Recovery capital and specialist treatment services

I’ve written about the issues surrounding the move of substance misuse treatment to Public Health before, but this week I’ve come back to thinking about it – and not because of anything to do with Dorset Public Health, I should point out.

I don’t have a neat conclusion to this post, and to some it will seem like either stating the obvious or a self-interested defence of the status quo.  However, I still think it’s important to make the case for existing forms of substance misuse treatment, and I do so unapologetically.

Although it’s some months old now, this week I read this article suggesting that social policy research, due to the background of researchers, can often focus on what might be called middle-class problems.  And on the same day, there was this article on the Guardian website, suggesting that Public Health has neglected middle-class, middle-aged alcohol consumption.

The incongruence immediately struck me – not least because thinking about the people substance misuse treatment might have missed has been high on our agenda in Dorset.

Then, I saw this work from Drug & Alcohol Findings reminding me of how recovery is possible – even more common – without formal treatment.

Given that I work as part of a team that commissions substance misuse treatment, it’s no surprise that I’m sceptical of these challenges to its efficacy.  However, I want to leave aside the self-promotion work of the (former) NTA.  Particularly when taken together, these various sources raise some fundamental issues about the nature and aims of treatment.

To be fair to Hannah Fearn, who was writing in the Guardian, her main point was that middle-class drinking can get neglected in public debates around alcohol, when the focus is almost invariably on ‘binge’ drinkers within the night-time economy.  I’d agree with this to a certain extent – there’s a plethora of ‘problems’ related to alcohol, and in order to put in place effective, targeted interventions (whether that’s minimum unit pricing, licensing conditions or access to residential rehab) we need to define the problem we’re concerned with.  Solutions to the ‘problem’ of ‘binge’ drinking (and apologies for all the quotation marks, but I think they’re necessary) won’t necessarily be solutions to the ‘problems’ of older people’s drinking.

So, before we consider what Public Health has or hasn’t been targeting – and it’s a bit odd to blame them for substance misuse services when this has been the responsibility of DAATs in England until April 2013 – it’s worth considering what the problems associated might be.

The role of Public Health is, as I mentioned in my previous post, pretty bold: “to protect and improve the nation’s health and to address inequalities”.  This idea of addressing inequalities (presumably in health, though that’s not exactly spelt out) is absolutely crucial in this context of determining priorities.

As I’ve suggested, there’s any number of possible policy concerns regarding alcohol: health harms (which might be acute or chronic), drink driving, disorder, crime, antisocial behaviour, and – as I’ve argued elsewhere – a general fear or dislike of intoxication, to name just a few.  There aren’t many people who argue that drinking over your daily recommended limit is wrong in itself; the point is more that you are felt to be risking your health.

But we know that not all people face the same risks.  For whatever reason, despite the fact that people from higher socio-economic groups seem to drink the most, it’s those from the lower socio-economic groups who suffer disproportionate harm.  Mark Bellis and his team are conducting some fascinating research investigating this ‘alcohol harm paradox’.  It might turn out that it’s less of a paradox than it first appears because of the way consumption is estimated through self-reporting – that is, it might only seem that the richest drink the most.  However, whether or not it is a paradox, the point remains that the health harm related to alcohol falls disproportionately on those at the lower end of the socio-economic spectrum.

So, let’s assume that alcohol consumption isn’t considered an evil in itself, but only a problem because of the effects on health and so forth.  Then, if we were to target provision where there is greatest need (a pretty core principle of good service commissioning), we wouldn’t focus on middle-class wine drinkers.*

Now, this position can be interpreted politically in two ways.  First, it could be argued that I am demonising working-class drinking, suggesting that middle-class drinking is OK.  Alternatively, I could say that I am defending services from being reconfigured to serve middle-class interests.  It’s really up to you to decide.

This is where the Findings analysis comes in.  Plenty of people recover from alcohol (or drug) dependence/addiction/misuse without accessing specialist treatment (as I was forcefully reminded by Keith Humphreys, talking to him after the Alcohol Research UK conference, when I suggested that DIP work could be successful in addressing issues of addiction and crime – he disagreed).

However, it seems to be the case that some people are better placed to achieve recovery than others.  In contemporary terminology, picked up on in the 2010 Drug Strategy, there are resources called ‘recovery capital’ – social, physical, human and cultural.  Some people might see these as a twist on Pierre Bourdieu’s forms of capital, which he actually uses to effectively define class.  That is, the distribution of these sorts of resources affects all sorts of life chances, and thus can be considered as something broader than the sum of their parts: class.

This isn’t just an issue of dependence or addiction.  As I wrote in my previous post, the insight of public health analysis is that all sorts of elements of social life are interlinked: educational attainment, health, employment, housing, and so on.  That’s exactly what Bourdieu was trying to get at with his broader notion of class – or EP Thompson, Raymond Williams or whoever you prefer.

By this logic, not only are the middle classes less likely to suffer alcohol-related harm, but also if they do they’re more likely to have access to the resources you tend to need to overcome alcohol issues.

Looking at what specialist treatment services tend to provide, it’s precisely these elements of recovery capital: social capital by providing a network of support; physical capital by helping someone into safe, stable accommodation; human capital by providing education and mental health treatment; cultural capital by analysing values and aspirations.  This is unsurprising when that’s exactly what the government wants its money spent on.  However, it doesn’t change the fact that these are resources that help to foster recovery – and the need for this support isn’t equal across the population.

Of course, none of this should detract from the fundamental point underlying that Guardian article: that alcohol issues shouldn’t solely be seen as the preserve of ‘binge’ drinkers, and we should have a public debate about drinking that tries to look at the whole spectrum of problems that might exist.  However, that doesn’t mean they all need the same levels of resource or attention.

*There is one caveat to this position, however.  It is possible that although most such drinkers aren’t facing issues now, they might be storing up problems for the future.  Some time in the not-too-distant future I plan to write a post about ageing and alcohol, and one of the core issues with this is how people are now drinking at very different levels as they hit retirement compared to those in previous generations.  Given that our ability to process alcohol decreases as we age, and some of these drinkers may have longstanding patterns or habits of drinking above general guidelines that may be hard to break, this may pose an increasing issue for services.  The truth at this stage, though, is that we simply don’t know – and that’s not a question of ‘only time will tell’; there simply hasn’t been enough good research looking at this issue.

Public Health and bedtime stories

Although I ended up rambling about municipal pubs, my last post was prompted by my enthusiasm after going to a public health conference hosted by the LGA.  As I’ve said before, I see real opportunity for public health to make a difference to a wide range of policies in local government, not necessarily through spending, but by being a voice around the table – or, given the discussions in London the other day, embedding that voice into the decision-making process by winning over other stakeholders, whether they’re within the council – say in the transport department – or outside, like pharmacists and dentists.

On the other hand, though, I’ve sometimes been wary of a public health approach.  Because the approach increasingly focuses on ‘lifestyle’ illnesses there’s a tendency to understand public health in individualistic terms where people are felt to be making bad ‘choices’.

There are two key problems with this approach.  First, there’s the liberal JS Mill argument that someone’s own way of living their life is the best almost by definition.  Second, there’s a question as to whether this model of individual free choices actually reflects reality, where certain choices are easier than others and people’s options and the relative attractiveness of them will be affected by structural factors, such as wealth, environment and so on.  (This point was made by several speakers at the LGA conference.)

On this front, say on smoking policy, the first point would question whether the state should have any role in trying to reduce smoking prevalence, as that’s just the expression of individuals’ decisions, balancing up the costs and benefits of smoking and deciding that the pleasures are worth the risks.  The second point (which would only be relevant if you didn’t accept the first) would note that people’s propensity to smoke seems to be affected by their background and other factors, so you’d need to do more than address individuals; you’d need to change those background factors.

Certainly I’ve made both of these criticisms in the past.  Why shouldn’t someone drink if they want to?  Who defines too much?  And let’s not, from ivory towers, guilt trip people about the joys of an abstemious life.  Sometimes, reading something like the Marmot Review, given what we know about how wealth and income inequality determine health, it can seem like the only way to achieve its objectives is a shift in political culture – instituting communism.*

However, this wasn’t the way I felt on Tuesday.  As I say, I felt enthused.

But I was reminded of these questions about the scope of public health when I heard about a public health initiative to ensure that children are told bedtime stories.**

This is in some ways exactly the sort of thing I was enthused about – public health looking at the broader determinants of health.   But it also raises the question as to whether this is really a public health intervention when its influence on health is so indirect.

In fact, because of the interlinks, such an intervention is best understood not as a health intervention, but as part of a broader project to foster fulfilment, and possibly the development of ‘good citizens’.

The principle of the bedtime story reading in its relevance to health is the same as the Good Behaviour Game, for example: strengthening what is sometimes called resilience.  To some extent, this idea of resilience could be seen as an attempt to combine the individual and the structural perspectives on public health.  One of its key defining features is the ability to make choices.

The vision of a resilient individual is one who makes wise, considered choices.  To some extent, this sort of intervention could be seen as neoliberal: an attempt to make people self-governing, rather than reshaping the structures around them.  I don’t want to discuss here whether I agree with this mode of governance or not; simply to acknowledge that there are other ways to ensure public health – more direct interventions, that focus less on individual choice, might be at least as effective.

Also – and this is what distinguishes neoliberalism from classical liberalism – the government has clear ideas of what ‘good’ choices are; it doesn’t really sign up to the Millian point that everyone’s own way of living their lives is by definition the best (within certain limits).

To some extent, the elements that constitute this new public health approach are not controversial, or specific to left or right wing agendas.  Equally, they are not aims that are specific to public health.  I was enthused by the discussion of initiatives within Wigan and Hertfordshire at the conference not because they would enhance people’s health, but because they are more than this – in the case of Wigan the campaign was explicitly about community and aspiration in general: “Believe in Wigan”.

As I said previously, when writing about Brighton’s public health report, I’m more engaged when education or community are invoked as, if not goods in their own right, then contributing to something like eudaimonia or fulfilment – rather than being ways of protecting one’s health.

And here’s the rub.  I was enthused by the projects described on Tuesday because they were about fostering wider fulfilment, happiness, eudaimonia – whatever term you prefer.  You might choose the term wellbeing – and indeed health and wellbeing boards are part of the governance for public health teams.  But this is not public health in itself.

I would like to think that the idea that local government should put in place conditions that allow people to flourish is uncontroversial.  However, what we mean by flourishing is certainly up for debate.  In Mill’s view, you wouldn’t want too many restrictions as people become fulfilled humans actually by the process of reasoning and choosing.  (You aren’t a moral person if the choice to behave in a certain way is made for you.)

This could bring us onto a discussion of liberalism and nudging – appropriate, as nudging was a theme of the conference – but the point I want to make here focuses on public health specifically.  I was uncomfortable with the idea of happiness in the Brighton report, where it seemed to be either a meaningless proxy for health or a means to achieve health.  Similarly, community, or education, or bedtime stories shouldn’t be justified as good things on the basis of public health.  This is not why we want these things.  Scientific evidence continually emerges, and we might find that there is some drug that ensures health and longevity better and more efficiently than any amount of green space, or bedtime stories, or cycle paths.  Would this mean that we should abandon encouraging these things?

Public health is at the moment a good strapline under which to group all sorts of concerns that are not directly financial.  Given that the overriding dynamic in local government policymaking at the moment is saving money, having such an emphasis can be helpful, and that’s why I found the discussions positive.  However, it’s attractive to embed these ideas across local government departments precisely because they are not specific to public health; they simply amount to good government.

Maybe, for the moment, public health teams are a useful tool to remind local authorities that there’s more to life than short-term balance sheets.  However, it’s helpful sometimes not to take too instrumental a view.  The language of price and value is embedded in social mobility discussions, with Alan Milburn stating a few days ago:

“When 2.3 million children are officially classified as poor it exacts a high social price. There is an economic price too in wasted potential and lower growth.”

Just as equality shouldn’t be justified on the basis of economic growth, there’s a danger in suggesting parents should tell bedtime stories to boost their children’s health and resilience.

*The way PHE’s aims are stated, it’s actually as if the core task is reducing inequality of any kind: ”Our mission is to protect and improve the nation’s health and to address inequalities”

**I should confess at this point that I know next to nothing about this specific intervention and how it’s delivered.  The points I’m making here, though, should still be valid as I’m talking about the general principles.

Working with the alcohol industry locally?

I was at an LGA event on Tuesday called ‘Changing behaviours in Public Health – to nudge or to shove?’  (See #LGAcwb on Twitter.)  It certainly sparked my enthusiasm by showing how public health has been embraced by local authorities around the country, and how areas like Wigan and Hertfordshire seem to have successfully engaged wider partners, such as dentists and pharmacists, as well as getting councillors and council officers on board with the wider public health agenda.  These are all things I feel we could do much better in Dorset.

However, as usually happens with me, I saw things very much in light of what I’ve been reading and thinking about recently.

Claire McDonald spoke persuasively and openly about mobilising private interests to advance public health causes – mentioning Unilever’s initiative to boost handwashing (and/or use of Lifebuoy soap?) and her own initiative to prompt women to tell their GP ASAP (As Soon As You’re Pregnant).

I could feel myself bristling, simply because I have a natural suspicion of the profit motive.  However, given that we don’t have a nationalised food industry (although many public health professionals certainly aren’t comfortable with private food companies), I can’t help but accept that the market is perfectly capable of providing good things, and often efficiently.  If we want to wash our hands more often, and this is a good thing, what’s wrong with a company finding a niche (and some money) in this?

The workshop discussion on alcohol policy also raised the same issues of whether industry has a legitimate role to play, featuring Emily Robinson from Alcohol Concern alongside Elaine Hindal from Drinkaware (funded by the industry) and (much more open about his industry links) Henry Ashworth from the Portman Group.*

This discussion didn’t quite lead to the clear argument I experienced at last year’s DrugScope conference (perhaps an indication that Henry and Elaine pitched their message better to the audience than Mark Baird did there), but there was certainly some scepticism from those in the room as to whether the industry could really foster a healthier drinking culture (a straw poll revealed almost unanimous support for ‘shoves’ over ‘nudges’).

Now here’s my hobby horse (for this week).  I’ve been thinking about neoliberalism (resubmitting an academic article) – the point being that certain policy options around alcohol seem unthinkable because of the dominance of this ‘mentality of government’, when in fact they’ve been in place at various times and places in history.  Reading Intoxication and Society I was struck by the example from James Brown of schemes that pre-date the Central Control Board or Gothenburg System by hundreds of years – where government took the profit motive away from those running drinking venues, so that they didn’t have a reason to sell people more alcohol.**

Given that very few councils have introduced Early Morning Restriction Orders (EMROs) or Late Night Levies, it’s no surprise municipal pubs aren’t on the agenda.

But this isn’t all about the need to abolish the profit motive surrounding something that is ‘no ordinary commodity’.  Canada also had a comparable system of retail regulation, analysed in a new book by Dan Malleck: Try to Control Yourself.  Unfortunately, I haven’t read it yet (but consider this me proposing myself as a reviewer to any journal that will have me).  However, I have read the (free) review in Brewery History by Matthew Bellamy.  The review questions Dan’s argument that the regulation was a key element in reshaping Canada’s drinking culture such that, in Bellamy’s words, ‘Controlling oneself and drinking moderately continues to define an important part of what it means to be Canadian’ – in contrast with the situation before Prohibition in 1916, when ‘It seemed as though there were only two types of Canadians . . . those who drank to excess and those who did not touch a drop’.

Let’s set aside for the moment the point that immediately occurs to me, which is that, unhelpfully, we often have a similar (but mistaken) understanding of alcohol consumption in the UK today.

Bellamy’s critique of Try to Control Yourself is that actually the culture change isn’t all about the regulation.  It’s also about the brewers.  (He’s writing in a journal called Brewery History, after all.)  Having an (economic, profit-based) interest in temperance not winning the day, they found that they could embrace the model of the responsible ‘citizen-drinker’ the Liquor Control Board of Ontario envisaged.

You can see the same sort of motive operating in other times and places – Chris Routledge makes the point that the creation of the fantastic Philharmonic Dining Rooms (and other Cain’s pubs) in Liverpool was a deliberate move to generate a sense of respectability around drinking, enhancing its social, cultural – and therefore political and economic – capital.

And there are lessons in this commercial dynamic for us today.  Not only is the industry a legitimate stakeholder in alcohol policy formulation, but it’s not a monolith.  In the debate around MUP, some organisations were in favour, others opposed – the divisions weren’t always neatly predictable, and some companies shifted their positions.

In Bellamy’s interpretation, it’s the brewers who put the pressure on the hotel [pub] managers to run things smoothly.  However, this needn’t be the dynamic today.

To bring us back to the LGA conference, in the alcohol workshop discussion, there was little mention of on-licensees.  Where retailers were concerned, ASDA was mentioned, but most of the discussion was implicitly focused on the producers that fund the Portman Group – perhaps because this organisation is more open about its industry links, whereas Drinkaware is less directly the CSR arm of its myriad of funders (including plenty of organisations with on-trade interests, such as Admiral Taverns, JD Wetherspoon’s, Punch Taverns and Marston’s, for example).

To be fair, Henry mentioned schemes such as Best Bar None, and there’s plenty of work local authorities and public health teams have already done with such initiatives and more, working with the on-trade.  However, I’d suggest that if we’re looking for innovative ways to change drinking cultures, there’s more that can be done.***  There is serious mileage in Henry’s proposal for encouraging the ‘nudge’ of house wines being weaker, for example.  And in the context of Claire’s enthusiastic (or pragmatic?) embrace of Unilever and Merck/MSD as partners for public health change, the idea of having to shove the industry seemed dispiriting.  (Of course, we could come back to the idea that, unlike Lifebuoy soap, alcohol is no ordinary commodity, but then neither are pharmaceuticals.)

Thinking about culture change locally, the alcohol policy options that have been pursued in the past, and the possibility of harnessing private enterprise to benefit public health, it’s not so much the producers who are worth targeting as the retailers – and, I would argue, the on trade specifically.  This is particularly the case in the LGA context, when licensing (as opposed to MUP or taxation) is in the hands of local authorities.

The reason I think there’s more opportunity to engage the on-trade, if we’re interested in changing cultures around alcohol, is that the on-trade is no longer overwhelmingly reliant on the trade in alcohol.  That is, to some extent the situation produced by state regulation in Carlisle or Gothenburg has come about organically.  Although it’s an unusual case, I believe the majority of the turnover these days in student unions such as Bournemouth’s is on food and soft drinks including coffee and tea, rather than alcoholic drinks.

In the case of handwashing, Unilever have an interest in selling soap, but public health professionals want to encourage people to use soap, so working together seems plausible.  In the case of the on-licensed trade, the mix today is such that the interest in profit doesn’t need to be an interest in selling (only) alcohol – and so there may be a potential overlap between the licensee’s interests and public health.

There are of course several issues with this claim.  Most importantly, not all venues have the same model, and it’s those which are the most dominated by selling alcohol at the moment that are most likely to worry public health teams – and they’ll also be the least likely to have common ground.  However, the converse point is to look at research like this (by Adrian Barton) and see that ‘pre-loading’ often happens in part because drinkers don’t like the option they’re being provided with by such venues, particularly early in the evening.  And yet drinking at home isn’t always the best idea either from the perspective of government and public health, as an uncontrolled environment with little precision around units.  Might one potentially beneficial outcome for both public health professionals and local licensees be to encourage people it’s better down the pub – or at least certain pubs?

There are also wider challenges in shaping the policymaking context.  The argument that the brewers in Canada were in favour of the responsible ‘citizen drinker’ depends to some extent on the spectre of temperance and prohibition, when, as Brian Harrison put it, the world of temperance can seem a long way away, with ‘unfamiliar arguments and forgotten attitudes’.  And yet for such a faraway movement it provided the policymaking context for the drinking laws that were in operation when Harrison was writing and, in slightly altered form, for the rest of the 20^th century.  One can trace the influence of such campaigning even if none of the key demands are met.

Similarly, organisations like Alcohol Concern can see themselves as providing a counterbalance to the drinks industry, and helping to shape the terms of the debate and possibilities seen by government, merely by being part of public discussions.  Andrew Barr suggests that the formation of the Portman Group itself was a response to an emergent neo-temperance movement.

Thinking of Alcohol Concern as a counterbalance as a positive development sits somewhat at odds with my previous complaint of the zero-sum, realpolitik of the two apparently opposing sides in alcohol policy debates – though to be fair I did talk about the ideal dream world where different stakeholders come together for open and honest debate with their different perspectives...

But rather than this pessimism, I’d rather end in the same vein as I began: extolling another potential opportunity for innovative, helpful public health work.  Now would seem as good a time as any to think about how the on-trade could be encouraging public health.  Although there’s been good work so far, the opportunities for development are plentiful: as well as offering an alternative to pre-loading in city centres, the idea of the pub as the hub will resonate in more rural areas, enhancing social capital (and therefore health).  In such a world, the industry doesn’t sound an amoral product of the profit motive.  Maybe I am converted to public-private partnership…  (Well, not quite yet.)

If you’re aware of interesting, effective work already going on please let me know.  As far as I'm aware, the sort of development I'm proposing doesn't seem to have been a feature of Community Alcohol Partnerships, for example, but if things are happening that would keep the fire of my enthusiasm (and envy) burning a little longer...

*In a shameless act of self-promotion, here’s the link to my previous post on this issue – and here it is in a more public forum.

**For those who don’t know about these schemes, I can’t recommend highly enough reading about them in, for example, James Nicholls’ The Politics of Alcohol or Paul Jennings’ The Local.

***This raises the question of whether we actually want to change drinking cultures, and whether this is a legitimate aim of public policy.  I’m not actually sure, but for this article it’s taken as read because it’s clearly a current public health aim.  And, as I mention, there is something to be said for the industry representing its own interests and public health representing its own.  They might sometimes overlap, but they won’t always and that’s why it’s useful and interesting to hear both perspectives.