Friday 15 September 2017

Why moderation might not be the best policy for drugs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thursday 7 September 2017

Principles and pragmatism: We need to talk about commissioning

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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