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.