouldn’t they be the ones investing to save?

But my point is to ask whether we’re really as far apart as it might seem.  Whenever I sit down with commissioners or providers – be it in relation to the police, housing, or mental health – it’s immediately clear that even if we’re not talking about exactly the same people (and we often are), then we’re talking about many of the same causes, symptoms and solutions: stable housing, strong personal relationships, stable employment, and so on.  All these things boost people’s chances of turning their lives around.

That is, when it gets down to serious discussion, we're actually pretty agreed about what a positive outcome is, and how to get it.

This is the attraction of a programme and slogan like ‘Jobs,Friends, Houses’ and the idea that addiction is simply an absence of social connection – an idea recently popularised by Johann Hari, citing the research of Bruce Alexander, who spoke at this conference last year.

And this is why I’m sometimes sceptical of the idea that there should be ‘alcohol’ services, or that we should think of ourselves as part of an ‘alcohol’ sector – or even a ‘substance misuse’ sector.  We need to make sure services are linked together and think about the ‘whole’ person, or the ‘whole family', to use the buzzwords of the moment.  As Nick Heather put it last year when discussing this, ‘addiction is a problem of living’.  You can’t separate it out from other aspects of life; it is part of life, part of living.

But one of the problems with that approach is that there isn’t a neat distinction between cause and effect, or symptom and disease, as there would be in an ideal medical/scientific model.  What I mean is: substance misuse can be both a cause of and caused by unstable housing, relationships and employment.  These are potentially part of a complex cycle (which may be vicious or virtuous).  So it might be that for some people, a housing first approach, or ensuring stable accommodation, starts them on the road to recovery.  But for someone else, this would be at best a harm reduction strategy, and no real change can be brought about without addressing alcohol use head on, and the primary problem.  Without being flippant, there isn’t one definition of an alcohol problem; there are myriad (in fact infinite) problems where alcohol is implicated.

All I’m trying to say here is that although different people and organisations might agree on outcomes, on a broad definition of what the ‘good life’ might be, this doesn’t mean that services can just be reduced to generic ‘life’ support.  There is a need for something alcohol specific.

So if there’s a need for alcohol services, that brings us back to that question of who can (or should) be buying them.

As I said at the beginning, there’s loads of organisations that can buy something that could be badged as an alcohol service.  And I’m not really precious about this.

But I want to make two critical observations or suggestions about the way things work at the moment.

First, I think debates about the perfect place to house budgets or responsibilities in relation to alcohol are a waste of time. (Though I still often engage in them!)

I might have a view that local authorities aren’t the best place to house commissioning of structured treatment that involves prescribing, but there it is, and to be honest it doesn’t make a great deal of difference what building I have to work in.  The politics and debates will be different, and the pressures and priorities might change, but they won’t go away.

I could complain about how it’s difficult to harmonise or integrate local authority commissioning with the CCG, or NHS England, or the Police, but fundamentally these barriers will always exist - and they even exist within organisations.  Even though Public Health is now nominally part of local authorities, this doesn’t mean that there is wonderful integrated commissioning with housing and homelessness support, or social care, or children’s services.  These things are pot luck, perhaps a ‘postcode lottery’.

And that’s the crucial bit.  They’re down to local decisions and working relationships.  That is, the fundamental issue isn’t the structure, but the people.  We know this in treatment: that potentially the single most important thing in your treatment is the therapeutic relationship with staff.

But we don’t talk about it so much in broader policy terms.  Politicians and broader policymakers and influencers such as think tanks seem to think that we’re justone grand reform away from having the perfect structure to address a problem.  If only we had truly ‘joint’ commissioning, or ‘integrated’ budgets.

But this is a fight with an imaginary enemy – or at least an eternal, elusive enemy.

We’re talking about substance misuse, or as I mentioned earlier, all aspects of life.  And that means that there can never be a single, perfect way to cut the cake, and equally you can’t just commission ‘life’ support services (if you’ll pardon the pun).  To take a simple example: first aid, x-rays, possibly surgery, casts, check ups and physiotherapy might all be part of healing a broken bone – but they’re not delivered or managed by the same person, or the same service, or in the same place.  The key is to make sure the different organisations and people talk to each other and work together, for the good of the patient.

And the same is true for commissioning or providing alcohol services.  The organisational boundaries will never be perfect; it’s about working to ensure whatever system is in place is as efficient and effective as possible.

So that’s the first point: let’s not imagine that there’s a perfect solution that we just have to reform for in terms of organisational boundaries or responsibilities.  In my experience, the reality is that pooling budgets and joint commissioning are a pipe dream in any case, even for relatively small areas or themes.  Any form of ‘joined up services’ is best implemented by simply getting on with it at the coal face and coordinating front line services in practice.

So there we go, that’s the first word of the title out of the way: the ‘who’.  The answer (or dodge) being that I don’t really mind, but at the moment there’s loads of people.

I promise I’ll get onto the other words.

And to be honest, I’ve already covered ‘alcohol service’.  It’s too narrow, but equally some type of service that’s specific to alcohol (or at least substance misuse) is necessary.

So what are we left with?

The key bit is that word ‘buy’.  There’s no doubt that we currently do ‘buy’ services from either the NHS or third sector organisations – or in fact in some cases, as in Bath and North East Somerset just up the road, from private providers like Virgin.  But I want to suggest that the word ‘buy’ in this context is misleading about what’s happening, or what perhaps could or should happen.

We think of commissioning as buying, and of buying as being something to do with this mythical idea of a ‘market’, or at the very least ‘competition’.  But the reality is nothing like buying breakfast cereal in a supermarket.

My job isn’t really about procurement or purchasing.  In fact, there’s a procurement team within the council who deal with the actual purchasing and contracting – which only happens every few years in any case.  My job is to help design services and work with managers to ensure the right sort of things are being done and we’re getting the outcomes we all want.  In fact, you’d probably best describe it as being either some kind of manager or a service design and development officer.  But I suppose we call it commissioner because that’s the popular or fashionable language.  And in reality, my actual official job title is the meaningless ‘Senior Health Programme Advisor’.

Commissioning, as defined by government, academics and think tanks, is about much more than buying, purchasing or procuring – however you want to label it.

If you look at the model of commissioning from the Institute of Public Care at Oxford Brookes (where I did my commissioning qualification), you’ll see that the actions of ‘analyse, plan, do, review’ could equally apply to any form of service delivery.  Maybe that inner circle wouldn’t apply, but if you just look at the outer ring relating to commissioning, it’s hard to imagine any sensible service not operating something along these lines: think about what you might do; do it; see how well it went.

So in some ways, this model of ‘commissioning’, where we emphasise procurement, isn’t actually that important.  In itself, it shouldn’t really change the assessment of need in the local community, or the design of services.  (I’m not making any comment here about how those things are shaped by local or organisational priorities, and the fickleness of politics in funding decisions.)  And as anyone who’s been through one of these processes knows, there’s a lot of discussion about transfer of staff from one provider to another, and you can often end up with much the same people doing much the same job, but perhaps under a different organisational banner.

But, based on a procurement process I’m in the middle of at the moment – and so can’t say too much about – I think there are potentially significant effects of this approach.  Fundamentally, a huge amount of my time over the past year has been spent:
  • writing reports for committees to approve certain budgets and processes;
  • writing service specifications for new contracts;
  • writing evaluation questions for prospective providers; and then
  • conducting evaluations;
  • organising and marking interviews; and
  • writing feedback.

There are positives to this: it means we can re-shape services, and we’re planning carefully for that.  But it comes at a cost – even if that cost is simply that we have to spend less time on the usual quality assurance or service development work.

And this is where the market analogy breaks down.  That just isn’t the same as any market I’ve ever shopped in.  You don’t buy years’ worth of Weetabix, find you don’t really like it or it’s leaving you hungry by mid-morning, and then just say: “well, I’ll just have to stick with it for another year or 18 months till I can buy something else”.

I know this is a flippant example, but it is actually relevant.  Within this model of procurement and commissioning, there is undoubtedly waste and miscommunication.  Some people have suggested to me that there would be much less stress and miscommunication if the whole process was less formalised.  In fact, if it was simply an ongoing conversation as it is outside of procurement periods.  And rather than setting up evaluations as a kind of exam, or jumping through hoops (“we’re not going to specify who our key partners are; it’s a test to see if they know”) commissioners and providers could just have a direct conversation.

And in fact we can run procurement more in that way.  There are ways we can do this whole thing called ‘commissioning’ better.  For example, the idea that local authorities must go out to tender every three years is a myth.  Commissioners can be more creative – particularly in the current climate where all bets are off about the future of local government funding and NHS commissioning practices.  The current regulatory framework allows for decision to be postponed in exceptional circumstances, and if the circumstances today in terms of changing budgets, shifting commissioning responsibilities, local government reform in many areas, and so on aren’t exceptional, I’m not sure what would be.

Moreover, decisions don't have to be made on the basis of price. We've set a budget, and we’re judging providers on how they're planning to spend that money (how much goes on ‘front line’ service delivery, for example), and how credible those plans are.

And this is my plea, then, to finish this rambling presentation.  Or rather, my two pleas.

First, we all need to campaign to make the system better, by which I simply mean ‘more efficient’ – which is ironic, given that commissioning and the supposed ‘market’ model is meant to be efficient by definition.

But as I said earlier, changing the system isn’t terribly useful in itself.  Usually the most efficient thing is to work within whatever is in place in the most sensible way possible – particularly given that what really matters is the people involved.  If you’ve got the right people, and they’re motivated, they can make good things happen.

And that’s the second plea.  We all – whether providers, commissioners, or interested observers – need to work in ways that make that system as close to optimal as it can be.  Let’s be pragmatic, canny, and calculating.  For example, why drive some charities out of business by competing in a zero-sum way?  Providers should be working in partnership, and not simply seeking to hoover up additional market share.  I know that’s easy for me to say, as I’m not a ‘business development’ officer whose salary is dependent on bringing in new contracts.  And I know commissioners have been guilty of setting up these conditions in which that kind of competition happens.  But both commissioners and providers can work differently.

And that brings me onto my final point, which I think the organisers of the conference were wanting to get at with this session, entitled: ‘Can we have traditional alcohol services?’  I think it’s getting harder to imagine, with the financial pressures as they are, that it would make sense to commission or provide a standalone alcohol service.  Increasingly, there are pressures to reduce transaction costs, which means commissioning one contract across an area, and let’s not forget that ‘joint commissioning’ is the flavour of the month.

But that doesn’t have to mean having just one agency.  It’s very possible that partnerships can exist, whereby a specific service or organisation with something to add provides the bit of the treatment system where they have expertise – say in club drugs, or perhaps alcohol, or even a specific element of alcohol – for example engaging increasing risk drinkers, rather than fully fledged dependent drinkers.  They might have specific expertise, or a local profile and reputation.  That could be what makes them particularly good at doing this on a relatively small, specialised scale.  And actually that specificity and expertise could be provided under a different banner or service, but by the same overarching organisation.  Wouldn’t that still be a dedicated ‘alcohol service’?  It’s not inevitable that specific or local expertise will be wiped out by ‘the market’.

So in conclusion, let’s not paint commissioning in simplistic terms as a form of magic market, or the devil’s work.  It’s just a word, and a broad set of principles that are reliant on people doing sensible things.

Of course, the context is the reduction of public sector budgets, and the idea that local authorities will be self-sufficient and fund all public health services (including substance misuse and sexual health) through business rates in a couple of years.  But that’s a tale for another day.  For the moment, I’d just answer the question: ‘can we have traditional alcohol services’ by saying, ‘Yes, if you actually want them enough.’  Whether we should – well, that’s a question for someone else.

Thank you.

* We talk about substance misuse, but not all substances are drugs, and the word ‘drugs’ is pretty meaningless, as Toby Seddon (amongst others) has pointed out.  And what about that word ‘misuse’?  Is it misuse to use substances that are narcotic, psychoactive or in some way affect one’s brain, for precisely that reason: to alter one’s mental state?

Sunday, 11 June 2017

Reflections on the Psychoactive Substances Act one year on

One of the most interesting developments in UK drug policy in the last few years has been the introduction of the Psychoactive Substances Act (PSA), which came into force just over a year ago in response to the emergence of 'new psychoactive substances', often known as 'legal highs'.

As this anniversary has come round, there's been quite a bit of media and policy discussions about how well it's worked, and whether it can be viewed as a positive development.

I've been involved in several discussions about this.

First, there are several recorded interviews or snippets of mine that have been broadcast on BBC Radio Solent:

Second, I've commented on an excellent event, the Psychoactive Supper, held around the time of the introduction of the Act.  The organisers put together a short film describing what happened, and then asked me and the excellent Neil Woods of LEAP to comment on it.  You can find this if you scroll down a bit here.  What I try to do in this piece is describe how the supper highlights the inconsistencies in the Act, and reflect on how well the Act may have worked in practical terms.

But if you want a more complete outline of my personal (optimistic) opinion, please read my recent piece on VolteFace, which was itself prompted by the most recent meeting of that group of academics.  I set the scene for a discussion of the Act by suggesting that we're kidding ourselves if we think we can have a perfect, neat, objective drug policy based on reducing 'harm'.  Harm is a really complicated concept that we can't use to put a single value on a substance, and if we try to identify substances we're going to legislate as 'drugs' then we've already begged the question: what is a drug?

And so I think the PSA is a potentially positive development because it's more open and honest: substances are banned and controlled not on the basis of some objective idea of harm, but simply because they alter our mental state - because they are psychoactive.  That means there's much more scope for discussion and disagreement when compared with a debate about drugs and 'harm'.  It's hard to disagree that something scientifically decreed to be 'harmful' should be closely regulated, and even illegal, but it's not so clear that everything that alters our mental state can or should be outlawed as a matter of course.

I look forward to the possibility of that more open debate about the aims and effects of 'drug' policy, but being very aware that public debate doesn't always lead to the kind of clear and open discussions I'd prefer.

I hope some of this at least is of interest.  I think there's no doubt that in terms of policy relating to alcohol and other drugs - or whatever we're going to call psychoactive substances - we live in interesting times.

Tuesday, 23 May 2017

Is research really something special?

As I've mentioned before on this blog, I've been pretty busy over the past few months, as we've been re-procuring almost all of the substance misuse treatment services across Bournemouth, Poole and the rest of Dorset.  So I can only apologise that several of the posts I'm writing currently are responses to events held or pieces published some time ago.  But as I always say, with a historian's perspective, the fundamental issues related to alcohol and other drugs don't really change - and certainly not in a month or two.

So here goes with some reflections from the Alcohol Research UK conference a month or two ago.  Unlike its usual format of what I think of as a kind of 'state of the nation' set of presentations from big names in the field or simply those with significant findings that need communicating to the wider sector, this year it had a very specific focus: public involvement in research.  In some ways I missed the standard approach, getting my latest update on the state of research in relation to alcohol harm.  But there were clear strengths to this approach.

First, there's no doubt that involving service users and the wider public in research and service provision is too often a token exercise, and this is something we're acutely aware of in Dorset: although we've included service user panels in our recent procurement exercise, and there are service user reps are included contract review meetings and relevant decision-making boards, there's still more we can do, particularly in relation to day-to-day business.  And this conference was full of pointers about how to start thinking about this process, from philosophical insights to practical tips.

Second, there's simply something positive about being encouraged to look at an issue from a different perspective.  In this case, I started to think about the broader point of how we often divorce research from practice.  A key presentation came from Simon Denegri of the NIHR, which funds a considerable amount of health research in the UK.  He emphasised the increasing importance placed on service user – or patient – involvement in research in the UK.  This should help shape the entire process of research, right from the initial setting of priorities for researchers and funders.  One of his insights was that actually, most patients expect there to be research going on in relation to healthcare, and so wouldn't be surprised to be asked to be involved.

This is an important insight in terms of more than the culture around healthcare research.  The reason people wouldn't find this strange is that they expect there to be work going on to ascertain what treatments work, and how they can be improved.  This is partly because medicine is so closely related to science, and the model of drug trials, and Randomised Control Trials (RCTs) fits so well, but that's no reason why we shouldn't expect people to apply the principle more broadly – to the full range of substance misuse treatment services, for example.

If we think of research at its simplest level, it's just trying to answer questions, which is exactly what we spend a lot of time doing whether at work or home.  How can I put up these shelves?  What sort of meal can I make from these ingredients in the fridge?  How can I swim faster?  In each case, we probably have a think using the knowledge we've already got, maybe consult a book or the internet to see what other people have found, and maybe we just give something a go and see how it works out.  All of these are part of any 'research' process.  And most fundamentally, all those example questions I've given have an implicit purpose: someone wants to be able to store books, or eat some tasty food, or win a swimming competition.

Now think about 'alcohol research'.  If we take Alcohol Research UK's overarching mission, the aim is to reduce alcohol-related harm.  And research can't do this on its own.  In fact, it needs policy and practice to 'do' anything, to make any difference.

Let's return to those 'research questions', such as how to make something for dinner.  Those are precisely the kind of questions practitioners should – and do – ask of alcohol treatment.  How can we optimise treatment for this client?  And they'll be working on all those bits I outlined: knowledge/experience they have, consulting maybe or similar resources to find out what others have done to achieve success, and maybe just trying something and reflecting on how it goes.

And this is precisely the same model as commissioners are encouraged to follow: analyse, plan, do, review.

Institute of Public Care, Oxford Brookes University.  See[1].pdf?res=true 

And wouldn't people in treatment or out of it find it strange if we weren't doing this?  If we weren't reflecting on our current practice to find out who needs support, what we think works for different groups, and how well we're delivering this?

This might seem like a bizarre discussion.  Like I've set up some kind of straw man.  And perhaps I have, but if so then it's a straw man that I've genuinely believed in – or at least been scared of – and that seems to inform thinking in universities, the NHS, and wider treatment services.

I benefited from a grant to do a PhD at Bournemouth University, and the only reason that grant existed was Vice Chancellor Paul Curran’s idea to transform Bournemouth into a 'research led' university, where it had previously been seen as a teaching and training university, according to the established wisdom: our department in particular trained people to be nurses and social workers.  I was part of the grand vision to sweep away old experts in teaching with a new cadre of young researchers.

I won’t reflect on how well that worked out, or whether it was even a good idea in the first place, but I’m very grateful for the opportunity it gave me.  My point is simply that the division between teaching and practice on the one hand, and research on the other, was an unavoidable aspect of how this issue was framed, and how it played out.  And similarly, at conferences in this field it sometimes feels that academics and practitioners don’t just talk different languages, but are different species.

(I’m assured this wasn’t always the case; that addiction studies and conferences like New Directions in the Study of Alcohol used to be filled with research active clinical psychologists – and I believe it.  Flicking through the 2002 New Directions journal (another illustration of the fact that the key issues and dilemmas don’t go away) you can read reflections on practice by Doug Cameron and Richard Velleman, amongst others.)

But in fact, any practitioner worth their salt would have been asking those questions I just outlined, and developing their practice accordingly.  And any researcher worth their salt should have been trying to answer them.  That is, there is no great divide in philosophy, epistemology or anything else between practice and research.  Some of us just choose to get precious about – or frightened of – this word ‘research’.  In fact, it really just means finding out, and we shouldn’t be dividing it off from practice; we should be embedding it in practice.

As I say, this may mean nothing to some readers, or seem like a straw man argument, but I would argue that if we embed a culture of being curious, seeking knowledge and looking for innovation into our practice, then we are de facto ‘researchers’ – and this is an approach that isn’t typical of services and commissioners today.  And if providers and commissioners are de facto researchers, so should those accessing the service be.  Then, as in healthcare more broadly, it wouldn’t seem odd or unusual to ‘involve’ service users – in fact it would be strange not to.

Wednesday, 29 March 2017

Is drug policy about drugs?

This week, I’ve been at a mini-conference to discuss prohibition through different periods of history and across different countries and societies.  Although I did (part of) my first degree in history, anything I write now is more based on what ‘I reckon’ rather than any genuine knowledge, historic or current.  So it’s not clear what I was doing there, but they let me in anyway.

(I should say at this point, as I did when I wrote about the original conference, that this is an amazing group of academics, and there’s a load of fascinating work going on at Warwick University more broadly.)

My contribution was born a year ago as a response to the 2016 Psychoactive Substances Act.  Unsurprisingly, at that point (and now), it was hard to find too many academics in history or social policy prepared to defend the Act.  So, being the attention-seeking contrarian that I am, I saw my role (or my way of getting a paper accepted) as being to be a bit more positive about the Act.  I suggested that it could be a catalyst for change in drug policy, as it reframes the debate from being about harm to being about psychoactivity itself.  But that’s a post I’ve kind of already written (though I can write it much more clearly, and will do sometime).

So what I want to do here is to reflect on what we were trying to do as a whole.  The idea was – and is – that we can usefully say something about the idea of prohibition through the ages.

But I was constantly reminded of a paper I saw at the wonderful ADHS conference a few years ago.  There, Lauren Saxton talked about how alcohol was understood to lead to infertility amongst women in France in the nineteenth century (because that was their major national concern), whereas at the same time, with the same substance in Britain, we were concerned that alcohol was leading women to have more children than they should do.

The point being: alcohol (or any other ‘drug’) has a meaning and set of concerns that are hugely dependent on the wider context.

So what’s that got to do with prohibition?

Well, hearing these accounts from France, Indochina, Mexico, Russia, America, Portugal, as well as the UK and the international community more generally, I started to think about how alcohol or any other drug offers something of a lightning conductor for any other concerns the public might have, be they in relation to race, gender, class, nationality, religion, productivity, industry, modernity, or anything else.

In some ways, use of morphine in the late nineteenth and early twentieth century could be seen as rational, pure, clean and reasoned, with the use processed ‘white drugs’ (like heroin and cocaine, as well as morphine) administered with precise dosage using the technical innovation of the syringe.  This was what Christopher Hallam was telling us the ‘bright young things’ of the interwar period were doing – elite, well-educated, white aristocrats.  ‘Brown drugs’ were less processed substances like hashish and opium, perhaps seen as ‘dirty’ and were more associated with the working class or ‘foreigners’ like Chinese immigrants.  (The white/brown binary here really is pretty transparent.)

But others, like Susannah Wilson, noted that in some cultures and periods, that scientific/natural binary doesn’t always have ‘science’ on top.  Of course, doctors can use it to defend their own use, as they did in nineteenth century France, but the precision and technical approach to drug use can be seen as new and frightening.  Soon, you get onto a discussion of the optimism and fear that equally surrounded ‘modernity’.  Is change exciting, frightening, or both?  Are ‘natural’ ingredients better than chemically pure, processed ones?  You’re probably thinking that it depends on who you are, what you’re doing and what you’re trying to achieve.  And so it is with drug debates.

Similarly, the idea of prohibition can symbolise any number of things.  It can be, as Mark Lawrence Schrad argued, an opportunity for emerging nations (such as Turkey, even when ruled by heavy drinker Ataturk) to expel foreign industries and express a new anti-colonial identity.  Or it could be an opportunity for the Protestant Ethic to express itself.  (And I should reference the work of Henry Yeomans at this point, as I didn’t do in that post.)  Or, in the early twentieth century, it could be a way for a nation to show it was part of the international club, which Cecilia Autrique noted was part of Mexico’s motivation in developing drug policy in the early to mid twentieth century.

Alternatively, rather than being anti-colonial, prohibition has been justified by discourses of anti-orientalism (that drug use is somehow characteristic of ‘weak’ nations like the Chinese, or Arabs, or whatever culture is viewed as negative in the time and place in question).

But even here, things are complicated.  Aro Velmet explained that the same forms of drug use were seen as appropriate to French Indochina in the early 20th century, because of the culture and climate – not just for people from that culture, but for French people living and working there – but inappropriate if they were continued on returning to France.

So amongst all this I started to wonder whether there was any coherence at all.  Notably, as James Nicholls has pointed out, there’s no straightforward position on the issue of ‘alcohol’ that can be produced by reference to even the relatively narrow definition of nineteenth century liberalism.  JS Mill argued that it wouldn’t be real freedom for us to abstain from alcohol if it was just what was required.  And yet TH Green maintained – invoking the same argument that led Mill to reject slavery, that we shouldn’t be given the opportunity to become dependent on alcohol – we’d be better off if alcohol was never available.

And as Mark pointed out, this is a more nuanced debate than we often acknowledge: the key organisation in the US was the Anti-Saloon League, rather than the Anti-Drinking-at-your-own-pace-at-home League.

So, given all our discussion, is really anything linking these themes at all?  I’m reminded of my concern about whether there is any point in trying to develop an ‘alcohol’ strategy.  ‘Alcohol’ or ‘drugs’ or ‘prohibition’ might be a lens through which to look at society, but what we end up actually looking at are the familiar themes of politics, identity, and so on.  It’s no surprise that a discussion of drug policy in the nineteenth and twentieth centuries ends up as simply a discussion of racism, anti-colonialism, nationalism, gender, class, and so on – the ‘fundamental’ issues of societies in that period.

So is there any point talking about ‘prohibition’ as a general concept (or more importantly as a useful academic concept)?

Well, only in as much as James Nicholls suggests alcohol is a useful lens through which to understand how people think of and enact liberalism (in principle and in practice).  But maybe what that means is that there’s not much point studying the phenomenon of prohibition in itself, or trying to understand what motivates people to ‘prohibit’.  Perhaps, just as with ‘alcohol’ and/or ‘drug’ strategies, the ‘take-home’ point should be that we need to think about what these substance-specific ideas tell us about life more broadly.

So, in answer to the title of this post, I’d say no, ‘drug policy’ isn't really about ‘drugs’.  But it's worth pointing that out. And as ever, I look forward to a more open, honest discussion.  And I’ll be writing again soon about how the 2016 Psychoactive Substances Act can be part of that more open and honest discussion.

Tuesday, 21 March 2017

Alcohol, productivity and morality

Work has been pretty busy lately, so I hope readers will forgive me posting about what might seem to be ‘old news’.  But, as anyone who’s studied policy relating to alcohol or other drugs for any length of time will surely agree, the issues tend not to go away, but cycle round to be viewed in a new light.  And it’s precisely that sense of history that’s prompted this post.

The blog started with a neat ‘parable’, credited to economist Frederic Bastiat, of a shopkeeper whose window is smashed, who tries to look on the bright side by saying that at least replacing the window will keep the glazier in business.  The point is, of course, that the shopkeeper would have been able to spend the same money on something else had the window not been broken, and kept maybe a cobbler in business while seeing a tangible improvement in his own life.  And similarly, it’s claimed, we shouldn’t worry about harming the economy if we reduce alcohol consumption or even the money spent on alcohol, as this can simply go on something else.

My initial reaction was to take issue with Aveek on two points.  First, whether the alcohol industry is really anything like the glazier in the story.  Isn’t the role of the glazier played by the police, NHS, or alcohol charities, repairing damage caused by alcohol?

But I suppose if the alcohol industry really is the glazier, then we’re not suggesting that all windows/alcohol are bad, or a waste of money; simply those where the spend is the result of some kind of damage.  By my understanding, the analogy would then run that we shouldn’t be vandalising (or consuming somehow irresponsibly), but windows/alcohol can be useful, beautiful, and part of a healthy economy.  Windows in themselves aren’t undesirable or immoral.

And this got me thinking: maybe I’m over-thinking this.

Aristotle! if you had had the advantage of being ‘the freshest modern’ instead of the greatest ancient, would you not have mingled your praise of metaphorical speech, as a sign of high intelligence, with a lamentation that intelligence so rarely shows itself in speech without metaphor, — that we can so seldom declare what a thing is, except by saying it is something else?  (Eliot, The Mill on the Floss)

So let’s aside whether the alcohol is like glass, and focus on the second area where I was going to take issue with the argument: that economics has anything to do with this at all.

Setting aside Aveek’s personal position, as everything I’ve read by him suggests he’s open, honest and sincere, I started to wonder how well this argument fitted with whatever corporate view the IAS might have.  I just wasn’t convinced that their hearts would really be in it.

I started to think of why I set up this blog in the first place: frustration at the disingenuous nature of much public policy debate in the two fields I’ve worked in.  Drug treatment was justified by painting ‘addicts’ as dangerous, and higher education funding was justified by boosting economic productivity.

Neither actually gets to the heart of why I think these things should be supported.  Drug workers haven’t come into the field to reduce crime, and most academics don’t see their vocation as being to enhance graduate ‘employability’ or develop a productive ‘spin-out’ company.

Moreover, from a pragmatic point of view, I’d worry that when economic times get hard despite the continued existence of Oxford University, or acquisitive crime becomes less of a hot-button topic, the power of those narratives falls.  You haven’t won the fundamental argument that these policies are a ‘good thing’.

Similarly, I wondered, was economics really why the IAS opposed alcohol, or certain forms of alcohol consumption?  What if the data shifted and suggested that alcohol was a genuine boost for the economy?  (That’s certainly a tactic being used by people seeking cannabis policy reform.)  Would that change their minds?  Of course not.  So I was going to write about how the IAS is using economics disingenuously to justify what is really about morality or public health.

But then I realised I was doing exactly what I complain about other people doing: simplifying the argument into an either/or, or looking for the single factor that ‘explains’ their position.

I stepped back, and started to think about how, in reality, we tend not to separate economics from morality.  Whether it’s debates about benefits or executive pay, the argument can rarely be boiled down to a question of objective market factors.

And the same applies to this issue of alcohol and morality, health and economics.  There’s a long history of ideas of productivity being linked with discipline, morality and temperance – just think of the Protestant Ethic and the strong influence of non-conformists in the temperance movement.

In fact, the IAS has its roots precisely in that tradition, being an outgrowth of the UK Alliance, itself founded by non-conformist advocates of temperance.

(I’m hoping I don’t get pulled up too much on my knowledge of Victorian religion and the temperance movement – I’m just making a broad point.)

So my point – apart from illustrating how I argue against myself in my own head – is simply to note how several motivations and perspectives might well come together at once.  When we think about productivity, we might well be thinking about morality too, and that might be tied up with an idea of a healthy, active body as much as an economically productive mind.  It really is a coherent vision of how we could all be fitter, happier and more productive if we only drank less.

The only problem with this is that, precisely because the worldview is coherent and consistent, it challenges the idea that these debates about economics are somehow objective.  This is, as ever, a discussion about ‘the good life’, to return to Aristotle.  And, inevitably, we won’t all share the same vision of what that is.

Monday, 13 March 2017

Stigma and drug regulation

Lately I’ve been thinking a lot about stigma and words relating to substance use.  Carl Hart recently wrote a piece arguing that understanding ‘addiction’ as a ‘brain disease’ contributes to social injustice, and when NACOA recently launched a manifesto for ‘children of alcoholics’, the write-up by Alcohol Policy UK got me wondering about that much debated word ‘alcoholic’.

Stigma is often cited as a reason to introduce drug reform.  It might be unfair, but sometimes I get the feeling – as Julian Buchanan suggests in that post I just linked to – that some reformers think stigma itself would be undermined by legalisation.  I think, aside from ignoring the experience of alcohol and ‘alcoholism’ in particular, this misunderstands what stigma is and where it comes from.

Plenty of research on drinking – including my own – suggests that there is huge stigma around certain forms of drinking behaviour, both amongst drinkers and policymakers (local as well as national), even though (or perhaps because) alcohol is legal.

I used to think (when I was working solely on alcohol policy) that it was the legal status of alcohol that brought out particularly odd, self-deluding arguments, as we each try to contort our reasoning to claim that it’s not our own drinking that’s problematic, but someone else’s.  We can’t condemn people for drinking per se, so we have to look for something else to dislike.  So if the government says drinking 14 (or even 21) units a week is a bad idea, we counter by pointing out that we haven’t caused any nuisance or engaged in any crime, unlike some people, and we spread out our units across the whole week.  But others would use precisely the same definition to argue that, even though they drink pretty heavily on one night of the week, they’re not drinking that much per night on average, and they certainly don’t drink every day, which would be a sign of a problem.

It’s true, this feels odd, and I got tired during my research of hearing people say that they didn’t drink to get drunk, but noting that this did – just coincidentally, obviously – happen when they went out with their friends.  I think at some level I felt this was dishonest: if you don’t drink to get drunk, but engage in the same practice almost every Friday night, and it always happens when you do, then surely you do intend to get drunk at some level?  And what’s wrong with admitting this?

But actually, having looked at drug policy, I can see this in a different light as somehow more open and honest.  Government and drinkers alike don’t actually condemn physiological intoxication, except where it relates to your ability to drive a car.  How could they, given this is seen as an inherent property of alcohol, which is legal?

(In fact, they could quite easily: through our weird attitude to ‘rationality’ and laws such as serving people who are drunk, drunk and incapable, etc.  But let’s set that aside for just a moment.)

When people deny that a certain level of consumption is problematic in itself, and that really we should care about behaviour and the setting of this, they are quite honestly getting to the heart of the matter.  It’s perfectly honest to say what’s actually a problem is violence, or disorder, or even simply being immodest.  What would actually be dishonest for most drinkers would be to suggest they’re offended by some ‘inherent’ or ‘objective’ property of a substance, or intoxication in itself.

But that’s precisely the basis of much drug policy debate: not just that drugs are ‘dangerous’ but that they are somehow morally questionable in themselves.

We like simple arguments: x causes y.  Famously, we’re not good at understanding the idea of risk and uncertainty, let alone accurately judging it and responding accordingly.  This is why debates about alcohol guidelines get lost in the mire of whether there is a J-curve of risk, and reports suggesting one way of dealing with harm related to cannabis get sucked into a fruitless debate of whether cannabis can ever be harmful at all, even when both sides are deliberately trying to avoid it.  (I was going to link to another thread on Twitter at this point, but I see it’s been somehow deleted – certainly not by me!)

And so we like the idea that we can define ‘drugs’ in general – or even specific substances – as dangerous (or not), or at least on a spectrum.  And Public Health campaigners like the idea that alcohol is inherently problematic: it’s no ordinary commodity and there’s ‘no safe level’ of consumption.

I appreciate that these are partly campaigning tactics: it’s easier to state that something is inherently ‘bad’ rather than look at nuances of social and cultural context – drug, set, and setting, to use some out-of-date terminology.

But the reality is unquestionably more complex.  There simply aren’t ever fixed, objective characteristics of a substance in any way that’s relevant for policymaking – and I don’t just mean the panic around crack cocaine that Carl Hart (amongst others) has so clearly debunked.

This is where the idea of alcoholism or addiction as brain disease is relevant.  Carl Hart, as I mentioned, sees this concept as perpetuating social injustice.  The point is that according to this theory, the fundamental issues of ‘addiction’ are due to how a chemical interacts with the brain.  This is understood as a (not very) simple ‘fact’ of neuroscience.

If that’s how addiction is understood – or what it’s reduced to – then as Hart points out, this means the issue (and therefore the ‘solution’) either lies with the substance or the brain.

For the past century, we’ve tended to see the solution regarding alcohol as being to address the brain.  Or, rather, the specific brains that have a problem with alcohol.  This is still the dominant view of addiction or alcoholism today.  We talk about certain people as having ‘addictive personalities’, and most people’s view of alcohol would be that controlled (or ‘responsible’) drinking is possible – but not for everyone.  ‘Alcoholics’ are effectively defined as the people who can’t simply have ‘one or two’ drinks.  As Mark Gilman puts it, some people ‘have the spots’.

But for ‘drugs’, we’ve tended to take the opposite position: that the danger is in the substance itself, not just that certain people are susceptible.  That’s certainly a good rationale for keeping drugs illegal: if one hit of heroin, crack or methamphetamine can lead to addiction (and sensible, well-educated, scientific people have insisted on this when I’ve suggested otherwise), who would allow people to buy and consume it?

But the crucial word there is ‘can’.  Even if it were true, it surely wouldn’t apply to everyone.  But as soon as we admit this, we have to think in shades of grey, rather than black and white, unless we simply fall back on the idea that some people ‘have the spots’.

Now this blog is really here as a way for me to write what I ‘reckon’, without having my argument fully formed or evidenced as I’d need in a professional or academic context.  And as I thought – reckoned – about this idea of addiction-as-brain-disease, another currently popular idea came to mind: that policy regarding a range of substances is converging.  Virginia Berridge most notably, but also Mark Monaghan and Henry Yeomans (this is the paper I’m thinking of), have written persuasively about how several jurisdictions seem to be categorising substances like cannabis and tobacco in similar ways – legal, but highly regulated – and this is related to a convergence in how we think about them: as legitimate consumption choices, but with some risks attached that merit the state getting involved.

It’s easy to attack someone on the simple basis that they use a particular ‘drug’, of the use of that substance is somehow inherently ‘wrong’.  However, if this convergence thesis is accurate, and we are increasingly seeing caffeine, nicotine and alcohol and other substances as ‘drugs’ in some sense, it becomes harder to maintain that simple but comforting fiction that ‘drugs are bad’ (mkay).

And bearing in mind our tendency to like  clear arguments and positions, if it’s not the substance that is the source of the problem – an assumption which can’t be so easily sustained if ‘we’ use ‘drugs’ like caffeine and alcohol too – it must be the person; the ‘addict’ with a ‘diseased’ brain.  These substances don’t cause everyone problems, so we should look out for the specific people who are likely to find them difficult to manage, probably due to some genetic predisposition.

This is remarkably similar to the idea of condemning young drinkers who don’t know their limits, rather than identifying alcohol or licensing policy as the issue.  (I’m not saying one of these is wrong or right; just pointing out that they’re different analytical approaches that lead to different policy ‘solutions’.)

And in both cases, whether relating to ‘drugs’ or alcohol, as Carl Hart suggests, we could do with a bit more social context to understand why some people are more likely to face problems than others.  Might this have something to do with wider social factors like housing, employment and wealth?

This is a potent reminder that policy ‘convergence’ and the call of ‘legalise and regulate’ won’t address stigma, which comes from somewhere deeper.  In fact, as the stigma surrounding particular substances reduces, you might even argue that the stigma attached to individual ‘flawed consumers’ could increase, as they bear the blame for running into problems or consuming them in the ‘wrong’ way, rather than being able to blame the substance itself.

The bigger task, then, is to try to inspire more nuanced thinking, as Carl Hart suggests, that moves beyond seeing problems as either the result of a ‘drug’ or an ‘addicted brain’, and looks at both of those in the wider context of the society we live in.  I hope this blog contributes something at least to that idea.

Wednesday, 15 February 2017

Ideology or technocracy in drug policy reform in 2017

Last week Volte Face published a report called ‘Black Sheep’ written by Lizzie McCulloch that aimed to highlight how substance misuse treatment services could better serve cannabis users who need support.  The conclusions could be thought of as having two elements: first, that the whole issue would be easier if cannabis wasn’t illegal, but rather formally regulated; second, that even if we keep the current legal status, our services could do better.

They brought together a panel of experts, including Lizzie, to discuss this.  Paul Hayes, former head of the NTA and now with Collective Voice, was there, as was Chris Ford, who I’ve followed through her regular DDN column, and Zaki Solosho, who’s previously run into problems with his own use of cannabis (and tobacco).  The discussion was chaired by award-winning scientist and journalist Suzi Gage.  And then they asked me to be there.  I’m not sure why, but I’m not one to turn down an invitation, so I went along.

For a clear write-up of the report and the discussion, check out this piece by Rosalind Stone.  As usual, I’m going to take a slightly different tack in my reflections; if you want to know what the report itself says, it’s not too long and it’s well-written, so there’s no point me paraphrasing here.  Read it!

The debate on Twitter beforehand and the event itself were eye-openers for me.  As Paul Hayes joked, some people really do seem to think cannabis is the only substance known to humanity that has no possible ill effects.  Of course, one of the reasons that VolteFace is interested in this issue is that it has a political mission.  It’s trying to affect the terms of the public debate about drug policy, and add a bit of nuance to the general starting point of ‘drugs are dangerous and therefore should be illegal’.

Of course, some people’s political calculation is that the best way to do this is to challenge it head-on and say that issues related to cannabis are ‘largely mythical’.  But other campaigners acknowledge there are harms related to cannabis, and then to suggest that the current policy approach actually makes these worse.  By taking the second approach, campaigners can’t be hit (so easily) with the accusation that they don’t care about risk or harm, and the argument potentially becomes less moral (heard as ‘drugs aren’t bad’) and more technocratic (how do we minimise harm).

This is a reasonable tactic, and can be seen as underpinning the introduction of needle exchanges in the 1980s and the expansion of drug treatment in the 2000s, but I wonder how powerful it is in today’s political climate.

Without wishing to turn this into yet another ill-informed blog post about Brexit and Trump, I do have some concerns about trying to mobilise public opinion by suggesting drug policy reform as a technocratic solution (even if it’s one that could save lives).  And as Paul Hayes’ response suggests, it’s not even one that the technocrats will all get solidly behind.

I’ve written before about alcohol policy, and how frustrating I find it when people criticise the methodology and findings of research, when their actual concerns are about the political philosophy of a policy.  That is, people attack the research behind drinking guidelines rather than simply sticking to the fundamental principle that people should be free to drink how they choose.

And I’ve been thinking about whether the same point applies to drug policy debates.  Campaigners could acknowledge, yes, that (for example) opiates in themselves aren’t terribly bad for people physiologically, and the harms of addiction are probably heightened by the way in which we regulate them – but then make the broader, more fundamental point that drug policy is really a question of liberty.

The idea of a ‘rational’, ‘technocratic’ drug policy is a chimera.  The harm of drugs isn’t inherent in the substance, and it isn’t inherent in drug policy either.  The harm is a result of a myriad of factors, including genetics and the wider social context.  Just look at how people drink differently in different societies – and for all that talk of safe continental drinking cultures, for most of the 20th century the French might have been restrained while drinking, but their liver disease rates certainly weren’t.

I started this blog as an attempt to comment on how policy debates could be more open and honest, having experienced odd distortions in the two fields I’ve worked in: substance misuse and higher education.  But which is more honest: an appeal to people’s emotions and principles in an age of post-truth politics, by saying drug policy is about liberty, or an appeal to rationality by claiming that legalisation – sorry, regulation – is a harm reduction initiative that we should implement regardless of our views on the morality of intoxication?

And actually, which is more realistic?  For all that this is supposedly an age of ‘alternative facts’ and emotional politics, where it’s no longer about ‘the economy, stupid’, the path to legalisation in the USA has been one of incremental, technocratic change – which then resulted in popular support because the terms of the debate had been changed.

And here’s where Paul Hayes and VolteFace have something in common: they’re both realists.  I’ve written before about my discomfort with the ‘bargain’ Paul (and others) made with policymakers and government, gaining funding for drug treatment by branding users as dangerous.  This was, in a way, disingenuous: the reason most of us are involved in this ‘sector’ is (and I don’t think this is overly idealistic) because of a wish to help people and make the world a better place; not because we think drug users need to be controlled.  And I’d say that slightly disingenuous bargain is exactly what VolteFace is trying to do with Black Sheep: making all the reasonable and technocratic arguments to change the terms of the debate, and steering clear from an unproductive discussion about the rights and wrongs of altering one’s mental state.

But then they part company.  Paul’s scepticism and realism informs his views on legalisation: he’s worried big business would take control (if not immediately), and harms would increase, as with tobacco, alcohol or gambling.  His is a full commitment to pragmatism.  The VolteFace view is more interesting: they’re taking a realpolitik approach to achieve an idealistic change.

I’m not sure which I prefer, though there is something easier about Paul Hayes’ consistency.  But equally, my ambivalence is probably fitting, given how frustrated I was at the launch event that there were two ‘sides’ of this debate (as in alcohol policy) and the atmosphere seemed to encourage people to choose one or the other, rather than acknowledging that under whatever regime, as long as humans are involved (not to mention cannabis), the situation will be imperfect.

Perhaps I can just remain an interested observer.

Monday, 30 January 2017

Faulty by design: the state of think tank thinking

This month, the think tank Reform have published a report criticising public sector commissioning.  The title certainly doesn’t mince its words: Faulty by Design.

Long-term readers of this blog will know I’m generally pretty sceptical of these kinds of reports, and specifically the work of Reform.  Some of this is natural defensiveness.  When I read sentences that state ‘commissioners … do not possess the necessary skills’ (p.11) I feel attacked personally.  But what I want to suggest here is that part of my frustration at these sorts of reports is about something more fundamental.

(Before I move onto the fundamentals, though, I can’t resist highlighting out the oddity of some points in the paper – for example where they disapprovingly note that 72% of local authorities are planning to cut substance misuse treatment budgets [p.23].  I’d love to know what the other 28% are planning to do, when public health budgets are being cut by central government by 20% up to 2020, at which point funding will reduce to zero.  Or when they note that services to address homelessness are ‘commissioned by a plethora of providers’, when a provider is someone who is commissioned, not someone who commissions.)

One of the recurring themes on this blog is that while straightforward and honest thinking and writing – thinking to some purpose – should be the aspiration of all those involved in politics and policy, humans are complex, as is the world they make around them, and so we shouldn’t imagine there are neat, perfect solutions that don’t require compromise.

Without wishing to violate the first of those principles – that I should be straightforward in my thinking and writing – I’d suggest that the ontological model of the Reform writers is na├»ve.

There is a section entitled ‘Not knowing what works’, which is to misrepresent and simplify the mechanics not just of commissioning but public policy more generally.  Public policy is not as simple as identifying a problem and then implementing a solution.  Any issue will be fused with others, and any ‘solution’ will affect not only that one issue but those others too.

And in any case, it’s not that commissioners don’t know what works; it’s that this can’t be represented as an ‘intervention’, or even a set of interventions, that can be managed as part of contracts.  This model of ‘commissioning for outcomes’ imagines a world of unilinear causality (if that’s a phrase): somewhere we you can pull a lever somewhere in the machine that is society, and then monitor and note the effects.  But society isn’t a machine, and policies and interventions aren’t levers.

What ‘works’ in addressing substance misuse, for example, is a complex mixture of housing, employment, relationships, education, and any number of other factors that most people would simply refer to as ‘life’.  No one organisation, no one ‘policy intervention’ can produce the relevant ‘social outcome’, to use the language of the report.

To be fair to the authors, they acknowledge that part of the problem is that the social world is ‘extremely complex’.  But they still conclude the section by suggesting that there is a solution to this, and that it is ‘greater development of the knowledge base and better dissemination of existing expertise’, with the development of ‘what works’ centres seen as ‘a positive step’ (p.14).

That is, the problem is framed as one of ‘knowledge’: if only we did more research, we could develop the magic lever.

Instead, I’d suggest, we’d have better public policy if we realised that striving for perfect knowledge is futile as there are no magic levers, and the question we should be asking cannot be as simple as ‘what works’.

As such, the approach of this report and others can feel like a lament about the fact that the world doesn’t fit into boxes or categories, or that people don’t behave in easily modelled ways.  When the report complains of the reality of STPs (p.35), this isn’t the fault of the idea of STPs, and it’s not something that a policy or structure can address; it’s simply poor management and people not doing their jobs terribly well.  When, on the same page, the authors describe the tension between ‘what works’ and what the voting public want, we’ve got to the heart of the matter.  Policy isn’t, can’t be, and shouldn’t be, simply about ‘what works’.

And just as there no magic ‘intervention’ that ‘works’, there is no ideal structure for public services.  The report laments ‘the cost of fragmentation’ (p.20), but the fact is that the idea of seamless integration, or a definitive structure, is a chimera.  The cake has to be cut somewhere, and there are pros and cons associated with every option.  Anyone who has observed health policy for more than four years or so will notice the incessant back and forth of the size of administrative units.  The grass may always seem greener, but it’s as if people are actually hankering after flowers that even the greenest of grass won’t produce.

A case in point is public health.  The report complains that locating public health departments in local authorities ‘has stood in the way of integration elsewhere in the NHS’, but equally locally its ‘prevention’ function in the NHS would hamper its ability to shape key influences on health that sit within local authorities, like transport, housing, planning, licensing, schools, and so on.

There is simply no ideal policy on this, and yet the report uses the word ‘integrated’ as if it simply means ‘good’ when there will inevitably be choices of what and how to ‘integrate’, and there will be pros and cons to any approach.  Setting aside the fact that ‘the NHS’ doesn’t really exist as an institution for a department to integrate with, we’d have to acknowledge that public health departments can either be ‘integrated’ with local authorities or ‘the NHS’ – unless of course you’re planning ‘integration’ of the whole set of public services.  But rather than cutting the Gordian knot, this would create one, with different strands of complexity inextricably linked to one another.  And even in that extreme example there would be a dividing line: we’d still have to decide what elements of life are ‘public’ and what ‘private’.

But at points in the document it really does seem that the authors imagine a world without boundaries or departments – of otherworldly ‘integration’.  In fact the language is oddly spiritual, suggesting public services should ‘transcend’ current service boundaries (p.25).  I can only assume they are imagining an all-encompassing ‘service’ (or ‘intervention’?), ‘commissioned’ presumably by some overarching ‘public commissioner’ – a leviathan of the police, community safety, social care, healthcare, transport, and so on ad infinitum.

To go back to a cake metaphor, it might seem like I’m having my cake and eating it – that I’m asking the impossible of the report’s authors as I criticise them for failing to provide a solution to a problem I think is intractable by definition.  But that isn’t quite what I mean.  I’m criticising them for noting the complexity of the world, and criticising commissioners for simplifying it, before they go on to simplify it in their own way, which is no more intellectually or practically justifiable.

Life is complex, and can be understood and arranged in an infinite number of ways.  None of these ways is perfect, and the reality is simply hard work on the ground, not a magical policy or structure being delivered by government, policymakers or a think tank.

The report presents the idea of integrating health and social care (which is already an article of faith of STPs and the Better Care Fund) as if it is groundbreaking or will make all the difference, rather than focusing on the fact that this kind of development is simply difficult and requires hard work.  There is no structure or approach that makes it easy.

And this is where my real unease with these think tank reports lies.  They always feel like they are written by ‘policymakers’ or ‘wonks’, rather than people who actually have to commission, design or deliver these services.

There can be ‘integration’, but it won’t come from breaking down departmental boundaries or fiddling with commissioning budgets.  There will never be a single department or budget where savings across every social policy field can be identified and pooled.

Instead, integration must come from the inevitable ‘plethora’ of commissioners and providers sitting together around a table and talking about the multiple needs of individual people, or groups of people, at a range of geographical levels.  The levels and groups of people around a table will never be perfect, but there’s no need for a report explaining this.  There’s just a need for people to talk to each other and get on with the work.

Friday, 6 January 2017

Dry January and sponsored marathon running

On Tuesday, presumably to break me into my first day back at work gently, I was asked to comment on Dry January for Radio 5’s Drive Time programme.  I’d been asked because they were looking for a slightly sceptical viewpoint, and although I was a little concerned that this might not fit terribly well with my Public Health Dorset role, the team were actually supportive of me offering a bit of balance in the discussion, particularly as I’m more probably more moderate than many of the alternative commentators available.  Unfortunately for Five Live, this meant that the discussion perhaps wasn’t the most electric you might hear – though I did interrupt another contributor at one point, for which I can only apologise.

As I say, it’s might not be the most interesting 20 minutes of radio you’ll ever hear, but if you want to listen to it, I’ve copied it to my SoundCloud account here:

I don’t want to exactly re-hash the piece here, but I wanted to outline my thoughts a bit more fully and clearly, and encourage a more involved debate either here or on Twitter.  (And something of a higher quality than this bizarre article pointed out to me by James Morris.  If you want a slightly different - and better - discussion of Dry January, you couldn't do much better than listening to this piece, including a contribution from James Nicholls.  It starts at around 15 minutes in.)

The first point I’d make is that it’s good anybody is talking about the possibility of going alcohol free.  Personally, I enjoy drinking and I don’t think health should necessarily be people’s number one priority when choosing how to live their lives.  But I do think we sometimes default to drinking alcohol when there’s no real reason to, and it might be worth reflecting on that occasionally – even if we then choose to carry on regardless.  Dry January opens out that possibility even for those of us who aren’t signed up.  By other people around me mentioning they’re drinking less, or not drinking at all, I might think twice myself (for better or worse, but at least for variety, and for the simple benefit of thinking at all).  And as I’ve pointed out a few times on this blog, lots of research – including my own – can be crudely summed up as proving that we tend to be pretty good at conning ourselves that it’s other people’s drinking that’s problematic, not our own.

And there’s no doubt that Professor Moore was right when he stated on the programme that there are significant benefits for lots of people from giving up alcohol, even if just for a month.

My concern is twofold, really.  What happens in the longer term, and is this something public sector organisations should be spending time (and potentially money) encouaraging?

In terms of the longer term point, my fear is that a month off alcohol doesn’t really fir terribly well with the standard approaches to behaviour change.  Generally, you look for realistic, sustainable change, which tends to mean small, gradual movements.  It could be argued that this isn’t the case with more extreme problems, such as addiction, where physiological detox is the starting point – but that’s generally undertaken where the long-term aim is abstinence.  In any case, Dry January is explicitly not designed for people who are dependent on alcohol.  That doesn’t mean that some of the people doing it won’t be looking to give up alcohol completely in the long-term, but that’s unlikely.

And that’s where my concern comes in: if you’re trying to encourage yourself to develop more ‘moderate’ consumption habits, complete abstinence isn’t a great way to train for that.  I wouldn’t enjoy Dry January.  I would find it hard and frustrating.  But I think I could probably do it (and I don’t think I’m entirely conning myself on this one).  But I wouldn’t necessarily have learnt a great deal about how to drink fewer pints when I do go out on a Friday evening, or how to not finish off a bottle of wine when it’s open – which are going to be the more useful ‘skills’ or habits in the long-term.

And what’s the message that a Dry January sends?  It’s drawing on the longstanding tradition of having a bit of a ‘detox’ in the new year to try to counteract the supposed ‘excesses’ of the Christmas period.  And so there’s a danger it just reinforces that pattern of drink heavily, then make up for it later by having some time off.  In fact, it looks like patterns of drinking are important in determining how harmful a particular level of consumption is.  Spreading the same amount of alcohol over several days or weeks is less damaging to your health than cramming it into one or two ‘binges’ or ‘bouts’.  As I said in the radio piece, it would be safer to drink exactly the same amount over two months, but rather than having December be ‘wet’ and then January ‘dry’, make both of these ‘damp’ – don’t take a feast and fast approach.  (The idea of labelling something 'damp' comes from this piece on 'damp feminism' - though personally I think I'd prefer the more idealistic 'wet feminism'.)

Of course there is some evidence that people do make changes to their drinking behaviour in the light of Dry January, and I would never deny that this might be a good thing for some people.  At the very least, you’ll reap some of those health benefits Professor Moore talks about.

But who is most likely to make these changes?  Well, unsurprisingly, looking at the main evaluation of Dry January in terms of who participated and made long-term changes (rather than Prof Moore’s work on the direct and immediate health effects), the people most likely not only to have low levels of drinking, but to have changed their drinking, are those who were drinking least to start with.

This isn’t really surprising, and isn’t a condemnation of Dry January, but it is something we should be aware of if the campaign is being advocated as something that will achieve public health aims.  Most of us don’t drink more than health guidelines advise, so it follows that for most people, while Dry January might be helping at the margins, that’s not where energy should be focused.  It’s not clear it’s that effective for higher risk drinkers.  And that’s only looking at the people who participate – which is in itself a self-selecting sample.  Again – and for both of these points we simply lack robust evidence – it seems that those most in need of support are those least likely to engage.

And that’s where I have my biggest concern about the coverage given to this campaign.  Is Dry January something public health departments should be encouraging?  Well, this year PHE aren’t pulling out the stops to support it this year, and in fact our local health improvement service is more likely to be running a campaign in February.

Although it wasn’t universally acclaimed, I have a lot of time for the review of evidence on alcohol interventions PHE published shortly before Christmas – and I’d argue that if we’re going to do anything to address alcohol consumption beyond treatment for those with dependency issues, we should be focusing our time and energy on the actions they identify as being evidence based.

That doesn’t mean that individuals shouldn’t do Dry January, and I welcome the development as a potentially useful natural experiment, but it needs a lot more evidence and people undertaking it need to be clear about what they’re trying to achieve with it.  It isn’t a get out of jail free card for previous or future excesses, unfortunately.

But as soon as it’s thought of as Dryathlon, now that’s a different story.  The whole movement makes more sense when I think of it like sponsored marathon running: it’s an excuse to get people to give to charity; it raises awareness of an issue; it’s not really going to engender long-term behaviour change – it’s about undergoing a trial and proving something to yourself (and other people).

(Incidentally, Dryathlon isn’t run by Alcohol Concern.)

So if you’re thinking of giving up alcohol for January, or Lent, or any other time – go for it (assuming you’ve not got signs of dependency that would make it risky).  You can even ask me to sponsor you, and I’ll probably do it out of some form of guilt.  Just make your choice of charity a good one, and remember that I’ll be giving grudgingly as I don’t really understand the point of sponsored events in the first place.  I’m happy just to give to a good cause, without any fancy dress or test of physical endurance being undertaken.