Alcohol isn't like sushi

I’m off work for a few days this week, so while I’ve been catching up on jobs around the house I’ve also been catching up on my podcast listening.  One of those I’ve made time for is Suzi Gage’s ‘Say Why To Drugs’.  I can absolutely recommend all episodes of this, and as someone who now works more on the practical (as opposed to academic) side of things, I really welcome the focus in this collection on practical issues like drinking in pregnancy, recovery from ‘addiction’, education in schools and broader drug policy.

I could write about all of these themes, but I don’t have a huge amount to add or question – except for one almost throwaway comment made in the episode on alcohol and pregnancy, which I thought might illuminate a wider idea about alcohol’s place in our society.

I should preface this discussion by saying that drinking in pregnancy is not my specific area of academic or professional expertise, and I’m aware I’m a man without children, so I’m not speaking from personal experience.  (However, it is a major issue in my work, as we look to improve guidance for professionals and patients during pregnancy.)  And I'm not criticising that almost throwaway comment itself; it's precisely because I think it's helpful that I want to use it to discuss some wider issues surrounding alcohol and drug policy.

So what comment am I talking about?  Well, both guests, Dr Kate Fleming and Dr Luisa Zuccolo, made reference to the fact that consuming alcohol is normalised in our society – that it even appears at seminars about alcohol harm, for example.  And one way in which this was discussed was how abstinence from alcohol during pregnancy is viewed differently from other ‘rules’ or ‘guidance’ that people are given at the same time.

That is, why is stopping drinking for 9 months (or quite possibly less) seen as more difficult or frustrating than giving up sushi, cured meat or certain cheeses?

I think the answer can be seen in the words I’ve just used.  You’ve read that sentence in italics, and hopefully understood what I mean.  I used the word ‘drinking’, but it was probably clear I was talking about alcohol specifically – about giving up beer, cider, wine and spirits.

Given we talk about ‘food and drink’, that phrasing makes it sound like giving up alcohol (‘drinking’) is like giving up something equivalent to food as a whole, which is going to make things sound psychologically challenging.

In fact, we’re not even talking about whole categories of food, like giving up all cheese, or all fish – just certain types or preparation.  And of course, we’re not talking about all ‘drinking’; just drinking alcohol.

But these are still very different categories.  If you think of that as focusing down using categories, you might construct something like: Food > Meat > Fish > Raw fish.  The comparable categories for ‘drinking’ might be: Drinking > Alcohol > Wine > Sparkling wine.

If you can’t have some cheese, there would be another cheese you could use as a substitute.  And any single item on the list might bring you pleasure, but there would be some other food-based pleasures available.  So the first thing to note is that asking someone to forgo raw fish isn’t like asking them to forgo alcohol as a whole, but perhaps sparkling wine – a particular form of wine that is unusual, but very much enjoyed by some people.

Of course there’s an argument here that I’m placing alcohol on a level with ‘meat’, when to many people it’s just a ‘nice to have’ or some kind of treat that we should be able to take or leave.  (I’ve written before on whether alcohol is like meat or potatoes, or neither.)

But here’s where it gets interesting.  Alcohol is effectively in a category of its own in our society.  It’s a legal, intoxicating drug.  We don’t really think of anything else available as being in the same category.  The intoxication from nicotine is more short-lived, and most people wouldn’t understand caffeine in this way at all.  (At this point, I’m not too interested in some scientific critique of these categories or distinctions; what’s more relevant for our purposes is how people actually understand the world around them.)

That’s perhaps as much about the nature of these ‘drugs’ as much as their legal status: alcohol is something lots of people use to relax or escape from the everyday, whereas caffeine at least is generally understood to help us focus or be more efficient – ways of being which people drinking are often deliberately trying to avoid.

So one immediate thought is that perhaps the term that’s analogous to ‘food’ isn’t ‘alcohol’, but ‘drugs’, and it would be good if we had an alternative to substitute.  And that’s where I think the discussion of ‘drinking’ makes a serious point about how narrow our options as a society are.

However, this is a big drug policy perspective, and in this specific example of drinking in pregnancy, it’s unlikely there are many low-risk alternative drugs to alcohol (though there are certainly lower-risk alternatives).  So what’s the alternative in pregnancy?  It is, as with so many elements of behaviour change (and indeed treatment for substance use disorders) to think about the function of the drug/behaviour.  What is alcohol actually doing in someone’s life?

Is it about signifying a change in time – maybe the switch from work to leisure?  In which case, it’s not really about intoxication, as Joseph Gusfield explained neatly, but a symbolic transition.  At times in my life when I’ve stopped drinking, I found personally that alcohol-free beer could serve this function pretty well.

But alternatively (or in addition), the function may be more directly related to the intoxicating properties of alcohol: genuinely altering the way we think and behave.  In that case, the options for replacement would be different: certain activities like watching a film, or playing an engrossing game might work better.

These aren’t really evidence-based suggestions, but I want to make that broader point: when we think about ‘drinking’, we’re not necessarily thinking about one pleasure that can easily be replaced with another, just as one preferred food might be.

In our society, alcohol has a unique status, as both drug and not-drug.  It is legal, and therefore different to ‘drugs’, and yet it is seen as having the properties of drug, in terms of intoxication, in a way that its other legal counterparts aren’t.

Our conversations about alcohol, then, are distorted for two reasons.  We separate it off from other drugs, but we also separate it off from other pleasures.  And this has important implications.

When lots of people who feel they need to stop drinking (whether because of ‘addiction’ or any other reason) are faced with some of the ‘substitutes’ above, it can initially seem that life is going to be somehow boring.  (There was some excellent discussion of this on an episode of BBC Hooked, while we’re on podcasts.). To be honest when I read it, I feel a slight inward groan.

This is partly because we separate out alcohol-related pleasure from other pleasures – as do lots of fervent campaigners for sobriety.  As I’ve written about before, pleasure in intoxication is sometimes seen as ‘cheating’, or less real or worthwhile than the pleasure someone might take in going for a run, reading a book or doing some yoga.  Or somehow someone who is intoxicated is less ‘authentic’ or ‘fulfilled’ than someone sober.

Sometimes this way of framing alcohol-related pleasure is helpful, in the same way that for some people the idea of a lifetime of complete abstinence from alcohol can be useful in giving clarity and structure (and even release).

But counterintuitively, I wonder if the ‘normalisation’ of alcohol, which is quite reasonably criticised in the podcast, is actually a function of its uniqueness.  It might be ubiquitous, but it’s far from ‘normal’.  The wine served at a seminar about alcohol issues or a school fete isn’t ‘normal’; it’s a treat.  If it were unremarkable, then it would make no difference if tea was served instead, but there would certainly be grumblings and surprise.  And no wonder, when it has this unique status as an intoxicating treat.  It is understood to be effectively irreplaceable.

So we’re back to that question of what alcohol is for.  As I’ve suggested before, I worry when alcohol is viewed solely as an intoxicant, and it has unique status in that.  And listening to another episode of Say Why To Drugs, with James Nicholls from Transform, I wondered if we could ever resolve this ‘specialness’ of alcohol while it is (seen as) our only legal intoxicant.

Perhaps, to continue a theme, I can end with another podcast reference, recommending Adrian Chiles in conversation with James Morris.  We maybe need to think more about our pleasure (or lack of it) in drinking, and understand why we do what we do.  If alcohol is no ordinary commodity, as many campaigners would suggest, it’s equally not uniquely extraordinary, and we would do well not to separate discussions off from other elements of our lives.

Fear or Compassion - what's the way to change policy?

I’ve been thinking a lot about the politics of drug and alcohol treatment recently.  Obviously this is something that’s on my mind in a certain sense anyway – it affects my day job, which is commissioning (putting in place contracts and managing them) treatment for people in Dorset and BCP (Bournemouth, Christchurch and Poole).  But there’s a specific context for this at the moment: the review into treatment being conducted by Dame Carol Black.

The two particular instances are last week’s NHS addictions provider alliance (NHS APA) conference, and a new article by some wonderful academics (Harry Sumnall, Ian Hamilton, Amanda Atkinson, Catharine Montgomery and Suzi Gage).

I won’t dwell too much on the NHS conference, other than to say that there were some uplifting, enlightening themes (notably from Ben Parker), and some important structural points (the lack of NHS residential/inpatient detox services), marred only by an increasingly common mischaracterisation of the past 30-40 years of addiction treatment.  Addiction treatment in the UK has never simply been a matter for NHS providers, or NHS commissioners.  You can read academic work on this (Alex Mold is great) or PHE publications.

Weirdly, some of the people presenting these ideas lived and worked in the era of the NTA and DAATs, when commissioning in earnest grew as part of ‘the new public management’ – and yet they hark back to times before 2013 as some kind of pre-commissioning age.  Perhaps it was for some of their services, but not for ‘the sector’.  Turning Point, Addaction (as was), CRI et al didn’t simply form or mushroom in the years after 2012; their growth had started well before that.

That last acronym – CRI – brings me neatly onto my next point.  CRI stands for Crime Reduction Initiative, and in my head is the emblematic name and organisation for the Paul Hayes / NTA era.  As part of being ‘tough on the causes of crime’, New Labour poured money into substance misuse (specifically ‘drug’) treatment services.

It was a realpolitik bargain: you paint people who use drugs (notably heroin) as ‘mad, bad and dangerous to know’, which is disingenuous and stigmatising, but a means to an end.  Sure, the people in the field aren’t working there because of this; they’re more likely to be motivated by compassion.  And it doesn’t feel right saying this because you’re painting all people who use drugs as dangerous.  But there were reasons people felt this was a price worth paying.

Crime was a huge political issue in the 1990s, and the way to get politicians to take an issue seriously – particularly as New Labour was keen to be taken seriously and be seen as hard-nosed, rather than ‘bleeding heart liberal’, as an argument for more funding based on compassion might have been.

But this isn’t without consequences.

Fundamentally, the argument potentially works against Release’s campaign that ‘Nice People Take Drugs’.

Some of this is about wider politics: it’s harder to reform drug policy in terms of decriminalisation and legalisation/regulation if people who use drugs are portrayed as being criminals not just for using drugs, but in a host of other frightening ways.  (Of course it doesn’t undermine those arguments – prohibition increases harm – but it does make them less straightforward.)

It’s also about treatment itself: people may be less likely to access help (or encourage someone else to) if they think this defines them as an undesirable.  And they may well think that, even if they did go in, treatment services founded on the principle of crime reduction aren’t likely to be places of compassion.

But the bargain has a point: millions of pounds more funding.  And it could be argued that there’d be far fewer people working in the field even now had it not been for this realpolitik.  We’ve still got more funding and staff than services did in the 1990s.  The potential stigma is therefore arguably a price worth paying, because in reality we got far more people into treatment, and were able to provide largely effective care.

However, there’s a sense now that perhaps this particular argument has had its day.  That is, even if the stigma was a price worth paying, then the power of ‘crime’ won’t work today.  The political strategy has been a victim of its own success.

What we’ve seen in the past few years in an enthusiastic embrace of the concept of Adverse Childhood Experiences (ACEs).  I don’t want to go into the detail of this now, as people more passionate and informed than me have discussed this plenty.  But suffice to say there’s considerable evidence that early life experiences help shape how we navigate the world as adults.

Like so much social science and public health research, this isn’t really news.  We’ve understood this for thousands of years (‘Give me the child…’), and it has resonated in our lifetimes through programmes like ‘7 up’.  Perhaps it seems more worthy of comment after 40 years of politics dominated by narratives that emphasise choice and individual autonomy.  And the research is potentially helpful because it gives a sense of legitimacy to what we’d always ‘known’.  Without evidence, it can sometimes be hard to get certain ideas accepted as the basis of policymaking.

The research by Harry Sumnall and colleagues tests (amongst other things) whether narratives that talk specifically about ACEs make people more sympathetic to people who use drugs than narratives that simply refer to having had a ‘tough life’.  It turns out that yes, giving the specifics makes people more sympathetic.

I am hugely simplifying here, and I recommend you read the actual paper, but that’s the specific finding that I’m interested in discussing here, because it has clear implications for policy.  If ‘crime’ is no longer our magic framing device, then perhaps ‘ACEs’ will suffice.

My first problem is that, while this framing might seem to challenge that ‘neoliberal’ idea that everyone is free to make their own choices and take the consequences, it’s still vulnerable to that line of attack.  And as I’ve thought this through, I’ve started to wonder whether there are several other issues.

First, then, I worry that this framing of drug use as the consequence of trauma has the potential to separate people who use drugs into an equivalent binary of the deserving and undeserving poor.  Have you experienced sufficient childhood trauma to deserve my sympathy (and therefore funding)?

Of course, as the 2014 Home Office report pointed out, ‘a sizable proportion of heroin/crack users do not resort to theft’.  But this is OK, because the logic runs in the other direction: if you are using heroin/crack but haven’t yet committed crime, we can justify funding treatment as a preventive measure.  Heroin use (in our society) is so dangerous that it ‘inevitably’ leads to crime, so it doesn’t matter whether you’ve technically done this or not; it’s surely only a matter of time?

This simply doesn’t work with ACEs.  In fact, it’s potentially counterproductive, because we know that plenty of people experience trauma and don’t end up using heroin or other drugs in a problematic way.

Thus, it’s worryingly similar to the deserving/undeserving poor arguments.  There’s a huge power in the narrative that runs: "I grew up in poverty / experienced trauma but I worked hard, was responsible, and built the successful life I have now.  If I can do it, why couldn’t they?"

This goes right to the heart of political arguments about opportunities, processes and outcomes, echoing the arguments within the post-war left that led Michael Young to write The Rise of the Meritocracy, which is still being debated on Radio 4 today.

This is why ACEs seems powerful to people as way of framing debates about treatment for ‘substance use disorders’.  It offers a more ambitious programme (not just to reduce crime, but to help someone thrive).  It presents people with problems as, well, just that: people.  It offers a solution that is not punitive (even superficially), but constructive and compassionate.  It’s also, to some extent, more honest: it reflects much better what people who use drugs are like, and what treatment is (or should be) like.

However, as someone involved in the practical implementation of policy, I worry as soon as we’re grappling with the big questions and principles that aren’t already part of the ‘accepted wisdom’.  There’s a role for challenging that, and organisations like Release and Transform are an important part of that process.  But what I need is an argument that will ‘make sense’ in a town hall or local paper.  That elected councillors can get behind.

ACEs could yet be that: treat these people with compassion because it’s the right thing to do.  The problem is maintaining that compassion and commitment when it comes up against a child who has a needle stick injury from digging in the sand on the beach.  How far will that compassion stretch in public debate?  We’re getting dangerously close to having to wheel out and discuss JS Mill’s ‘harm principle’ – another big idea we’ve not been able to agree on.

Sometimes pragmatism, common sense and problem-solving are more likely to win you support.  Interestingly, some of the most vocal opponents of locating a treatment centre in an area where there was already visible drug use were simultaneously supportive of the idea of a drug consumption room – because this was seen (perhaps optimistically) as an immediate, hard-nosed solution to issues of discarded needles.

This brings us back round to the NHS.  One response would be that this would all be bypassed if we weren’t having to persuade town councillors, and if treatment were simply considered part of the NHS.  Setting aside the slightly undemocratic undertone of this (shouldn’t we aim to have widespread community support for the work we do?), it wouldn’t bypass national politics, and we can’t imagine that the same trade-offs and negotiations don’t happen in the NHS, even if they’re less visible.

We know that not all the funding that was allocated in substance misuse contracts in the past was spent on those services – though the cross-subsidisation of, for example, mental health services may well have been appropriate and justified use of resources.  (However, let’s not pretend the issues around ‘dual diagnosis’ and access to mental health support for people who use substances were an invention of the 2012 Health and Social Care Act, and that people were receiving intensive, integrated support before then.)  Perhaps it would be more accurate to say we don’t know precisely what it was spent on, and it may have all been spent on substance misuse.

This isn’t a criticism of the NHS.  Big organisations – including local NHS trusts – find it notoriously hard to identify exactly how much time and resources have been spent on a particular element of their work.  I speak from personal experience, compiling returns for government / PHE, that this kind of exercise can be potentially misleading and quite likely counterproductive:  critiques of the New Public Management would suggest that constant measuring and auditing aren’t always as helpful as they might seem.  They give reassurance, but that may be a false sense of security rather than actually reflecting a better service.

So even if we imagine ringfenced budgets and tightly managed contracts that (claim to) show where the money goes, it’s hard to imagine this working outside of specialist organisations – and there’s a benefit to slightly porous boundaries.

I’m acutely aware that this post may not be well received.  At one level, I’m writing based largely on my own experience and interpretation of policy (both locally and nationally) rather than any large-scale research or insights.  But that’s what this blog is for: it’s about ideas that I’m considering, rather than fully-formed, evidence-based, peer-reviewed conclusions.  I’ll leave that to the professionals.

But people are more likely to be disagreeing for different reasons.  I’m conscious people may feel the discussion doesn’t reflect well on me personally.  I’ve focused on pragmatic politics, not compassion.  I could be seen to have questioned whether the NHS is really best placed to support people who use drugs.

But in a sense that’s the whole point.  To talk about compassion and the brilliance and commitment of NHS staff would simply be preaching to the converted.  I’m assuming most people reading this post already have a passion for supporting people who’ve run into issues with substance use.  I’m assuming you’d like to see services better funded, with improved quality, and better links and support from the NHS.  (I personally think the separation of substance misuse treatment from the NHS is challenging – but in a sense I’m more angry at the GP contract a decade before the move of public health to local authorities.)

I’ve not talked about those things we probably agree on, but about the areas where we disagree – or actually as a ‘sector’ we’re lacking in coherent, persuasive ideas and strategies.  That’s where we need to debate, discuss and make a difference.

If the last 10 years have taught us anything, it’s surely that, in politics, having noble aims doesn’t necessarily improve people’s lives.  If we care about the future of treatment services, we need to make sure other people care too, and they may not be coming with the same knowledge, beliefs and assumptions.  Let’s have those discussions and disagreements, and come up with some ways that we can work together effectively to drive change.

Is it always best to think local?

I’m quite a fan of the New Local Government Network (NLGN).  Their starting point is that government in the UK could be more efficient and effective if more power lay in the hands of local authorities and local communities.

In the past few weeks, their director, Adam Lent, and today deputy director, Jessica Studdert, have made points that have got me thinking about where localism might not quite work as a policy solution.

As in so many areas of politics and policy, debates can end up framed as adversarial – in this case, a choice between ‘localism’ and ‘centralism’.  Given that any conclusion will involve some level of both central and local control, the argument needs to be framed as finding the right balance.  I know that advocates of localism would acknowledge this this, and their fundamental argument is simply that we’ve got the balance wrong, but I want to suggest that too often this leads to suggestions that a local solution will be better when experience tells us something different.  I think more than this, though, I want to be pragmatic about the politics.

First, I want to consider Adam’s critique of Michael Gove’s speech on the future of government.  I think this sets the scene well for the sorts of issues both localists and centralists (if that’s not perpetuating the false binary) are grappling with – and offers an insight into why localism is a powerful idea.

Gove* suggests that there are two key problems with government today: (i) there is rising inequality; (ii) people have lost trust in the ability of (central) government to improve their lives – and these two issues are linked.  Paraphrased by Adam Lent, Gove’s argument is: ‘government is not very good at understanding what makes people’s lives better. As a result, government rarely does make people’s lives better – hence inequality – and the people no longer trust government to actually make their lives better – hence mistrust.’

Gove’s solution is for more expertise in government, to be achieved by two key changes.  First, different people should be recruited to the civil service: more mathematical and scientific experts, rather than ‘those with social science qualifications’.  Second, these staff should be given more stability in their posts, allowing them to develop deeper experience.  These experts will then be brought closer to the people literally: more government should be based in places like Newcastle (in contrast to Sheffield and Bristol, apparently).

The critiques of this that I have seen are twofold.  First, as Abby Innes has argued, the solution to genuine complexity and unpredictability is not simply more ‘expertise’ and ever more complex statistical models; it’s accepting that there will always be issues and situations where decisions have to be made with imperfect information and uncertain consequences.  This approach, she suggests, has more in common with the post-Stalinist Soviet Union than English conservatism.

(I have to say that I find this apparently renewed emphasis on the tenets of New Public Management disappointing almost to the point of feeling exhausted, given that it seemed this might be receding - a development celebrated in the work of people like Toby Lowe and Simon Parker.  In practical, personal terms, my job commissioning substance misuse treatment services has been changed by the fact that the central control and emphasis on ‘performance data’ from the National Treatment Agency has been replaced by advice and support from Public Health England, but more of that later.)

The second critique is that locating ‘experts’ in Newcastle won’t bring government closer to people in any real sense.  As Adam Lent concludes (unsurprisingly for the Director of a think tank that champions the value of localism), what is really needed is ‘a major programme of decentralisation of power and resources; a more participatory and deliberative approach to democratic decision-making; and a fundamental shift away from the paternalism of councils and public sector towards a community-led model.’

I agree with the core of this – that for people to feel trust and a sense of connection to politics, we need ‘a more participatory and deliberative approach to democratic decision-making’ – but I worry that the idea of ‘a major programme of decentralisation of power and resources’ sets up an adversarial debate between ‘centralism’ and ‘localism’, where we have to pick sides.  And it is itself a major programme of bureaucratic reorganisation.

I think this is particularly clear in Adam’s recent comment on the idea that a national social care service could be established to raise the profile of social care and improve its quality and efficiency.  He states: ‘The NHS is an overly hierarchical, bureaucratic, unstrategic institution with a poor organisational culture. Plus it is far too subject to the whims of politicians. Why anyone would want to emulate that in social care is beyond me.’

Again, the solution instead is ‘to localise the NHS under the control of councils and their communities not centralise social care under the control of Westminster.’  Jessica Studdert has expanded on this in today’s piece in the Guardian.

I am not an unequivocal supporter of the NHS.  I have written before about how it is often unfairly used as a way to criticise local commissioners of services, who are seen as ‘privatising’ provision and preferring private or third sector providers.  It can be disappointing.

However, my experience of commissioning substance misuse treatment services since 2011 suggests there are two key advantages to the NHS – or, rather, a national care organisation.

The first point is about funding and politics.  As Jessica notes, “At one level, the issue for social care begins and ends with money”.

Crucially, almost all public sector funding comes from national sources.  We can imagine a world in which regional or local government had more control over revenue-raising, but it seems a long way off at the moment.  And many sources are likely to remain national: VAT, income tax, duty on imports and products such as alcohol and tobacco, to mention a few.

The trouble with local government is that the operation of the service is separated from the source of the revenue.  Central government raises and distributes revenue, then local areas make decisions.  This is why local government has been targeted as part of austerity: it allows central government to effectively outsource the cuts.  The blame for what has been cut and how can be placed onto the local decision-makers, not Whitehall.

A national politician is held to account for a national service.  This is why the health services in the NHS have seen their budgets largely protected (in cash terms, at least), in contrast with those in local authorities (like sexual health, school nursing, health visiting and substance misuse treatment), which have seen theirs cut by 20%.

Civil servants supportive of substance misuse treatment effectively made a gamble when deciding where to put it as a result of the 2013 health reforms: should it go into local authorities or the NHS?  Prior to this it had straddled both, with PCTs commissioning some services and local partnerships generally led by councils commissioning the rest.

It ended up in local authorities, the theory being that substance misuse funding in the NHS had never effectively been ringfenced; it was often used to cross-subsidise other (under-funded) areas like mental health.  As critiques like those of the NLGN suggest, money is too easily lost in such a large, unaccountable organisation.  (Or rather such large organisations, as the NHS is not one entity with a single culture.)

In local authorities, it was thought, the funding could be more easily insulated.  This is probably true,  But it wasn’t foreseen that budgets (including the public health grant) could be more easily cut in local authorities than in the NHS.  Yes, the budget has been relatively well insulated when compared to the NHS, but it’s still got smaller and smaller.

So having social care as a national service might mean that national politicians would be more likely to protect the funding.

Of course it could be argued that we need to revolutionise local government finances, allowing councils to raise more money themselves, but I still struggle to see how there could be genuinely local taxes to generate sufficient income to support all their services, or how this could be equitable across the country.  Is there enough business to support the care needs of the ageing population through local taxation in a rural council area like Dorset?  Or to support the complex needs of a town like Blackpool?  There would surely have to be national funding agreements, and with them the reality of national politics.

Even if we could fund social care locally, I’d suggest there’s another benefit to a national arrangement.  Let’s think again of substance misuse treatment.  The CQC regulates some (though not all) services, but you can’t rely on their occasional inspections to ensure quality provision.  That needs other forms of management and quality assurance.  And the design of services is left up to local areas too, as well as the prioritisation of different issues.

In the eyes of advocates for localism, this is a boon: it means that services can be adapted to local need and preferences.  These days, not every local authority has to have a ‘crack strategy’ to deal with crack cocaine if they feel this isn’t an issue.  And if pharmacies aren’t the best way to deliver needle exchange in their area, they can use other sites instead.

But at the same time, this approach can be inefficient.  Every local authority writes its own audit plans.  Every local authority writes its own specifications.  And so on.

Yes, there can be collaboration, and we’re hopefully seeing this with the creation of a national substance misuse commissioners forum.

But think of what this variation means in practice.  We know that the NHS isn’t truly a national service.  Different medications are available in different areas.  This is also true in local substance misuse services.  In the past, for example, you were more likely to be prescribed buprenorphine in Dorset than in Bournemouth.

But the variation in local services is about more than this: the actual dosages varied dramatically, despite national guidance suggesting that the therapeutic range was typically between 60mls and 120mls of methadone.

This was down to local organisational culture, and part of a pattern (of almost random variation) that could be seen across England.  I’m not suggesting that these kind of variations don’t happen in the NHS; simply that the broader oversight, with national data collection and comparison, means they are less likely. (A positive development on this front is that the National Drug Treatment Monitoring System as of this financial year now collects prescribing data.)

Moreover, although Adam worries about the NHS being dependent on the ‘whim’ of national politicians, the variation in these doses and drug choice is partly dependent on local politicians.

Decisions that shaped these patterns were based on NHS or local authority commissioners and managers interpreting national guidance, with their interpretations inevitably shaped to some degree by both local and national political rhetoric.

Low medication dosages and falling numbers of people in treatment are the result of a ‘recovery’ agenda, most prominently expressed by Iain Duncan Smith, but also embraced by many local council officers and politicians.  Politics and rhetoric affected the quality of the treatment available.

If ‘success’ was defined locally as reducing the number of people in treatment, so it looked like fewer people had a ‘drug problem’, that could be engineered (albeit not always consciously).

What this means is that every local authority has to win the argument to provide treatment in line with the evidence base.  National guidance is not enough.

It might seem that this is less risky than centralisation: if political issues mean that Bournemouth struggles with this, for example, at least we haven’t necessarily lost Dorset into the bargain; whereas a national decision covers everywhere.  But the apparent weakness of the NHS is also a key strength: it may be hard to manoeuvre, but that means it’s also harder to universally manipulate.  If this sounds like a distrust of politicians, it’s not my distrust, but Adam’s.  We’re back to those dangerous 'whims' of politicians again.

The issue comes down to where one sees the greatest risks, and I’m not clear about the answer.  I certainly can’t say the solution is obviously either centralism or localism.  Do we have the level of resource and expertise to invent the wheel in almost 150 local authorities in England?  Or are we better off getting something more nationally controlled and mandated?

In my experience, looking at the history of substance misuse treatment, we were better off with the inefficiencies of the centrally-controlled regime, rather than attempting to create independent solutions in every area.  People who seemed to hate the National Treatment Agency at the time now seem to long for it.

And as Jessica points out, “care is essentially about people and relationships, not buildings and services”.  I’d absolutely echo that point.  But I’d therefore emphasise that the key is not to think too much about the structures, given that what makes a difference is people.

And let’s not imagine that this wouldn’t constitute a form of bureaucratic reorganisation.  We’re all agreed that the current arrangements are unsustainable.  Jessica suggests that “There is no question that the care system is in urgent need of funding reform, but nationalising social care wouldn’t solve its problems”.  I would argue that without changing the political arrangements, there can be no funding solution.  Of course, I don’t want to position myself into the same adversarial central/local argument that I started this piece by describing, and there are other options for organising services that we should be considering.  But I worry that the dream of localism could lead to a reality of poorly funded services with inadequate quality assurance.

 

*I’m never quite sure how to refer to people in these kind of pieces.  In an academic article, you’d just say ‘Gove’, ‘Lent’ and ‘Studdert’ and not worry about it.  But this seems oddly formal and stilted for a blog.  Here, I’ve decided that I’m saying ‘Gove’ because I’ve never met him, and this seems appropriate for a national politician, whereas I’m referring to ‘Adam’ and ‘Jessica’ because I have once met them – and they’re not national politicians who are often referred to only by their surnames.  I hope that seems reasonable and sufficiently human!

The rise and fall (and rise and fall) of neoliberalism in alcohol policy?

Between 2006 and 2009, I was doing research into alcohol and the night-time economy.  This still felt like a time of ‘peak booze’.  The new licensing laws had come into force in 2005, and it wasn’t yet clear that our drinking had started to decline at a population level.  Generation sensible was nowhere to be seen as the papers panicked (and gawped) at ‘Binge Britain’.  Urinating on memorials isn’t a new thing.

A dominant debate at this point (which fortunately for my attempts at academic publishing continued under the Coalition government) was about the relevance of the idea of ‘neoliberalism’.  I’ve wrote about this quite often (particularly here – or here for free), including on this blog.  In my understanding, neoliberalism in alcohol policy is about having your cake and eating it: liberalising regulations, but then complaining when things unfold exactly as other have predicted.

Words and concepts that are valued in this understanding include ‘market’, ‘rational’, ‘individual’, ‘responsible’.  Some of the best descriptions of neoliberalism can be found in the work of David Garland and John Clarke.

It’s not classical liberalism, because you’re not accepting that a person’s own choices about their own life are by definition the most sensible for them.  But it’s not the classic post (First World) war consensus approach, because you’re not changing the environment to re-shape people’s choices.  (Don’t imagine that Thaler and Sunstein were the first people to think about choice architecture and nudging people towards healthier choices – alcohol policy reports were talking about food offers, glass size and vertical drinking in the 19^th century, and putting this into practice by the early twentieth).

Paul Chatterton and Robert Hollands used a very helpful model to structure discussions of alcohol policy – think about consumers, producers and regulators.  Their focus was on public drinking – or the ‘night-time economy’, and so producers, of course, could be the people who actually brew the beer, for example, or the retailers who sell it (like nightclubs); they’re both ‘producing’ the night-time economy space.

A neoliberal approach by ‘regulators’ (i.e. local and national government) could be characterised by a tendency to blame individuals for behaving poorly, while freeing up the producers to make alcohol more available and affordable.  A contrary interpretation would be claim that those changes mean that young people are ‘invited to binge’, and so the blame should lie with regulators and producers for being irresponsible and disingenuous.  This was an academic debate as well as one of policy and politics – that phrase ‘invited to binge’ comes from an exchange in the journal Town and Country Planning from 2004.

I feel like these debates have largely faded away in politics recently.  Perhaps this is because I’m not in academia now, so I’m not analysing politics and policy as much as experiencing them through local government.  It’s also a function of Brexit blocking out all other issues.  But there’s something more: alcohol isn’t the political issue it was in 2004.  (Or at least it wasn’t until recently.)  We’ve had our debate about licensing, ‘binge Britain’ is perhaps less visible, and minimum unit pricing (MUP) for alcohol has effectively been framed as an issue of devolved governments, with Scotland and Wales introducing it, rather than something to be argued over at Westminster.  (It’s hard for the Conservatives to oppose it too much, as they committed to it in their 2012 Alcohol Strategy.)

But now these debates about ‘responsibility’ are back, brought into focus again by COVID-19.  The photos of people on beaches – and particularly drinking in Soho – have led to discussions of whether it’s irresponsible drinkers, greedy producers or negligent regulators who are to blame.

Suddenly, I thought, those ideas of neoliberalism and alcohol policy might be valid again: the economy needs a boost, and people need the distraction that a good night out can give.  And having evidence that some groups (possibly unlikely to vote for them in any case) may not have adhered to guidelines may not be the worst thing for a government preparing for a ‘second wave’.

Perhaps one difference this time round might be local authorities, I thought.  Rather than embracing the night-time economy as a way to re-create Bologna in Birmingham and Madrid in Manchester (and raise much-needed revenue), this time round, perhaps influenced by their Directors of Public Health, it seemed like drinking in a time of COVID-19 might case them a headache.

But fundamentally, we were straight back into these age old debates of whether we should trust people to make ‘sensible’ decisions (and blame the ‘irresponsible minority’ when they don’t), or be more pragmatic and controlling and re-shape the environment to actively encourage (or even enforce) ‘responsible’ drinking.

Then came yesterday’s budget – sorry, ‘Plan For Jobs’.  In this, the VAT cut and ‘meal deals’ announced by the Chancellor, Rishi Sunak, explicitly did not include alcoholic drinks.  This will boost some pubs and venues, and not others.  This seems to be the result of an acceptance that consuming alcohol during lockdown may be an issue, but it is distinctly at odds with the divide and rule approach of New Labour, as outlined by Tessa Jowell in proposing the 2003 Licensing Act: “Our role is to give adults the freedom they deserve, while giving the yobbish minority the rough and tough treatment that they deserve.”

This is the same approach I thought I was seeing in the government’s approach to re-opening the pubs, and the public reaction to scenes in Soho and elsewhere.

Perhaps, as with the claim to be drawing on FDR’s New Deal, there is a tension within government.  Maybe this is Rishi Sunak positioning himself as responsible centrist, interested in rules, as opposed to the neoliberal individualism of Dominic Cummings and Boris Johnson.  But given that it’s Michael Gove talking about FDR, this could simply be a case of the government having an interest in presenting (trialling?) a range of approaches.

Whatever it is, it seems a good time to be dusting off all those references from the 1990s and 2000s.  I’ve written before about the false dawn of some kind of communitarianism or post-liberalism – at least in relation to alcohol policy.  In fact that was my first published article going over these arguments about neoliberalism.  And the Coalition never did introduce MUP.

Wetherspoons in a time of COVID-19

I originally started this blog as a place to write about things I wasn’t too sure about – developing ideas that weren’t quite up to academic standards of peer review.  Somewhere to say what I ‘reckon’, rather than necessarily what I definitely ‘know’.  (Yes, of course, all knowledge is contingent etc, but you know what I mean.)

Recently, I worry that I’ve been too cautious in just writing about what I ‘reckon’, for fear that I might be wrong, so this is an attempt to get back to that original approach.

Sometimes I feel nervous about this in relation to discussions of drinking and alcohol policy.  The field seems hugely coloured by people’s personal preferences and experiences – those who don’t enjoy being drunk often don’t seem to understand those who do, for example.  Politicians seem to believe that anyone who uses their freedom to behave differently simply needs more ‘education’ or ‘information’ – as if there is one ‘rational’ way to behave in relation to a drug that is attractive precisely because it removes rationality.

(Of course, my ‘objectivity’ is equally compromised, but it is possible to claim some moral (or epistemological) high ground by at least being aware of this, and acknowledging some of one’s own biases.  It’s then up to other people to see how useful my ‘reckoning’ is.)

Maybe I’m overplaying it, but I feel like Wetherspoons is some kind of lightning conductor for these personal views about alcohol (mixed, of course, with concerns about class).  This has probably ramped up, given the controversies around Tim Martin’s position on Brexit, and his use of Wetherspoons to get his message across.

Seeing a discussion of this on Twitter got me thinking this could be the perfect way to get back into writing about what I 'reckon'. (Actually, talking about alcohol and class isn’t just what I ‘reckon’; it’s one of those rare bits of my thinking that has gone through peer review - here and here, for example.)

Wetherspoons is often portrayed as not being a ‘real’ pub, or being a kind of immoral capitalist organisation that exploits its own staff and the breweries it buys from.

The objections are also aesthetic and cultural.  There’s a common argument that Wetherspoons are just ‘drinking barns’, to used Deborah Talbot’s phrase.

But spaces are also what people make of them.  The question is about community.  Wetherspoons brings together a range of people united partly by price and convenience (but also by culture).  They are the classic ‘chameleon’ venues, welcoming business travellers for breakfast, families and work groups for lunch, students in the evening, and so on.

To me, this is a key quality of a pub, and genuinely public, social drinking.  If people’s time is split simply between home and work, with limited interaction while shopping (particularly given how much is done online), then we have pretty narrow social circles, mediated only by social media.  A good local pub, by contrast, offers an opportunity for people to interact more widely (though obviously there’s plenty of research, including mine, on how venues segregate and distinguish between people).  Check out work by people like Claire Markham, for example.

But this isn’t just about price.  People actively choose Wetherspoons and it can provide a shared culture.  Perhaps it’s different in cities, but in towns like Dorchester, where I live – or even Bournemouth – you can see this sense of community in Wetherspoons.  Apart from the nightclubs or late opening pubs with ‘loud music and dancing’ (apparently the new definition of a ‘nightclub’), Wetherspoons – with neither of these features – is the place most likely to have ‘free and familiar contact’, with people bumping into old friends and different conversation groups interacting.

Around Christmas it’s genuinely a joyful place, full of community, with local football clubs bumping into each other (don’t ask about the rivalry between Piddlehinton and Puddletown) and former schoolmates meeting up as they’re back visiting parents.  Or even on an ordinary Friday night, as work groups merge as people bump into friends of friends.

And this is before we get into the David Gutzke idea of Wetherspoons being more welcoming to people who typically feel uncomfortable in traditional pubs.

This isn’t to praise Wetherspoons, or claim these things don’t happen in other venues.  If offered a choice, this isn’t my personal favourite venue in Dorchester.  And maybe I’m over-sensitive about these criticisms of it, as I see them feeding into the broader classed narratives of what are ‘good’ venues and what is ‘responsible’ drinking. 

I’m certainly sensitive to the fact that people who have comfortable houses and gardens or can afford more expensive venues are particularly privileged at the moment in being able to resist the temptation of the pub.  I always think of Robert Roberts’description.

Or perhaps the pub simply isn’t a temptation, and people don’t understand the attraction, just like I don’t understand gambling.  Either way, let’s not be too lazy in thinking about Wetherspoons.  My perspective is certainly that I have lots of good, locally-specific, sociable memories of them.

Policy change to address COVID-19

This is the first time I’ve blogged here since COVID-19 really hit. 

If you’re interested in broader reflections on what the crisis might mean for alcohol policy, I’ve written about that for the wonderful Drinking Studies Network here. 

But here I want to identify four specific areas where I think policy change or government guidance could be game-changing for people receiving treatment for issues with substance use.  This doesn’t mean they’re the most important areas of activity or policy at the moment; to be honest keeping on doing the ‘bread and butter’ tasks of substance misuse treatment is the core challenge.  But these are the issues where I think the biggest change could be delivered by relatively simple, almost technical, interventions.  These changes aren’t about the detail of delivering treatment so much as freeing people up to deliver support in the most efficient and effective ways we can manage. 

(1) Buprenorphine and (2) the supervision of medication 

First, I want to talk about buprenorphine.  This is one of basically two drugs recommended to as part of opioid substitution treatment (OST), which means people can avoid withdrawals from heroin (or other opioids) and not have to think about funding their habit, as they’re prescribed medication.  The evidence is strong that these interventions reduce crime and the transmission of blood-borne viruses. 

In normal times, lots of people on OST attend a pharmacy every day to be supervised taking their medication.  This helps ensure that (a) they’re definitely taking it and getting the specified dose; and (b) they’re not having any kind of adverse reaction that means the dose needs tweaking. There’s also a valuable safeguarding role: the pharmacist is seeing them in person and so can see any broader deterioration in health or make a judgement about potential wider issues, such as domestic abuse. 

But there’s a downside to this level of supervision during COVID-19.  Going into town every day increases your risk of catching COVID-19, and the pressure on pharmacies a few weeks ago meant that there were queues as well – at best simply off-putting, and at worse further increasing your risk of contracting the virus. 

So the solution introduced (often well ahead of formal government guidance) was to balance up those risks and ask people to attend pharmacies in person less often than they would normally.  This might increase other risks, of course.  If you’re taking home a whole week’s worth of medication rather than just a day or two, then there’s a greater risk of overdose if you take it all at once, or it could be used as a tool of control by an abusive partner or organised crime group. 

Treatment providers are aware of these risks, and are making decisions on a case-by-case basis, balancing up those risks against those of catching COVID-19, particularly given that lots of people in treatment may already have complicating factors (like hepatitis or COPD) that make them more vulnerable.  And commissioners like me are trying to keep a track on all of this to see if we’ve got the balance right.  (Maybe if pharmacies aren’t so busy, a few of the clients more at risk should have face-to-face contact a bit more often again?) 

One of the other ways we’re managing these risks is to make greater use of buprenorphine, one of the key OST drugs along with methadone.  Generally, in line with national guidance, most people in treatment are prescribed methadone, as it’s cheaper and easier to supervise (drink a liquid rather than dissolve a pill under your tongue), and there’s no any clear evidence buprenorphine delivers better outcomes – in fact, in the early stages methadone seems to keep more people engaged. 

So why use more buprenorphine?  Well it’s less risky if you’re taking it home in larger quantities, as there’s less risk of overdose and less to be gained by using heroin ‘on top’ of your medication. 

And this is exactly what the guidance from Public Heath England, issued a few weeks ago, recommends.  The challenge, though, that buprenorphine is considerably more expensive than methadone, and it costs about seven or eight times as much as it did a couple of years ago.  Some very rough local modelling suggests switching someone from methadone onto buprenorphine costs over £1,000 extra per year.  That might not sound like much till you scale it up: a small shift in a client base of 1,000 (not unusual in large local authorities) will cost £100,000s.  Not easy to find at a time when local authorities are losing large sums every week. 

Of course buprenorphine in its conventional tablet form isn’t the only option; it could part of a range of changes we could make. 

One would be to introduce, as has been done in Wales, ‘depot’ buprenorphine, which works like some long-acting reversible contraception injections: it gives a steady dose of the drug over a week or a month, gradually dissolving – meaning you have stability, certainty, and have to see a nurse or pharmacist less often.  The COVID-19 guidance states local areas could consider this, but resource requirements (amongst other things) will probably make this challenging.  We’re certainly considering this locally, as we have been for a few years (we were hoping for guidance from NICE/PHE this spring, though that’s now clearly not going to happen). 

Another, simpler option, is to introduce delivery of medication, which allows services to still see patients eye-to-eye.  We’re doing this in Dorset and BCP, but at the moment we’re reliant on drivers from other areas of the council, and they don’t have the expertise to offer any kind of clinical judgement as pharmacists might, so we’re both vulnerable to those staff being reallocated, and we need to ensure we’re providing specialist support where necessary.  Both of those will cost money. 

One solution could lie in community pharmacies.  This whole issue of switching people to buprenorphine arises because people aren’t being seen in person so often.  Given that we pay pharmacies for each time they see a client, then surely we’ll have some savings on that ‘supervised consumption’ budget?  Wrong.  In the same section where PHE recommends moving people onto buprenorphine so they don’t have to come into the pharmacy, it also states that local authorities should carry on paying pharmacies their standard amounts for supervised consumption even if they’re no longer doing this as much. 

This makes sense: we don’t want pharmacies to struggle and close, and it’s an accepted principle in the NHS response to COVID-19.  But local authorities aren’t funded like the NHS, and the additional funding being offered by central government is unlikely to meet these costs (if it even makes its way to public health departments). 

So those are my first two asks.  If the government is recommending we keep paying pharmacies while still requiring us to find alternative ways of delivering this kind of supervision, then it needs to find that funding.  And if it thinks generic buprenorphine is a solution, then it would need, again, to find the funding for that. 

I know this might sound like the typical call for ‘more money please’, but these aren’t areas where ‘efficiency’ can solve things on its own.  Buprenorphine and trained staff time simply cost money, and we’re being asked to deliver more of them without being given the means to do so. 

(3) Electronic prescribing 

But if efficiency on its own isn’t the answer, that doesn’t mean we’re not looking at trying to be more efficient.  One of the most surprising things about OST services today is that most of them are still doing their prescribing on paper.  Every one of the, say, 1,000 clients in an area needs a new prescription every fortnight.  This has to be created on an electronic system, printed out, signed by a nurse or doctor, delivered to a pharmacy, stored by the pharmacy and then sent off the NHS Business Services Authority so the pharmacy can claim back funding.  For almost every other medicine all this can be done remotely.  The prescriber creates a prescription on the electronic system, presses send and it appears in the pharmacy on their electronic system.  No printing, no signing in person. 

This sounds inefficient, but in a time of COVID-19 it’s more than that; it’s risky to staff.  The admin staff involved in printing, and the prescribers, all have to share the same office.  Perhaps they can work out a relay system, where people only come in on certain days, but they either have to come in, or the paper (with possible associated infection risk) has to make its way from the printer in the office, to their house, and back out to the pharmacy.  Not practical.  Someone who is self-isolating or shielding, even if they’re currently fit to work from home, can’t. 

There’s been legislation in place since 2015 that means things don’t have to be this way.  Controlled drugs can be prescribed electronically.  The challenge is that this hasn’t been technically applied to ‘instalment’ prescribing.  That is, you can only send through a prescription that involves one interaction between patient and pharmacist, when (in normal times) most of our prescriptions involve people attending more than once a fortnight.  In fact, even in COVID-19 times, most people are still collecting their medication at least weekly – which would mean they’d need a new electronic prescription every time. 

You might think that’s just a technical problem, and still easier than all the paper we use now, but every prescription can of course carry a prescription charge, so if I’m suddenly having to pay every week rather than every fortnight you’ve just doubled my costs as a patient. 

And this isn’t just about the patient; it’s about the pharmacy again.  Often (and particularly in these times) even though they’ll have one ‘prescription’ and they’ll be giving a week’s worth of medication to someone, this won’t simply be as a single bottle of methadone – the safer, easier option is to sub-divide this into seven, pre-measured doses.  And the pharmacist gets paid different amounts, quite rightly, depending on whether they’ve done this pre-measuring or not.  If it’s just one prescription, with no guidance about those ‘instalments’, then they can only be paid the standard amount. 

I’ll repeat that this is a technical, not a legal, problem – and one that can’t be solved by local areas; it’s a national issue, effectively with IT. 

(4) Supplying alcohol 

Finally, and briefly, supplying alcohol.  Suddenly stopping drinking can have serious health risks if you are dependent on alcohol, so the PHE guidance quite rightly notes the risks of people struggling with alcohol supply in a time of COVID-19 if they’re dependent.  If someone is short of funds, or self-isolating, they may struggle to get hold of alcohol, and therefore unintentionally put themselves at risk. 

Local treatment services can of course support people through this process and assess their needs, but it’s not clear from the guidance whether they’re also meant to be helping people get hold of alcohol.  And if they were, there’s a downside: unlike with buprenorphine, for example, there aren’t clear processes and guidance on the ‘prescribing’ and ‘dispensing’ of alcohol.  But PHE hasn’t issued any either; it’s just said people should make sure they continue to drink.  Lots of areas are developing their own protocols, but these are all slightly different, meaning that there is local variation without necessarily any need.  There is much more to say on this, but that’s probably enough for now: I would welcome national guidance on who is best placed to do this, and how. 

So there you have it.  Four policy asks: 

• Funding for continued payments to pharmacies 
• Funding for buprenorphine or similar approaches to reduce risk of overdose and COVID-19 
• Prioritising electronic prescribing for OST 
• Policies/guidance for providing alcohol to dependent drinkers who can’t access it. 

I’m not saying we can’t do anything on these – in fact we’re working hard to take all of them forward.  But they’re all areas where central government intervention could make all the difference.  I don’t just mean government could make my life easier; I mean government could actively save lives.