Hoping for a genuine drug policy debate worth winning

This week there has been lots of media coverage of the opening of The Thistle - the UK's first official drug consumption room.  Some of this - particularly this piece in The Spectator - has made me feel frustrated and disappointed with public policy and media debates.

I don't want to talk about the detail of the issue, but there are two key lines that reveal how disingenuous this kind of piece is.

The first is the headline: "Scotland's safe consumption room won't solve the drugs crisis". This is complete straw man stuff. No single intervention could 'solve' the crisis, and no-one has said it will, so stating this is completely irrelevant. It's like saying 'grass is green'. Yes, fine, but why is that relevant here? Just because something isn't an instant panacea, it doesn't mean we shouldn't give it a go.

Unfortunately that headline sets the oppositional tone for the whole debate. It's framed as a binary question of whether this particular intervention is the sole solution.

But perhaps I'm being harsh. After all, it's probably not the author who writes the headline, and whoever did is trying to generate emotions (as they did with me) to get clicks and reads.

But then within the first paragraph you get more disingenuous weasel words: "will it make any real difference to the national drugs death crisis?" This phrasing does the same thing as the headline: setting an impossible bar for the intervention to clear. One intervention in central Glasgow is somehow meant to address a national crisis. And presumably by 'real' difference we're talking a dramatic shift in the national numbers of drug-related deaths. Again, unlikely from this one intervention.

For all that I often hear that 'our' sector of alcohol, other drugs and 'addiction' is particularly emotive and politically charged, I think this pattern can be found in all sorts of policy debates. Setting up ideas as binaries and zero-sum games, where one intervention must be magic solution to a policy problem.

I suggest we need to challenge this kind of thinking wherever we find it, and emphasise that delivering positive 'outcomes' will invariably take hard work at a detailed level, employing a range of techniques and interventions.

The answer isn't to shrug our shoulders and suggest this kind of analysis isn't worth reading or listening to. And, although it can feel rewarding, the answer isn't to become a similar kind of cheerleader for the opposite position, and over-claim, for example, what a safer consumption site might deliver.

This isn't about being technocratic and lacking ambition. I think we can and should be more ambitious than this government has shown so far - but we also need to be clearer and more honest. This government is pinning too much on the promise of 'growth', which means it's arguably ducking some of the genuinely 'tough decisions'. Let's be open about those decisions and their implications, and try to genuinely win the debate - or at the very least make it a genuine debate worth winning.

These thoughts were originally posted on LinkedIn.

Alcohol labelling and rationality

The Sun reported yesterday that public health ‘nannies’ are planning on introducing calorie labelling on alcoholics drinks, including in pubs, bars and restaurants.  This has prompted understandable and predictable outcries, along the lines of: don’t we have more important public health issues to worry about, and is this an attempt to distract from the handling of the pandemic?

Edit: since I wrote this I've seen this piece on CapX, which presents these arguments very neatly - but (as you'll see from the below) in my opinion mistakenly or even disingenuously.

I’m interested in what this tells us about the state of alcohol policy debate in the UK, or more specifically England.  If you’ve come here for analysis on the ins and outs or rights and wrongs of labelling, you’re in the wrong place.  This is going to be a bit more pretentious than that – though I’d say more important in the long run.

Firstly, I should note that the framing above is classic whataboutery.  Two things are only set against each other as an argumentative device.  (I could say ‘rhetorical’, but I think this is actually argumentative.)

Think of two problems in your own life, that may or may not be related.  For me, say, I have an issue with a wisdom tooth that I need to get sorted, and I have a chronic problem with my ankle, which I sprained years ago, meaning I limp and struggle to run.  I don’t have to fully sort one of these problems before I think about the other, even if sorting one might help the other.  If I get the tooth sorted, maybe I’ll feel more like running and exercising, which might help the ankle.  But I shouldn’t stop exercising the ankle as if that will somehow mean the dentist can remove the wisdom tooth sooner.

It’s the same with these issues.  Set aside all the intricacies of who or what organisation is to blame for various issues in responding to COVID-19.  (Was it PHE or NHSE or the government more directly who failed to implement recommendations from Exercise Cygnus?  Would those even have been relevant to a coronavirus rather than a ‘flu, etc…)  If developing alcohol labelling is a good idea, and we have the resources to implement it, then we should do it.

Let’s take the issue of resources first.  On the face of it, it seems that we do have the resources and the costs would be reasonable (depending on the benefits).  Analysis of drinks and labelling/menus already exist, so we’re talking about tweaking something rather than inventing from scratch.

The Sun quotes a figure of £92m in costs, but I find it hard to see what this would be made up of (though I could be persuaded).  If there are additional costs, they should largely be in setup and this could be rolled out gradually, as labels and menus are regularly changed in any case.  The detail of this is important (e.g. do the producers provide things automatically, or do operators have to) - so it's not something that should simply be written off out of hand.  And interestingly the proposal seems to refer only to large operators of 250 employees or more, so we're not talking about a small independent free house having to develop their own labelling or menus.

And in fact it’s not ‘the booze industry’ that has been hit by COVID, as the Sun suggests, so much as the hospitality sector and specifically the wet-led trade.  The alcohol producers are doing relatively well at the moment and so should be able to afford this, and we know that alcohol is, in historical terms, very affordable and therefore a small one-off hit could be absorbed by the market.

This is obviously a simplification, and the detail could be argued with, but it’s certainly not enough to write the idea off to start with.

And we certainly shouldn’t tie this into the quite reasonable point that the hospitality industry has had a hard time through COVID restrictions.  I’m a supporter of pubs (and indeed of people’s freedom to get drunk) and I absolutely agree that they’ve been poorly served by COVID restrictions.  It’s nice to think that my own research and analysis is being used in analysis of what the government might have got wrong.

But if we’re talking about saving the off-trade we need to focus on ideas (like this or this) that might genuinely support it rather than continue to expand home drinking.  (I’m also slightly sceptical of the ‘reopen the pubs’ chant, when this may not actually be what frontline staff want – see slightly differing viewpoints here and here.)

So why is labelling a big deal?  On the surface, at least, it shouldn’t be.  The costs would probably be marginal, and I can’t see that it would significantly alter consumption patterns.  Think of sugar as a comparable issue to alcohol.  Soft drinks have had ingredients and information on them for years, but what really changed what people consume was a ‘sugar tax’ that prompted reformulation.

So if alcohol labelling is low cost and low impact, why does anyone care much?

This makes sense if we see the issue through the lens of realpolitik.  Imagine there are simply two diametrically opposed sides to this debate.  One wants the population to drink more (or at least spend more money on alcohol) – the ‘industry’ – and one wants the population to drink less – ‘public health’.  If this ‘public health’ measure succeeds, then the interests or industry are hit.  If it doesn’t, then the industry will expect the public health lobby not to stop, but to use the findings to argue that even more intervention in the market is required.  And hence (neo)liberal campaigners and policy commentators become interested.

Soft drink labelling ‘failed’, and led to the ‘sugar tax’; the ‘industry’ wants to avoid that for alcohol, as do economic liberals.

So this is, in a sense, such an emotive issue precisely because the likely impact is low.  But the debate is most interesting to me as it illustrates how ostensibly free market thinking is nothing of the sort.

Again as an oversimplification, the logic behind this kind of market liberalism is often presented as being about individual choices: in Millian terms, a person’s own decisions about their life are – except in extreme cases – by definition the best for them, as they know their own minds and competing interests.  In some formulations, this depends on those individuals having ‘perfect’ information on which to base their choices – which is where it would seem alcohol labelling is ‘rational’ and in-keeping with classical economic liberalism.

Indeed regulation and labelling of food and drink was a key plank of classic liberal approaches to regulate markets in order that they could work efficiently.  Based on what is largely a historical accident, we are told less about what is in drinks containing alcohol than their ‘soft’ counterparts.

But economic modelling and thinking has often become more aggregated and technical, distanced from this model of the individual ‘rational actor’, and focusing instead at overall outcomes.  This is where ideas of ‘neoliberalism’ come into play: what was historically seen as a means to an end – the market – becomes an approach to be protected in itself.  Where once the market was seen as a useful way of meeting individuals’ needs and wants efficiently, it is now seen as something to be prioritised and protected from interference almost as an article of faith.

Whatever is said about pubs, or individual drinkers, this debate about ‘nannying’ and labelling seems to have little to do with drinkers and their experiences.

It’s the ‘free market think tank’ the Adam Smith Institute that is quoted in the Sun piece.  Their quote states simply “Brits backing their locals are well aware that too many pints makes beer belly more likely.”  But that’s not consistent with their approach to advertising.

When alcohol advertising is criticised, it’s defended by these kind of commentators on the basis that it’s not aiming to expand the overall consumption of alcohol, but simply encouraging people to switch products – much like toilet roll advertising.  Advertising helps create that scenario of ‘perfect information’.

And yet the same claim could be made for providing calorie counts and other information for drinks.  Perhaps if I’m watching my weight, I might choose a Carling rather than a Stella.  What could be wrong with that?

We know this kind of brand switching can make a big difference in relation to alcohol risk more broadly: if you’re having 2 pints a night, and switch from, say, Greene King Abbot Ale (5%) to their IPA (3.6%), you’ll go from consuming over 39 units a week to 28.  Sure, that’s still double the low-risk guidelines, but it’s a considerable reduction (well over a quarter, at more than 28%).

This isn’t just an academic example; it’s a common harm reduction technique for people who are thinking of cutting down their alcohol consumption.  We already have the information about alcohol content to make that choice; but we don’t for calories.

So this reveals that this opposition to labelling can’t simply be about consumers/drinkers.  Even if we accept that this initiative would significantly increase costs, which I’m yet to be persuaded on, any cost needs to be balanced against potential benefits.

Advertising costs the industry plenty already, and this is absorbed by shareholders and customers.  Yet that kind of dispensing information is supported by the same people who oppose giving people more information about what is in their drink.

This approach, therefore, doesn’t have the consumer at the heart of the model.  In fact, they’re not mentioned as making a decision in any of this.  The philosophy simply states that it’s better at an aggregate level for a large company to make a choice about the information provided, rather than their government.

It’s hard to see how this is a consistent approach from the perspective of the consumer; it feels much more like the consistent thread is that these think tanks – and indeed the whole neoliberal approach – supports large companies over individual consumers or the overall system outcomes.  (And I say large companies pointedly, as the current proposal appears to only apply to companies employing 250 or more people.)

I look forward (but without much hope) to a clear, honest debate about the costs or benefits of this policy.

The Eighteenth Brumaire of Generation Sensible

This morning I was doing the lecture I do once a year to keep my position as a ‘visiting fellow’ at Bournemouth University.  This year, I had to tweak it a bit as the unit has changed, but basically I’m trying to get the students to think about resistance and controversy in culture by taking the concept of the carnivalesque and applying it to their own lives, as I worry that there can be a tendency in anthropology and criminology to point to other cultures or people and see controversy, conflict or disruption as something that happens ‘over there’, perpetuating ‘othering’ and discrimination.

This year, I was emphasising how ‘binge’ drinking has been seen as a development of ‘rave’ or ‘club’ culture.  That producers and retailers of alcohol got worried that a whole generation were foregoing their offer in favour of other places and drugs.  Rather than pubs, people were using fields and warehouses, or at best clubs – and when they went to these places they were more likely to use MDMA than alcohol.

So, according to people like Fiona Measham, Kevin Brain or Howard Parker, the alcohol industry shifted tack to sell alcohol as intoxicating (as opposed to classic masculine ideas of being able to ‘hold’ your drink), and this fed into the specific products and imagery, as well as wider elements such as the design of venues.  Drinks weren’t marketed as brewed or fermented or natural, so much as efficient, easy-to-drink, brightly-coloured products.  Pubs and beer were seen as extension of local community and the everyday, with their local connections and designs echoing the Victorian home.  Post-industrial clubs and alcopops were something quite different.

To the great mass of manual workers the local public house spelled paradise … they held an attraction with which nothing in present-day society can quite compare. After the squalor from which so many men came there dwelt within a tavern all one could crave for – warmth, bright lights, music, song, comradeship, the smiling condescension of a landlady, large and bosomy, for ever sexually unattainable, true, but one could dream. (Roberts, 1990, The Classic Slum, p.120)

A second reason for the popularity of clubs over pubs is that the latter are continuous with their locality and tend to use the cosy decorative rhetoric of the home (often the Victorian home). Clubs, however, offer otherworldly environments in which to escape; they act as interior havens with such presence that the dancers forget the local time and place. (Sarah Thornton, Club Cultures, p.21)

And the argument runs that we (specifically people like me who reached legal drinking age in the 1990s or early 2000s) swallowed all this – hence alcohol consumption bounced back from that late-1980s slump, and rose right through from 1995 through to 2004.

Taken from Institute of Alcohol Studies https://www.ias.org.uk/uploads/pdf/Factsheets/FS%20consumption%20022018.pdf 

Since then, we’ve supposedly had ‘generation sensible’, who have eschewed alcohol and other drugs while working hard through school and university, put off alcohol by their heavy-drinking parents and worried into conformity by the bleak job market and lack of financial security.

Some interpretations of this post-war history remind me of Marx’s Eighteenth Brumaire of Louis Napoleon: ‘first as tragedy, then as farce’.

The ‘real’ sub-cultures like mods, rockers and punks, were ‘tragic’ as along came Thatcherism.

But the ‘farce’ is the way that a genuinely resistant club/rave culture was clamped down on and co-opted by big business and government to become the ‘binge’ drinking that revived the ‘night-time high street’ in the 1990s, endorsed by the New Labour government’s optimistic aspiration to create Bologna in Birmingham and Madrid in Manchester.

There’s no real ‘resistance’ in getting drunk on a beer brewer by a multi-national, in one of a chain of clubs owned by a multi-millionaire.  And you’re not even creating some potentially powerful form of solidarity while doing it.

Some of these commentators even think that people my age don’t know what real friendship is.

[F]or most, traditional friendship seems to have been largely displaced by superficial, temporary and fragile alliances based on competence in the competitive display of consumer-lifestyle symbols (Winlow & Hall, Violent Night, p.91)

This is why the concept of the ‘carnivalesque’ was so interesting to me.  Carnival, as Terry Eagleton said, has always been a ‘licensed’ event.  The church provided the ale, and the state permitted the ‘time out of time’ in the hope that it would allow some steam to be blown off and people could tolerate work and social structures a bit longer.

When we look at British drinking in that longer context, it’s not clear how ‘binge’ drinking was particularly conservative or disappointing.  The politics looks a lot like more of the same to me.  In his description of the archetypal pub, Robert Roberts doesn’t just talk about the ‘bosomy’ landlady, but also ‘her husband … a man of the world dispensing wit and wisdom – and Tory politics too, of course: publicans were Tories almost to a man, and the party’s self-appointed agents’.  And indeed the brewers genuinely were often their political representatives – think of Robert Cain in Liverpool.

So if these were the ‘good old days’, they certainly left plenty to be desired – particularly for women, or those who didn’t fit the standard (white) model of masculinity.  (There’s plenty still to be desired today.)

But what about the promise of postwar sub-cultures?  Well, punks ended up selling butter and having to apologise for racist and misogynist abuse.  Maybe all that ‘resistance’ wasn’t as revolutionary as some might have hoped.

So perhaps we need to look again at ‘generation sensible’.  When discussing potentially resistant spaces or practices in the seminar this morning, I wondered if part of being ‘sensible’ is to be more straightforward and literal.  Hairstyles aren’t particularly resistant, but the sub-culture, the youth culture, the resistance of today is to be found in more directly political practices: protest in person and discussion online, particularly through social media, directly challenging certain views.  Those were the occasions the young people I was speaking to this morning said they’d experienced something ‘carnivalesque’: free and familiar contact between people; the opportunity to challenge established structures or authority; the feeling that those in power IRL maybe can be challenged.

Of course it’s not a new idea that the internet offers a potentially resistant space (though Cambridge Analytica and the like have meant it’s taken quite a battering in recent years).  But I think it’s worth us looking again at youth culture and taking off our rose-tinted spectacles.  It all feels like it’s got a bit personal.

Winlow and Hall challenged us in 2006 not to think that ‘"the kids are alright", that they are free-willed, resistant and innovative’ (p.194).  That was presumably my generation they were talking about (Who pun again intended), given that I was 22 when the book was published.  The book reads like a lament for industrial, working-class masculinity and its supposedly classic haunts such as the pub.

And in more recent years it’s felt a little like some people who came of age around the time of 'peak booze' have been, to quote another song, asking ‘generation sensible’: if you don’t smoke and don’t drink, what do you do?

But maybe this time we won’t have either tragedy or farce, and instead something approaching sensible progress.

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.