Monday, 2 July 2018

From competition to partnership?

A bit over a week ago, I went to the EXCO conference.  EXCO stands for EXcellence in COmmissioning for opioid use disorder services and it was organised by the Expert Faculty on Commissioning, chaired by Mark Gilman and supported by Camerus.

There are lots of things that I could write about as a result, and I want to apologise that this post won’t be uplifting.  That’s not because there weren’t huge numbers of positive, impressive people there; it’s more about the wider context we’re working in.  The fact that I have something to write about is in itself a ringing endorsement of the conference, which I found very useful – and I think the Faculty could go on to genuinely improve commissioning.  However, I want to focus here on some of my concerns.

Most of the attendees were commissioners of treatment services, with some service users and one or two provider representatives.  As a result, a large part of the conference felt to me like a mutual aid group – but for commissioners.  Or perhaps more accurately a mutual moan group.  That is, lots of us spent our time lamenting the difficulties of a world where people have complex lives, complex problems, and the provider and commissioner landscape is complex (think of primary care, secondary care, mental health care, housing, employment, etc) and all this is complicated by one key simple fact: there’s not enough money.

I started the day stuck in my usual default pessimism, wondering if we’d move beyond that.  There’s a value in a problem shared, but there are already plenty of forums for moaning; I was more interested in action.

But of course this was a conference, not a decision-making forum; it was a place to share ideas.  And the most powerful point, for me, was made by Annemarie Ward from Favor UK: “You guys work in isolation, conflict and competition”.

The immediate implication of this statement, particularly when we’re discussing commissioning, is to think about 3 year cycles of tendering and how providers are reluctant to share innovation because it could be the way they win the next contract.

I certainly have some concerns about this – and my pessimism prior to the day was partly because I’m disillusioned  with the whole idea of commissioning.  There’s the procurement element, which I’ve written about before, which I think includes a huge amount of waste and disruption, but the same pattern applies once contracts are in place.  While it’s not impossible, the job of a commissioner in managing contracts is challenging: responsibility without (direct) authority.  How many times can you ask a provider to do something?  Is the threat of withholding some funding powerful?  Is it effective to appeal to the provider’s better nature that we’re all trying to do ‘good work’?  Would a reluctant provider ever really believe you were going to terminate their contract and reopen the procurement process when you only got one or two bids last time round?

(And that’s not to mention the issue that you can’t change the conditions we’re working under: for example, it’s simply not straightforward to recruit nurse prescribers into substance misuse treatment at the moment.)

All these are the classic questions of management: what techniques are most likely to bring change and good practice – but they’re applied without the usual levers available to direct managers or leaders.

And that’s the rub: partnership is more difficult than leadership or management.

And that’s why I think Annemarie’s point can be understood more broadly than just being about competition in procurement.  It’s not just about providers competing; it’s about how well commissioners work with providers and it’s about how well commissioners work with each other (as well as other organisations).

The importance of this, not just locally but nationally, was made (indirectly) by Rosanna O’Connor of PHE.  I think most people in the sector are aware of the concern that everyone involved in the creation and analysis of data – from the service user describing their situation to their keyworker through to the Minister (or even Prime Minister) – wants to say and hear that everything is OK and progress is being made.  But if the reality on the ground is that cuts or commissioning practice is making life difficult, how do we expect this to be believed if the story of the data is still so glowing and smooth?  There are still hardly any waiting times over 3 weeks recorded in the system…

Resolving this kind of issue needs open, honest partnership, so we’re not just telling well-intentioned lies or talking past each other.

And at some level, this is what EXCO or the Expert Faculty is (or should be) about: commissioners working together to share best practice and good ideas.  And that’s fine.  I think it could be.  There were interesting perspectives shared by a range of speakers on the day about how they’ve approached various problems, and some of the most useful elements I took away were from 1:1 conversations in breaks with other commissioners, describing how they had dealt with particular situations.

But, apart from the obvious critique that PHE, particularly through its regional structures, should be doing this work of sharing good practice already, I have a concern.  Mark Gilman described part of the role of the Expert Faculty as being a counterpart voice to Collective Voice and the NHS Substance Misuse Provider Alliance.  They are the ‘go to’ organisations for the experiences of providers.  There are also service user organisations (including Favor UK who were represented at the conference), but Mark made reference to a ‘sister faculty’ for service users.

This sounds like a kind of corporatist approach: you could consult all the groups in the field and then triangulate their positions.  And there’s certainly a strength in that.  But if we go back to that idea that we “work in isolation, conflict and competition,” it’s not clear how this will resolve this.  There’s a value in seeing oneself as having a specific role or even being a cog in a machine, where each cog is specifically made to fit its unique purpose.  But if we look at the sector today, is that really how these organisations feel (or make us feel)?

I worry that rather than resolving that competitive, adversarial approach by fostering an idea of partnership, these organisations will serve to set us apart from each other, leading to less communication and collaboration.  (I’m not saying this will happen, and this is definitely not the intention, but my pessimism makes me worry.)

And, perhaps just because of where I find myself professionally and psychologically, I worry about a personal, ego-driven element to all this.

Sharing of best practice is helpful, but in my experience the discussions between partners are (counterintuitively) more productive when people come with problems, not solutions.  Then the person concerned will probably start by finding that they’re not alone in having this issue, and we can all find ourselves contributing and feeling useful.

Too often, when we start by ‘sharing good practice’, the conversation becomes a lecture where one individual broadcasts how they’re a brilliant and influential innovative problem-solver.  I felt this happened one or two times at EXCO.  This is no criticism of the conference, it’s inevitable of any such discussion - and even more so when there are invited speakers who have effectively been asked to ‘broadcast’ their experiences (which, like the data, tend to focus on achievements more than challenges).

But why does this frustrate me so much?  It’s not just because these ‘broadcasts’ are often misleading.  (Is it a victory to have cut £2m from your treatment budget before the cuts even hit?)  It relates to why, although in some ways the sharing at EXCO led me to feel more optimistic, it also left me a bit deflated personally.  I completely understand the impulse to boast and broadcast (why else would I have started this blog and continued to publish academic articles after leaving academia?), and I know it can take a bit of humility to see that you’re not that unique or innovative.

I don’t mean that it dawned on me, sitting at the conference, that there are these great geniuses doing perfect work while I’m bumbling around.  I mean that it was a reminder that all commissioners are mere mortals, more or less bumbling around doing the same stuff and occasionally striking gold.

So why, if I’m not intimidated by the ‘geniuses’ on show with their ‘best practice’, is this frustrating?

Well I don’t find it uplifting that we’re all bumbling around individually; I find it depressing and a waste of time.  We’re all facing the same challenges, (re)inventing solutions, and actually despite (because of?) this, things aren’t that great.

So this isn’t just about ego or even psychology more broadly – those feelings come from somewhere for a reason: things really aren’t that great, and we know it.

A forum to share ‘best practice’ or develop shared solutions is potentially useful (though again I don’t see why PHE isn’t already serving this function) but it’s a sticking plaster to deal with the fundamentally flawed approach of ‘commissioning’ in the first place.  It props us this approach of seeing providers, commissioners, service users, regulators/advisors as separate entities with their own interests, rather than a truly innovative approach of people treating people as people.

So without this post ending like a cry for help, I want to finish with a question that’s really designed for other commissioners, but perhaps other people in the sector too.

When I don’t believe in the structures or roles that frame the potentially valuable work that can be done, when I don’t trust that we have the right resources in the right place, and when I’m not sure it’s possible to find meaning in this work (commissioning at least), what use is there in continuing the job?

Thursday, 7 June 2018

New Directions in the Study of Life

I spent Thursday at the annual conference of the New Directions in the Study of Alcohol Group.  This is always excellent, and never the same.  The tone and the themes are always driven by the people speaking and those attending, though it retains an open and forgiving atmosphere towards curious and uninformed people like me.

Throughout the day, there were some common themes that struck me.  I’m not quite sure how I can link them together coherently (or even if I should – perhaps that would be a misrepresentation) but I’m going to do my best here.

(I haven’t mentioned everyone who presented by name, but all the presentations were fascinating, as well as the comments from the floor.  Although I don’t talk about them in detail here, I found the presentations by Tim Leighton and Josie Soutar particularly interesting and useful, as they talked about the practicalities of delivering effective treatment services.  To find out more about the conference, check out #NDSAG2018 on Twitter.)

Although it probably reflects my interests and prejudices, I felt that several of the presentations were arguing against the drawing of clear lines.  If this sounds abstract and meaningless, I’ll give a couple of examples.  James Morris and Claire Melia spoke about the language used by clients and professionals: is it the same, and does this make a difference?  Does the language of ‘alcoholism’ serve to exclude people who would benefit from support just because they don’t identify as ‘alcoholics’?

James suggested that we’d do better to understand problems related to alcohol as being on a spectrum.  This would allow the full range of people who might benefit from help to have a way of talking about their issues, which makes it more likely they will identify these.

Meanwhile, Claire was pointing out that a key element of recovery (and this was echoed by other speakers) is having a kind of ‘in-group’ identity.  That is, people do self-identify as being in recovery, and the social element of this is crucial.

But how are these consistent?  If we take away the idea of a defining ‘disease’, or a clearly defined group with a ‘problem’, and replace it with the idea that everyone is somewhere on a spectrum, how can there be a neat group identity?  What would separate someone who had stopped drinking having had a physical dependency from someone who had decided they were drinking a bit over the recommended limits and did a programme like One Year No Beer?  How could you have a strong in-group identity if we’re all on a spectrum?  Does that matter?

And it wasn’t just the idea of having a spectrum of problems that produced this uncertainty about identity and dividing lines; the same thing could be seen with the potential solution or end point to these problems.  I was thinking maybe there’s a clearer sense of group identity through the treatment process.  Certainly in the field it can feel like there are tribes of fellowship supporters and those who advocate a more cognitive approach, even if it still involves groups, like SMART.

But the discussions made it clear that most people are not actually signed up to a single, coherent philosophy or ideology.  Instead, they behave like magpies in terms of recovery/addiction discourses and ideas, taking a creative and flexible approach and picking up what they find useful and acceptable from any particular approach and leaving the rest.  So as David Best described, you can find people who step out of a therapeutic community and then go to AA meetings, despite the fact that these two approaches have quite different understandings of the nature of the problem a person is likely to be facing, and how this is best dealt with.  This shouldn’t really be surprising.  It’s odd to find anyone whose actions (or stated beliefs) accord precisely with any given ideology or belief system.  Even Marx, famously, maybe wasn’t a Marxist.

But if it’s not about what ‘problem’ you have, or what treatment you’re receiving, perhaps there’s a group defined by where you end up.

The subject of the conference was ideas of recovery, and I wondered whether, if we couldn’t hang onto an in-group identity of recovering from something clearly defined (like ‘alcoholism’) then maybe the key is in the what you’re recovering towards.  This was certainly important for plenty of speakers.  Being in recovery meant making social connections and contributing to a community – and this provides a sense of identity and wellbeing, as powerfully explained by Simon Morgan.

But as so often when this comes up and people try to define it, I was struck by the universality of the concept of recovery.  What I mean by this is that when people spoke about recovery, they were talking about something that could be applied to everyone’s lives, not just people with an identified ‘addiction’ or substance use disorder.

David Best referred to recovery as a search for ‘eudaimonia’.  This is a term from Aristotle that I’ve written about before, and although it’s generally translated as ‘happiness’, it really means something like ‘fulfilment’ or ‘flourishing’.  Recovery, he suggested, represents a shift from ‘hedonism’ (pleasure-seeking) to something more rounded and whole (‘eudaimonia’).

Apart from the fact that I’m suspicious of anything that distinguishes pleasure from fulfilment, given that we can’t as a human race (or even society) agree on what a fulfilling life for a person looks like, this has some wider implications for what recovery might mean and how it might apply to thinking about substance use.  The definitions of recovery being discussed really amounted (as the use of the term ‘eudaimonia’ suggests) to a whole life philosophy.

This raises the question not just whether there’s a tight enough group defined, but whether there’s even any point thinking about substances.  And Tim Leighton pointed out, reporting on his research with staff and service users, that most people don’t talk much about substances in describing what’s good about treatment; they’re more likely to refer to trust between each other and having developed a new set of values and priorities.  A key part of this isn’t thinking about substances so much as finding alternative ways to process other emotions, to change the standard response from being that someone would just pick up a drink to cope with a particular situation.

And here’s the rub: if we’re interested in helping people to lead fulfilling lives, through processes of trust and developing internal conversations, what has this got to do with alcohol?  As James Morris suggested, wouldn’t we all benefit from some psychotherapy?

(And this is before we start to think about how problems where alcohol is implicated often have their roots (and solutions) in issues around employment, housing, education and personal relationships, rather than the simple chemical substance of ethanol.)

So were we all really attending a discussion of New Directions in the Study of Alcohol, or just New Directions in the Study of Life?  I started to wonder whether we’re looking at this right.  If it’s all shades of grey, then why are we so keen to draw dividing lines?

Writing this I’ve remembered my facetious claims as a student that basically everything we study is sociology (well, at least the humanities and social sciences).  History is just the sociology of the past.  English is just the sociology of literature.  Economics is just a specialised branch of sociology.  But all I really meant was these were subjects that were studying people and societies.  Sure, if you take that broad a view it’s all sociology, but what’s the point calling it that?  It’s just semantics and it doesn’t get us further because we’ll probably need to specialise to study these things.

Why are my student pretensions relevant?  Well, the same applies to studies and treatment of alcohol and other drugs.  Yes, we can say it’s all a spectrum and it’s shades of grey, but we’ll still have to draw some lines somewhere.  Those lines will be imperfect – and we need to remain conscious of that and not start seeing them as the truth, or the tail wagging the dog.  But we do need them in some form.

But there’s still an element of this that makes me wonder about how many of those lines we really need, and how permeable they ought to be.  That is, it was noted that in general there isn’t a huge need to separate men and women into gender-specific groups for treatment.  And I’ve always said of our local drug and alcohol services that when alcohol users are persuaded to walk through the door, they tend to get significant benefits from sharing group time with users of other drugs.  It isn’t the case that we always need separate groups.  As Wendy Dossett pointed out in discussion, one of the things people find most useful about having group treatment, and one of the key ways that ‘in group’ identity is formed, is the sharing of shame – of knowing that other people have done the same things you have.

One potential response to this is to say that lots of us have done things we are ashamed of, whether when dependent or intoxicated on a substance or neither.  If we’re all sharing this idea of ‘eudaimonia’ or the good life, and it’s meant to entail human connection, why is it limited to those with substance use issues?  Is the ‘treatment’ we provide really only for those who have a substance use disorder?

I don’t mean to be flippant, and I understand that if we provide something for everyone, we probably provide something for no-one.  And there’s certainly a policy case to be made that having some elements of work ringfenced can be protective, preventing particular workstreams simply being co-opted into a wider mainstream concern.

But all the same, I wonder.  What makes this about alcohol?  What makes recovery something specific to our ‘sector’?  How does it relate to mental health?  And how does treatment relate to housing, employment and personal relationships, which we know are so influential?  And at what point does talking about developing a different way of living, a different way of organising society, stop being a discussion of alcohol treatment and policy and simply become a political project?  Is that what we should actually be doing as professionals – campaigning for a different social and economic structure?  Here’s to New Directions in the Study of Life.

Wednesday, 6 June 2018

Is drug testing a public health issue?

Like a lot of people in the field, I’ve been thinking about drug testing lately – meaning the testing of drugs that people might use, rather than people who might use drugs.  A good introductory piece was written in The Times by Hugo Rifkind (with the inevitable response from Peter Hitchens), but although this was presented as encouraging a pragmatic approach, focused on what we can do right now to reduce deaths related to drug use, the reality is that a statement in favour of this approach in principle doesn’t get us much closer to delivering it in practice.

I would say this is where I come in, but actually the most fundamental points are dealt with by chemists, harm reduction workers and the Police: how can people actually get a useful, timely service within the law?  I’m not going to comment on those; The Loop are the experts on that.

What I mean is the other fundamental issue: who is going to pay for this?

This was a question that soon emerged in discussions of how we should respond to the deaths at Mutiny, and my initial response was exactly in line with Max Daly’s (as on many other things).  But since then I’ve had to think in a bit more detail, as it’s become a more real question for us in Dorset with discussions around Bestival, and this is where I’ve got to.

And for me the root of this issue is the question: is drug testing a public health issue?

So here are my not-terribly-original-or-insightful thoughts…

I want to start by stating some of my assumptions.

First, these kinds of facilities aren’t a complete solution to the problems, but they should be available at festivals.  In the absence of drug regulation, these services are the best bet we have for reducing deaths at festivals and elsewhere; if only because they enable better harm reduction information to be put out that the generic comment of ‘there seems to be a bad batch out there, so be careful’ (this is almost exactly the wording used by Mutiny).  People will always think it’s not their batch that’s bad, and if you advise that things are ‘strong’ this isn’t always helpful for explaining how people should behave.

By contrast, The Loop are able to give specific warnings about specific pills – not only to individuals, but across social media.  They also provide harm reduction advice to people there and then regardless of the test results.  How many of these people would otherwise have asked for this advice, or ever have received it?  The answer appears to be as low as 1 in 10 of the people who currently access The Loop’s service.

And there are some good, clear messages available for harm reduction, such as ‘crush, dab, wait’.  Or even, if we want to digest things even further: ‘no-one should be popping whole Es in 2018’.

So if the service works, who should fund it?  Well, in my experience local authorities have tended not to fund the harm reduction and health services at these kind of events previously.  Mostly it’s the responsibility of the organisers to sort that – though the local authority might place some kind of condition on the licence it grants, or offer advice to the organisers.

The only time I’ve got involved in this was when a new festival ran just outside Dorchester, and because it was likely to be a local crowd we made sure that the independent health and first aid team on site had leaflets to signpost people to local drug and alcohol support services – but it wasn’t those services that were providing the support on the day.  And we didn’t contribute directly to the costs of providing the first aid team; in fact, if I remember rightly, the festival organisers gave free entry to some local authority staff partly so they were on-site to see how things were progressing, and partly as a gesture of goodwill.  So if anything it was the organisers that would have been contributing, rather than the local authority.

But that’s only the past, or convention.  What should the local authority be contributing?  Well from my perspective, I’d be happy for local services to be on site and offering advice and information to either/both the health and first aid teams and the public directly.  These services are commissioned to be open to anyone in Dorset, and they should be going out to where people who might need support actually are, rather than waiting for them to walk through the door.  A local festival seems like a pretty good bet for this to me.

The thing is, The Loop already offer this kind of support as part of their comprehensive package, and so I’m not sure whether local services going into festivals would be efficient or appropriate.  But that’s just an operational question.

The involvement of the local authority in terms of harm reduction (as opposed to emergency planning, licensing etc) isn’t likely to be in direct provision so much as answering that question of money.

If we’re imagining a local public health team might fund this from their substance misuse treatment budget, I suggest we think again.  Will this be an efficient, effective and equitable approach?  Will it narrow health inequalities?  I think that’s hard to sustain, particularly at a time when we’re having to cut services that help reduce drug-related deaths in greater numbers – that is, opiate substitution treatment, which helps reduce opiate overdoses, which remain by far the most significant category of drug-related deaths.

At a time when we’re not prepared to take the legal or financial risk of publicly introducing a drug consumption room in an English local authority, and local politicians still oppose treatment being provided in areas that needs it, I find it hard to look at the positivity around drug testing at festivals without thinking back to my academic background of reading Bourdieu and thinking about distinction.  Are some drug users more deserving of investment than others?

Any money spent on drug testing will have to be taken from a treatment budget, and could mean one fewer member of staff in a service.  I understand that the costs of running a service like this somewhere like Bestival would be around £20,000.  This is not insignificant for a local budget.

It might be different if we were talking about an offer in a town centre, as part of the broader work to ensure that the night-time economy is as safe as it can be.  But this is a private event, on private land, with paying customers.  It’s not entirely clear why this would be the local authority’s responsibility.

That isn’t to say, of course, that this isn’t a public health issue, though.  And perhaps I’m just being defensive because I know the financial constraints we’re operating under.  Maybe it’s not fair to pit one group or issue against another, even if that’s how politics and policy work in practice.  It might still be something we should be providing, even if we can’t easily do that at the moment.

So let’s think in more detail about whether this is genuinely a public health issue, and what that means for who should be stepping up to be counted.

I want to make an analogy with the selling of unregulated products in the nineteenth century (or earlier).  The state wasn’t, as in Hugo Rifkind’s eye-catching analogy, actively poisoning burgers to reduce obesity, or allowing people to drink paint thinner as a warning against alcoholism.  Rather, people were putting their own health at risk by eating meat and drinking water they knew was risky, because there was no real alternative.  It was all they could get.  No-one was making a rational choice, Friday Night Dinner style, to eat rotten meat.

(I should point out here that I am not a historian of public health, so I’m making a point about the principles more than the details.  But please correct me in the comments if I’m wrong on something substantive.  If the analogy isn’t good, it’s got to go.)

In these circumstances, the appropriate public health response is not to ban all meat, or suggest people only eat vegetables; it’s to regulate the food industry and ensure that they only sell safe products that are accurately advertised.

Of course, MDMA does not occupy the same place on the hierarchy of needs as food and water, but if we’re thinking of pragmatic policy, there’s little doubt that (a) while not every human enjoys intoxication, it is unrealistic to imagine a human society where this impulse does not manifest itself in some way for a significant proportion of people; and (b) the substances that are being used cannot be undiscovered or uninvented.

And actually we’re not talking about all food or drink; it is possible to live as a vegetarian, so why not just say that meat-eaters should look out for themselves.  Meat is a luxury and ‘caveat emptor’.  It’s the customer’s choice to buy meat, so it’s their risk and duty to check it’s safe.  If they’re not happy with the risk, they should stop eating it.  It’s no-one else’s fault if they fall ill after eating it when they could just have had a nut roast like some other people.

But that isn’t the public health response to unsafe meat.  So what should its response be to unsafe drugs?

Well, we can lobby as individuals or as a group (and the Royal Society for Public Health has done this), but in the immediate term we have to operate in the current situation – which was Hugo Rifkind’s primary response to Peter Hitchens: given we can’t change the situation regarding supply today (whether to further restrict it or regulate it), what should we do right now?

Well in the absence of any proper regulation for these substances, which means we can’t stop people being sold substances of questionable quality, all we can offer is a service to consumers to test the product they’ve brought.  Not everyone will use this, and not everyone will respond to what they’re told in what we might consider a ‘rational’ way, but it’s hard to see what other options there are.  Of course more people will use this service if it’s free.

So I’ve stated that drug testing is a public health issue, and there should be free testing for it.  So shouldn’t the local authority be funding testing at Bestival?  Is the only reason not to the austerity levels of funding available?

Well let’s think about that meat example, even if it is a bit tenuous.  The state doesn’t pay for free customer testing of meat.  Rather, it relies on producers to ensure quality and safety, with the understanding that there will be periodic tests and the costs of ensuring safety will be passed on to the customer in the price.

Thinking of another example, health and safety inspections occur, but we expect leisure centres to be responsible for ensuring the safety of their swimming pools.

By the same logic, the onus for testing at a private event on private property shouldn’t be placed on local authority public health teams, and festival organisers should ensure harm reduction measures (the equivalent of lifeguards, safe water, rubber rings) are available and accessible.

Following these analogies, we can imagine a situation where the local authority did some trading standards style spot testing, but this isn’t possible under the current legal framework (though interestingly it was appropriate while there were still ‘legal highs’ before the Psychoactive Substances Act).

So that’s the answer to the question that no-one (apart from me) asked: drug testing is a public health issue, but that doesn’t necessarily mean that local public health teams should be funding it.  Now let’s get on with trying to encourage a more coherent approach to regulating these substances so this kind of discussion becomes redundant.

Thursday, 24 May 2018

Changing the narrative with personal stories

Yesterday I was at an amazing conference – InterAction 2018 – hosted by Adfam and funded by Alcohol Research UK.  The mixture of speakers was fantastic, including researchers, policy people, practitioners, carers, service users, and even a social historian.  And there was an open dialogue about key, fascinating issues, conducted in a collegiate way.

There were innumerable striking stories and insights, and each person will have their highlights.  But for me, having spent the day before sat in a meeting with health colleagues and an inspector from CQC, the story that hit home hardest was Tina Williams’ description of how her son died of lung cancer on a Sunday, having only been diagnosed on the Monday – because his health needs were not even identified, let alone met, by a system that fails people who use drugs, particularly when these substances are used to self-medicate for physical and mental pain.

The point that perhaps got the strongest reaction all day was also from Tina, when she called for providers to stop promising to commissioners that they can deliver everything desired for a bargain price.  It’s not possible and gives a false sense of security to decision-makers while giving potential service users and their families inflated expectations, and the problem has become even more acute as funding has reduced.

My response – a point made at the event by Paul Hayes – would be that I think there is actually an increasing sense of realism amongst both commissioners and providers.  I don’t think there will be many commissioners who aren’t concerned about ‘market failure’, given the publicity around instances like Bristol.  I don’t think commissioners are expecting the world from providers, and I don’t think they would get promised it either.  I don’t think areas are inundated with bids for substance misuse contracts these days – any kind of choice is seen as a vindication of the model and budget – and even the big third sector providers are reluctant to bid if they don’t already have a foothold in an area.

As part of our recent recommissioning experience in Dorset, I’ve wondered how good we are at practising what we preach.  Not just us as commissioners (talking about ‘partnership working’ and ‘open and honest’ dialogue) but practitioners.  The bread and butter of substance misuse practitioners should be ‘change talk’ – and yet how good are staff at dealing with change in their own work lives?

I’ll leave that question open, but the same theory applies to the wider ‘sector’, as we kept referring to it.  The discussions suggested that we, as providers and commissioners, have reached a stage of acceptance: we agree that we as ‘the sector’ have a problem.  That’s a really positive first step – but as with all behaviour change it leads to a second question: what are we going to do about it?

There seem to be two elements to the potential ‘solution’.  The first is immediate and practical.  Let’s have realistic commissioning, and ensure our staff and services are operating the highest quality service possible, with the widest reach and impact possible.  (The word ‘possible’ here is a way of expressing my concern about capacity/funding challenges.)

But there’s also a longer-term question: how can we fundamentally change the situation from one of limited and falling funding to one of increased resources?  Of course, as Paul Hayes would be the first to acknowledge, the political context has to be right.  But if we assume our arguments won’t fall on deaf ears, what arguments should we be making?  If ‘years of plenty’ ever return, then we won’t be the only people queuing up to argue for more funding, claiming that our cause is respectable and deserving.  We might, though, find our audience to be naturally sympathetic.

At the conference, there were effectively two sets of suggestions as to how we might make ourselves heard, both of which I’ve talked about on this blog before: crime and children.  Basically, we can win funding by suggesting that people who use drugs – I would say problematically, but I think we all know that’s a distinction that’s hard to maintain when we’re talking about stigma – are mad, bad, and dangerous to know.  That is: they’re likely to commit crime so we should treat their problem to reduce crime in order to feel safer; and/or they’re a risk to children, so we should treat them to protect the next generation, who can’t protect themselves.

There’s certainly some power in these arguments.  And there is of course that risk of stigma.  Some people might even feel that this is disingenuous: arguing that people are bad and dangerous when in fact most people’s reason for making this claim is compassion and human kindness.  Another presentation at the conference – by Mike Ashton – poked holes in the foundational NTORS evaluation of treatment, saying that it overstated its case (in the terms it defined).  Should we sacrifice accuracy in order to get the right outcome?

I won’t rehearse my moral squeamishness about this here.  Perhaps I’m becoming more hardened to political realities.  (I can’t imagine an argument for funding drug treatment based on compassion would get too far in today’s political environment, as the Home Secretary defends Stop and Search.)

What I want to ask is not whether we should stretch the interpretation of some statistics.  I want to think about the broader arguments they might be put to work for, particularly with those two points in mind: how can we provide a high quality service, and how can we get services better resourced?

In that 1990s/2000s era, crime reduction (‘tough on the causes of crime’) was the narrative that statistics and evidence like NTORS were marshalled to support.  This was powerful and secured sustainable – and even increased – funding through the National Treatment Agency for a decade.  But today, crime just isn’t such a powerful political issue, partly due to the successes of drug treatment.  As Paul Hayes pointed out, the last thing you want as a civil servant in Whitehall (and, I would add, in town halls) is to be successful.  If you ‘solve’ an issue, that means you instantly lose ministerial attention – and the funding that goes with it.

But if crime isn’t much of an issue, maybe drug-related issues still are.  The wider public doesn’t seem too concerned about drug-related deaths, but at a local level they certainly are about drug-related litter.  Where I live, for example, discarded needles are a regular front page feature of the Dorset Echo.

And yet, when this is used as a reason to explain provision of substance misuse treatment services in the area, the reaction is far from positive.  Some people who would acknowledge – even shout about – the fact that an area has an issue will object to facilities being established locally.  They just want the problem – by which they mean the people – to go away.

Some would suggest this is a particular issue in seaside towns like Weymouth, where there is a narrative that problems are brought in by ‘outsiders’ who see somewhere by the sea at the end of the train line as a good place to try to escape their problems.  But I think this issue of narrative is a universal problem for local policymakers.  People acknowledge there is a problem, and would even welcome a solution – so long as the location (unlike the original problem) is ‘not in my back yard’.

So how can we make this appeal more positive?  I was feeling less than positive at this stage.

Perhaps we need to resort to the familiar chant ‘think of the children’.  And that might well have some traction with local authorities, but even if there was a ‘magic money tree’, I’m not convinced this refrain would deliver funds for treatment for people who misuse drugs, rather than support for safeguarding processes, care services, fostering and so on.  Support to get the problem (again – actually the people) away from the children.

But as I listened to the presentation by Darren Murinas from Expert Citizens, who was astonishingly articulate, engaging and insightful while describing his less-than-ideal childhood, I was reminded of a commissioner from another local authority area complaining that people have plenty of compassion for ‘the children’ in cases of abuse – but not when these children become adults with a host of issues, including substance misuse, that are all-too-predictable.

I started thinking: why can’t we mobilise that compassion to support our services?  What is it we’re doing wrong?  Or perhaps it’s a na├»ve idea.  As I say, a politics based on compassion seems an impossible dream at the moment.

But then Oliver Standing stood up to give his personal summary of the day.  Two points from this really hit home for me.

First, for all that we can talk about the power of value for money stats, or the evidence of randomised control trials, that’s not always how politics works.  He gave the example of the new funding for work with children of dependent drinkers, and, while acknowledging that £6m shared between several local authorities is not a very large pot of money, he emphasised that it is worth considering why there’s any money being granted at all.  Oliver suggested that the key turning point from a lobbying perspective was a personal narrative: Jon Ashworth’s speech in the House of Commons about his own childhood, which moved a government minister to tears.

Second, that over the course of the day a lot of people talked about ‘the system’.  I don’t think Oliver quite said it, but my impression was of a tension between this big, abstract idea of a ‘system’ as compared to the detailed, touching, personal narratives – and the undeniable fact that this ‘system’ is made up of a range of people trying to improve their own and others’ lives.  Oliver’s point was that if we’re looking to improve that system, then we should start with one of the classic first steps in design: empathy.  That is, whether you’re designing a health system, a phone app or a chair, you should put yourself in the shoes of the end user.

So by the end of the day, I was feeling more positive.  If we’re thinking about ‘changing the narrative’ around substance misuse, the best way to do that is with some narrative of our own, and as we shape services.  Perhaps the most powerful way of doing this, at least at the moment, isn’t necessarily value for money stats or health economics, so much as personal stories.  And those are the kind of narratives we have in abundance.  Every person has a story.  Rather than complaining that drugs policy isn’t ‘evidence-based’, as many people do, perhaps we could think about the practical point: how do we actually get that change?  The first step could be to start the public thinking less about a ‘problem’ or a ‘risk’, and more about ‘people’.  It’s harder to say ‘I don’t want those people in my town’ than it is to say ‘I don’t want this problem in my town’.

That’s an idea for the longer-term question: how we secure adequate funding for this field.  But there’s also implications for today.  Those of us who work in ‘the sector’ could maybe do with thinking like this a bit more.  The ‘sector’ is also a collection of people doing things with people to help people.  These kind of narratives can remind us of what we should be doing and why.  This isn’t just sentimentality; it’s about a different way of thinking: let’s think less about organisations, and structures, and more about the most important element of treatment: individual connections between human beings.

Wednesday, 28 March 2018

What are drug consumption rooms for?

I’ve been thinking a lot about drug consumption rooms lately – often referred to in the field as DCRs.  They’ve been an issue nationally, with the debates around the Glasgow proposal as well as noises from Durham and other places.  And it’s no secret that drug-related litter has been an issue in Bournemouth and Weymouth, which my job covers, so it’s a day-to-day thing too.

The arguments are pretty familiar.  There’s not any real doubt that these facilities can have a positive impact for people who use drugs and the wider community.  However, there’s a debate about the scale of that impact and whether scarce resources are best spent on these kinds of facilities rather than other, more established, initiatives.  We’re never going to live in a utopia where everything that everyone needs or wants is funded and so these questions are real: what would we be trying to achieve with DCRs, and would it be worth it?

(For those of you who don’t follow these debates in as much detail as me, the term DCR can cover a range of things, but generally means somewhere to inject drugs under supervision.  The arguments in favour are that they reduce risks to people who use drugs as they have somewhere cleaner and safer, where someone is checking that they’re OK – but it’s not just about the users themselves, as they can potentially reduce public use and drug-related litter as well as drug-related crime.  If you want a good summary, Glasgow and Southampton councils have done great work on this.)

The view of the ACMD is that DCRs might be useful, but as part of a wider package of interventions; they shouldn’t be seen as a panacea on their own.  That is, of course, fair, but it’s not the most practical advice for commissioners who are struggling with increasing numbers of drug-related deaths, an ageing cohort of people who aren’t making great progress in treatment, and rising rates of homelessness and public injecting.  A comprehensive package of interventions would be great, but we didn’t have that in 2010, and now we’ve got cuts of 20% already, with no funding at all guaranteed beyond 2020.

So can – or rather should – DCRs be part of the picture in terms of commissioning under austerity?

When this debate comes up, it’s often framed in terms of the ‘methadone wars’ – that harm reduction has been sacrificed on the altar of ‘recovery’.  But (and I’m not alone on this, it’s not an original thought) I can’t get my head around this invented binary.  How does anyone achieve recovery without reducing the harm from their substance use?  How can giving someone advice and information about substance use be counterproductive to them achieving recovery?  Or, putting it bluntly: you can’t recover if you’re dead.

And a lot of people who use drugs are dying.  I don’t think this can be overstated – though it’s not necessarily the most powerful political argument in favour of drug treatment.

But setting aside this idea that treatment has been damaged by a focus on recovery or ‘successful completions’ (which I appreciate is some people’s experience, but it’s not mine), if we’re coming at this issue fresh, without the baggage of previous political debates, what should we do about DCRs?

Well the first point I often hear is that we should (to reference John Major) get ‘back to basics’.  If only we did needle exchange (and possibly opiate substitution treatment [OST]) properly, then there wouldn’t be these issues.  I’m informed that we’ve lost specialist needle exchanges and pharmacies offer a poor replacement.

But I don’t recognise this picture.  Commissioners find contracting with pharmacies frustrating: there’s lots of them and their local authority ‘business’ (whether needle exchange, supervised consumption of methadone or sexual health services) is a fraction of the overall turnover from NHS England or the commercial side of their work.  You can’t effectively manage a hundred contracts of this type.  The provider doesn’t care about your element of the service that much, and as a commissioner you can’t spare the time or energy to manage each one of them with the same intensity you’d apply to a specialist provider.  So inevitably the service isn’t great.

But that’s no criticism.  In fact, it’s in line with NICE guidelines, which suggest a tiered approach to needle exchange where specialist services offer the gold standard, including harm reduction advice, but we can’t provide that in every neighbourhood and indeed this level of involvement might put some people off, so we need to offer accessible facilities in a wide range of locations too.  It wouldn’t be possible to have a specialist needle exchange in every town or village in Dorset, but it’s possible to deliver this through pharmacies – though inevitably at a lower level of intensity.

I just don’t recognise the picture I’ve seen (or rather heard) painted that commissioners have lost all the structure and experience of 30 years ago, seen as the heyday of harm reduction.  Maybe it’s true elsewhere, but although we’re always able to improve our needle exchange offer, and the past few years haven’t been ideal, I can’t see that we’re moving away from specialist services to pharmacies.

If anything, as I say, I would have thought that the public health experience of having to directly commission pharmacies to do all sorts of bits and bobs that you wouldn’t have thought were the local authority’s responsibility (the morning after pill, for example) would have made commissioners more reluctant to use this as some kind of efficient escape route from the problems they’re facing.  There’s more uncertainty and less control – how’s that a recipe to sleep easier at night?

The issue is more likely to be integration – not only between pharmacies and the wider treatment system, but simply between needle exchange and more structured treatment.  I’ve been told that many service users actually prefer using pharmacy needle exchanges to the specialist services -precisely because they don’t get those hassling harm reduction initiatives or people trying to engage them into ‘structured’ treatment.

And that’s where we get to a really difficult point.

DCRs are often sold, following the ACMD argument, as an opportunity to engage people into treatment.  A DCR can be a hub for the full range of harm reduction activities and wider social interventions like housing, benefits, employment, probation and so on.  The argument is that some of the people most in need of support are going to come into this facility, so it’s an opportunity to get a whole range of ‘wrap around’ services put in place as part of a broader treatment ‘plan’.

But most DCRs aren’t just harm reduction hubs; they also offer – for example in the Glasgow proposal – structured treatment, often heroin assisted treatment.  Certainly there’s all sorts of services operating from most, from methadone dispensing to housing benefit advice.  That can sound like a great idea; an opportunity to engage people straight from injecting illicit substances to being on a legal prescription.

But equally it can sound like the opposite of what some harm reduction advocates would hope.

In Weymouth, we have brought all our services under one roof.  There used to be a site for prescribing, a site for harm reduction and group work, and a site for the criminal justice team.  And then the abstinence-based ‘aftercare’ operated from a range of sites (like church halls) that weren’t permanent fixtures.

(It’s not just austerity that brought services together; it’s also service user feedback.  One (unnamed) individual used what’s become known locally as ‘the dentist analogy’: imagine if you had to go one place to have your anaesthetic, then walk down the road to get your tooth drilled, then hop on a bus to then get the filling actually put in.  That’s what dealing with substance misuse treatment (and all the other related services) felt like to them.  Saving on rental costs by sharing premises won’t dig us out of our financial hole; one member of staff can cost more than the rent on a workable building – just check rightmove.  It’s the people that make the difference in services, and quite rightly that’s what commissioners are mostly paying for.)

So what’s the problem with bringing services under one roof, as they would be to some extent with a DCR?  Well, it means that by definition you don’t have dedicated harm reduction services; they’re operating from the same premises as the prescribing provider who will be (more often than not) part of the NHS.  So our needle exchange now operates from the Weymouth Community Hospital site.  Since it moved from a dedicated third-sector ‘drug agency’ base, the numbers accessing needle exchange there have fallen.  People, we’re told, find it intimidating to access needle exchange at the same site where they pick up their prescription.  (And equally, people who are now abstinent find it a challenge to step through the door of a facility where people are still in ‘active addiction’.)

I appreciate this is rambling.  I haven’t got (as I often ask for in the day job) a clear definition of ‘the problem’ or a proposed ‘solution’.  But that’s the point.  A lot of people (including me) are excited by DCRs, but if I’m honest that’s partly because they’re shiny and new to a UK audience – and therefore untainted and full of promise.

On this blog I’ve often moaned about how minimum unit pricing for alcohol is an empty vessel into which people pour all their (alcohol policy) desires: it’ll stop underage drinking, binge drinking, dependent drinking, excessive everyday drinking, and so on.  It’ll even revive the pub trade.

I worry that DCRs will become the same thing for drug policy: they’ll reduce drug-related litter, public injecting, blood borne viruses, crime, antisocial behaviour, and they’ll foster recovery and abstinence while they’re at it.

Will DCRs really be a harm reduction hub?  And if they are, should they also be a site for delivering treatment?  Or will that scare people off?  (Both people who aren’t ready for treatment and those who want to see a bit more stability in their lives.)  To return to my regular themes on this blog, I think we need to work out what we’re trying to achieve before we start leaping to solutions.

Friday, 23 March 2018

The future of Alcohol Research and Concern

Alcohol Research and Concern are, as you'll probably be aware, merging, and they're currently conducting a consultation on various aspects of their work to think about what the shape and aims of the new organisation might be.  They will be inviting comment on specific issues and questions and I'd really encourage people with any interest in alcohol-related issues to comment.  Here's what I wrote on treatment (you can access the original post by Richard Piper asking for feedback just by going to the home page of either organisation):

In terms of the specific questions you ask, yes I think there’s the potential for greater private/charity involvement in delivering to a wider group of people without addition state support.  Certainly our services (deliberately) focus on areas of greatest socio-economic need, so there may be opportunities to increase charity donations or encourage people to contribute to their own treatment or intervention – even if that’s just paying to download an app.  But this has (at least) two potential problems: (1) how do you ensure that it’s only those who can afford to pay that feel they have to; and (2) are you OK with this position politically/ethically in terms of diluting a commitment to universal healthcare free at the point of use?

As to whether the charity should seek to influence government, I think it’s perfectly reasonable to campaign for greater use of evidence-based programmes.

In terms of innovation, there’s not only technical stuff but also more general evidence that could make services more efficient and effective.  This means not just encouraging people to go online but also viewing their issues as part of a wider life, especially thinking about family, employment and housing.

Families can of course be crucial to recovery, as other respondents have emphasised, but there are plenty of people who are at risk who don’t have accessible or supportive family networks: family can be absent or indeed as much a part of the problem as the solution.

And while taking ‘a whole family approach’ is the current popular phrase for PHE and local authorities, this is often at root about reducing costs for children’s services.  I’m suspicious of this instrumentalism, given the experience of New Labour and the NTA failing to achieve sustainable acceptance of drug treatment using crime as a fig leaf for what was really about providing health and care to a group of people in need of support.  So there are key dangers with focusing on ‘family’: first, the neglect of drinkers who don’t live with children; and second the pathologising of all parental drinking, or at best painting it all with the same brush when in fact there are myriad problems where alcohol is implicated.

And this is the key point: although the Alcohol Concern/Research charity will inevitably be focused on alcohol – and this is reasonable as it is a specific and unique substance with its own history and policy – people relate to this substance in an infinite number of ways, in connection with everything else in their lives, and therefore any analysis, policy or treatment cannot and should not focus on an ‘alcohol problem’ that the UK has.  Alcohol may play a role in people’s problems, but that’s something quite different.  Even dependence is hard to isolate as a uniform condition, and certainly its implications vary.  It may or may not be seen as part of a wider ‘substance use disorder’.

And so my plea would be to avoid discussing ‘alcohol treatment’ as a monolith (when there will be a range of issues, and solutions must look beyond alcohol) and not to equate this with something that is designed to address ‘dependence’.  But you and your colleagues know all this already.  Good luck!

Saturday, 17 March 2018

Can alcohol policy accept moderate intoxication?

Having recently finished a draft of what will hopefully become a book chapter on the Psychoactive Substances Act, I’ve tried to clear my desk out this weekend, and came across all sorts of incoherent pencil notes on scraps of paper that were intended to be transformed into blog posts.  One of them, however, stood out.  It’s not fully formed, and it would need a lot more work to become coherent and worthy of proper publication, but it’s exactly that kind of half-baked, incoherent rambling that’s the hallmark of this blog: thoughts that aren’t neat (or long) enough to become academic articles (or perhaps even conference papers).

So here goes.  This should probably be read in tandem with my previous ramblings on the Psychoactive Substances Act, given that I think this was an earlier version of the chapter I’ve ended up putting together – or perhaps a response to it.  (I've updated mentions of the Psychoactive Substances Bill to 'Act', as it passed some time ago now.)

I think it also works quite well with a book I'm reading at the moment by Ingrid Walker.  Go buy that!

Before I start, I should state a key assumption: we’re never going to be able to pin down what the government is concerned about in relation to drinking (alcohol) into a single idea, like ‘pleasure’, ‘disorder’ or ‘intoxication’.  My previous attempt (with the ‘carnivalesque’) is a bit of a cheat to put together a whole ragbag of things (excess, disgust, class, gender, etc) and doesn’t tell the whole story even then.

As James Nicholls and others have argued, alcohol tends to become a lightning rod for broader social and political questions to be played out: freedom, agency, morality.  I saw a good example of this at the Alcohol and Drug History Society conference in 2013, where in the same session different presenters described British and French attitudes to women’s drinking in the nineteenth century.  Lauren Saxton described how the French, who were worried about underpopulation, seeing themselves as slipping behind other European powers in a kind of population arms race, expressed concern that drinking led women to be infertile, or at least to have fewer children.  Presentations from Thora Hands and Stella Moss, (on Twitter here and here) showed that the British, meanwhile, were concerned by overcrowding in cities and people’s inability to feed their families, and saw alcohol as leading people to have more children then they would otherwise – with less money to spend bringing them up because they were spending it on booze.

Previously, I've been somewhat dismissive of the idea that government has been 'criminalising' pleasure and/or intoxication, arguing that this doesn't quite capture the specific concerns it expresses in relation to 'binge' drinking.  But, as that example shows, this is because my focus has generally been on alcohol policy, where I think the situation is more complicated because of the legal status of alcohol in Britain today.  The situation is different when we look at other substances that might be grouped as 'intoxicants'.  And I think, grouped in this way, we can start to see a common thread between all of them, despite initial appearances.

The new Psychoactive Substances Act [not so new, now I'm typing this up] is precisely targeted at intoxication, and tries (pretty clumsily) to pin down a scientific description of 'psychoactivity' to do this.

In the same way, successive alcohol strategies have been targeted at those who 'drink to get drunk', also known as 'binge' drinkers.
Now this needn't imply opposition to intoxication per se, and there are certainly other societies past and present where certain limits to intoxication have been applied (rather than absolute opposition to intoxication).

We can see this in Jennifer Richards' rejection of the approach based on Norbert Elias' concept of a 'civilising process' that sees early modern writers as giving drinking advice based on opposing ideas of 'excess' and 'restraint'.  According to Richards, 'the preoccupation with restraint and excess has left the conviviality of moderate intoxication, light-headedness, and its rhetorical practice - the witty adaptation of sayings - overlooked and undervalued' (p.172).

This view would be very familiar to the drinkers of many research studies, whether the young women described by Farringdon as trying to tread a 'fine  line' of feminine drinking, or the older drinkers in Carol Emslie's work.

But today's UK government cannot see alcohol consumption or use of any other 'drugs' in these terms.  Alcohol strategies don't talk about 'fuddled joy', for example, and the alcohol industry is not allowed to suggest that drinking enhances sociability - something that many of us would struggle to argue with.

Alcohol as possible health-enhancer, alcohol as tasting good, alcohol as a valuable part of the UK economy, yes.  'Moderate intoxication'?  This, in alcohol policy debates, seems to be considered an oxymoron.  The phrase is surely unimaginable in a policy document.

The government, if no-one else, is still very much signed up to the Norbert Elias model of good and bad drinking as being about restraint versus excess, where any intoxication - or at least 'drunkenness' - is by definition excessive.  The 2012 Strategy noted that 'in moderation, alcohol consumption can have a positive impact on adults' wellbeing, especially where this encourages sociability' - but the example of how this happens has nothing to do with the 'intoxicating' or 'psychoactive' properties of the substance: 'Well-run community pubs and other businesses form a key part of the fabric of neighbourhoods, providing employment and social venues in our local communities' (p.3).

(Of course, in acknowledging the setting of drinking this government, like its Labour predecessor, was showing it is familiar with the important work of Norman Zinberg.)

This approach, whereby 'moderate' and 'safe, sensible, social' drinking cannot mention intoxication does suggest that government is concerned with mind alteration specifically.  But actually the awareness of the importance of setting and so forth reminds us that the concerns are indeed broader.  Psychoactivity gives a neat rationale and pseudoscientific position, but in reality the concerns are about things like crime and antisocial behaviour - or more widely the disruption of everyday norms (see my work on the carnivalesque where the concerns are more about 'norms' being disrupted then chemical intoxication).  The Psychoactive Substances Act effectively brings this position out into the open, by separately, as explicit exceptions, those substances that are viewed to have forms of consumption consistent with those 'everyday' norms: alcohol, nicotine and caffeine.  But even then: 'moderate consumption', yes (though not even that in terms of nicotine), but never 'moderate intoxication'.  Here's hoping for a shift in the narrative.