Thursday 17 September 2020

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.