Wednesday, 11 November 2020
Thursday, 17 September 2020
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.
Monday, 20 July 2020
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!
Thursday, 9 July 2020
Saturday, 4 July 2020
Monday, 11 May 2020
- Funding for continued payments to pharmacies
- Funding for buprenorphine or similar approaches to reduce risk of overdose and COVID-19
- Prioritising electronic prescribing for OST
- Policies/guidance for providing alcohol to dependent drinkers who can’t access it.