Yesterday I was at an amazing conference – InterAction 2018
– hosted by Adfam and funded by Alcohol Research UK. The mixture of speakers was fantastic,
including researchers, policy people, practitioners, carers, service users, and
even a social historian. And there was
an open dialogue about key, fascinating issues, conducted in a collegiate way.
There were innumerable striking stories and insights, and
each person will have their highlights.
But for me, having spent the day before sat in a meeting with health
colleagues and an inspector from CQC, the story that hit home hardest was Tina
Williams’ description of how her son died of lung cancer on a Sunday,
having only been diagnosed on the Monday – because his health needs were not
even identified, let alone met, by a system that fails people who use drugs,
particularly when these substances are used to self-medicate for physical and
mental pain.
The point that perhaps got the strongest reaction all day
was also from Tina, when she called for providers to stop promising to
commissioners that they can deliver everything desired for a bargain
price. It’s not possible and gives a
false sense of security to decision-makers while giving potential service users
and their families inflated expectations, and the problem has become even more
acute as
funding has reduced.
My
response – a point made at the event by Paul Hayes – would be that I think
there is actually an increasing sense of realism amongst both commissioners and
providers. I don’t think there will be
many commissioners who aren’t concerned about ‘market failure’, given the
publicity around instances
like Bristol. I don’t think
commissioners are expecting the world from providers, and I don’t think they
would get promised it either. I don’t
think areas are inundated with bids for substance misuse contracts these days –
any kind of choice is seen as a vindication of the model and budget – and even
the big third sector providers are reluctant to bid if they don’t already have
a foothold in an area.
As part of our recent recommissioning experience in Dorset,
I’ve wondered how good we are at practising what we preach. Not just us as commissioners (talking about
‘partnership working’ and ‘open and honest’ dialogue) but practitioners. The bread and butter of substance misuse
practitioners should be ‘change talk’ – and yet how good are staff at dealing
with change in their own work lives?
I’ll leave that question open, but the same theory applies
to the wider ‘sector’,
as we kept referring to it. The
discussions suggested that we, as providers and commissioners, have reached a
stage of acceptance: we agree that we as ‘the sector’ have a problem. That’s a really positive first step – but as
with all behaviour change it leads to a second question: what are we going to
do about it?
There seem to be two elements to the potential
‘solution’. The first is immediate and
practical. Let’s have realistic
commissioning, and ensure our staff and services are operating the highest
quality service possible, with the widest reach and impact possible. (The word ‘possible’ here is a way of
expressing my concern about capacity/funding challenges.)
But there’s also a longer-term question: how can we
fundamentally change the situation from one of limited and falling funding to
one of increased resources? Of course,
as Paul Hayes would be the first to acknowledge, the political context has to
be right. But if we assume our arguments
won’t fall on deaf ears, what arguments should we be making? If ‘years of plenty’ ever return, then we
won’t be the only people queuing up to argue for more funding, claiming that
our cause is respectable and deserving.
We might, though, find our audience to be naturally sympathetic.
At the conference, there were effectively two sets of
suggestions as to how we might make ourselves heard, both of which I’ve talked
about on this blog before: crime and children.
Basically, we can win funding by suggesting that people who use drugs –
I would say problematically, but I think we all know that’s a distinction
that’s hard to maintain when we’re talking about stigma – are mad, bad, and
dangerous to know. That is: they’re
likely to commit crime so we should treat their problem to reduce crime in
order to feel safer; and/or they’re a risk to children, so we should treat them
to protect the next generation, who can’t protect themselves.
There’s certainly some power in these arguments. And there is of course that risk of
stigma. Some people might even feel that
this is disingenuous: arguing that people are bad and dangerous when in fact most
people’s reason for making this claim is compassion and human kindness. Another presentation at the conference – by Mike Ashton – poked holes in the foundational NTORS
evaluation of treatment, saying that it overstated its case (in the terms
it defined). Should we sacrifice
accuracy in order to get the right outcome?
I won’t rehearse my
moral squeamishness about this here.
Perhaps I’m becoming more hardened to political realities. (I can’t imagine an argument for funding drug
treatment based on compassion would get too far in today’s political environment,
as the
Home Secretary defends Stop and Search.)
What I want to ask is not whether we should stretch the
interpretation of some statistics. I
want to think about the broader arguments they might be put to work for,
particularly with those two points in mind: how can we provide a high quality
service, and how can we get services better resourced?
In that 1990s/2000s era, crime reduction (‘tough on the
causes of crime’) was the narrative that statistics and evidence like NTORS
were marshalled to support. This was
powerful and secured sustainable – and even increased – funding through the
National Treatment Agency for a decade.
But today, crime just isn’t such a powerful political issue, partly due
to the successes of drug treatment.
As Paul Hayes pointed out, the last thing you want as a civil servant in
Whitehall (and, I would add, in town halls) is to be successful. If you ‘solve’ an issue, that means you
instantly lose ministerial attention – and the funding that goes with it.
But if crime isn’t much of an issue, maybe drug-related
issues still are. The wider public
doesn’t seem too concerned about drug-related deaths, but at a local level they
certainly are about drug-related litter.
Where I live, for example, discarded needles are a regular front page
feature of the
Dorset Echo.
And yet, when this is used as a reason to explain provision
of substance misuse treatment services in the area, the
reaction is far from positive. Some
people who would acknowledge – even shout about – the fact that an area has an
issue will object to facilities being established locally. They just want the problem – by which they
mean the people – to go away.
Some would suggest this is a particular issue in seaside
towns like Weymouth, where there is a narrative that problems are brought
in by ‘outsiders’ who see somewhere by the sea at the end of the train line as
a good place to try to escape their problems.
But I think this issue of narrative is a universal problem for local
policymakers. People acknowledge there
is a problem, and would even welcome a solution – so long as the location (unlike
the original problem) is ‘not in my back yard’.
So how can we make this appeal more positive? I was feeling less than positive at this
stage.
Perhaps we need to resort to the familiar chant ‘think of
the children’. And that might well have
some traction with local authorities, but even if there was a ‘magic money
tree’, I’m not convinced this refrain would deliver funds for treatment for
people who misuse drugs, rather than support for safeguarding processes, care
services, fostering and so on. Support
to get the problem (again – actually the people)
away from the children.
But as I listened to the presentation by Darren Murinas from Expert Citizens, who was astonishingly
articulate, engaging and insightful while describing his less-than-ideal
childhood, I was reminded of a commissioner from another local authority area
complaining that people have plenty of compassion for ‘the children’ in cases of
abuse – but not when these children become adults with a host of issues,
including substance misuse, that are all-too-predictable.
I started thinking: why can’t we mobilise that compassion to
support our services? What is it we’re
doing wrong? Or perhaps it’s a naïve
idea. As I say, a politics based on
compassion seems an impossible dream at the moment.
But then Oliver
Standing stood up to give his personal summary of the day. Two points from this really hit home for me.
First, for all that we can talk about the power of value for
money stats, or the evidence of randomised control trials, that’s not always
how politics works. He gave the example
of the
new funding for work with children of dependent drinkers, and, while
acknowledging that £6m shared between several local authorities is not a very
large pot of money, he emphasised that it is worth considering why there’s any
money being granted at all. Oliver
suggested that the key turning point from a lobbying perspective was a personal
narrative: Jon
Ashworth’s speech in the House of Commons about his own childhood, which
moved a government minister to tears.
Second, that over the course of the day a lot of people
talked about ‘the system’. I don’t think
Oliver quite said it, but my impression was of a tension between this big,
abstract idea of a ‘system’ as compared to the detailed, touching, personal
narratives – and the undeniable fact that this ‘system’ is made up of a range
of people trying to improve their own and others’ lives. Oliver’s point was that if we’re looking to
improve that system, then we should start with one of the classic first steps
in design: empathy. That is, whether you’re designing a health
system, a phone app or a chair, you should put yourself in the shoes of the end
user.
So by the end of the day, I was feeling more positive. If we’re thinking about ‘changing the
narrative’ around substance misuse, the best way to do that is with some
narrative of our own, and as we shape services.
Perhaps the most powerful way of doing this, at least at the moment,
isn’t necessarily value for money stats or health economics, so much as
personal stories. And those are the kind
of narratives we have in abundance.
Every person has a story. Rather
than complaining that drugs policy isn’t ‘evidence-based’, as many people do,
perhaps we could think about the practical point: how do we actually get that
change? The first step could be to start
the public thinking less about a ‘problem’ or a ‘risk’, and more about
‘people’. It’s harder to say ‘I don’t
want those people in my town’ than it is to say ‘I don’t want this problem
in my town’.
That’s an idea for the longer-term question: how
we secure adequate funding for this field.
But there’s also implications for today.
Those of us who work in ‘the sector’ could maybe do with thinking like
this a bit more. The ‘sector’ is also a
collection of people
doing things with people to help people.
These kind of narratives can remind us of what we should be doing and why. This isn’t just sentimentality; it’s about a
different way of thinking: let’s think less about organisations, and
structures, and more about the most important element of treatment: individual
connections between human beings.
