You can't be an expert on your own

After attending EXCO 2018 a couple of weeks ago, I don’t have the answers to what Excellence in the Commissioning of Opioid Use Disorders looks like.  But then I wouldn’t expect to.  In fact, I think I’m giving the conference the highest praise possible when I say that it got me thinking in depth about commissioning and how we do it. 

Any conference has, almost by definition, some element of ‘broadcasting’; people telling a room what they’ve done, and ideally reflecting on what they’ve learned.  But sometimes the most useful part of a conference is the human contact, the genuine sharing of ideas.  In simple terms, a conversation rather than a lecture.  It’s this that sets a conference apart from reading a book or an article, or even watching a webinar. 

EXCO was no exception.  For me, some of the most interesting and useful moments were in conversations over coffee or lunch. 

And I think this applies more widely: there’s a real need for genuine conversations in commissioning.  I don’t necessarily mean sitting over coffee and chatting things through.  This kind of exchange of ideas could be virtual, through online communities (I’ve just joined an interesting group on Knowledge Hub, generally used by local government staff). 

And in fact it’s not just about actual conversations, whether virtual or ‘IRL’.  I’m thinking more of an exchange of ideas.  It was in some ways a point from Annemarie Ward about our sector being in competition that got me thinking again about how we might approach things differently – and that wasn’t part of a conversation so much as her point percolating through my mind on the (long!) drive home from Manchester. 

But writing about how we need ‘an exchange of ideas’ is exactly the sort of thing that generally winds me up.  It’s no wonder that when commissioners like me use this kind of phrase we get told, quite rightly, ‘you talk, we die’. 

But I think it’s important.  It’s about the way we approach our jobs – and without doing this in the right way, we really are in danger of pointless talk. 

What do I mean by pointless talk?  Well, the kind of ‘broadcasting’ I talked about earlier.  Too often, when a group of professionals come together to share ‘best practice’, it turns into a bragging session.  Too often, when an organisation like Public Health England (PHE) or the Local Government Association (LGA) release a guide to something it’s full of ‘case studies’ that are simply puff pieces – opportunities for people to boast about how wonderful their organisation (and, by implication, their own work) is. 

My fear about an ‘expert’ faculty is precisely that: it will become an opportunity for those involved to broadcast information that confirms their status as ‘experts’.  We don’t need another organisation like that.  Instead, we should be more honest and collaborative.  Perhaps if, instead of talking, we made more of an effort to listen, share and cooperate, then fewer people would die. 

I know this sounds rich coming from someone who actively blogs, tweets and writes, sharing his own views, but maybe it takes one to know one.  I like a bit of attention, and I find it rewarding to feel like an expert, but on lots of things – actually, everything – the attention shouldn’t be paid to me, and I’m not the ‘expert’ voice you should be listening to. 

But what does this mean in practice?  It means that I think the Faculty could be a great vehicle for these conversations.  But I would suggest we need to approach these conversations differently to lots of interactions I see (and participate in!) at the moment. 

(I appreciate it’s slightly odd that I’m stating a definitive opinion at the same time as I’m denying expertise or that anyone has the answer.  I’m afraid you’ll have to live with that.) 

So let’s turn a management platitude on its head: don’t come to me with solutions, come with problems.  If you come to a group with a problem, there’s instantly a conversation.  If you come with a solution, you’re often just grandstanding. 

You might have thought PHE could play this role as a facilitator of conversations, but it’s clear it’s not quite managing it at the moment.  Having heard Rosanna O’Connor speak at EXCO, I wonder if we – local commissioners – are part of the problem.  (Of course we are.)  She made the point (though not in these words) that the sector can look a bit like it’s crying wolf about funding cuts when all the stats still look rosy, because no-one wants to admit that things aren’t going well in their team, their organisation, their local authority.  And if we don’t want to tell them things aren’t working, how can they host open, honest conversations? 

So I think there is a potential role for a Faculty of Commissioning, but while I’d love to be an expert, a person can’t be one on their own.  Perhaps this faculty could be a place to share mistakes and problems as much as ready-made expertise. 

It’s this slightly pessimistic vision that could make me optimistic.  How about you? 

Addiction and the common cold

As you could probably tell if you read my last blog post, I’ve been thinking a lot about what the ‘problem’ (or rather what problems) in relation to alcohol it is that policy and treatment are trying to solve, and whose responsibility these might be.  An analogy that’s often bandied about is one of wider health or healthcare – addiction is a health, not a criminal justice, issue – particularly if we note parallels with mental health.

One of the best pieces I’ve read about mental health care was this article by Hannah Jane Parkinson.  It starts by considering the common analogy that we don’t think of people with broken legs the way we do people with mental illness, and if we did there would be less stigma and people would be more likely to receive effective treatment.  But the challenge she puts back is that, in fact, mental illness isn’t much like having a broken leg.  I agree, but, being a bit of a contrarian, I want to suggest the analogy might still be useful – or at least some form of analogy with physical health.

If you look at many physical health conditions, although the pathway won’t be immutable or the same for every patient, you can be given a pretty good idea of what it’s likely to look like, and where the decision points might be along the road.  I’m not sure we’ve always managed that in substance misuse treatment services.

But it’s not just about that kind of learning.  If we think a bit differently, then an analogy like a broken leg or the common cold does actually make a lot of sense – and perhaps even helps illuminate who might be seen as responsible for the various elements of prevention, vaccination, rehabilitation and cure (or however we badge things).

Take the common cold, which is a regular source of frustration to me: why haven’t we found a cure yet?  Why did we stop the trials at l(well, near) Porton Down?  (No, not those trials.)  Well the answer is that what we see and diagnose as the common cold could be seen as a set of symptoms; there are many different viruses that actually cause them.  And even if two people have the same virus, it might affect their bodies in different ways: when I get a cold it always starts with a sore throat; for other people it’s sneezing or a runny nose.

So let’s apply this as an analogy to substance use disorders (SUDs).  Think of that DSM-V definition.  It, just like our understanding of the common cold, is a set of symptoms.  And it’s plausible to see the cause as similar: a range of things lead people to use in these ways, even if they can be grouped together in the same way that cold viruses can be (as adverse childhood experiences, for example).  And what that disorder looks like will be different to different people.  Not everyone has a sore throat when they get a cold, and not every DSM will be ticked for substance use disorders.  And, importantly, not every cold you get has the same symptoms – sometimes there’s no blocked nose, sometimes there is – and so not every episode of substance misuse will look the same even for the same individual.

So that tells us how SUDs look like common colds.  But what can we learn about how we address them?

First off, let’s think about prevention.  We talk about good habits: coughs and sneezes spread diseases, wash your hands, don’t go into work needlessly if you’re ill, get lots of sleep, etc.  There are precautions you can take as an individual to reduce the work to yourselves and others.  The same is true for SUDs.  So local and national government has a role in making sure social structures and opportunities don’t foster illness.

In terms of treatment for a cold, we just relieve the symptoms.  We take medication like Lemsip.  We avoid making it worse, maybe by taking some time off work.

We can do the same for SUDs – though maybe methadone is a more likely medication than Lemsip, and harm reduction interventions include needle exchange rather than honey and lemon.  This is where substance misuse treatment services come in.

But none of that stops me being grumpy about the common cold, and wondering if we couldn’t do more.  Why did we stop those experiments at Porton?  Well, apart from the ethics, from what I can tell it was felt that although the symptoms looked similar, the viruses were too different, and mutating, for us to develop a single treatment or vaccine.

Instead, what looks more promising is accepting there probably won’t be a vaccination, but developing medications that, rather than just easing the symptoms, stop our bodies from providing what the virus needs to replicate.

Interestingly, and encouragingly (or frustratingly, depending on your outlook on life) none of this is alien or new to substance misuse services.  We can try, but we won’t ever completely stop people being exposed to risk factors for substance misuse.  So when they are exposed, we want to make sure they have resilience, and then decent self care if they’re in an episode of misuse.  Then, we can provide medication – Naltrexone, for example – that reduces the chances that someone’s exposure will lead to another episode.

So maybe that analogy with physical illness isn’t terribly useful – but not because it’s not accurate; rather it doesn’t tell us much we don’t know already.  (So this was definitely a worthwhile blog post…)  It perhaps tells us that we sometimes underestimate how complex and inexact medical science is, even for apparently straightforward ‘physical’ illness.

And it’s not just the common cold.  Let’s go back to the broken leg analogy.  That is, effectively, a symptom.

There are lots of potential causes of a broken leg – including skiing and playing rugby – and lots of people will carry on putting themselves at risk after they’ve broken their leg once and it’s healed.  (Perhaps, without being too flippant, being a rugby player is a chronic, relapsing condition that’s harmful to your health and family relationships?)

We can try to reduce people’s exposure to risk, and we can try to reduce their risk by ensuring diet and behaviour gives people relatively strong bones, but people will still break their leg.  And once they have, sometimes it’s easily healed, sometimes not.  Sometimes there are long term consequences (you’re unable to play rugby again); other times life is pretty much back to normal.

The treatment will involve a number of different professionals, even if what is being treated is just the broken leg itself.  (Think of doctors, nurses, drug workers, social workers etc helping with SUDs.)

But if the broken leg is a symptom of something broader, like osteoporosis, and just stopping playing rugby won’t be enough to prevent it happening again, then other specialists might need to get involved – and only then are we talking about something more than symptomatic relief.

Fundamentally, none of this is terribly illuminating, I must admit.  And what I certainly don’t want to do is undermine the crucial point that treating mental health or substance use disorders is like ‘treating’ a broken leg.  They’re not, exactly – though the analogy can actually be comforting: we do what we can.  What this discussion can remind us is that maybe substance misuse isn’t quite the special case we might think it is.  Medicine, even for physical health, isn’t in practice an objective science so much as a personal, human and nuanced practice of care.  Sometimes it’s nice not to be special.

Binges, bouts and gaps in treatment

I’m going to suggest in this post that the approach of alcohol policy and treatment in the past few decades has had a crucial blind spot.  As ever, it’s not peer-reviewed research, so what you’ll find is the usual mix of personal and professional experience, in this instance prompted by literature.

This is a relatively short piece and isn’t meant to be watertight or academic.  It doesn’t go into the full debates around definitions of dependency, addiction, alcoholism, substance use disorder, etc.  I just hope it’s useful and can be judged on its merits (or lack of them).

I’ve written before about how definitions of problems associated with alcohol change over time.  The characteristic drinker seen as having a problem in the nineteenth century wasn’t doing the same things as someone we might see as having a problem in the 21^st century.

I have to confess I get most of my feeling for this from fiction.  I say ‘confess’ as if I feel guilty about this.  I don’t.  (Though I will be making a reference to a proper confession in a minute.)  There’s plenty of histories of the concept of ‘alcoholism’ or ‘addiction’, and I’m not the person to write more on that; I’m certainly no historian of medicine.  But I have read my fair share of scientific definitions of problem drinking.  In fact, those studies have set for the scene for my thinking based on fiction.

When I was starting out studying ‘binge’ drinking (as defined by the media – i.e. getting drunk on the night-time high street), I naturally wanted to know if there was a ‘real’, ‘scientific’ definition of a ‘binge’.  At the time (2006) there was quite a bit being written about how the idea of ‘binge’ had become a ‘confused concept’ in contrast with a time when it had meant something more specific to the likes of Jellinek when discussing a technical definition of ‘alcoholism’.  And perhaps rather than a ‘binge’ we should have been referring to young drinkers as having ‘bouts’ of drinking.

Basically (and here I emphasise again that I’m no scientist, or medic, or medical historian), a ‘binge’ in old-school parlance meant a period of several days when someone fell off the wagon quite spectacularly.

And here’s where the literature comes in.  One of the most famous examples is The Lost Weekend – the drinker goes through periods of sobriety, before going on a binge, which comes to a natural conclusion in a detox (either in hospital or at home) after period of extreme drinking has run its course.  (I’ve never seen the film, only read the book, so apologies if this doesn’t fit.  Interestingly, the Wikipedia page for Charles Jackson refers to ‘his binge drinking’.)

You can see the same sort of theme in nineteenth-century descriptions of ‘drunks’ – who don’t spend all their time drinking, but get drunk with serious consequences.  Think of Joseph Poorgrass in Far From The Madding Crowd, who it seems can go a long time without a drink, but when he does have one, it ends up being more.  He even takes the opportunity to stop while driving a coffin back from town, parking it up outside the pub…

I want to suggest that in some ways we’ve lost sight of this form of trouble with alcohol.  Or perhaps just treatment services and policy people have.

At first sight, this references might seem like classic forms of ‘alcoholism’, following the AA definition.  Someone who has, as I once heard it described, ‘got the spots’ can’t have just one drink – though they might go years without any.  One drink always leads to ‘too many’.  And this is how a lot of people who would see themselves as ‘sober’ or ‘in recovery’ would define their problem with alcohol.  Check out Laurie McAllister’s blog, particularly the contributions from a range of other people.

But I don’t think this is quite how professionals and policy people look at the world.  I would suggest that there seem to be two definitions of problem drinking in the UK today – or perhaps England more specifically.

I want to think about how the problem is defined.  First, there’s the idea that lies behind unit guidelines: drinking alcohol increases your risk of certain illnesses like cancer.  This is what means we have stats on low, increasing and higher risk drinking.  This discussion of drinking isn’t about whether people currently have a ‘problem’, or are suffering ill-effects from alcohol; it’s about whether people are putting themselves at risk of developing problems in the future.

Second, it seems that alcohol policy doesn’t really talk about ‘alcoholism’ much any more.  Instead, to convey the idea of a group of particularly heavy drinkers, the statistics talk about ‘dependent’ drinkers.  This means that you’re drinking at a level where your body has become physiologically dependent on alcohol, and withdrawal will have a harmful health impact that probably needs to be managed with medication.

And this isn’t just about the stats.  Consider how we think of an alcohol problem that needs treatment (as opposed to a ‘brief’ or ‘behaviour change’ intervention that groups alcohol with other issues like diet and exercise).  Generally, we’re referring to someone who drinks every day and has a level of dependency.  That classic question in the screening tools of whether you drink every day, or even have drink in the morning to get yourself going.  What’s the treatment available?  Detox.

I’m not saying that everyone who engages with community treatment services could or should have a ‘detox’.  However, there’s no getting away from the fact that that element is the most clearly defined and regulated.  Prescribing for withdrawal is in many ways more straightforward than trying to identify what ‘talking therapies’ or other interventions might foster ‘recovery’.

I don’t have a reference to cite here.  This is my individual reflection on how treatment services are organised today.  There are two prongs of structured treatment, according to the national database: pharmacological (prescribing) and psychosocial (talking therapies).  This is partly the legacy of a system that was set up to capture the work done to treat opioid use disorders, where prescribing is such a central part of the standard model, but it does to some extent reflect how we think about these systems, and how we commission services.

But think back to those accounts on Laurie McAllister’s blog, or Joseph Poorgrass.  They don’t drink every day.  But alcohol is still a problem that needs something more substantial than a ‘have a word’ approach of: ‘have you thought about drinking a bit less?’

So should we be treating people who have ‘binges’ or ‘bouts’ of drinking?  This idea actually makes me feel uncomfortable.

Why?  I think it’s because this drinking to oblivion is often seen as dysfunctional or maladaptive by definition.  Deliberately drinking to drunkenness, whether called a ‘binge’ or a ‘bout’ is indicative of some kind of underlying problem.

My work on ‘binge’ drinking reframed it (as have other people) as ‘carnivalesque’, to try to convey that it is ambivalent for all concerned, whether producers, drinkers or government/regulators.

And this ambivalence struck me again over the weekend, reading Doris Lessing:

Mr Clarke earned fifty pounds a month which was more than he would earn anywhere else.  He was a silent, hardworking man, except when he got drunk, which was not often.  Three or four times in the year he would be off work for a week, and then Mr Macintosh did his work for him till he recovered, when he greeted him with the good-humoured words: ‘Well, laddie, got that off your chest?’  ‘The Antheap’, Five, p.193

He [James] would get really drunk several times a year, but between these indulgences kept to his three whiskies at sundown.  He would toss these back, standing, one after the other, when he came in from work; and then give the bottle a long look, a malevolent look, and put it away where he could not see it.  Then he took his dinner, without pleasure, to feed the drink; and immediately went to bed.  Once Paul found him at a week-end lying sodden and asleep sprawled over the table, and he was sickened; but afterwards James was simple and kindly as always; nor did he apologize, but took it as a matter of course that a man needed to drink himself blind from time to time.  This, oddly enough, reassured the boy.  His own father never drank, and Maggie [his mother] had a puritan horror of it; though she could offer visitors a drink from politeness. It was a problem that had never touched him; and now it was presented crudely to him and seemed no problem at all.  ‘Eldorado’, Five, p.171

In both of these instances, like Paul in the second extract, I find it hard to see that there’s much wrong with these men’s drinking.  Perhaps, given the fact that Mr Clarke has lost other jobs because of his drinking, and James obviously has some kind of ‘malevolent’ feeling towards alcohol, this isn’t an entirely healthy relationship, but then all of us do (or fail to do) things that other people would see as unwise or unhealthy in the long term.  (I’m reminded of the Church of England confession with its call to sobriety: we’re all ‘miserable offenders’.)

And it’s partly this need to distinguish heavy drinking from problematic drinking that’s made the medical model so attractive: dependence is a diagnosis without judgement; it’s about physiology.

And at this point the disease model of alcoholism/addiction is relevant.  A disease is a medical problem, and it feels natural to us to treat a disease with medicine – hence the idea that a physiological detox is the core treatment for alcohol problems.  And it is in fact a highly effective, evidence-based treatment for physiological dependency.  But dependency is not the same thing as ‘alcoholism’, and even if we just talk about ‘the disease concept of alcoholism’, remember that Jellinek stated: ‘The subject of this study represents not more than a small section of the problems of alcohol – a very small section indeed.’

And here’s the rub: we can never have a clear, objective definition of an alcohol ‘problem’ based on actual drinking behaviour unless we’re prepared to group Joseph Poorgrass and Mr Clarke together.  They both drink, occasionally, to oblivion, but one does it in a planned way, as a holiday; the other does it while he’s transporting a coffin, complete with corpse.

It’s true that this could be captured by elements of the DSM definition – the fact that Joseph Poorgrass’ drinking does damage his work, for example.  But I want to suggest that in practice it’s really hard to actually distinguish between this and the drinking by James in Doris Lessing’s ‘Eldorado’.  I know this is the purpose of tools like AUDIT and SAD-Q, but here I just want to question this pseudo-scientific approach, and wonder out loud as to whether this medicalisation of alcohol problems is actually helpful.

That is, we have a tendency to look back in time and think that terms like ‘drunkard’ were unscientific and unhelpful, and even stigmatising.  We now live in a more scientific and less moralistic world with our ideas of disease and dependency.  But my question is: does this comfort of apparent science and objectivity mean that we fail to offer support to everyone who needs it?

As I said at the beginning, this isn’t a peer-reviewed, evidence-based piece.  It’s just some reflections on my recent experiences, prompted by reading for fun.  Maybe I’m wrong about the nature of ideas of disease and dependency and medical models of treatment, and their influence on services today.  I’d love to know what other people’s thoughts and experiences are.

Why service user choice might frighten commissioners

I wrote down some thoughts a couple of weeks ago, prompted by the EXCO conference hosted by the Expert Faculty on Commissioning.  The Faculty has since posted a summary of the conference on their own website, along with videos from the day.  (I can’t stress how valuable this is, and how unfortunate it is that our sector seems to have lost FEAD.)

Reading this again has reminded me of the core debate I had on the day, which I found very difficult.

I’ve talked on this blog before about the idea of ‘tailoring’ services to local areas, or personalised commissioning.  I had planned to talk (which I did) about the same sorts of problems, but I was extremely nervous about doing this after there had been such strong presentations on the value of service user involvement and choice in treatment earlier in the day, particularly from Kerrie Hudson.

What I’m going to do here is just post the ‘abstract’ I’d written to prepare for my presentation.  I would strongly recommend you watch the video of Kerrie’s talk as well.  You’ll find that she’s more positive about choice than I am.  That might in part be a personality thing, but it’s also about our roles: the idea of service user choice in small villages in Dorset fills me with dread – not because I’m frightened of choice or service user autonomy, but because I worry we can’t offer all parts of the county truly equitable choices.  Will they really be able to choose from the same menu of options that would be available if they lived in a more densely populated area like Poole or Bournemouth?

This isn’t an easily resolved question.  In fact, I’m not sure it can ever be resolved once and for all.  The idea of equity of service isn’t a unique problem for substance misuse services, and it’s not something that’s ever going away.  Looking at the programme for the conference, for all the optimism about new technologies and tailored treatment driving improved outcomes and greater efficiency, I just felt we needed a dose of pessimistic realism about what that might mean for commissioners.

And, to the great credit of the conference organisers and all the attendees, my fears were largely unfounded: there was a very reasonable, realistic discussion of what the future of treatment might look like, as opposed to the soundbites some of us have become inured to.

So here it is, my contribution to that necessary, never-ending debate.

Individualised treatment planning: what are the goals and the reality

It’s common to hear how ‘individualised’, ‘personalised’ or ‘tailored’ treatment are best practice, and indeed the future.  It’s virtually impossible to think that tailored treatment could be a bad thing: shouldn’t a care plan by definition take account of the individual service user’s strengths and weaknesses, needs and assets?  More than this, tailored treatment is often presented as a solution to tightening budgets: it would mean we would target resources better, therefore getting more bang for our buck.  Individualised treatment is not only more effective, but more efficient.

But is this a false dawn?  As I say, care plans should already be a collaboration between the service user and a professional, taking account of the unique circumstances that person finds themselves in.  And if tailor-made things are really more efficient than off-the-peg versions, why don’t people buy tailored suits and custom-made furniture when they’re on a tight budget?

This is, like most issues, a question of balance.  We do need to take account of individual circumstances, but we also need to think about economies of scale and planning activity.  Choices in most aspects of life are more nuanced than this.  We do not have to choose between the Fordist mantra of ‘any colour as long as it’s black’ and custom-made cars; most choices are between different options on a menu.

My particular concern is that those ‘menu choices’ won’t be the same for everyone, depending on where they live.  This isn’t just about a postcode lottery of variation between different commissioners; it’s particularly about how any form of choice can realistically be offered for people who live in small towns or villages where there simply can’t be multiple options available.  This means tailored plans need to be developed not just for individual service users but more broadly for different geographical areas and local populations.

So let’s welcome service user choice and individualised treatment, but let’s not present this as a false choice between ‘one size fits all’ and ‘personal budgets’.  It’s more difficult and complicated than that.  Individualised treatment might seem attractive for if we aim to make treatment more effective, but thinking about the other ‘e’s of commissioning, even if it delivers efficiency, will it compromise equity?

From competition to partnership?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New Directions in the Study of Life

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Is drug testing a public health issue?

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

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

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

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

I should really preface this whole discussion by saying that in my head this is a very similar issue to drug consumption rooms: there are other things that are more fundamental to improving the lives of people who use drugs, legal questions abound, and the whole thing would be easier if the substances were somehow regulated rather than outlawed.  And as with DCRs, my angle is the same: what are they for (and therefore where is the money coming from)?

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

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

I want to start by stating some of my assumptions.

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

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

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

Staff from The Loop have written really well about this.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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