Is your drinking like meat and potatoes?

As I noted recently, I’m maybe not as quick on the draw with these posts as I used to be, but I hope they’re still interesting (and maybe even useful) when I do manage to write something.  (And this time, as I'm able to release this post as minimum unit pricing is in the news again, as we wait for the latest court judgement.)

Minimum unit pricing was in the news again a couple of weeks ago, because of the announcement that it was being considered for Wales.  There are lots of angle to this, and most of them re-hash arguments that are ongoing and will never be resolved even if and when such policies are introduced in the UK, as ‘real world’ evidence on the impact of a policy is just as questionable as ‘modelling’, given that no policy is implemented in a vacuum.

What I want to think about is the impact on pubs, because this was specifically discussed with me by a few people on Twitter.

The key argument was put to me most clearly by Chris Snowdon, who pointed me in the direction of a post of his that features a neat and illustrative analogy based on meat and potatoes (or meat and rice, really).  The point is that as the price of rice rises, people on low incomes in China don’t buy less rice and switch to other things; they buy even more rice.  How can this possibly be, given the laws of supply and demand?  Well, they have a fixed income and rice is a more efficient thing to eat than meat, for example.  The lesson is that when times are hard, you buy less of the luxuries, and consolidate the essentials.

The argument is that a pint of beer in the pub equates to the meat in this analogy, while beer bought to drink at home is the rice or potatoes.  As Chris notes, if MUP raises the price of home drinking there are lots of ways people might respond to this (they could reduce their home drinking to maintain the number of their pub visits), but it’s pretty unlikely that spending on the ‘luxury’ of pub beer is going to increase.

Before anyone gets too technical, I want to point that I’m going to set aside the question of how likely it is that MUP would affect most people’s home drinking costs significantly, as I think that’s deserving of its own, proper, detailed discussion.  I’m just going to assume that there would be some noticeable effects that would be worth considering and potentially responding to for most drinkers.

As I said, I really like how neat and clear the analogy is (and he explains it better than me), and I think a key issue with policies like MUP is that they potentially de-normalise drinking alcohol, which of course could have a negative effect on pubs but also on drinking styles more generally.  However, I just don’t think the underlying assumptions behind the analogy hold for most people when we think about it in a bit more depth.

The key point is that there is a huge range of ways in which people consume alcohol, and how they think about this consumption.  And in fact I think there are some weaknesses or gaps in the Sheffield research on MUP, in terms of how the modelling takes account of these potential differences.  I think the Sheffield group would probably admit that although they look at on-trade vs off-trade consumption and prices, the impact on the pub industry specifically hasn’t yet been modelled in as much detail as it could be – possibly because this hasn’t been a specific priority of those who have funded the research.

But let’s think back to the meat and potatoes of the issue.  This is a persuasive analogy for certain sorts of drinkers and certain sorts of pubs, but you have to have a very specific view of alcohol that I’m not actually sure most of the population – at least consciously, or perhaps more accurately openly – would acknowledge.

When Chris Snowdon talks about drinking, he’s envisaging someone rather similar to the imaginary health-conscious unit-counter: someone who is (whether consciously or not) viewing alcohol as a single thing.  But plenty of sociological research would suggest that this is a pretty unusual position to take.

First off, most people don’t talk about their drinking in terms of ‘alcohol’.  In my research, most drinkers were keen to downplay the idea of units or alcohol content, instead emphasising behaviour or time spent in the pub/club.  For example, one man in his thirties noting that he and his friends were less likely to cause trouble than 18-year-olds who had two pints of ‘Stella’, even though they’d been drinking all day and consumed a huge amount of alcohol.  Very few people I spoke to expressed any ideas close to counting units, drinks, or even expenditure.  Most felt that the whole idea of counting was at odds with relaxing and having fun, and even those that made an effort to try this admitted that their efforts never worked in practice.

But this is a small, particular group of people, at a particular location and a particular moment in time.  There’s certainly the possibility that 18-24 year-olds today are more likely to be counting units, calories, and anything else they can lay their hands on, if there’s an app for it.

But most importantly, if we’re trying to think about the impact of MUP on pubs specifically, this all comes down to what people see a pub visit as being.  Is it actually the same category as home drinking, or is it more about going to a quiz, going out for a meal, playing a skittles match (you can tell I live in Dorset), or simply meeting up with a particular group of friends?

In research on drinking – and interestingly the Sheffield group themselves are doing some work on this more qualitative side of things – people tend to be clear about having different approaches to drinking depending on who they’re with, when and where.  It’s the old ‘Drug, Set, Setting’ approach.

If you think about it, as with most social research, this intuitively makes sense is something you already know.  (I’m trying to avoid saying that social research is pointing out the bleeding obvious, which is difficult, having listened to quite a bit of Thinking Allowed recently…)

It’s quite easy to imagine a regular drinker who always drinks beer when he goes out to the pub, but mostly drinks wine at home.  I know plenty of drinkers like this, and I’m not sure they’d think of the two things as being particularly linked, or as home wine and pub beer as coming from the same ‘budget’.  The beer is more likely to be up there with cinema visits or meals out.  Sure, if MUP had a serious effect on their household budget it could affect drinking out, but not necessarily any more than it would affect going to the cinema.

It might be that the beer drinkers for whom the meat and potatoes analogy makes sense are precisely those keeping many pubs open.  And in fact I think I’m one of them, as I only really drink beer, I go to the pub about three times a week and drink at home in between.  But I think it’s worth noting that, across the population – and even just looking at drinkers or people who go to pubs – these beasts are a rare breed.

For this to be about switching forms of consumption, the beer drinker has to be consuming a decent amount of beer both at home and in the pub.  In Chris Snowdon’s analogy, the beer drinker is having 10 beers a week.  Let’s assume these are 2.3 units, which would be a pint of 4% beer, which is on the low side for lots of people, but then you might only be having 500ml bottles at home, and equally some people might drink some beer marginally below 4%, for example – like Butcombe’s Rare Breed I just linked to.  That would be 23 units a week, just placing you in the ‘increasing risk’ category (according to the old definitions) whether you’re a man or a woman, which means that you would be in the top 26% of drinkers in terms of your consumption.  (I’m basing this analysis on the Sheffield report that underpins the Welsh Government’s decision.)

Sure, that group of ‘increasing’ plus ‘high’ risk drinkers accounts for 65% of the money spent on alcohol, but that sort of illustrates my point: pubs (and the industry more broadly) are relying on a small section not only of the population, but a small section of drinkers.

The analogy simply doesn’t fit how most people think about alcohol.  Like I say, I’m one of that ‘rare breed’, and perhaps that’s more likely amongst people who have a particular interest in the subject of alcohol policy – we’re more likely to think and write about ‘alcohol’ – and so this idea has a tendency to dominate debate.

That’s true whether you’re the Institute of Economic Affairs calling for a flat rate tax on ‘alcohol’, the Scotch Whiskey association claiming that ‘a unit is a unit’, or public health professionals arguing that people should count their units.

But actually, ‘drinking studies’ academics would be quick to point out how varied understandings of different drinks and drinking occasions can be.  Champagne is not the same as Stella Artois or WKD.

And more than that, we know that in public health terms a unit quite definitely does not simply equal a unit.  The drug, set and setting affects the effects.

Now maybe this idea of alcohol being alcohol and a unit being a unit is seeping into the public imagination, along with the tendency to monitor yourself and count things like ‘steps’ that I mentioned earlier.  But it’s certainly not how all people in all societies have thought of alcohol.  Countries like Germany and Russia have taken a different legal approach to drinks of different alcoholic strengths and I’m yet to see much evidence it’s how most drinkers in the UK think.  Certainly in terms of regulation we tax them quite differently, and licensing has long thought of premises in different ways depending on what sort of thing they sold – a beerhouse was most definitely not a tavern.

Of course, a key challenge here is whether what people say matches what they actually do, and whether MUP as a policy works at a conscious or unconscious level.  But it’s certainly worth considering.  Meat and potatoes both sit in the same analytic – and probably budget – categories of ‘food’, and they’re often purchased in the same place at the same time, or at least in the same trip.  What I wouldn’t feel confident about is whether most people, most drinkers, and even more specifically most regular pub-goers, think of drinks at home and in the pub as being in the same category.  That’s the key question.  Is this an issue of meat and potatoes or meat and washing powder?  Or even meat and Netflix?

Fitter, no happier, but more productive

In the past couple of weeks I’ve not been drinking any alcohol.  This isn’t part of any grand plan; it’s just for a short period of time for some personal health-related reasons.  As I’m not generally much of an advocate for Dry January or Go Sober for October, it’s an interesting experience, which I wouldn’t otherwise have chosen.

I won’t deny that I seem to be fitter and more productive.  I don’t weigh myself, but I seem to have lost a bit of weight – which is particularly surprising given that I haven’t been able to exercise because I broke my toe three weeks ago.  And I’m more likely to tidy up the kitchen at the end of the evening rather than just leave it for the morning (or, more likely, the following evening before doing the next round of cooking).

That’s all great, but what about that third element of the Radiohead song: being ‘happier’?

Well, in some ways now isn’t the best time to ask, as work is far from perfect and my home life is facing some particular challenges (the reasons I’m off alcohol in the first place).  But actually, that’s precisely what’s been interesting about the whole experience.

Basically, I have an unusual energy and focus.  I feel a little bit like I’m back at school, working hard, being responsible and disciplined.  But, like at school, it’s not making me very happy.  And that’s because having energy and focus without a goal is worse than simply being apathetic.  You’re a conformist without a cause.  That is, for me, one of the positives of alcohol: it distracts.

For some people this is a failing from a moral perspective.  The sort of people who see substance use as a ‘shortcut’ to pleasure, which doesn’t offer real fulfilment.  Personally, I am unsure what ‘real’ fulfilment would be, given that anyone who has ever had goals knows that achieving them offers something less than satisfaction.  Life, for better or worse, goes on, as writers and philosophers throughout history have known.

For Dostoevsky, the answer to the illusory nature of achievement seems to be the love of a good woman and a bit of religion.*  And maybe, as I’ve written before, ‘just surviving is a noble fight’.

Alcohol, as used by many people, is a variant of Dory’s famous mantra: ‘just keep swimming’.  I was once warned ‘don’t think too much’, and alcohol (on the surface and in the short-term, at least) helps stop that.  To quote another 70s soft rock classic, ‘don’t let the sound of your own wheels drive you crazy’.  In fact, that’s precisely what mindfulness is intended to do, for better or worse.

And rather than just being a personal moan, I want this piece to have a broader point, linked to my previous blog post about how drug-related deaths are about more than just treatment services.

I’ve always been suspicious of the idea of ‘aspiration’ in political discourse.  Blairites offered is as a warning to anyone proposing policies that weren’t carefully triangulated and safe.  The implicit definition of ‘aspiration’ according to this approach has always seemed materialistic to me – that people want more money, or more stuff, and they’ll just stay docile if a ‘rising tide lifts all boats’.  Don’t talk about redistribution because people want to believe that someday they’ll be millionaires.  (This is usually presented as a patronising lecture from one well-meaning, middle-class, top-down politician to another, complaining that they don’t understand ‘ordinary’ [read ‘working-class’] people’s ‘aspirations’.)  And when it’s not in the hands of third way politicians too scared to talk about their actual beliefs, ‘aspiration’ as a concept is worryingly used to explain poverty as being caused by a lack of aspiration.

But to bring this back to my moan, I think what I’ve found difficult is that without the distraction of alcohol (and I mean the trips to the pub as much as the actual substance – given that this is about ‘set’ and ‘setting’ as much as ‘drug’) I’m lacking ‘aspiration’.  My increased fitness and productivity is without purpose, as there’s too much other stuff going to enable me to feel any happier.

This isn’t a blinding insight, and I certainly don’t want this to read like a ‘poor me’ post.  I’m well aware that there are plenty of people around me who are worse off.  My point is simply to note that a lack of ‘aspiration’, or visible, achievable life goals, is pretty common and not clearly related to substance use.  The fog does not magically lift and a ‘purpose’ appear; and even if it did, most of the barriers to this are still there whether the alcohol is or not.

Now I want to be clear that I am not comparing my situation to an ‘addiction’ or ‘substance use disorder’, or whatever your preferred terminology is.  Neither am I suggesting my life is terribly traumatic or hard.  But that’s precisely the point.  Something we know to be true is quite rarely applied to broader policy issues: we often fail to think of people as a whole person, in a wider social context.  Banal, perhaps, but given my previous post it struck me that it’s still surprisingly worth saying.  Remove the alcohol (or other drug) and, as I’ve written before, that’s all you’ve done.  Too narrow a focus on substance use specifically, and how it is problematic in itself, doesn’t help anyone.

Addition @ 4.45pm:

After an exchange with Aveek Bhattacharya, where we agreed that part of the challenge with going alcohol-free is that pubs - and therefore alcohol - are the default option for socialising and evening activities, I got thinking about specifically why I haven't gone to the pub much.

It's not just that I don't see their appeal when I'm not drunk; I often stay for a drink when I'm driving, and either eke out a small amount of beer or have coke, which I'm not particularly fond of.

And I don't think it can be that the mark-up on soft drinks offends me specifically - it's always cheaper to stay in if you just want to drink.

I think it's something about what I see as the specific appeal of the pub: not just that it's a different atmosphere from drinking at home, but that you're drinking something different.  This might not be the case for everyone - often people might prefer the wine they have at home, or the gin and tonics they make themselves, and I don't know whether Fosters on draft is somehow more exciting than from a can.  (I do, actually - there's plenty of research on the Drug, Set and Setting line that notes that the type of glass and the space you're in affects what you taste.)  But for me, I think the struggle is getting interested in going somewhere to drink Becks Blue when that is precisely what I have available at home, but for a fraction of the price.  I just can't compare bottled beer with cask beer, and most of the pubs I go to feature beers that I can't (or don't) generally buy in bottles anyway.  But maybe I'm a special case.

*I was going to put this quote in the body of the text, but as I was typing it out I wanted to include so much that it’s better here.  It’s from Notes from the Underground:

Man is a frivolous and incongruous creature, and perhaps, like a chess player, loves the process of the game, not the end of it.  And who knows (there is no saying with certainty), perhaps the only goal on earth to which mankind is striving lies in this incessant process of attaining, in other words, in life itself, and not in the thing to be attained, which must always be expressed as a formula, as positive as twice two makes four, and such positiveness is not life, gentlemen, but is the beginning of death.  Anyway, man has always been afraid of this mathematical certainty, and I am afraid of it now.  Granted that man does nothing but seek that mathematical certainty, he traverses oceans, sacrifices his life in the quest, but to succeed, really to find it, dreads, I assure you.  He feel that when he has found it there will be nothing for him to look for.  When workmen have finished their work they do at least receive their pay, they go to the tavern, then they are taken to the police-station – and there is occupation for a week.  But where can man go?  Anyway, one can observe a certain awkwardness about him when he has attained such objects.  He lovesthe process of attaining, but does not quite like to have attained, and that, of course, is very absurd.  In fact, man I s a comical creature; there seems to be a kind of jest in it all … And why are you so firmly, so triumphantly, convinced that only the normal and the positive – in other words, only what is conducive to welfare – is for the advantage of man?  Is not reason in error as regards advantage?  Does not man, perhaps, love something besides well-being?  Perhaps he is just as fond of suffering?  Perhaps suffering is just as great a benefit to him as well-being?  Man is sometimes extraordinarily, passionately, in love with suffering, and that is a fact.

Are local authority commissioners responsible for rising drug deaths?

I’m not quite as quick on the draw with blog posts as I used to be.  There’s just more things for me to be thinking about at the moment, it seems.  But I wanted to go back to an article from a couple of weeks ago and question some of the assumptions – or maybe more accurately the inferences I think readers were meant to make.

This was the Guardian article about how drug-related deaths are highest in the areas that have cut funding to treatment services the most.

The first thing to note is that I’m sceptical about the validity of claims based on these kinds of FOI responses.  It can be very difficult to compare year on year spending – particularly in the last few years when substance misuse budgets (or at least the representation of them) will have been hugely affected by the movement from NHS to local authorities.

But more substantially, there’s an implication of causality: that these areas are seeing higher drug-related deaths because they’ve made deeper cuts.

I’m not sure that holds, as this wouldn’t just be about the level of cuts, but the way they’ve been implemented.  From my perspective, if a drug treatment service could only do one thing, it would be needle exchange.  If it could do two, I’d add in a simple, low threshold methadone maintenance service.  And that isn’t just my personal preference; that’s because those interventions are the most evidence-based for reducing overdose, crime, and illness or even death from blood borne viruses like HIV and Hepatitis C.

Of course, there’s an argument to be made that you collect evidence about things you’re interested in, and so we have evidence on these things because that‘s what government was interested in the NTA era.  But that’s a side issue.  The main point is that if you were making cuts you could (should?) still maintain the key services that keep people alive.

But that sentence reveals another key assumption: if you were making cuts.  The fact is that all local authorities are making cuts because the funding they receive from central government is being slashed and public health in particular should be worried given the current proposal to fund all their activity (which includes things like sexual health services, health visitors and school nurses*) from local business rates.

And historically it’s the more deprived areas (which are those more likely to have drug deaths because of multiple inequalities) that receive a bigger chunk of their funding from this centrally-allocated pot.  So when these cuts hit, it’s not just that drug treatment is hit; every service is hit harder than in more affluent areas, which are less reliant on central funding to start with, and also more able to top up their funding through business rates and council tax.

What I mean is, the key thing that links areas of high drug related deaths and high levels of budget cuts is simple: deprivation.

To be fair, this is exactly the point that Alex Stevens makes in the article, but I worry that the tone of the article is kicking local councils on one thing where they don’t deserve it, and then letting them off the hook on another.

The tone is that cuts lead to drug related deaths, and maybe they do, but I’m not sure these stats show that and actually I think that in terms of the evidence and the cost of some interventions, it’s easier and cheaper to keep someone alive than it is to get them into ‘recovery’ – partly because we don’t have so much evidence to guide us (if we could agree on what ‘recovery’ is).

That is, the cuts aren’t local government’s fault, and so they shouldn’t be hammered for that; but how they implement the cuts is their decision, and instead Colin Drummond seems to suggest that approaches to treatment were centrally mandated.

Another factor in rising drug mortality, said Colin Drummond, from the Royal College of Psychiatrists, was the coalition government’s decision to treat heroin users with methadone less often and with lower doses, which he described as “political interference in what is essentially a clinical issue”.

He cited examples where “people disengaged from treatment, stopped taking methadone, went back to street drugs and then overdosed”.

I was never convinced by the emphasis the Coalition Government, and Iain Duncan Smith in particular, placed on ‘full’ recovery and the wonders of residential rehab, but my experience was that these statements came from central government at the same time as the NTA lost its teeth and any practical control over local treatment decisions.  That is, central government might have talked about ‘full recovery’, but there was no barrier to local areas maintaining harm reduction services and sticking to Orange Book and NICE guidelines on methadone maintenance and needle exchange so long as there was the will from officers and elected officials within the council.

So kick councils on how they’ve implemented the cuts by all means: have they made methadone maintenance and/or needle exchange less accessible?  Is that evidence-based?  Is it appropriate?  If they’ve maintained it, what has it been at the expense of?

But don’t kick them for making cuts to treatment, or for the perfect storm of the wider cuts and changes to the welfare state that mean overdose and death is more likely.  Think also of housing, benefits, mental health, wider healthcare.  (Not to mention that people are simply ageing, and having to deal with the long-term consequences of a lifetime of smoking.)  Those factors are just as much (or more?) at fault for rising drug-related death rates as the cutting of a group work programme from 5 to 3 days a week.

Of course, you might have read the article with none of those assumptions and reactions.  It just touched a nerve with me as a local authority commissioner.  I’m happy to defend our decisions about how we’ve managed the cuts to our budget, but don’t ask me why we’ve cut the budget, as that’s not my decision.

*Oddly, Izzi Secombe from the Local Government Association seems to have forgotten that the spend on 0-5s healthcare in the Public Health budget dwarfs substance misuse treatment – just look at Figure 2 here: https://www.kingsfund.org.uk/blog/2017/07/local-government-public-health-budgets-2017-18

Why moderation might not be the best policy for drugs

For some reason the other day I thought about this article by Mark Monaghan and Henry Yeomans.  It builds on the work of Virginia Berridge to argue that there’s a convergence in policy relating to alcohol and other drugs, despite the fact that there’s still a ‘regulatory divide’ between legal and illegal drugs.

The convergence isn’t simply the common observation that as we become more restrictive about tobacco and alcohol marketing, pricing and sales places around the world are loosening regulation on substances like cannabis.  Mark and Henry also suggest that in terms of what we condemn, we’re concerned with the same things: i.e. not ‘drug’ use per se so much as the people and the behaviour associated with them.

I'd agree that we’re not concerned about drinking in general, but (amongst other things) what I would call the carnivalesque – forever something that the middle classes can observe and play with while they define others by their participation.

And Henry and Mark argue that the same is true of drug use: although all drug use is defined by government policy as dangerous and wrong, the reality of policy is that it focuses on particular groups of drug users, seen to form part of an ‘underclass’ – whether that’s David Cameron attacking rioters in 2011, or Iain Duncan Smith questioning benefits payments being spent on alcohol or other drugs.

This isn’t a terribly controversial point in itself.  As Nick Cohen pointed out in a recent article, in certain middle class circles taking cocaine is more acceptable than smoking tobacco.  (Perhaps this is a metropolitan thing, as it doesn’t chime with my experience in Dorchester.)   And in policy terms we’re not so concerned about the use of cannabis per se so much as the behaviour of some of those who do - illustrated nicely in a recent Professor Green documentary by the different fears and freedoms experienced by people from different backgrounds.

Interestingly, Mark and Henry cite Steve Wakeman, who’s suggested that decriminalisation and certainly legal regulation is much more about middle class concerns (and, to be fair, those involved in production) than issues that affect the poorest users: “While such a shift would certainly benefit middle- and upper-class users (allowing them to indulge their chemical proclivities without risking their comfortable jobs) the effects this would have on users like Ryan would be very different. He depends upon the moral economy of heroin for so much and, ultimately, this socio-economic system currently depends upon its illicit status.”

And maybe it’s reading this from Steve – as well as watching an episode of the BBC Queers series where a (fictional) man of retirement age complains in 1967 that the change in the law is trying to make him respectable – that makes me worry for the vision of happy, liberal convergence.

As I’ve written before, any approach to regulation, or ideology, will be infused with its local context – so English alcohol policy isn’t simply about profit, economics and market models – it’s also about the kind of drinking we find unsettling, regardless of its economic ‘value’ (even if government policy seems to allow economics to trump moral or social discomfort).

That’s why I use the term neoliberal despite the fact it’s often used pretty indiscriminately and is in danger of losing its meaning.  I would suggest that in general, recent UK governments have actually been pretty uncomfortable with the kind of liberalism that says it’s your body, your life, do what you want.  You know how many pints of beer you want to drink, or cigarettes you want to smoke, so go ahead.

Of course part of the reason we’re uncomfortable about this is that no man is an island, and healthcare costs of the individual – at least in Britain – affect us all.  But there’s also all the stuff my academic work looked at: we do tend to enjoy distinguishing ourselves from other people.  Most of us, if we care to admit it, have views on what ‘good’ drinking or drug use looks like.

Thinking back to that academic stuff, I was reminded of Robin Bunton’s work on pleasure and policy: governments tend to favour ascetic and disciplined pleasure.

And this is where I get a bit worried about models of regulation, particularly in light of Steve’s point.  Are we looking to regulate and approve just a particular model of substance use?  Just a particular vision of what the ‘right’ way of doing things is?  Are we trying to regulate the pleasure out of drugs?

It’s an interesting idea, when lots of academics (and campaigners) ask of discussions of drugs ‘where is the pleasure’, taking a sociological approach of not seeing drug use as a problem in itself.  Why don’t do we seem to feel the need to describe what would happen under a regulated system as 'adult', 'responsible' or 'moderate'?  Why do campaigners feel uncomfortable acknowledging in a political discussion that using alcohol or other drugs is, for many people, simply fun?

Or perhaps 'fun' isn't the right word.  My work on the carnivalesque was trying to suggest that government isn't always uncomfortable about fun, and in fact lots of things people do when drinking aren't exactly 'fun', and certainly aren't comfortable.  But whatever it is, it isn't about rational, calculating moderation.

Of course there are all sorts of good arguments for decriminalisation or regulation of intoxicating substances, not least the effects in producer countries/communities.  But let’s just think about the effect on users for a moment.

I often complain (here and here, for example) that we approach alcohol in a weird way, where we almost deny that it’s intoxicating – no-one seems to drink to get drunk, or we think people shouldn’t.  And I don't think that's healthy.

I can see that suggesting psychoactive substances are relatively innocuous and we’d all use them ‘responsibly’ and ‘moderately’ might be a good PR move for campaigners, but wouldn’t it be a missed trick?  Wouldn’t it perpetuate stigma?  Wouldn’t we end up in just the same place as we are for alcohol at the moment, where we condemn – as Mark and Henry point out – the people as much as the behaviour or the substance?

So if there is this convergence going on, let’s not kid ourselves with a Whiggish notion of history that sees us marching forward to a utopia of ‘legalised and regulated’ substances.  That might not be such a great place to be.

And if we are converging, perhaps something like meeting in the middle would be better than everything coming over to the side of alcohol and tobacco.  It's not just that we haven't been restrictive enough with alcohol and tobacco; I'm not sure we've got the 'culture' of regulation right.  Perhaps I'm overstating it.  Maybe it's just my impression of the campaign materials I've seen.  But all the same, it's worth thinking about.

I wonder if we could take a fundamentally different approach to policy and celebrate diversity and something other than disciplined and ascetic pleasure.  It has been done in the past, and it can be done again.  Here’s to a bit of Rabelais.

Principles and pragmatism: We need to talk about commissioning

Yesterday the ACMD released a report on the commissioning of substance misuse, and this sort of thing is really the bread and butter of this blog, so I feel like I should overcome my lethargy and comment on it.  And it is worth commenting on, because it makes some important points – but obviously I’m going to challenge a few of its claims and assumptions, otherwise this would be a pretty short and uninteresting post.

I’m going to do this in a format that’s pretty unusual for this blog, which is to go through several of its conclusions and recommendations in turn and assess them.  This is partly to be clear and systematic, and partly because I don’t have any other clever ideas about how to tackle it.

First, then, it’s hard to argue with its statement that ‘reductions in local funding are the single biggest threat to drug misuse treatment recovery outcomes being achieved in local areas’.  Fundamentally, we know that the relationship with a client is crucial to good outcomes, and the less money there is the more thinly spread staff time is and the less training investment and time the staff will receive.

However, I’m less sold on the idea that the commissioning of treatment should be housed within the NHS.  There were good (pragmatic) reasons why substance misuse treatment responsibilities ended up with local authorities – not least because it was felt this agenda would get swallowed up within the behemoth that is the NHS.

A lot of the document (particularly given that it starts with a kind of history lesson on the funding of treatment since 1998) feels like a lament for the glory days of the NTA.  Maybe this isn’t fair, but I can certainly say that placing commissioning within the NHS would not be anything like those days.

My experience of NHS commissioning is that – partly because of the sheer scale of contracts – it’s not as detailed and hands-on as either substance misuse work under the NTA or local authority commissioning more generally.  Let’s assume, for example, that you were commissioning your local community health trust to deliver at least the prescribing element of the treatment system.  If you were sitting with the CCG, that would likely (for ‘efficiency’) be embedded as just one element of a much bigger contract covering all kinds of services – just have a look at the website of Dorset HealthCare (DHC).  At one stage, as a commissioner, there were three levels of meetings at which the Dorset prescribing would be considered: the overall CCG-DHC contract review; a specific substance misuse CCG-DHC contract review sub-group so that some people with direct knowledge of this service were in the room; and a DAAT-DHC meeting where we actually discussed activity and performance.  I wouldn’t want to go back to that, but I can see how it would be justified on paper as managing the contract more ‘efficiently’.

And the idea that the budget wouldn’t get raided as much as in local authorities is, to me, laughable.  NHS organisations, in my experience, find it much more difficult – quite understandably, because of their size and the range of services they’re providing – to give definite, accurate figures for staff time and costs of specific elements of service (like substance misuse) than (small) dedicated third sector agencies do.  It requires inventing quasi-market calculations like internal rents and charges.  Sure, this is a consequence of the slightly odd commissioning system – but that would make for an argument for getting rid of the whole system, not simply shifting responsibility from one silo to another.

Next, the report suggests clearer and more transparent financial reporting.  And you can already predict my issue with this: it’s really like looking inside the sausage factory.  At a national level, aggregating figures, I can believe this is helpful.  I’d be much more worried about doing this where comparisons are made at local authority level, comparing one year with another.  Huge elements of local budgets – like res rehab, inpatient detox, drug costs, dispensing fees – will not only vary significantly based on a few coincidences, but bills can come at all sorts of times with all sorts of delays that skew the figures from one year to the next.  And would it be timely?  You often don’t get a bill for the drugs you’ve prescribed for months, and then that bill might have to be passed from the CCG or provider to the commissioner to pay, so the actual spend on a crucial element of the budget would just be either forecasted or missed off – particularly where prescribing arrangements have changed in a year (which we’re told later in the document happens with worrying frequency).  I worry that there’d be some kind of league table of spend per head, which I just wouldn’t trust and could certainly be manipulated.

However, other measures referred to sound sensible (and some have already been mentioned in the Drug Strategy).  It’s a good idea to try to assess what proportion of the people with substance misuse issues living in an area have recently been engaged in treatment – but then this is something that we already do, and have done for years, based on information provided by PHE and before them the NTA.

The second conclusion of the report is very similar to the first: ‘The quality and effectiveness of drug misuse treatment is being compromised by under-resourcing’.  Again, it’s all about the money.  And again, I agree, but I don’t entirely sign up to the recommendations.  I’m not sure how national bodies developing ‘clear standards’ would prevent a ‘drive to the bottom’, unless there is actually more money in the system.

And I’m a bit uncomfortable with the phrasing in the report that seems to suggest that everyone apart from nurses, doctors and psychologists (and presumably psychiatrists?!) are ‘unqualified’.  (Interesting also that social workers aren’t name-checked.)  They’re unregistered, perhaps, but that’s quite a dichotomy to draw.  My view is very clear that there shouldn’t be this kind of dichotomy in a treatment system, because (without sounding too trite) different people and professions have different jobs and contributions to make.  Those registered staff should be focused on the functions that they are uniquely well-placed to deliver.

But perhaps I’m being unfair.  The report is saying that the Drug Strategy Implementation Board should be defining what an appropriate balance of these (supposed) two groups should be, and obviously I’d hope any final figure would be reasonable and reflect this reality.

I’m still a little worried, though, that the implication is that there aren’t enough registered professionals in the system at the moment, and the proportion needs to be higher.  Whether we like it or not, raising the proportion of these professionals will (in a world of even fixed, let alone reducing budgets) result in fewer frontline staff.  That is a trade-off that commissioners and providers are having to deal with all the time in service design.

The next conclusion is that there’s a disconnect between treatment services and wider health structures.  I don’t know what I think about this.  Personally, I’d be happy for treatment commissioning to be part of the NHS, and there do need to be strong connections with services.  But the reference is made to CCGs and STPs when plenty of crucial elements aren’t currently the responsibility of CCGs – for example custody healthcare and mental health liaison and diversion services sit with NHS England.  And that’s not to mention that better links with wider criminal justice services like probation would be helpful.

Perhaps treatment commissioners aren’t managing it currently, but given the wider needs of many service users, being commissioned by the same organisation as social care, safeguarding, family services, sexual health and housing shouldn’t be a bad thing.  Based on my experience, I’m pretty sure you’d find local authorities and the LGA quickly complaining about the lack of connections with safeguarding and family services if commissioning moved over to the NHS.

This isn’t to say that links to wider health services can’t or shouldn’t be improved, but reading this does make me want to re-emphasise the complexity of public services.  Does the recommendation really amount to anything more than the platitude that partnership is good?

The fourth conclusion is that ‘frequent re-procurement of drug misuse treatment is costly, disruptive and mitigates treatment recovery outcomes’.  I couldn’t agree more, and I’d point interested readers to my long and hard-to-read commentary on exactly this from a few months ago.

But again I wonder how realistic and sensible the recommendation is.  It is suggested that commissioning should be undertaken in cycles of 5 to 10 years.  This would certainly remove some of the churn, and it would basically mean there wasn’t commissioning.  I think this is fine, and it certainly fits with the direction of travel to accountable care organisations, where the commissioners just hand responsibility over to a single provider along with a budget for them to manage directly.

However, given the system at the moment, it would be an odd thing to do.  Imagine having written a 10 year contract in 2006.  You’d have given more money to the provider as budgets increased for a few years, and then in the last four years or so you’d be reducing it by about 5% a year.  There are reasons commissioners tend to go for three year periods (as we’ve just done in Dorset), and it’s not just some blind adherence to a (largely mythical) requirement of procurement regulations.  The reality is that it’s risky to promise something for a long period, and there’s something to be said – for both providers and commissioners – in offering certainty and security for a relatively short period, rather than guaranteed uncertainty for a longer period.

And actually, given that however you wrap it up the impending budget challenges will mean significant service re-design if not now then very soon, and possibly again in a few years, it’s not immediately obvious that one long contract with a stable provider (or group of providers) is the easiest or best way to do that.  You might find (perhaps based on that ‘balance’ of different types of staff) that the organisation that’s best at providing a service in stable times of relative plenty is not the same organisation you’d want at a time of tight budgets and political upheaval.  And perhaps there’s something to be said for the idea that a new broom sweeps clean, when big changes are required.

And that’s kind of what the document is getting at when it warns that ‘a system that has been seen nationally and internationally as highly successful is at risk of being undermined’.  The new broom will be sweeping out a system that’s good.

But to quote the irritating cliché, ‘we are where we are’.  I sometimes wonder when I read commentaries on commissioning whether people really understand that – particularly in relation to substance misuse – this really isn’t about people maliciously or naively reducing the budget.  The overall public health grant is being reduced, as is the broader grant to local authorities, and there’s no indication that either will exist in a few years, at which point local authorities will magically become ‘self sufficient’.

In reality, I’m not sure it would be responsible or sensible to start a commissioning cycle in 2017 based on a ten year (or even five year) period.  The broader context is that there is (a) ‘no money’ and (b) there are no reliable predictions on the wider political or economic context.

To think about practical solutions, there is (as I’ve written before) too much ‘churn’, and re-procuring services is often hugely wasteful.  But as well as extending contract periods, there are other things that can be done to reduce that churn, through having open, sensible processes, encouraging partnership working, designing the procurement process to offer a range of opportunities, and so on.  In fact, all the bits of good practice that commissioners have been being told and taught about for decades.

The final recommendation (and a bit of a tangent for this blog post) is about research.  The ACMD seems to be concerned that third sector providers aren’t as well linked into structures for clinical research as NHS providers.  Research is a good thing, and it’s probably just my sensitivity that makes this feel like another plea to commission NHS providers or house commissioning within the NHS, but I do want to offer an alternative perspective.

When we commissioned some research locally, it was actually those NHS structures that meant the staff and service users within our NHS provider found it far more difficult to engage in the process than those involved with our third sector partners.  There were so many hoops to jump through for what was an innocuous piece of research asking service users what they thought of services and how they felt their recovery could be strengthened.

Perhaps what the ACMD mean is that the NHS is better at jumping through those hoops.  But it’s interesting that it’s only at this point, in relation to research governance within the NHS, that the ACMD chooses to make its recommendation on the basis of the world as it is currently, rather than recommending a change to that world, as it does with budget constraints and political and economic uncertainty.

Overall, there’s a lot of sense in this report, and it’s hard to disagree with most of the conclusions, or indeed the principles behind the recommendations, but fundamentally I’d suggest things are a lot more complicated than they might seem.  Of course that’s partly my need to be contrarian and find something to disagree with.  (And citing ‘complexity’ is always a good way to do that.)  And it’s also simply the inevitable result of writing a clear report with definite conclusions.  This is a policy report, not a nuanced academic thesis about the challenges of commissioning drug services in 2017.

But most of all, I think it just highlights that we need to talk about commissioning, particularly of substance misuse treatment services.  If you caught me at another moment, feeling less defensive, you’d hear me say our team should sit within the CCG, so I certainly complain at this suggestion.

But as in my presentation to New Directions this year, I’d end by emphasising that the most important thing in commissioning or providing a service is the people.  Let’s not get too hung up on structures, or where a desk sits.  We can do most of this stuff from within local authorities or the NHS, and there will be strengths and weaknesses either way.  More important is just to get on a do good stuff on the ground, and try to ignore – or maybe even engage constructively with – the inevitable ‘churn’ around you.

But if we do need to talk about commissioning, this report certainly isn’t a bad place to start.  I just think as we conduct this conversation we need to be clear about how much we’re focusing on pragmatism or principles, and, probably because of the job I do, that seems to be where I depart from the ACMD approach.

Are we all alcoholics now, or is none of us?

This post is really a reflection on a recent article by Nick Cohen in Prospect, prompted by an exchange on Twitter between Andrew Brown and James Morris about whether the use of word ‘alcoholic’ is accurate or helpful.

So before I launch into something of a critique, I should say that the article itself is definitely worth reading.  It’s brilliant at identifying how drinkers are so adept at deflecting criticism of their own drinking (though they’re not unique in this – think of how we all seem to think we’re above-average drivers).

But he’s also great at conveying the emotions linked into drinking with a more personal perspective.  I’m going to quote at length here, which I hope isn’t a breach of copyright:

At the end of January 2017, I could not find a good enough reason to start drinking again. I still remembered the allure of alcohol, its promise of comradeship, love and simple pleasure. For me the most romantic lines in English poetry are from Edward Fitzgerald’s Rubaiyat of Omar Khayyam:

“Here with a Loaf of Bread beneath the Bough,

A Flask of Wine, a Book of Verse—and Thou

Beside me singing in the Wilderness—

And Wilderness is Paradise enow.”

But after too many years and too many flasks, neuroticism replaces romance. No one who hasn’t experienced it can appreciate the obsessiveness of the determined drinker. Questions build up as the evening approaches. Where am I going to drink? Who can I hassle into a pub? Can I sneak another one in without anyone noticing?

By the time you wake up in the morning, obsessiveness has metamorphosed into paranoia. What did I do? Why can’t I remember? Who did I offend? How did I get home?

If you find yourself asking these questions too often, the best answer is: “I give up.” How best to give up is, like everything else to do with alcoholism, infuriatingly hard to pin down.

All of that resonates probably a little too much with me.  I feel that ‘allure of alcohol’ and its ‘promise of comradeship’, but equally feel that these are, in reality, pretty illusory.  From a personal perspective I have asked all those questions at various times – though more recently I’ve decided that I don’t mind if anyone notices I’m having another drink; it’s no longer a question of ‘sneaking’ it in.

But from a professional perspective, one point is particularly resonant – perhaps without Cohen realising it.  He suggests that if we’re asking those questions too often we should just ‘give up’.  And I’d respond in the same way: if ‘everything to do with alcoholism [is] infuriatingly hard to pin down’ then I suggest we ‘give up’ using the word too.  It can’t possibly be helping, given that the purpose of a concept like this is to make sense of world – or at least create some useful questions – not simply ‘infuriate’ the interested thinker.

This is particularly odd when Cohen goes on to critique the disease model, emphasising that this is really a problem of behaviour (at which point I should plug the New Directions group and the (even ‘newer’) Addiction Theory Network, as well as this excellent blogpost on the disease model of mental health.

He challenges the idea that ‘alcoholics’ are this special breed, easily identifiable – because we are so bad at pointing the finger at the other easily identifiable groups: “The true alcoholic is always someone else. The old man in the park no one wants to know, the young woman sprawled on the pavement. Anyone and everyone, except you.”

And yet he goes on – just after criticising industry involvement in alcohol policy – to write that “Most drinkers are fine and healthy and good luck to them. Public policy needs to concentrate on helping alcoholics” – a line straight out of the industry playbook.

Of course, as I’ve written many times before, simply because something is said by an industry spokesperson, doesn’t make it untrue.  But as Cohen’s just pointed out, “the line between the heavy drinker and the terminal drunk is as blurred as your vision after a “good” night out.”  And if that’s the case, aren’t we really better talking about ‘heavy drinkers’ in general?  That would catch the attention of the right people without the risk they’ll ignore the message.

Of course the case could be made – as Andrew Brown did – that ‘alcoholism’ is a good way to grab attention for an important issue.  This is more about journalism than technical accuracy.

But again, he’s just told us that ‘alcoholic Calibans always see someone else’s face in the mirror’, so if someone talks to us about ‘alcoholism’ then we won’t be thinking of ourselves.  I just don’t think trying to redefine and re-purpose an ‘infuriating’ and indefinable concept is a good marketing or communications tactic.

The article seems to be trying to have its cake and eat it: we define ‘alcoholic’ too narrowly, seeing them as a special breed when in fact lots of us have problems and don’t acknowledge it; but equally most people drink safely and happily and we just need to focus on that special problematic group of ‘alcoholics’.

I think the biggest problem in this argument is that concept of alcoholism, which takes us down blind alleys of trying to define it in an effective way when, as I suggested at the beginning, we’d be much better off if we just gave it up.

The most important insight in the piece is perhaps about moving forward from problems.  Cohen writes, “The best guess is that drinkers stop when they have the usual prospects of happiness to fight for: a life worth living and the love of others.”

The problem, and therefore the solution, lies in a broader understanding of what makes life worth living – and although there are similarities, we all have our unique challenges and issues with this.  To go back to that lengthy section I quoted at the beginning, that’s why it’s an ‘infuriating’ task to define exactly how best to give up: each person is unique.  ‘Alcoholism’ as a concept, for me, just skims over these differences and challenges and encourages us to think only about the booze.  As Cohen would surely agree, there’s a lot more to life than that.