tag:blogger.com,1999:blog-1256532416156354882024-03-13T12:21:36.105+00:00Thinking to some purposeWill Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.comBlogger141125tag:blogger.com,1999:blog-125653241615635488.post-7001546571318528382021-04-14T17:26:00.001+01:002021-04-14T17:34:39.763+01:00Alcohol labelling and rationality<p>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: <a href="https://twitter.com/mrrbourne/status/1382092351250833410?s=21" target="_blank">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</a>?</p><p><i>Edit: since I wrote this I've seen <a href="https://capx.co/the-last-thing-britains-pubs-need-is-mandatory-calorie-counts/" target="_blank">this piece</a> on CapX, which presents these arguments very neatly - but (as you'll see from the below) in my opinion mistakenly or even disingenuously.</i></p><p>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.</p><p>Firstly, I should note that the framing above is classic <a href="https://en.wikipedia.org/wiki/Whataboutism" target="_blank">whataboutery</a>. Two things are only set against each other as an argumentative device. (I could say ‘rhetorical’, but I think this is actually argumentative.)</p><p>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.</p><p>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 <a href="https://en.wikipedia.org/wiki/Exercise_Cygnus" target="_blank">Exercise Cygnus</a>? 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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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 <a href="https://eprints.bournemouth.ac.uk/21547/" target="_blank">people’s freedom to get drunk</a>) and <a href="https://twitter.com/williamhaydock/status/1346535346348019712?s=21" target="_blank">I absolutely agree</a> that they’ve been poorly served by COVID restrictions. It’s nice to think that <a href="https://twitter.com/jennyathatcher/status/1373666517091516417?s=21" target="_blank">my own research and analysis is being used in analysis of what the government might have got wrong</a>.</p><p>But if we’re talking about saving the off-trade we need to focus on ideas (like <a href="https://twitter.com/victimofmaths/status/1367126926998011904?s=21" target="_blank">this</a> or <a href="https://www.robertlargan.co.uk/news/high-peak-mp-joins-75-colleagues-push-draught-beer-tax-cut" target="_blank">this</a>) 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 <a href="https://twitter.com/fermenttherich/status/1354710290634592256?s=21" target="_blank">here</a> and <a href="https://twitter.com/jennyathatcher/status/1379382849363718145?s=21" target="_blank">here</a>.)</p><p>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.</p><p>So if alcohol labelling is low cost and low impact, why does anyone care much?</p><p>This makes sense <a href="https://thinking-to-some-purpose.blogspot.com/2013/06/public-health-realpolitik.html" target="_blank">if we see the issue through the lens of realpolitik</a>. 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.</p><p>Soft drink labelling ‘failed’, and led to the ‘sugar tax’; the ‘industry’ wants to avoid that for alcohol, as do economic liberals.</p><p>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.</p><p>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.</p><p>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.</p><p>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 ‘<a href="https://thinking-to-some-purpose.blogspot.com/2014/07/neoliberalism-again.html" target="_blank">neoliberalism</a>’ 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.</p><p>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.</p><p>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 <a href="https://www.adamsmith.org/blog/regulation-industry/under-the-influence" target="_blank">their approach to advertising</a>.</p><p>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 <a href="https://iea.org.uk/blog/advertising-far-less-powerful-you-think" target="_blank">toilet roll advertising</a>. Advertising helps create that scenario of ‘perfect information’.</p><p>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?</p><p>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%).</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.)</p><p>I look forward (but without much hope) to a clear, honest debate about the costs or benefits of this policy.</p>Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-35112920129248246532021-03-16T19:12:00.003+00:002021-03-16T19:12:50.876+00:00The Eighteenth Brumaire of Generation Sensible<p>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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><span style="text-align: justify;">So, according to people like </span><a href="https://twitter.com/FMeasham" style="text-align: justify;">Fiona Measham</a><span style="text-align: justify;">, </span><a href="http://www.opengrey.eu/item/display/10068/403043" style="text-align: justify;">Kevin Brain</a><span style="text-align: justify;"> or </span><a href="http://www.howardparker.co.uk/6203.html" style="text-align: justify;">Howard Parker</a><span style="text-align: justify;">, 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.</span><span style="text-align: justify;"> </span><span style="text-align: justify;">Drinks weren’t marketed as
brewed or fermented or natural, so much as efficient, easy-to-drink,
brightly-coloured products.</span><span style="text-align: justify;"> </span><span style="text-align: justify;">Pubs and
beer were seen as extension of local community and the everyday, with their local
connections and designs echoing the Victorian home.</span><span style="text-align: justify;"> </span><span style="text-align: justify;">Post-industrial clubs and alcopops were
something quite different.</span></p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;"></p><blockquote>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, <i><a href="https://www.goodreads.com/book/show/567906.The_Classic_Slum">The Classic
Slum</a></i>, p.120)</blockquote><p></p><p class="MsoNormal" style="text-align: justify;"></p><blockquote>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, <i><a href="https://en.wikipedia.org/wiki/Sarah_Thornton#Club_Cultures:_Music,_Media,_and_Subcultural_Capital">Club
Cultures</a></i>, p.21)</blockquote><p></p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">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.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgw4TiDW0xQ4MXI4Y7pPDoMg8_10HSwYNxaA9PuxF7WgQ61uz12v4e1Nb3Ossk7hckBITMsru52IOdBsXW-gXrKjGG0eAzt_ic_xWQxAKuAbmJk9AMeqSTw15thEBiuzigjj73UGjeAEZdG/s878/Alcohol+from+the+1980s.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="467" data-original-width="878" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgw4TiDW0xQ4MXI4Y7pPDoMg8_10HSwYNxaA9PuxF7WgQ61uz12v4e1Nb3Ossk7hckBITMsru52IOdBsXW-gXrKjGG0eAzt_ic_xWQxAKuAbmJk9AMeqSTw15thEBiuzigjj73UGjeAEZdG/s320/Alcohol+from+the+1980s.png" width="320" /></a></div><div style="text-align: center;">Taken from Institute of Alcohol Studies https://www.ias.org.uk/uploads/pdf/Factsheets/FS%20consumption%20022018.pdf </div><div><span style="text-align: justify;"><br /></span></div><div><span style="text-align: justify;">Since then, we’ve supposedly had ‘</span><a href="https://www.bbc.co.uk/news/education-45510432" style="text-align: justify;">generation sensible</a><span style="text-align: justify;">’,
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.</span></div><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">Some interpretations of this post-war
history remind me of Marx’s Eighteenth Brumaire of Louis Napoleon: ‘<a href="https://en.wikipedia.org/wiki/The_Eighteenth_Brumaire_of_Louis_Bonaparte#First_as_tragedy,_then_as_farce">first
as tragedy, then as farce</a>’.</p><p class="MsoNormal" style="text-align: justify;">The ‘real’
sub-cultures like mods, rockers and punks, were ‘tragic’ as along came
Thatcherism.</p><p class="MsoNormal" style="text-align: justify;">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 <a href="http://news.bbc.co.uk/1/hi/uk_politics/3115485.stm">Bologna in Birmingham
and Madrid in Manchester</a>.</p><p class="MsoNormal" style="text-align: justify;">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.</p><p class="MsoNormal" style="text-align: justify;">Some of
these commentators even think that people my age don’t know what real friendship
is.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<blockquote><p class="MsoNormal" style="text-align: justify;">[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, <i><a href="https://www.bloomsbury.com/uk/violent-night-9781845201647/">Violent Night</a></i>,
p.91)</p></blockquote><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">This is why the concept of the ‘<a href="https://doi.org/10.1177%2F0038038515588460">carnivalesque</a>’ was so interesting
to me. Carnival, as <a href="https://www.versobooks.com/books/415-walter-benjamin">Terry Eagleton</a> 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.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">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 <a href="https://chrisroutledge.co.uk/books/cains/">Robert Cain in Liverpool</a>.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">So if these were the ‘good old days’,
they certainly left plenty to be desired – <a href="https://books.google.co.uk/books/about/Patriarchy_and_Pub_Culture.html?id=YrMOAAAAQAAJ&redir_esc=y">particularly
for women</a>, or those who didn’t fit the standard (<a href="https://metro.co.uk/2021/02/18/why-people-of-colour-feel-like-they-dont-belong-in-pubs-13968396/">white</a>)
model of masculinity. (There’s plenty
still to be desired today.)</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">But what about the promise of
postwar <a href="https://www.bloomsbury.com/uk/inside-subculture-9781859733523/" target="_blank">sub-cultures</a>? Well, punks ended
up <a href="https://www.youtube.com/watch?v=8hzQsvxtLTM">selling butter</a> and
<a href="https://www.bbc.co.uk/news/entertainment-arts-56407232">having to
apologise for racist and misogynist abuse</a>.
Maybe all that ‘resistance’ wasn’t as revolutionary as some might have
hoped.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">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.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">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.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">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.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">And in more recent years it’s
felt a little like <a href="https://www.spectator.co.uk/article/what-s-up-with-generation-sensible-">some
people</a> who came of age around the time of '<a href="https://www.newstatesman.com/politics/health/2015/10/peak-booze-how-my-generation-became-uk-s-heaviest-drinkers" target="_blank">peak booze</a>' have been, to quote another song, asking ‘generation sensible’: if you <a href="https://www.youtube.com/watch?v=27Tj-Xo_eqI">don’t smoke and don’t
drink, what do you do</a>?</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>
<p class="MsoNormal" style="text-align: justify;">But maybe this time we won’t have
either tragedy or farce, and instead something approaching sensible progress.</p><p class="MsoNormal" style="text-align: justify;"><o:p></o:p></p>Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-31419705248676204162020-11-11T19:09:00.000+00:002020-11-11T19:09:16.158+00:00Alcohol isn't like sushi<div>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 <a href="https://twitter.com/soozaphone?s=21" target="_blank">Suzi Gage’s</a> ‘<a href="https://play.acast.com/s/saywhytodrugs" target="_blank">Say Why To Drugs</a>’. 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 <a href="https://play.acast.com/s/saywhytodrugs/alcoholinpregnancy" target="_blank">drinking in pregnancy</a>, <a href="https://play.acast.com/s/saywhytodrugs/thesecretdrugaddict" target="_blank">recovery from ‘addiction’</a>, <a href="https://play.acast.com/s/saywhytodrugs/drugeducation-withthedsmfoundation" target="_blank">education in schools</a> and <a href="https://play.acast.com/s/saywhytodrugs/drugregulation-withtransform" target="_blank">broader drug policy</a>.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>So what comment am I talking about? Well, both guests, <a href="https://www.liverpool.ac.uk/population-health-sciences/staff/kate-fleming/" target="_blank">Dr Kate Fleming</a> and <a href="https://research-information.bris.ac.uk/en/persons/luisa-zuccolo" target="_blank">Dr Luisa Zuccolo</a>, 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.</div><div><br /></div><div>That is, <i>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></div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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. (<a href="https://thinking-to-some-purpose.blogspot.com/2017/10/is-your-drinking-like-meat-and-potatoes.html" target="_blank">I’ve written before on whether alcohol is like meat or potatoes</a>, or neither.)</div><div><br /></div><div>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.)</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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?</div><div><br /></div><div>Is it about signifying a change in time – maybe the switch from work to leisure? In which case, it’s not really about intoxication, <a href="https://www.taylorfrancis.com/books/9781315888873/chapters/10.4324/9781315888873-9" target="_blank">as Joseph Gusfield explained neatly</a>, 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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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.</div><div><br /></div><div>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 <a href="https://www.bbc.co.uk/programmes/p0867lz8" target="_blank">an episode of BBC Hooked</a>, while we’re on podcasts.). To be honest when I read it, I feel a slight inward groan.</div><div><br /></div><div>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, <a href="https://thinking-to-some-purpose.blogspot.com/2015/11/the-pleasures-of-intoxication.html" target="_blank">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</a>. Or somehow <a href="https://www.philmellows.com/PhilMellows_Diary_06_01_20.htm" target="_blank">someone who is intoxicated is less ‘authentic’ or ‘fulfilled’ than someone sober</a>.</div><div><br /></div><div>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).</div><div><br /></div><div>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.</div><div><br /></div><div>So we’re back to that question of what alcohol is for. <a href="https://thinking-to-some-purpose.blogspot.com/2014/08/budget-day-and-de-normalisation-of.html" target="_blank">As I’ve suggested before</a>, 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 <a href="https://twitter.com/jamestdpf?s=21" target="_blank">James Nicholls</a> from <a href="https://transformdrugs.org/" target="_blank">Transform</a>, I wondered if we could ever resolve this ‘specialness’ of alcohol while it is (seen as) our only legal intoxicant.</div><div><br /></div><div>Perhaps, to continue a theme, I can end with another podcast reference, recommending <a href="https://alcoholpodcast.buzzsprout.com/1275176/6089527-ep-1-drinkers-like-us-in-conversation-with-adrian-chiles" target="_blank">Adrian Chiles in conversation</a> with <a href="https://twitter.com/jamesmorris24?s=21" target="_blank">James Morris</a>. 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 <a href="https://oxford.universitypressscholarship.com/view/10.1093/acprof:oso/9780199551149.001.0001/acprof-9780199551149?gclid=CjwKCAiAtK79BRAIEiwA4OskBjs65K8JK0GssX6NSekyeEVsSKuYGx8KNA9YZ5sYoqZIO1d2nwBr-xoCZnkQAvD_BwE" target="_blank">no ordinary commodity</a>, 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.</div><div><br /></div>Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com2tag:blogger.com,1999:blog-125653241615635488.post-49346444265456358602020-09-17T18:12:00.004+01:002020-09-17T18:12:38.011+01:00Fear or Compassion - what's the way to change policy?<p>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: <a href="https://www.gov.uk/government/publications/independent-review-of-drugs-part-2-terms-of-reference/independent-review-of-drugs-part-2-prevention-treatment-and-recovery-terms-of-reference">the
review into treatment being conducted by Dame Carol Black</a>.</p><p>The two particular instances are last week’s <a href="https://www.nhsapa.org/post/download-apaconf">NHS addictions provider
alliance (NHS APA) conference</a>, and <a href="https://www.tandfonline.com/doi/full/10.1080/09687637.2020.1820450">a new
article</a> by some wonderful academics (<a href="https://twitter.com/profhrs">Harry
Sumnall</a>, <a href="https://twitter.com/ian_hamilton_">Ian Hamilton</a>, <a href="https://twitter.com/DrAMAtkinson">Amanda Atkinson</a>, <a href="https://twitter.com/cathymonty_psy">Catharine Montgomery</a> and <a href="https://twitter.com/soozaphone">Suzi Gage</a>).</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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 <a href="https://thinking-to-some-purpose.blogspot.com/2019/08/has-substance-misuse-treatment-been.html">an
increasingly common mischaracterisation of the past 30-40 years of addiction
treatment</a>. Addiction treatment in
the UK has never simply been a matter for NHS providers, or NHS commissioners. You can read academic work on this (<a href="https://doi.org/10.1332/204080512X632728">Alex Mold</a> is great) or <a href="https://www.gov.uk/government/publications/drug-misuse-treatment-in-england-evidence-review-of-outcomes">PHE
publications</a>.</p>
<p class="MsoNormal">Weirdly, some of the people presenting these ideas lived and
worked in the era of <a href="https://thinking-to-some-purpose.blogspot.com/2016/06/the-good-old-days-of-nta.html">the
NTA</a> and DAATs, when commissioning in earnest grew as part of ‘<a href="https://en.wikipedia.org/wiki/New_Public_Management">the new public management</a>’
– and yet they hark back to times before 2013 as some kind of pre-commissioning
age.<span style="mso-spacerun: yes;"> </span>Perhaps it was for some of their
services, but not for ‘the sector’.<span style="mso-spacerun: yes;">
</span>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.</p>
<p class="MsoNormal">That last acronym – CRI – brings me neatly onto my next
point.<span style="mso-spacerun: yes;"> </span>CRI stands for Crime Reduction
Initiative, and in my head is the emblematic name and organisation for the <a href="https://www.theguardian.com/society/2014/nov/25/uk-drug-strategy-home-office">Paul
Hayes</a> / NTA era.<span style="mso-spacerun: yes;"> </span>As part of being ‘tough
on the causes of crime’, New Labour poured money into substance misuse (specifically
‘drug’) treatment services.</p>
<p class="MsoNormal">It was a realpolitik bargain: you paint people who use drugs
(notably heroin) as ‘<a href="https://en.wikipedia.org/wiki/Lady_Caroline_Lamb">mad,
bad and dangerous to know</a>’, which is disingenuous and stigmatising, but a
means to an end.<span style="mso-spacerun: yes;"> </span>Sure, the people in the
field aren’t working there because of this; they’re more likely to be motivated
by compassion.<span style="mso-spacerun: yes;"> </span>And it doesn’t feel right
saying this because you’re painting all people who use drugs as dangerous.<span style="mso-spacerun: yes;"> </span>But there were reasons people felt this was a
price worth paying.</p>
<p class="MsoNormal">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.</p>
<p class="MsoNormal">But this isn’t without consequences.</p>
<p class="MsoNormal">Fundamentally, the argument potentially works against Release’s
campaign that ‘<a href="https://www.release.org.uk/nice-people-take-drugs">Nice
People Take Drugs</a>’.</p>
<p class="MsoNormal">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.<span style="mso-spacerun: yes;"> </span>(Of
course it doesn’t undermine those arguments – prohibition increases harm – but it
does make them less straightforward.)</p>
<p class="MsoNormal">It’s also about treatment itself: <a href="https://journals.sagepub.com/doi/full/10.1177/0192513X15581659">people may
be less likely to access help (or encourage someone else to) if they think this
defines them as an undesirable</a>.<span style="mso-spacerun: yes;"> </span>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.</p>
<p class="MsoNormal">But the bargain has a point: millions of pounds more
funding.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>We’ve still got more
funding and staff than services did in the 1990s.<span style="mso-spacerun: yes;"> </span>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.</p>
<p class="MsoNormal">However, there’s a sense now that perhaps this particular
argument has had its day.<span style="mso-spacerun: yes;"> </span>That is, even if
the stigma <u>was</u> a price worth paying, then the power of ‘crime’ won’t
work today.<span style="mso-spacerun: yes;"> </span>The political strategy has
been <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/332963/horr79tr.pdf">a
victim of its own success</a>.</p>
<p class="MsoNormal">What we’ve seen in the past few years in an enthusiastic embrace
of the concept of <a href="http://www.healthscotland.scot/population-groups/children/adverse-childhood-experiences-aces/overview-of-aces">Adverse
Childhood Experiences (ACEs)</a>.<span style="mso-spacerun: yes;"> </span>I don’t
want to go into the detail of this now, as <a href="https://publichealthy.co.uk/good-intentions-but-the-right-approach-the-case-of-aces/">people
more passionate and informed than me have discussed this plenty</a>.<span style="mso-spacerun: yes;"> </span>But suffice to say there’s considerable
evidence that early life experiences help shape how we navigate the world as
adults.</p>
<p class="MsoNormal">Like so much social science and public health research, this
isn’t really news.<span style="mso-spacerun: yes;"> </span>We’ve understood this
for thousands of years (‘<a href="https://en.wikiquote.org/wiki/Ignatius_of_Loyola#Disputed">Give me the
child…</a>’), and it has resonated in our lifetimes through programmes like ‘<a href="https://en.wikipedia.org/wiki/Up_(film_series)">7 up</a>’.<span style="mso-spacerun: yes;"> </span>Perhaps it seems more worthy of comment after
<a href="https://journals.sagepub.com/doi/10.1177/0261018313514804">40 years of
politics dominated by narratives that emphasise choice and individual autonomy</a>.<span style="mso-spacerun: yes;"> </span>And the research is potentially helpful
because it gives a sense of legitimacy to what we’d always ‘known’.<span style="mso-spacerun: yes;"> </span>Without evidence, it can sometimes be hard to
get certain ideas accepted as the basis of policymaking.</p>
<p class="MsoNormal">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’.<span style="mso-spacerun: yes;"> </span>It turns out that
yes, giving the specifics makes people more sympathetic.</p>
<p class="MsoNormal">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.<span style="mso-spacerun: yes;"> </span>If ‘crime’ is no longer our magic framing
device, then perhaps ‘ACEs’ will suffice.</p>
<p class="MsoNormal">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.<span style="mso-spacerun: yes;"> </span>And as I’ve thought this through, I’ve
started to wonder whether there are several other issues.</p>
<p class="MsoNormal">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.<span style="mso-spacerun: yes;"> </span>Have you experienced sufficient childhood
trauma to deserve my sympathy (and therefore funding)?</p>
<p class="MsoNormal">Of course, as <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/332963/horr79tr.pdf">the
2014 Home Office report</a> pointed out, ‘a sizable proportion of heroin/crack
users do not resort to theft’.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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?</p>
<p class="MsoNormal">This simply doesn’t work with ACEs.<span style="mso-spacerun: yes;"> </span>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.</p>
<p class="MsoNormal">Thus, it’s worryingly similar to the deserving/undeserving
poor arguments.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>If I can do it, why couldn’t they?"</p>
<p class="MsoNormal">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 <i>The Rise of the Meritocracy</i>, <a href="https://www.bbc.co.uk/programmes/m000mbhq">which is still being debated on
Radio 4 today</a>.</p>
<p class="MsoNormal">This is why ACEs seems powerful to people as way of framing
debates about treatment for ‘substance use disorders’.<span style="mso-spacerun: yes;"> </span>It offers a more ambitious programme (not
just to reduce crime, but to help someone thrive).<span style="mso-spacerun: yes;"> </span>It presents people with problems as, well,
just that: people.<span style="mso-spacerun: yes;"> </span>It offers a solution
that is not punitive (even superficially), but constructive and compassionate.<span style="mso-spacerun: yes;"> </span>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.</p>
<p class="MsoNormal">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’.<span style="mso-spacerun: yes;"> </span>There’s a role for challenging that, and organisations
like Release and Transform are an important part of that process.<span style="mso-spacerun: yes;"> </span>But what I need is an argument that will ‘make
sense’ in a town hall or local paper.<span style="mso-spacerun: yes;">
</span>That elected councillors can get behind.</p>
<p class="MsoNormal">ACEs could yet be that: treat these people with compassion
because it’s the right thing to do.<span style="mso-spacerun: yes;"> </span>The
problem is maintaining that compassion and commitment when it comes up against <a href="https://www.dorsetecho.co.uk/news/15332479.family-day-out-on-weymouth-beach-turns-into-every-parents-worst-nightmare-as-five-year-old-henry-stabs-finger-on-used-syringe/">a
child who has a needle stick injury from digging in the sand on the beach</a>.<span style="mso-spacerun: yes;"> </span>How far will that compassion stretch in
public debate?<span style="mso-spacerun: yes;"> </span>We’re getting dangerously
close to having to wheel out and discuss JS Mill’s ‘<a href="https://en.wikipedia.org/wiki/Harm_principle">harm principle</a>’ –
another big idea we’ve not been able to agree on.</p>
<p class="MsoNormal">Sometimes pragmatism, common sense and problem-solving are
more likely to win you support.<span style="mso-spacerun: yes;">
</span>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.</p>
<p class="MsoNormal">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.<span style="mso-spacerun: yes;"> </span>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.</p>
<p class="MsoNormal">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.<span style="mso-spacerun: yes;">
</span>(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.)<span style="mso-spacerun: yes;"> </span>Perhaps
it would be more accurate to say <u>we don’t know</u> precisely what it was
spent on, and it <u>may</u> have all been spent on substance misuse.</p>
<p class="MsoNormal">This isn’t a criticism of the NHS.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>I speak from personal experience, compiling
returns for government / PHE, that this kind of exercise can be potentially
misleading and quite likely counterproductive: <a href="https://www.centreforpublicimpact.org/"><span style="mso-spacerun: yes;"> </span>critiques of the New Public Management</a> would
suggest that constant measuring and auditing aren’t always as helpful as they
might seem.<span style="mso-spacerun: yes;"> </span>They give reassurance, but
that may be a false sense of security rather than actually reflecting a better
service.</p>
<p class="MsoNormal">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.</p>
<p class="MsoNormal">I’m acutely aware that this post may not be well received.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>I’ll leave
that to the professionals.</p>
<p class="MsoNormal">But people are more likely to be disagreeing for different
reasons.<span style="mso-spacerun: yes;"> </span>I’m conscious people may feel the
discussion doesn’t reflect well on me personally.<span style="mso-spacerun: yes;"> </span>I’ve focused on pragmatic politics, not
compassion.<span style="mso-spacerun: yes;"> </span>I could be seen to have questioned
whether the NHS is really best placed to support people who use drugs.</p>
<p class="MsoNormal">But in a sense that’s the whole point.<span style="mso-spacerun: yes;"> </span>To talk about compassion and the brilliance
and commitment of NHS staff would simply be preaching to the converted.<span style="mso-spacerun: yes;"> </span>I’m assuming most people reading this post
already have a passion for supporting people who’ve run into issues with
substance use.<span style="mso-spacerun: yes;"> </span>I’m assuming you’d like
to see services better funded, with improved quality, and better links and
support from the NHS.<span style="mso-spacerun: yes;"> </span>(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.)</p>
<p class="MsoNormal">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.<span style="mso-spacerun: yes;">
</span>That’s where we need to debate, discuss and make a difference.</p>
<p class="MsoNormal">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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Let’s have those discussions and
disagreements, and come up with some ways that we can work together effectively
to drive change.<o:p></o:p></p>Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-11727469265005143552020-07-20T12:08:00.001+01:002020-07-20T12:08:31.229+01:00Is it always best to think local?<p class="MsoNormal">I’m quite a fan of the <a href="http://www.nlgn.org.uk/public/">New Local Government Network</a> (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.<o:p></o:p></p>
<p class="MsoNormal">In the past few weeks, their director, <a href="https://twitter.com/adamjlent">Adam Lent</a>, and <a href="https://www.theguardian.com/society/2020/jul/20/nhs-taking-over-social-care-disaster-make-services-local">today</a>
deputy director, <a href="https://twitter.com/jesstud">Jessica Studdert</a>,
have made points that have got me thinking about where localism might not quite
work as a policy solution.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">First, I want to consider <a href="http://www.nlgn.org.uk/public/2020/michael-goves-reform-plans-reinforce-the-elitism-he-claims-to-despise/">Adam’s
critique</a> of <a href="https://www.gov.uk/government/speeches/the-privilege-of-public-service-given-as-the-ditchley-annual-lecture">Michael
Gove’s speech on the future of government</a>.
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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.’</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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).</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">The critiques of this that I have seen are twofold. First, <a href="https://blogs.lse.ac.uk/politicsandpolicy/gove-ditchley-lecture/">as Abby
Innes has argued</a>, 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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">(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 <a href="https://twitter.com/tobyjlowe">Toby
Lowe</a> and <a href="https://medium.com/@SimonFParker/conservative-anarchism-self-organisation-and-the-future-of-government-2ef5447b7f02">Simon
Parker</a>. 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.)</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.’</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">I think this is particularly clear in <a href="https://twitter.com/adamjlent/status/1277146718027624449">Adam’s recent
comment</a> on the idea that <a href="https://www.theguardian.com/society/2020/jun/28/calls-for-national-care-service-as-crisis-leaves-homes-in-critical-state?CMP=Share_iOSApp_Other">a
national social care service could be established</a> 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.’</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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 <a href="https://www.theguardian.com/society/2020/jul/20/nhs-taking-over-social-care-disaster-make-services-local">today’s
piece in the Guardian</a>.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">I am not an unequivocal supporter of the NHS. <a href="https://thinking-to-some-purpose.blogspot.com/2019/08/has-substance-misuse-treatment-been.html">I
have written before</a> 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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">The first point is about funding and politics. As Jessica notes, “At one level, the issue
for social care begins and ends with money”.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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), <a href="https://www.ippr.org/blog/public-health-cuts#anounce-of-prevention-is-worth-a-pound-of-cure">which
have seen theirs cut by 20%</a>.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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 <a href="https://thinking-to-some-purpose.blogspot.com/2019/08/has-substance-misuse-treatment-been.html">PCTs
commissioning some services and local partnerships generally led by councils
commissioning the rest</a>.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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
organisation<u>s</u>, as the NHS is not one entity with a single culture.)</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">So having social care as a national service might mean that
national politicians would be more likely to protect the funding.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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 <a href="https://www.cqc.org.uk/">CQC</a> 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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">Yes, there can be collaboration, and we’re hopefully seeing
this with <a href="https://drinkanddrugsnews.com/commissioning-quality/">the
creation of a national substance misuse commissioners forum</a>.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">But the variation in local services is about more than this:
the actual <u>dosages </u>varied dramatically, despite <a href="https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk-guidelines-on-clinical-management">national
guidance</a> suggesting that the therapeutic range was typically between 60mls
and 120mls of methadone.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.)</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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. <a href="https://doi.org/10.1016/j.drugpo.2014.01.015">Politics and rhetoric
affected the quality of the treatment available</a>.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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).</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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?</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal"><a href="https://thinking-to-some-purpose.blogspot.com/2019/03/can-we-build-more-trusting.html">In
my experience</a>, looking at the history of substance misuse treatment, we
were better off with the inefficiencies of the centrally-controlled regime,
rather than <a href="https://thinking-to-some-purpose.blogspot.com/2019/07/local-substance-misuse-services-or.html">attempting
to create independent solutions in every area</a>. People who seemed to hate the National
Treatment Agency at the time <a href="https://thinking-to-some-purpose.blogspot.com/2016/06/the-good-old-days-of-nta.html">now
seem to long for it</a>.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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 <a href="https://thinking-to-some-purpose.blogspot.com/2017/06/new-directions-and-dangers-of.html">the
key is not to think too much about the structures, given that what makes a
difference is people</a>.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal">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.</p><p class="MsoNormal"><o:p></o:p></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">*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!<o:p></o:p></p>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-54971630169939095332020-07-09T00:35:00.000+01:002020-07-09T00:35:05.182+01:00The rise and fall (and rise and fall) of neoliberalism in alcohol policy?<br />
<div class="MsoNormal">
Between 2006 and 2009, I was doing research into alcohol and
the night-time economy.<span style="mso-spacerun: yes;"> </span>This still felt like
a time of ‘<a href="https://www.newstatesman.com/politics/health/2015/10/peak-booze-how-my-generation-became-uk-s-heaviest-drinkers">peak
booze</a>’.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>Generation sensible was nowhere to be seen as the papers panicked (and <a href="https://www.semanticscholar.org/paper/Gender%2C-class-and-'binge'-drinking-%3A-an-ethnography-Haydock/48981948a905e13a3e12229eef8728be37ed8513/figure/0">gawped</a>)
at ‘<a href="https://www.telegraph.co.uk/news/uknews/5355792/Lonely-Planet-guide-Welcome-to-Britain-a-nation-of-binge-drinkers.html">Binge
Britain</a>’.<span style="mso-spacerun: yes;"> </span><a href="https://www.dailymail.co.uk/news/article-1220579/Carnage-Shame-drunken-student-caught-urinating-war-memorial-mass-pub-crawl.html">Urinating
on memorials isn’t a new thing</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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’.<span style="mso-spacerun: yes;"> </span>I’ve wrote about this quite often (particularly
<a href="https://doi.org/10.1177%2F0261018313514804">here</a> – or <a href="http://eprints.bournemouth.ac.uk/21549/">here</a> for free), including <a href="https://thinking-to-some-purpose.blogspot.com/2014/09/whats-new-about-neoliberalism.html">on
this blog</a>.<span style="mso-spacerun: yes;"> </span>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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Words and concepts that are valued in this understanding
include ‘market’, ‘rational’, ‘individual’, ‘responsible’.<span style="mso-spacerun: yes;"> </span>Some of the best descriptions of neoliberalism
can be found in the work of <a href="https://www.jstor.org/stable/23638075?seq=1">David Garland</a> and <a href="https://doi.org/10.1177%2F0261018305057024">John Clarke</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It’s not classical liberalism, because you’re not accepting
that a person’s own choices about their own life are <u>by definition</u> the
most sensible for them.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>(Don’t imagine that <a href="https://en.wikipedia.org/wiki/Nudge_(book)">Thaler
and Sunstein</a> 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 <a href="https://iris.ucl.ac.uk/iris/publication/870475/1">in the 19<sup>th</sup>
century</a>, and putting this into practice <a href="https://historicengland.org.uk/research/current/discover-and-understand/military/the-first-world-war/first-world-war-home-front/what-we-already-know/land/state-control-of-pubs/">by
the early twentieth</a>).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Paul Chatterton and Robert Hollands used a very helpful
model to structure discussions of alcohol policy – think about consumers,
producers and regulators.<span style="mso-spacerun: yes;"> </span>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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;"> </span>A contrary
interpretation would be claim that those changes mean that young people are ‘<a href="https://scholar.google.com/scholar_lookup?hl=en&publication_year=2004&pages=235-236&author=+Hadfield%2C+P.&title=Invited+to+binge%3F">invited
to binge</a>’, and so the blame should lie with regulators and producers for
being irresponsible and disingenuous.<span style="mso-spacerun: yes;">
</span>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.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I feel like these debates have largely faded away in politics
recently.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>It’s also a function of Brexit blocking out all other issues.<span style="mso-spacerun: yes;"> </span>But there’s something more: alcohol isn’t the
political issue it was in 2004.<span style="mso-spacerun: yes;"> </span>(Or at
least it wasn’t until recently.)<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>(It’s
hard for the Conservatives to oppose it too much, as they committed to it in
their 2012 Alcohol Strategy.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But now these debates about ‘responsibility’ are back,
brought into focus again by COVID-19.<span style="mso-spacerun: yes;"> </span>The
photos of people on beaches – and particularly drinking in Soho – have led to
discussions of whether it’s <a href="https://twitter.com/ChrisBrosnahan/status/1279719705553580033">irresponsible
drinkers, greedy producers or negligent regulators who are to blame</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.<span style="mso-spacerun: yes;">
</span>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’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Perhaps one difference this time round might be local
authorities, I thought.<span style="mso-spacerun: yes;"> </span>Rather than
embracing the night-time economy as <a href="http://news.bbc.co.uk/1/hi/uk_politics/3115485.stm">a way to re-create
Bologna in Birmingham and Madrid in Manchester</a> (and raise much-needed
revenue), this time round, perhaps influenced by <a href="https://www.local.gov.uk/topics/social-care-health-and-integration/public-health">their
Directors of Public Health</a>, it seemed like <a href="https://twitter.com/MyDoncaster/status/1278713534600355842">drinking in a
time of COVID-19 might case them a headache</a>.<o:p></o:p></div>
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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.<o:p></o:p></div>
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Then came yesterday’s budget – sorry, ‘Plan For Jobs’.<span style="mso-spacerun: yes;"> </span>In this, <a href="https://twitter.com/WSTA_Miles/status/1280841079189901313">the VAT cut</a>
and ‘<a href="https://www.bristolpost.co.uk/whats-on/food-drink/you-cant-use-rishis-restaurant-4306609">meal
deals</a>’ announced by the Chancellor, Rishi Sunak, explicitly did not include
alcoholic drinks.<span style="mso-spacerun: yes;"> </span>This will boost <a href="https://twitter.com/WSTA_Miles/status/1280836646385209350">some pubs and
venues, and not others</a>.<span style="mso-spacerun: yes;"> </span>This seems
to be the result of an acceptance that <a href="https://alcoholchange.org.uk/blog/2020/covid19-drinking-during-lockdown-headline-findings">consuming
alcohol during lockdown may be an issue</a>, but it is distinctly at odds with the
divide and rule approach of New Labour, <a href="https://publications.parliament.uk/pa/cm200405/cmhansrd/vo050125/debtext/50125-22.htm">as
outlined by Tessa Jowell in proposing the 2003 Licensing Act</a>: “Our role is
to give adults the freedom they deserve, while giving the yobbish minority the
rough and tough treatment that they deserve.”<o:p></o:p></div>
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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.<o:p></o:p></div>
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Perhaps, as with <a href="https://www.gov.uk/government/speeches/the-privilege-of-public-service-given-as-the-ditchley-annual-lecture">the
claim to be drawing on FDR’s New Deal</a>, there is a tension within government.<span style="mso-spacerun: yes;"> </span>Maybe this is Rishi Sunak <a href="https://twitter.com/RobDotHutton/status/1280840290417479681">positioning
himself as responsible centrist</a>, interested in rules, as opposed to the
neoliberal individualism of Dominic Cummings and Boris Johnson. <span style="mso-spacerun: yes;"> </span>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.<o:p></o:p></div>
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Whatever it is, it seems a good time to be dusting off all
those references from the 1990s and 2000s. <span style="mso-spacerun: yes;"> </span><a href="https://journals.sagepub.com/doi/10.1177/0261018313514804">I’ve written
before</a> about the false dawn of some kind of communitarianism or
post-liberalism – at least in relation to alcohol policy.<span style="mso-spacerun: yes;"> </span>In fact that was my first published article
going over these arguments about neoliberalism.<span style="mso-spacerun: yes;">
</span>And the Coalition never did introduce MUP.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com1tag:blogger.com,1999:blog-125653241615635488.post-87104139562561060482020-07-04T15:38:00.000+01:002020-07-05T09:57:59.728+01:00Wetherspoons in a time of COVID-19<br />
<div class="MsoNormal">
I originally started this blog as a place to write about
things I wasn’t too sure about – developing ideas that weren’t quite up to academic
standards of peer review.<span style="mso-spacerun: yes;"> </span>Somewhere to
say what I ‘reckon’, rather than necessarily what I definitely ‘know’.<span style="mso-spacerun: yes;"> </span>(Yes, of course, all knowledge is contingent
etc, but you know what I mean.)<o:p></o:p></div>
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Recently, I worry that I’ve been too cautious in just writing
about what I ‘reckon’, for fear that I might be wrong, so this is an attempt to
get back to that original approach.<o:p></o:p></div>
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Sometimes I feel nervous about this in relation to discussions
of drinking and alcohol policy.<span style="mso-spacerun: yes;"> </span>The
field seems <a href="https://thinking-to-some-purpose.blogspot.com/2020/01/drug-policy-and-scientific-morality.html">hugely
coloured by people’s personal preferences and experiences</a> – those who don’t
enjoy being drunk often don’t seem to understand those who do, for example.<span style="mso-spacerun: yes;"> </span>Politicians <a href="https://journals.sagepub.com/doi/10.1177/0261018313514804">seem to
believe that anyone who uses their freedom to behave differently simply needs
more ‘education’ or ‘information’</a> – as if there is one ‘rational’ way to
behave in relation to <a href="http://eprints.bournemouth.ac.uk/17420/">a drug
that is attractive precisely because it removes rationality</a>.<o:p></o:p></div>
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(Of course, <a href="https://thepsychologist.bps.org.uk/volume-32/july-2019/everyone-has-something-add-conversation">my
‘objectivity’ is equally compromised</a>, but it is possible to claim some
moral (or epistemological) high ground by at least being aware of this, and
acknowledging some of one’s own biases.<span style="mso-spacerun: yes;">
</span>It’s then up to other people to see how useful my ‘reckoning’ is.)<o:p></o:p></div>
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Maybe I’m overplaying it, but I feel like Wetherspoons is
some kind of lightning conductor for these personal views about alcohol (mixed,
of course, with concerns about class).<span style="mso-spacerun: yes;"> </span>This
has probably ramped up, given the controversies around Tim Martin’s position on
Brexit, and <a href="https://www.theguardian.com/business/2019/nov/10/wetherspoon-tim-martin-brexit-leave-agm-corporate-governance">his
use of Wetherspoons to get his message across</a>.<o:p></o:p></div>
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Seeing <a href="https://twitter.com/prossertj/status/1279333728272166913" target="_blank">a discussion of this on Twitter</a> got me thinking this could be the perfect way to get back into writing about what I 'reckon'. (Actually, talking about alcohol and class isn’t just what I ‘reckon’;
it’s one of those rare bits of my thinking that has gone through peer review - <a href="https://journals.sagepub.com/doi/abs/10.1177/0309816814550455">here</a>
and <a href="https://www.tandfonline.com/doi/full/10.1080/19407963.2014.900989">here</a>,
for example.)<o:p></o:p></div>
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Wetherspoons is often portrayed as <a href="https://twitter.com/MikP1927_mike/status/1279356414058803200">not being a
‘real’ pub</a>, or being a kind of immoral capitalist organisation that <a href="https://www.theguardian.com/global/video/2019/jan/25/owen-jones-meets-tim-martin-wetherspoons-no-deal-brexit-poverty-wages-dont-ask-childish-questions-video">exploits
its own staff</a> and <a href="https://www.morningadvertiser.co.uk/Article/2019/09/11/JD-Wetherspoon-beer-price-cut-concern-for-SIBA">the
breweries it buys from</a>.<o:p></o:p></div>
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The objections are also aesthetic and cultural.<span style="mso-spacerun: yes;"> </span>There’s a common argument that Wetherspoons
are just ‘<a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1468-2427.2006.00642.x">drinking
barns</a>’, to used Deborah Talbot’s phrase.<o:p></o:p></div>
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But spaces are also what people make of them.<span style="mso-spacerun: yes;"> </span>The question is about community.<span style="mso-spacerun: yes;"> </span>Wetherspoons brings together <a href="https://www.newstatesman.com/politics/uk/2016/10/cult-wetherspoons-why-does-pub-chain-inspire-such-devotion">a
range of people united partly by price and convenience</a> (but also by
culture).<span style="mso-spacerun: yes;"> </span>They are the classic ‘<a href="https://www.sciencedirect.com/science/article/abs/pii/S0264275106000448">chameleon</a>’
venues, welcoming business travellers for breakfast, families and work groups
for lunch, students in the evening, and so on.<o:p></o:p></div>
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To me, this is a key quality of a pub, and genuinely public,
social drinking.<span style="mso-spacerun: yes;"> </span>If people’s time is
split simply between home and work, with limited interaction while shopping (particularly
given how much is done online), then we have pretty narrow social circles,
mediated only by social media.<span style="mso-spacerun: yes;"> </span>A good
local pub, by contrast, offers an opportunity for people to interact more
widely (though obviously there’s plenty of research, including mine, on how
venues segregate and distinguish between people). Check out work by people like <a href="https://twitter.com/culturalclare?s=09" target="_blank">Claire Markham</a>, for example.<o:p></o:p></div>
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But this isn’t just about price.<span style="mso-spacerun: yes;"> </span>People actively choose Wetherspoons and it
can provide a shared culture.<span style="mso-spacerun: yes;"> </span>Perhaps it’s
different in cities, but in towns like Dorchester, where I live – or even
Bournemouth – you can see this sense of community in Wetherspoons.<span style="mso-spacerun: yes;"> </span>Apart from the nightclubs or late opening
pubs with ‘loud music and dancing’ (<a href="https://assets.publishing.service.gov.uk/media/5eb96e8e86650c278b077616/working-safely-during-covid-19-restaurants-pubs-bars-takeaways-030720.pdf">apparently
the new definition of a ‘nightclub’</a>), Wetherspoons – with neither of these
features – is the place most likely to have ‘<a href="https://en.wikipedia.org/wiki/Rabelais_and_His_World#Carnival">free and
familiar contact</a>’, with people bumping into old friends and different conversation groups interacting.<o:p></o:p></div>
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Around Christmas it’s genuinely a joyful place, full of community, with local football clubs bumping into each other (don’t ask about
the rivalry between Piddlehinton and Puddletown) and former schoolmates meeting
up as they’re back visiting parents.<span style="mso-spacerun: yes;"> </span>Or
even on an ordinary Friday night, as work groups merge as people bump into
friends of friends.<o:p></o:p></div>
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And this is before we get into <a href="https://manchesteruniversitypress.co.uk/9780719052651/">the David Gutzke
idea</a> of Wetherspoons being more welcoming to people who typically feel
uncomfortable in traditional pubs.<o:p></o:p></div>
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This isn’t to praise Wetherspoons, or claim these things don’t
happen in other venues.<span style="mso-spacerun: yes;"> </span>If offered a choice,
this isn’t my personal favourite venue in Dorchester.<span style="mso-spacerun: yes;"> </span>And maybe I’m over-sensitive about these
criticisms of it, as I see them feeding into the broader classed narratives of
what are ‘good’ venues and what is ‘responsible’ drinking.<span style="mso-spacerun: yes;"> </span><o:p></o:p></div>
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I’m certainly sensitive to the fact that <a href="https://twitter.com/JamieJBartlett/status/1279371640174977024">people who
have comfortable houses and gardens or can afford more expensive venues are
particularly privileged at the moment</a> in being able to resist the temptation
of the pub.<span style="mso-spacerun: yes;"> </span>I always think of <a href="https://books.google.co.uk/books?id=QAW1igHbTxwC&dq=robert+roberts+the+classic+slum" target="_blank">Robert Roberts’description</a>.<o:p></o:p></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4v6UxZMFJ38mt6bVWO-4lm-_EFek0SERVg2j6AszL1dI7n7chtIM40i1L2lyGeMuotggy2k9q3JDmtGThQIcEqcngx-uPByk14ZWwZpxlKSVRmjaSq3NQTgl4nI2Ws39eqz93KOVwSHlJ/s1600/Roberts1.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="431" data-original-width="792" height="174" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4v6UxZMFJ38mt6bVWO-4lm-_EFek0SERVg2j6AszL1dI7n7chtIM40i1L2lyGeMuotggy2k9q3JDmtGThQIcEqcngx-uPByk14ZWwZpxlKSVRmjaSq3NQTgl4nI2Ws39eqz93KOVwSHlJ/s320/Roberts1.JPG" width="320" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEht9km9PBV0l53e-MW2MSAYXPNd0ji9TwcMlp9OVmmHgpJYmCuFyPVvyptNVuFwetff4YzwmWtnwIRUkj4FONkeX5X_ejKLPDVsJoZOhMYGGRhj49X6_CSD78r2hOyqK-OvToXHxTSu1cQJ/s1600/Roberts2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="40" data-original-width="788" height="16" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEht9km9PBV0l53e-MW2MSAYXPNd0ji9TwcMlp9OVmmHgpJYmCuFyPVvyptNVuFwetff4YzwmWtnwIRUkj4FONkeX5X_ejKLPDVsJoZOhMYGGRhj49X6_CSD78r2hOyqK-OvToXHxTSu1cQJ/s320/Roberts2.JPG" width="320" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAhBugu2J_tIdyKtFmvgVCDsxAzdodlhVT0dnoLR1hE76abSbb638qxhkxGbCQ5DqwU9-HUcN4B97neiHl7ksd4oBn40TpkJKRrtthWP7KJpOjyeC2sWL2LFNwHT__UfRLl0PCaQVpivi7/s1600/Roberts3.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="146" data-original-width="760" height="61" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAhBugu2J_tIdyKtFmvgVCDsxAzdodlhVT0dnoLR1hE76abSbb638qxhkxGbCQ5DqwU9-HUcN4B97neiHl7ksd4oBn40TpkJKRrtthWP7KJpOjyeC2sWL2LFNwHT__UfRLl0PCaQVpivi7/s320/Roberts3.JPG" width="320" /></a></div>
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Or perhaps the pub simply isn’t a temptation, and people don’t
understand the attraction, <a href="https://thepsychologist.bps.org.uk/volume-32/july-2019/everyone-has-something-add-conversation">just
like I don’t understand gambling</a>.<span style="mso-spacerun: yes;">
</span>Either way, let’s not be too lazy in thinking about Wetherspoons.<span style="mso-spacerun: yes;"> </span>My perspective is certainly that I have lots
of good, locally-specific, sociable memories of them.<o:p></o:p></div>
<br />Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-57880364264612426942020-05-11T11:37:00.001+01:002020-05-11T11:37:37.546+01:00Policy change to address COVID-19<div class="OutlineElement Ltr BCX1 SCXW107060886" style="direction: ltr;">
<div class="Paragraph BCX1 SCXW107060886" paraeid="{7ddcb53e-dc1f-40f6-aebe-9b9fd58be1ea}{170}" paraid="1249856458" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">This is the first time I’ve blogged here since COVID-19 really hit.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<span style="font-family: inherit;"><br /></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{7ddcb53e-dc1f-40f6-aebe-9b9fd58be1ea}{176}" paraid="1307164552" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">If you’re interested in broader reflections on what the crisis might mean for alcohol policy, I’ve written about that for the wonderful Drinking Studies Network </span><a class="Hyperlink BCX1 SCXW107060886" href="https://drinkingstudies.wordpress.com/blog/" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">here</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{7ddcb53e-dc1f-40f6-aebe-9b9fd58be1ea}{187}" paraid="671907629" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">But here I want to identify four specific areas where I think policy change or government guidance could be game-changing for people receiving treatment for issues with substance use. This doesn’t mean they’re the most important areas of activity or policy at the moment; to be honest keeping on doing the ‘bread and butter’ tasks of substance misuse treatment </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">is</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> the core challenge. But these are the issues where I think the biggest change could be delivered by relatively simple, almost technical, interventions. These changes aren’t about the detail of delivering treatment so much as freeing people up to deliver support in the most efficient and effective ways we can manage.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<span style="font-family: inherit;"><u><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886">(1) </span></span><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886">Buprenorphine and </span></span><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886">(2) </span></span><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886">the supervision of medication</span></span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></u></span></div>
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<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">First, I want to talk about buprenorphine. This is one of basically two drugs recommended to as part of opioid substitution treatment (OST), which means people can avoid withdrawals from heroin (or other opioids) and not have to think about funding their habit, as they’re prescribed medication. The evidence is strong that these interventions reduce crime and the transmission of blood-borne viruses.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">In normal times, lots of people on OST attend a pharmacy every day to be supervised taking their medication. This helps ensure that (a) they’re </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">definitely </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">taking</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> it</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> and getting the specified dose</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">; and (b) they’re not having any kind of adverse reaction that means the dose needs tweaking.</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> There’s also a valuable safeguarding role: </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">the pharmacist is</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> seeing them in person </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">and so can see any broader deterioration in health or make a judgement about potential wider issues, such as domestic abuse.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{7ddcb53e-dc1f-40f6-aebe-9b9fd58be1ea}{239}" paraid="1058129743" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">But there’s a downside to this level of supervision during COVID-19. G</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">oing into town every day increases your risk of catching COVID-19, and the pressure on pharmacies a few weeks ago meant that there were queues as well – at best simply off-putting, and at worse further increasing your risk of contracting </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">the virus</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{7ddcb53e-dc1f-40f6-aebe-9b9fd58be1ea}{251}" paraid="947080532" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">So the solution introduced (</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">often </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">well ahead of </span><a class="Hyperlink BCX1 SCXW107060886" href="https://www.gov.uk/government/publications/covid-19-guidance-for-commissioners-and-providers-of-services-for-people-who-use-drugs-or-alcohol/covid-19-guidance-for-commissioners-and-providers-of-services-for-people-who-use-drugs-or-alcohol#access-to-opioid-substitution-treatment" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">formal government guidance</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">) was to balance up those risks and ask people to attend pharmacies in person less often than they would normally. This might increase other risks</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">, of course. I</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">f you’re taking home a whole week’s worth of medication rather than just a day or two, then there’s a greater risk of overdose if you take it all at once, or it could be used as a tool of control by an abusive partner or organised crime group.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{15}" paraid="462226802" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">Treatment providers are aware of these </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">risks, and</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> are making decisions on a case-by-case basis, balancing up those risks against those of catching COVID-19, particularly given that lots of people in </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">treatment may already have complicating factors (like hepatitis or COPD) that make them more vulnerable. And commissioners like me are trying to keep a track on all of this to see if we’ve got the balance right. (Maybe if pharmacies aren’t so busy, a few of the clients more at risk should have face-to-face contact a bit more often again?)</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{27}" paraid="1540324823" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">One of the other ways we’re managing these risks is to make greater use of buprenorphine, one of the key OST drugs along with methadone. Generally, </span><a class="Hyperlink BCX1 SCXW107060886" href="https://www.nice.org.uk/guidance/TA114/chapter/1-Guidance" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">in line with national guidance</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">, most people in treatment are prescribed methadone, as it’s cheaper and easier to supervise (drink a liquid rather than dissolve a pill under your tongue), and there’s no any clear evidence buprenorphine delivers better outcomes – in fact, </span><a class="Hyperlink BCX1 SCXW107060886" href="https://www.nice.org.uk/guidance/ta114/chapter/4-Evidence-and-interpretation" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">in the early stages methadone seems to keep more people engaged</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{43}" paraid="924056544" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">So why use more buprenorphine? Well it’s less risky if you’re taking it home in larger quantities, as there’s less risk of overdose and less to be gained by using heroin ‘on top’ of your medication.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{49}" paraid="553359069" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">And this is exactly what </span><a class="Hyperlink BCX1 SCXW107060886" href="https://www.gov.uk/government/publications/covid-19-guidance-for-commissioners-and-providers-of-services-for-people-who-use-drugs-or-alcohol/covid-19-guidance-for-commissioners-and-providers-of-services-for-people-who-use-drugs-or-alcohol" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">the guidance from Public Heath England</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">, issued a few weeks ago, recommends. The challenge, though, that buprenorphine is considerably more expensive than methadone, and it costs </span><a class="Hyperlink BCX1 SCXW107060886" href="https://www.theguardian.com/politics/2018/sep/29/heroin-withdrawal-generic-drug-price-hike" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">about seven or eight times as much as it did a couple of years ago</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">. Some very rough local modelling suggests switching someone from methadone onto buprenorphine costs over £1,000 extra per year. That might not sound like much till you scale it up: a small shift in a client base of 1,000 (not unusual in large local authorities) will cost £100,000s. Not easy to find at a time when </span><a class="Hyperlink BCX1 SCXW107060886" href="https://news.dorsetcouncil.gov.uk/2020/04/23/dorset-council-reports-on-the-impact-of-covid-19-on-its-financial-position/" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">local authorities are losing large sums every week</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{70}" paraid="1486280043" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">Of course</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> buprenorphine in its conventional tablet form isn’t the only option; it could part of a range of changes we could make.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{78}" paraid="383009093" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">One would be to introduce, </span><a class="Hyperlink BCX1 SCXW107060886" href="https://www.dailypost.co.uk/news/north-wales-news/revolutionary-new-slow-release-drug-18212896" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">as has been done in Wales</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">, </span><a class="Hyperlink BCX1 SCXW107060886" href="https://www.smmgp-fdap.org.uk/clinical-guidelines-for-use-of-depot-buprenorphine-buvidal-in-the-treatment-of-opioid-dependence" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">‘depot’ buprenorphine</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">, which works like some long-acting reversible contraception injections: it gives a steady dose of the drug over a week or a month, gradually dissolving – meaning you have stability, certainty, and have to see a nurse or pharmacist less often. The COVID-19 guidance states local areas could consider this, but resource requirements (amongst other things) will probably make this challenging. We’re certainly considering this locally, as we have been for a few years (we were hoping for guidance from NICE/PHE this spring, though that’s now clearly not going to happen).</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">Another, simpler option, is to introduce delivery of medication, which allows services to still see patients eye-to-eye. We’re doing this in Dorset and BCP, but </span><a class="Hyperlink BCX1 SCXW107060886" href="https://www.publichealthdorset.org.uk/news/medicines-to-vulnerable-residents.aspx" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">at the moment we’re reliant on drivers from other areas of the council</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">, and they don’t have the expertise to offer any kind of clinical judgement as pharmacists might, so we’re both vulnerable to those staff being reallocated, and we need to ensure we’re providing specialist support where necessary. Both of those will cost money.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{105}" paraid="1689406371" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">One solution could lie in community pharmacies. This whole issue of switching people to buprenorphine arises because people aren’t being seen in person so often. Given that we pay pharmacies for each time they see a client, then </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">surely</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> we’ll have some savings on that ‘supervised consumption’ budget? Wrong. In the same section where PHE recommends moving people onto buprenorphine so they don’t have to come into the pharmacy, it also states that local authorities should carry on paying pharmacies their standard amounts for supervised consumption even if they’re no longer doing this as much.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{115}" paraid="699208745" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">This makes sense: we don’t want pharmacies to struggle and close, and it’s an accepted principle in the NHS response to COVID-19. But local authorities aren’t funded like the NHS, and the additional funding being offered by central government is unlikely to meet these costs (if it even makes its way to public health departments).</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{121}" paraid="755856194" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">So those are my first two asks. If the government is </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">recommending</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> we keep paying pharmacies while still requiring us to find </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; font-style: italic; line-height: 19.42px;" xml:lang="EN-GB">alternative</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> ways of delivering this kind of supervision, then it needs to find that funding. And if it thinks generic buprenorphine is a solution, then it would need, again, to find the funding for that.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{133}" paraid="2014017440" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{135}" paraid="1794715227" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">I know this might sound like the typical call for ‘more money please’, but these aren’t areas where ‘efficiency’ can solve things on its own. Buprenorphine and trained staff time simply cost money, and we’re being asked to deliver more of them without being given the means to do so.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{139}" paraid="1953781085" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{141}" paraid="1897892845" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><u><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886">(3) </span></span><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886">Electronic prescribing</span></span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></u></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{149}" paraid="771471312" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">But if efficiency on its own isn’t the answer, that doesn’t mean we’re not looking at trying to be more efficient. One of the most surprising things about OST services today is that most of them are still doing their prescribing on paper. Every one of the, say, 1,000 clients in an area needs a new prescription every fortnight. This </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">has to</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> be created on an electronic system, printed out, signed by a nurse or doctor, delivered to a pharmacy, stored by the pharmacy and then sent off the NHS Business Services Authority so the pharmacy can claim back funding. For almost every other medicine all this can be done remotely. The prescriber creates a prescription on the electronic system, presses </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">send</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> and it appears in the pharmacy on their electronic system. No printing, no signing in person.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{161}" paraid="751269661" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{163}" paraid="2066829599" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">This sounds inefficient, but in a time of COVID-19 it’s more than that; it’s risky to staff. The admin staff involved in printing, and the prescribers, all </span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">have to</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> share the same office. Perhaps they can work out a relay system, where people only come in on certain days, but they either have to come in, or the paper (with possible associated infection risk) has to make its way from the printer in the office, to their house, and back out to the pharmacy. Not practical. Someone who is self-isolating or shielding, even if they’re currently fit to work from home, can’t.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{171}" paraid="771890766" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{173}" paraid="575757452" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">There’s been legislation in place since 2015 that means things don’t have to be this way. Controlled drugs can be prescribed electronically. The challenge is that this hasn’t been technically applied to ‘instalment’ prescribing. That is, you can only send through a prescription that involves one interaction between patient and pharmacist, when (in normal times) most of our prescriptions involve people attending more than once a fortnight. In fact, even in COVID-19 times, most people are still collecting their medication at least weekly – which would mean they’d need a new electronic prescription every time.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{177}" paraid="643310056" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{179}" paraid="504986075" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">You might think that’s just a technical problem, and still easier than all the paper we use now, but every prescription can of course carry a prescription charge, so if I’m suddenly having to pay every week rather than every fortnight you’ve just doubled my costs as a patient.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{183}" paraid="1382317914" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{185}" paraid="1953928130" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">And this isn’t just about the patient; it’s about the pharmacy again. Often (and particularly in these times) even though they’ll have one ‘prescription’ and they’ll be giving a week’s worth of medication to someone, this won’t simply be as a single bottle of methadone – the safer, easier option is to sub-divide this into seven, pre-measured doses. And </span><a class="Hyperlink BCX1 SCXW107060886" href="https://psnc.org.uk/dispensing-supply/dispensing-controlled-drugs/methadone-dispensing/" rel="noreferrer noopener" style="text-decoration-line: none;" target="_blank"><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="none" lang="EN-GB" style="color: #0563c1; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886" data-ccp-charstyle="Hyperlink">the pharmacist gets paid different amounts</span></span></a><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">, quite rightly, depending on whether they’ve done this pre-measuring or not. If it’s just one prescription, with no guidance about those ‘instalments’, then they can only be paid the standard amount.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{194}" paraid="68116782" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{196}" paraid="1561322540" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">I’ll repeat that this is a technical, not a legal, problem – and one that can’t be solved by local areas; it’s a national issue, effectively with IT.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{200}" paraid="1169246783" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{202}" paraid="677414866" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><u><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886">(4) </span></span><span class="TextRun Underlined BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"><span class="NormalTextRun BCX1 SCXW107060886">Supplying alcohol</span></span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></u></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{211}" paraid="1031412146" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">Finally, and briefly, supplying alcohol. Suddenly stopping drinking can have serious health risks if you are dependent on alcohol, so the PHE guidance quite rightly notes the risks of people struggling with alcohol supply in a time of COVID-19 if they’re dependent. If someone is short of funds, or self-isolating, they may struggle to get hold of alcohol, and therefore unintentionally put themselves at risk.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">Local treatment services can of course support people through this process and assess their needs, but it’s not clear from the guidance whether they’re also meant to be helping people get hold of alcohol. And if they were, there’s a downside: unlike with buprenorphine, for example, there aren’t clear processes and guidance on the ‘prescribing’ and ‘dispensing’ of alcohol. But PHE hasn’t issued any either; it’s just said people should make sure they continue to drink. Lots of areas are developing their own protocols, but these are all slightly different, meaning that there is local variation without necessarily any need. There is much more to say on this, but that’s probably enough for now: I would welcome national guidance on who is best placed to do this, and how.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<span style="font-family: inherit;"><br /></span></div>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{223}" paraid="1237055699" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">So</span><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB"> there you have it. Four policy asks:</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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<ul>
<li><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-family: inherit; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">Funding for continued payments to pharmacies</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"134233279":true,"201341983":0,"335559739":160,"335559740":259}" style="font-family: inherit; font-size: 11pt; line-height: 19.42px;"> </span></li>
<li><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-family: inherit; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">Funding for buprenorphine or similar approaches to reduce risk of overdose and COVID-19</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"134233279":true,"201341983":0,"335559739":160,"335559740":259}" style="font-family: inherit; font-size: 11pt; line-height: 19.42px;"> </span></li>
<li><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-family: inherit; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">Prioritising electronic prescribing for OST</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"134233279":true,"201341983":0,"335559739":160,"335559740":259}" style="font-family: inherit; font-size: 11pt; line-height: 19.42px;"> </span></li>
<li><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-family: inherit; font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">Policies/guidance for providing alcohol to dependent drinkers who can’t access it.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"134233279":true,"201341983":0,"335559739":160,"335559740":259}" style="font-family: inherit; font-size: 11pt; line-height: 19.42px;"> </span></li>
</ul>
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</ul>
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<div class="Paragraph BCX1 SCXW107060886" paraeid="{da6c3768-cb67-4ab0-a4cc-89225d2ef9ab}{249}" paraid="180206271" style="color: windowtext; padding-left: 0px; padding-right: 0px; vertical-align: baseline;">
<span style="font-family: inherit;"><span class="TextRun BCX1 SCXW107060886" data-contrast="auto" lang="EN-GB" style="font-size: 11pt; line-height: 19.42px;" xml:lang="EN-GB">I’m not saying we can’t do anything on these – in fact we’re working hard to take all of them forward. But they’re all areas where central government intervention could make all the difference. I don’t just mean government could make my life easier; I mean government could actively save lives.</span><span class="EOP BCX1 SCXW107060886" data-ccp-props="{"201341983":0,"335559739":160,"335559740":259}" style="font-size: 11pt; line-height: 19.42px;"> </span></span></div>
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Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-64105290373899789292020-01-16T18:37:00.003+00:002020-01-17T08:35:53.368+00:00Drug policy and scientific morality<br />
<div class="MsoNormal">
David Nutt is in the news again, talking about the dangers
of alcohol (and incidentally promoting his book).<span style="mso-spacerun: yes;"> </span>He was <a href="https://twitter.com/ProfDavidNutt/status/1217740520811831297">on Radio 5
this morning</a>, I think, but <a href="https://www.theguardian.com/society/2020/jan/16/share-a-pint-or-glass-of-wine-to-drink-safely-says-expert">this
piece in <i style="mso-bidi-font-style: normal;">The Guardian</i></a> offers a
good summary of his current position.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="https://thinking-to-some-purpose.blogspot.com/2016/04/what-do-we-mean-by-drugs.html">I’ve
written before</a> about the idea of single ‘harmful’ scores for individual
substances and how I find them unhelpful – not just because they’re simplistic,
but because they perpetuate a particular approach to drug regulation that I
think is naïve and therefore gets ignored.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But I just want to highlight a particularly odd position
David Nutt takes in this article.<span style="mso-spacerun: yes;"> </span>He
suggests that people should share a pint of beer, as just 5g a day is the ‘optimal’
dose.<span style="mso-spacerun: yes;"> </span>This is less than a UK ‘unit’, and
works out (apparently), as about 40ml of wine – less than a fifth of a large
glass you’d be served in a pub or a restaurant.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Even though it's been suggested <a href="https://twitter.com/Drug_Science/status/1217726059174617088" target="_blank">focusing on this is misleading</a>, as <a href="https://twitter.com/Riobux/status/1217780247808151553" target="_blank">it's likely to have been a throwaway comment used as an illustration</a>, <a href="https://twitter.com/ProfDavidNutt/status/1217764084478808065" target="_blank">the article has been endorsed by David Nutt</a> - and more importantly it's a revealing, and inconsistent comment.<span style="mso-spacerun: yes;"> </span>But at least it’s consistently inconsistent.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As a campaigner for drug policy reform, David Nutt
acknowledges the desire to take ‘drugs’ – indeed he proposes that rather than
seeking a world in which people don’t use alcohol, <a href="https://www.theguardian.com/science/2019/mar/26/an-innocent-drink-could-alcosynth-provide-all-the-joy-of-booze-without-the-dangers">we
actively create and regulate an alcohol-like intoxicant that is less harmful,
and allow people to use this</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Apart from the fact that this proposed ‘alcosynth’ relies on an assumption that we can create and adopt a genuinely new substance to take the
place of <a href="http://www.bbc.com/earth/story/20170222-our-ancestors-were-drinking-alcohol-before-they-were-human">something
that has been part of society since before we were human</a>, the rationale for
trying sounds like pragmatic harm reduction: acknowledge an impulse to get
intoxicated, and rather than ignoring it or pretending it can be legislated out
of existence, provide a safer way that it can be satisfied.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Yet suggesting an ‘optimal’ dose of 5g doesn’t do this.<span style="mso-spacerun: yes;"> </span>This is only ‘optimal’ if you don’t want to
be intoxicated.<span style="mso-spacerun: yes;"> </span>And here we get to the nub
of so much alcohol policy discussion: <a href="https://thepsychologist.bps.org.uk/volume-32/july-2019/everyone-has-something-add-conversation">we
bring our own preferences and prejudices</a>.<span style="mso-spacerun: yes;">
</span>An ‘optimal’ dose can only be judged by the person using it, even if we
know ‘objectively’ its effects, whether in terms of intoxication or harm.<span style="mso-spacerun: yes;"> </span>I might value my long-term health less than
other people, and I might value intoxication more highly.<span style="mso-spacerun: yes;"> </span>In which case 5g isn’t so much an ‘optimal’
dose as distinctly ‘sub-optimal’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is a strange position for a drug reformer to take.<span style="mso-spacerun: yes;"> </span>The whole basis of David Nutt’s campaign against
the current drug laws is that they have imposed some kind of moral, philosophical
or political priority (intoxication is bad) rather than listening to ‘objective’
science.<span style="mso-spacerun: yes;"> </span>But of course there is no universal,
objective cost-benefit analysis of drugs, so the language around ‘optimal’
immediately raises the spectre of one set of personal judgements – those of ‘experts’,
speaking as an oracle* – simply replacing another.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Previously, I’ve thought of this ‘rational’ approach to drug
reform as simply naïve about <a href="http://thinking-to-some-purpose.blogspot.com/2014/11/on-irrationality-of-drug-policy.html">not
only policymaking</a>, but <a href="https://thinking-to-some-purpose.blogspot.com/2016/04/what-do-we-mean-by-drugs.html">the
reality of social existence</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
To summarise, the naivety about policymaking is first that telling
politicians they’re behaving irrationally isn’t a great lobbying technique, and
second imagining that ‘harm’ is the only thing drug policy could ever be about
is misguided.<span style="mso-spacerun: yes;"> </span>Not only can we not define
‘harm’ in any practical way that acts as a guide for policymakers, but there
are plenty of other (legitimate) influences on policy other than reducing ‘harm’.<span style="mso-spacerun: yes;"> </span>Balancing freedom, economy and morality is no
mean feat.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And the naivety about social existence is simply that even
if we’d like to start from some kind of ‘year zero’ in regards to drug policy, we’re
dealing with substances that have a social history.<span style="mso-spacerun: yes;"> </span>Whether we like it or not, the fact that
alcohol has been legal and available in Britain for thousands of years makes a
difference, when it’s compared with the substances that are currently illegal.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But looking at this again, I realise there’s something else
that has troubled me about this approach, at a more emotional level.<span style="mso-spacerun: yes;"> </span>I’ve been chatting about PSHE this week at
work, and a couple of us were reminiscing about how, when we were at school,
drugs education consisted of handing out booklets that contained key
information on all the major drugs – where they tended to be available, how
much they were likely to cost, what the effects were and how long these were
likely to last.<span style="mso-spacerun: yes;"> </span>Whether you ended up
taking them or not, most people looked at that booklet and did a quick
cost-benefit analysis to see which would be their preferred drug.<span style="mso-spacerun: yes;"> </span>Perhaps not the intended response, but it
illustrates a key point for drug policy: we didn’t all agree.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I think my problem, fundamentally, with the Delphi model is
that someone else has done this cost-benefit analysis for me, and I don’t
agree.<span style="mso-spacerun: yes;"> </span>(Or perhaps more accurately, they’ve
listed the costs, but <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/add.12545">not the
pleasures that might balance them</a>.)<span style="mso-spacerun: yes;">
</span>What I’ve previously thought is naivety about policymaking or reality
is, I think, arrogance.<span style="mso-spacerun: yes;"> </span>A belief not
that government making decisions about personal pleasures is wrong, but simply
that they’re making the wrong decisions.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Back in the first few months I was writing this blog, I said
that <a href="https://thinking-to-some-purpose.blogspot.com/2013/04/alcohol-policy-and-industry.html">the
most powerful and fundamental argument the alcohol industry could make in
relation to alcohol policy would be based on liberalism</a>, not on the
technical details of research and modelling.<span style="mso-spacerun: yes;">
</span>I understand why it might help to undermine or muddy the waters of ‘public
health’ evidence, but that’s not really the fundamentals of this debate.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The same applies to drug policy reformers.<span style="mso-spacerun: yes;"> </span>The debate is fundamentally about freedom:
why should one person’s preferred drug (alcohol) be legal, while another’s
(cannabis, or MDMA) is illegal?<span style="mso-spacerun: yes;"> </span>Harm
helps frame this debate, but it can’t drive it.<span style="mso-spacerun: yes;">
</span>That’s not a question of naivety or pragmatism, but ethics.<span style="mso-spacerun: yes;"> </span>Drug policy really can’t just be about
science.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
*Hence <a href="https://en.wikipedia.org/wiki/Delphi_method">the
Delphi model</a> of research <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109763/">so favoured in
these approaches</a>.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-33275926963212157252020-01-03T16:20:00.000+00:002020-01-03T16:27:43.488+00:00Thinking beyond a spectrum of alcohol use<br />
<div class="MsoNormal">
It’s January, so I shouldn’t really be surprised there seem
to be a lot of stories about alcohol in the press and online.<span style="mso-spacerun: yes;"> </span>The particular one that’s caught my eye is <a href="https://pointsadhs.com/2020/01/02/self-help-isnt-the-solution-its-the-problem/">this
academic response to the ‘new sobriety’ movement</a>, and <a href="https://twitter.com/philmellows/status/1212760310626566144">an exchange
on Twitter</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="https://twitter.com/AlcoholChangeUK">Alcohol Change
UK</a> could claim all this as a success, given that much of this is due to the
prominence of ‘<a href="https://alcoholchange.org.uk/get-involved/campaigns/dry-january">Dry
January</a>’.<span style="mso-spacerun: yes;"> </span>(For those who aren’t aware,
this is a voluntary commitment to give up alcohol for the month of January.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Last year (<a href="https://thinking-to-some-purpose.blogspot.com/2017/01/dry-january-and-sponsored-marathon.html">as
in most years</a>) <a href="https://thinking-to-some-purpose.blogspot.com/2019/01/the-downside-of-dry-january.html">I
wrote about some of my misgivings about the campaign</a> - or rather, about how
it’s interpreted.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Perhaps most obviously, we know that the people most in need
of ‘behaviour change’ (and therefore support) tend not to undertake Dry
January, and <a href="https://s3.eu-west-2.amazonaws.com/files.alcoholchange.org.uk/documents/R.-de-Visser-Dry-January-evaluation-2019.pdf?mtime=20191221122957">if
they do then they’re less likely to complete it successfully</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One interpretation would be that this isn’t necessarily a
bad thing: stopping completely in the way Dry January implies isn’t appropriate
for some of the people most in need of support, if they’re physically dependent
on alcohol.<span style="mso-spacerun: yes;"> </span>And we shouldn’t be surprised
that the people who have the most entrenched issues find it hardest to give up –
that’s the definition of having a more serious problem.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
What’s been on my mind this year is a slightly broader interpretation
of this issue.<span style="mso-spacerun: yes;"> </span>It’s not entirely new,
but I think it’s worth highlighting. And as I do, I think it’s also worth mentioning
that, unlike last year, I’m actually doing Dry January this year.*<span style="mso-spacerun: yes;"> </span>This is absolutely not a post attacking the
campaign.<span style="mso-spacerun: yes;"> </span>The point is that I think anyone
in the field should feel obliged to use this moment of media interest to raise
wider questions around alcohol, rather than simply trumpeting the merits of ‘choosing’
to stop drinking for a month.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If you look at <a href="https://s3.eu-west-2.amazonaws.com/files.alcoholchange.org.uk/documents/R.-de-Visser-Dry-January-evaluation-2019.pdf?mtime=20191221122957">the
evaluation of Dry January</a>, it tells us what we’d expect for any similar behaviour-change
programme: successful participants (defined as completing the month without
consuming any alcohol) are most likely to be women, to have a university degree,
and to be on a higher-than-average income.<span style="mso-spacerun: yes;">
</span>They’re also more likely to report good physical health at the start of
the month.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As I say, this isn’t really a surprise.<span style="mso-spacerun: yes;"> </span>We know from other areas of public health
that <a href="https://jech.bmj.com/content/67/9/715.short">these characteristics
make people more likely to find success in these kind of campaigns based around
individual choice</a>.<span style="mso-spacerun: yes;"> </span>And that’s fine;
it’s horses for courses – some approaches will work for some people and not
others.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The danger is that those factors that make people more
likely to find behaviour change approaches helpful are exactly those that mean
they’re less at risk of harm in the first place.<span style="mso-spacerun: yes;"> </span>Because <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-2766-x">harm
from alcohol isn’t simply correlated with consumption</a>.<span style="mso-spacerun: yes;"> </span>(The ‘alcohol harm paradox’ shows that
although it’s the richest in society who tend to drink the most, it’s the
poorest who suffer the most health harm related to alcohol.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is where it gets interesting.<span style="mso-spacerun: yes;"> </span>At the same time as there have been various
pieces written about Dry January, I’ve seen a few things about ‘alcoholism’ and
the idea of a spectrum.<span style="mso-spacerun: yes;"> </span>In fact, they’re
kind of prompted by each other.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="https://twitter.com/AmyDresner">Amy Dresner</a> has
expressed <a href="https://drinkanddrugsnews.com/ddn-magazine-december-2019/">some
frustration with the ‘new sobriety’ movement</a> (which some would see Dry
January as being linked with), because it underplays how difficult just ‘choosing’
not to drink can be for those with a more serious issue – which she labels as ‘alcoholism’.<span style="mso-spacerun: yes;"> </span>I’ve written about this idea of alcoholism before,
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="https://twitter.com/jamesmorris24">James Morris</a>
has suggested that <a href="https://twitter.com/jamesmorris24/status/1212729655427510272">this perpetuates
an unhelpful alcoholic/not alcoholic binary</a>, when the reality is that
people will be facing a range of issues across a whole spectrum.<span style="mso-spacerun: yes;"> </span>Just because you don’t fit the classic definition
of ‘alcoholic’, doesn’t mean you don’t have an issue with alcohol.<o:p></o:p></div>
<div class="MsoNormal">
<blockquote class="twitter-tweet" data-lang="en-gb">
<div dir="ltr" lang="en">
I guess inevitable to some degree Dry Jan etc will be contrasted with abstinence based recovery etc. <br />
<br />
Again though this is a false binary - the 'alcoholic or not' qu. may be a default reference point but for most alternative framings need wider promotion</div>
— James Morris (@jamesmorris24) <a href="https://twitter.com/jamesmorris24/status/1212729655427510272?ref_src=twsrc%5Etfw">2 January 2020</a></blockquote>
<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>
<o:p><br /></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
What I want to suggest here is that we need to see this
spectrum as something more than a one-dimensional discussion of the severity of
alcohol issues.<span style="mso-spacerun: yes;"> </span>This has been proposed
before, with people like David Nutt saying the best way to understand
problematic substance use would be to abandon terms like ‘addiction’ or ‘alcoholism’
and simply look at ‘<a href="https://www.ncbi.nlm.nih.gov/pubmed/23926213">heavy
use over time</a>’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Currently, though, when people think about problems with alcohol,
these aren’t just about alcohol.<span style="mso-spacerun: yes;"> </span>In diagnosing
a ‘substance use disorder’ <a href="https://www.verywellmind.com/what-are-the-official-criteria-for-addiction-22493">you
might well look at consequences to someone’s home, relationship, work and so on</a>.<span style="mso-spacerun: yes;"> </span>In very few cases are these issues likely to
be solely the result of substance use.<span style="mso-spacerun: yes;"> </span>Things
can enter a vicious circle, of course (substance use might intensify as other
problems mount, as a form of escapism that only serves to make things worse).<span style="mso-spacerun: yes;"> </span>But I mean something more than that: other
issues may mean that the consequences of a particular level of alcohol use are
worse for one person compared to another.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In a strange way, the reason there’s potentially tension
between people who subscribe to a narrow definition of ‘alcoholism’ and those
who advocate ‘new sobriety’ is that they share a lot of the same ground.<span style="mso-spacerun: yes;"> </span>Alcohol is seen as absolutely crucial to
both.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
According to AA, the ‘alcoholic’ is a specific category of
person who effectively has an ‘allergy’ to alcohol, and is best living without
it entirely.<span style="mso-spacerun: yes;"> </span>According to some of ‘new
sobriety’ narratives, all the person had to do was remove alcohol from their
life and they were suddenly able to wake up early with enthusiasm for their job
(or with the passion and clarity of vision to start something completely new),
and able to buy a house, and build better relationships with friends, family
and lovers.<o:p></o:p></div>
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First, I should point out that both of these are
caricatures.<span style="mso-spacerun: yes;"> </span>In AA it’s widely accepted
that the hard work starts once you’ve stopped drinking, and there are plenty of
‘new sobriety’ style advocates who would say the same.<span style="mso-spacerun: yes;"> </span>And the reason the narratives are similar is
because often we’re talking about people who have faced the same, serious issues.<span style="mso-spacerun: yes;"> </span>As Amy Dresner points out, ‘If you CANNOT do
a full month without drinking or if your life gets exponentially better when
you stop drinking you might actually be an alcoholic’.<span style="mso-spacerun: yes;"> </span><a href="https://twitter.com/cjflood_author">Chelsey
Flood</a> and <a href="https://twitter.com/Soberistas">Lucy Rocca</a> are
particularly good examples of people who could be seen to bridge the gap
between these two camps.<o:p></o:p></div>
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<br /></div>
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But the point remains: in both narratives, alcohol is
central and fundamental.<span style="mso-spacerun: yes;"> </span>For ‘alcoholics’
there’s no life without removing alcohol, and for ‘new sobriety’ advocates’, <a href="https://www.bbc.co.uk/news/uk-england-norfolk-48367976">just removing
alcohol improves life immeasurably</a>.<o:p></o:p></div>
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And this helps explain why Dry January works for some people.<span style="mso-spacerun: yes;"> </span>Let’s go back to those successful Dry January
participants.<span style="mso-spacerun: yes;"> </span>They didn’t just tend to
be healthy, highly educated, female and well-off.<span style="mso-spacerun: yes;"> </span>They tended to believe they had a problem with
alcohol, and this was confirmed through their AUDIT questionnaire (though of
course this is dependent on self-reporting – we may each define problems and
issues in different ways).<o:p></o:p></div>
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This makes sense psychologically and sociologically: we’re
more likely to address a problem and persevere with solutions if (a) we
genuinely believe it’s serious; and (b) we have some key resources behind us (‘recovery
capital’ as they’re sometimes called) to support us.<o:p></o:p></div>
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In reality, for most of us who have issues in our lives and
who drink what some people would see as ‘too much’, the precise role of alcohol
is less clear.<span style="mso-spacerun: yes;"> </span>Perhaps I’ll be proved
wrong by the end of the month, but <a href="https://thinking-to-some-purpose.blogspot.com/2017/10/fitter-no-happier-but-more-productive.html">my
previous experience suggests</a> that I do not some hidden passion or clarity
of vision that is simply waiting to be unleashed once alcohol is removed from
my life.<span style="mso-spacerun: yes;"> </span>And I can’t see that the things
that make me angry or upset, for example, are going to be resolved by drinking
less.<o:p></o:p></div>
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But it’s about more than that: it’s that for plenty of people
you could remove the alcohol from their lives and things wouldn’t get
demonstrably better.<span style="mso-spacerun: yes;"> </span>Or it’s not just
about removing alcohol to reduce their risk of health damage.<span style="mso-spacerun: yes;"> </span>(Think of that alcohol harm paradox work.)<o:p></o:p></div>
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Therefore, if there’s an axis of ‘severity of alcohol use
disorder’ that’s relevant to problems, there could also be another axis representing
how much this is really about alcohol.<o:p></o:p></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5kg5Eq7s5o-Pd-OH9L6M5NgqZDNvkPp8SrPVFu6om9ofCs6vGMqt8wY0v8MBw7iG2hCfS9UNHtLl4csCf0k4J-7sduxAokUw8VwEQQj2HrmzJMIFFri9lh0XL5gkQZC-aAG9nOHiU77v8/s1600/IMG_20200103_153327.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5kg5Eq7s5o-Pd-OH9L6M5NgqZDNvkPp8SrPVFu6om9ofCs6vGMqt8wY0v8MBw7iG2hCfS9UNHtLl4csCf0k4J-7sduxAokUw8VwEQQj2HrmzJMIFFri9lh0XL5gkQZC-aAG9nOHiU77v8/s320/IMG_20200103_153327.jpg" width="320" /></a></div>
<br />
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What does this mean for policy and advocacy though?<o:p></o:p></div>
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It means that anyone who’s serious about reducing ‘alcohol-related
harm’ needs to think about more than just how many units people consume.<span style="mso-spacerun: yes;"> </span>This is partly about patterns of consumption,
but it’s also about wider social factors – exactly those things that make some Dry
January participants more likely to succeed than others: wider health, employment,
education, income, and so on.<o:p></o:p></div>
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This has clear implications for how we support people who do
have issues with alcohol.<span style="mso-spacerun: yes;"> </span>These can’t simply
be addressed by appealing to individual choice, or by focusing on a person’s drinking.<span style="mso-spacerun: yes;"> </span>There’s a need for services arranged around
people’s actual lives as they live them.<span style="mso-spacerun: yes;">
</span>(I’ve written about this before – for example <a href="http://thinking-to-some-purpose.blogspot.com/2017/06/who-can-buy-alcohol-service.html">here</a>
and <a href="https://thinking-to-some-purpose.blogspot.com/2019/07/local-substance-misuse-services-or.html">here</a>.)<o:p></o:p></div>
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There’s also a need for policies that address the wider
structures that shape people’s choices and their lives – something that I’ve
suggested in the past the sector has neglected, in its tendency to focus on a
single initiative, whether that’s <a href="http://thinking-to-some-purpose.blogspot.com/2014/01/mup-as-lightning-conductor.html">minimum
unit pricing</a>, alcohol labelling or Dry January.<o:p></o:p></div>
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So what does this mean for the value of Dry January?<span style="mso-spacerun: yes;"> </span>It’s potentially helpful for a lot of people
at an individual level, but for me its key contribution is about culture
change, which then provides a space for policy change.<o:p></o:p></div>
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First, it prompts everyone to think about their alcohol
consumption, and that fits perfectly with Alcohol Change UK’s admirable goal of
getting everyone to make well-informed decisions.<o:p></o:p></div>
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Second, it provides an opportunity for commentators and
policymakers to note that alcohol isn’t just any other commodity, and for all
its strengths the individual-focused approach of Dry January doesn’t work for
everyone, so we need more.<o:p></o:p></div>
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Anyone not making this case when talking about Dry January
is, in my view, missing an opportunity, and even perpetuating health
inequalities.<o:p></o:p></div>
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*Disclaimer: I did drink on 1<sup>st</sup> January, so I’ve
started late.<span style="mso-spacerun: yes;"> </span>Someone who had come to
our New Year’s Eve party had brought a ‘polypin’ of about 9 pints of locally-brewed
beer, and not all of it got drunk.<span style="mso-spacerun: yes;"> </span>My Presbyterian
heritage of ‘waste-not-want-not’ in this instance overrode the Presbyterian
tradition of temperance, and I drank the remainder on New Year’s Day in front
of the football on the TV.<o:p></o:p></div>
<br />Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com4tag:blogger.com,1999:blog-125653241615635488.post-89955281141221971412019-09-04T12:22:00.002+01:002019-09-04T12:22:45.965+01:00From pleasure to vice to addiction<br />
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I’ve been reading quite a bit of fiction and non-fiction
about substance use and ‘addiction’ lately, and some of the latest things have
sparked me to wonder if we think carefully enough, or fundamentally enough
about the issues.<o:p></o:p></div>
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I’m going to focus here on David Courtwright’s new book <a href="https://pointsadhsblog.wordpress.com/2019/07/18/points-interview-david-courtwright/"><i>The
Age of Addiction: How Bad Habits Became Big Business</i></a>, but the points
apply equally across a lot of the debate currently.<span style="mso-spacerun: yes;"> </span>Although this reads a bit like a review, I’m
trying to make a broader point that we’re sometimes not as clear as we could be
about what the problem is and how we’re trying to solve it – and this is
important if we’re going to develop effective public policy.<o:p></o:p></div>
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Courtwright’s book is a whistle-stop tour through the
history of substance use, from prehistory and the development of agriculture
through to the industrial revolution and more recent developments such as
digital technology and online markets and interactions.<span style="mso-spacerun: yes;"> </span>Although not mentioned in the title of the book,
the argument hangs on a couple of key concepts.<span style="mso-spacerun: yes;">
</span>He’s concerned with ‘vices’ and how something he calls ‘limbic
capitalism’ has made us more vulnerable to developing these.<o:p></o:p></div>
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Courtwright argues that there are parallels in the ways we
can get into trouble with different substances, whether we understand them as ‘drugs’
or not, and behaviours like sex and gambling.<span style="mso-spacerun: yes;">
</span>What start off as being ‘pleasures’ can transform into ‘vices’ and
eventually ‘addictions’.<span style="mso-spacerun: yes;"> </span>In this way,
the book is about sugary food and drink as well as gambling as much as more
familiar issues grouped under the banner of ‘addiction’ like alcohol and other drugs.<o:p></o:p></div>
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Courtwright suggests that with industrial capitalism certain
pleasures became more attractive and available, as urbanisation fostered psychological
as well as geographical disruption.<span style="mso-spacerun: yes;"> </span>For
example, drink was more available in cities, you could indulge in pleasures
with less fear of judgement as there are more anonymous spaces, and you had
more reason to as there was less social connection and the work and living conditions
were less stable and rewarding.<span style="mso-spacerun: yes;"> </span>So the
industrial age was one of vices, not mere pleasures.<o:p></o:p></div>
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But Courtwright’s warning is that we have moved beyond this
form of capitalism and its associated vices to a new form – ‘limbic’ capitalism
– and the issues emerging deserve the label of addiction, not just ‘vice’.<span style="mso-spacerun: yes;"> </span>The word ‘limbic’ refers to the ‘limbic’
system, an idea Courtwright takes from the work of people like <span style="mso-spacerun: yes;"> </span><a href="https://www.amazon.co.uk/Thinking-Fast-Slow-Daniel-Kahneman/dp/0141033576">Daniel
Kahneman</a>. The idea is that humans have two ways of acting: through rational
deliberation, making use of their ‘head’; and through more automatic
mechanisms, often labelled as a ‘gut’ reaction.<span style="mso-spacerun: yes;">
</span>It’s the ‘limbic’ system that’s responsible for the latter.<span style="mso-spacerun: yes;"> </span>(Incidentally, I think <a href="https://www.amazon.co.uk/Risk-Science-Politics-Dan-Gardner/dp/0753515539/ref=sr_1_17?keywords=risk&qid=1567088519&s=books&sr=1-17">Dan
Gardner</a> is more relevant in this context.)<o:p></o:p></div>
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Thinking about these two systems is one way of understanding
the paradox at the heart of the concept of addiction: that we can knowingly act
against our best interests.<span style="mso-spacerun: yes;"> </span>When we employ
our ‘head’ to think about things, we know a particular course of action is
unwise, and we want to avoid it; but when, in the heat of the moment, we rely
on our ‘gut’, we make a mistake – or a ‘lapse’.<o:p></o:p></div>
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Courtwright’s contention is that capitalism today is
increasingly efficient at mobilising the ‘gut’ at the expense of the ‘head’,
meaning that ‘addiction’ is more common.<span style="mso-spacerun: yes;">
</span>Examples include the formulation and marketing of unhealthy food and
drink and the design and delivery of computer games and social media through the
internet and mobile devices.<o:p></o:p></div>
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The elegance of the this argument makes it attractive, though
I would take issue with some of the claims.<span style="mso-spacerun: yes;">
</span>I don’t want this to be a comprehensive book review, so I won’t go into detail
here, but I worry that this view idealises the past and misrepresents the nature
of addiction.<o:p></o:p></div>
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Prehistoric and agricultural societies were not innocent
worlds where ‘pleasures’ never transformed into ‘vices’ – and although that isn’t
what Courtwright is saying, there’s something about the argument that suggests
there was some golden age where we had our ‘guts’ and ‘heads’ in balance.<o:p></o:p></div>
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Crucially, the ‘gut’ and ‘head’ are not entirely separate and
we can’t quite explain ‘addictive’ behaviour in this way.<span style="mso-spacerun: yes;"> </span>Representing two systems like this risks
reproducing a Cartesian mind/body dualism, which has been critiqued to death.<span style="mso-spacerun: yes;"> </span>While a Cognitive Behavioural Therapy (CBT)
approach to issues around substance use might take the approach of getting
people to actively reflect using reason, that isn’t quite the philosophy behind
other approaches that many people rely on, including Alcoholics Anonymous (AA).<span style="mso-spacerun: yes;"> </span>These approaches to recovery aren’t simply about
prioritising the ‘head’ over the ‘gut’; they’re about re-training your ‘gut’.<span style="mso-spacerun: yes;"> </span>Just as genetics and early experiences help
determine what ‘pleasures’ we are most vulnerable too, so we can ‘re-train’ ourselves
to form different tastes and habits.<span style="mso-spacerun: yes;"> </span>The
reflective can become automatic – so much so that the reformed smoker or meat-eater
can find the smell of cigarettes or frying bacon viscerally disgusting.<o:p></o:p></div>
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But in a sense that’s by the by for Courtwright’s
argument.<span style="mso-spacerun: yes;"> </span>It could still be claimed that
this is prioritising the ‘head’ in order to understand what is genuinely in our
best interests, and then we can use the ‘head’ to slowly turn round the ‘gut’.<span style="mso-spacerun: yes;"> </span>(I’m not quite convinced by this; encouragement
to fake it till you make it and just keep attending meetings don’t feel exactly
‘rational’, or something the ‘head’ can entirely justify.)<o:p></o:p></div>
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But more important than these details are the issues of language
and concepts.<span style="mso-spacerun: yes;"> </span>Courtwright isn’t exactly
clinical in defining what makes an erstwhile pleasure a ‘vice’ or ‘addiction’.<span style="mso-spacerun: yes;"> </span>I suppose he would say that a vice is an indulgence
in a perhaps fleeting pleasure where, at least in the long run, either you or
someone else around you is harmed, and this can be understood as an ‘addiction’
where there is some sense of compulsion.<o:p></o:p></div>
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And perhaps this lack of clarity is forgivable in what is
essentially a book outlining a grand narrative.<span style="mso-spacerun: yes;">
</span>At some level my frustration with this is simply a matter of personal
style and preference.<span style="mso-spacerun: yes;"> </span>The sort of books
and authors Courtwright is drawing on don’t do a lot for me – Kahneman, <a href="https://en.wikipedia.org/wiki/The_Better_Angels_of_Our_Nature">Steven Pinker</a>,
<a href="https://en.wikipedia.org/wiki/Sapiens:_A_Brief_History_of_Humankind">Yuval
Noah Harari</a>, <a href="https://en.wikipedia.org/wiki/Nudge_%28book%29">Thaler
and Sunstein</a> and so on.<span style="mso-spacerun: yes;"> </span>For me, too
much gets lost in the grand sweep of the arguments, and they often include
errors or oversights.<o:p></o:p></div>
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But it’s also a question about the purpose of these
discussions (and these kinds of books).<span style="mso-spacerun: yes;">
</span>Courtwright is writing because he’s concerned about trends in behaviour,
and the economic and political forces that are moulding these.<span style="mso-spacerun: yes;"> </span>The book ends for a call for us to avoid ‘excess’,
both in enjoying pleasures and in our politics.<span style="mso-spacerun: yes;">
</span>(I’m sure some members of <a href="https://drinkingstudies.wordpress.com/research-clusters-2/understanding-excess/">the
Drinking Studies Network</a> would have plenty to say on this.)<o:p></o:p></div>
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Maybe it’s my personal baggage, but it all feels a bit ‘<a href="https://www.theguardian.com/commentisfree/2017/oct/04/centrist-dad-labour-corbyn-neoliberal">centrist
dad</a>’, like a cry for us to grow up and become ‘rational’ adults.<span style="mso-spacerun: yes;"> </span>I felt like I was being told to drink less,
go to bed earlier, and probably vote Lib Dem.<o:p></o:p></div>
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The thing is, that isn’t necessarily ‘rational’ for
everyone.<span style="mso-spacerun: yes;"> </span>One person’s pleasure is
another’s vice.<span style="mso-spacerun: yes;"> </span>The key question is how to
define and police the boundaries between these categories of pleasure/vice/addiction.<span style="mso-spacerun: yes;"> </span>Can we?<span style="mso-spacerun: yes;">
</span>Should we?<o:p></o:p></div>
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If this is a call for a return to classical liberalism, we
can’t be sure how we should regulate pleasure.<span style="mso-spacerun: yes;">
</span>A reliance on single word like ‘excess’ cannot resolve the fundamental
tensions in liberal thought, even if we could all agree to call ourselves
‘liberals’.<span style="mso-spacerun: yes;"> </span>Think of <a href="http://undercurrentphilosophy.com/long/philosophy-of-alcohol-in-conversation-with-dr-james-nicholls/">TH
Green and JS Mill arguing in the nineteenth century about what the truly
liberal position on alcohol was</a>.<span style="mso-spacerun: yes;">
</span>When, where and how can lines be drawn defining competence, capacity,
freedom and harm?<span style="mso-spacerun: yes;"> </span>You might think I
drink too much, but who can genuinely judge that apart from me?<span style="mso-spacerun: yes;"> </span>What if I know the risks and I think what you
might consider ‘excessive’ is actually perfectly balanced?<o:p></o:p></div>
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This might sound a bit abstract and overblown, but I want to
illustrate that these are real, live and important issues for practice and
policy at the moment.<o:p></o:p></div>
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First, let’s look at some of the things Courtwright seems to
define as vices.<span style="mso-spacerun: yes;"> </span>For example, he seems
to worry about young people having no-strings-attached sex in the gap between
high school and college (p.203), which, in itself, I can see little problem
with.<span style="mso-spacerun: yes;"> </span>The devil is, of course, in the
detail of safety and consent – but that’s more complicated than condemning this
kind of experience in itself.<o:p></o:p></div>
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Oddly he worries: ‘Me-not-them remains a popular game.<span style="mso-spacerun: yes;"> </span>Try vaping instead of smoking.<span style="mso-spacerun: yes;"> </span>Try cannabis for pain instead of opioids …
Disney lobbied to keep casinos from competing for tourist dollars in its
Florida backyard.<span style="mso-spacerun: yes;"> </span>Yet it hired
sommeliers to recommend wines in its restaurants’ (p.231).<span style="mso-spacerun: yes;"> </span>None of these particularly worries me.<span style="mso-spacerun: yes;"> </span>They sound like reasonable, pragmatic
approaches that could well lead to more positive outcomes.<span style="mso-spacerun: yes;"> </span>I’m not unquestioningly in favour, but I’d
need a bit more persuasion from Courtwright to understand why each of them is a
bad idea.<o:p></o:p></div>
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Courtwright even seems to suggest that banning e-cigarettes
can be considered an ‘achievement’; a statement that itself would worry many
public health professionals, let alone liberals.<o:p></o:p></div>
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Behind each of these statements are fundamental questions
about what ‘the good life’ looks like.<span style="mso-spacerun: yes;">
</span>Courtwright, for example, praises ‘mercantile and industrial capitalism’
for fostering ‘self-discipline, future orientation, and efficient time
management’ (p.210) as if these are all unquestionable virtues.<span style="mso-spacerun: yes;"> </span>As if they don’t exist on the same kind of
spectrum as pleasure/vice/addiction.<span style="mso-spacerun: yes;"> </span>Surely
not all those writing during the industrial revolution would have agreed with the
claim that ‘Innovation and competition, however fair and orderly, tend to make
the social consequences of improved production worse, not better’ (p.226).<o:p></o:p></div>
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He therefore also seems to dodge the implicit question about
<a href="https://people.kth.se/~gryne/papers/OldWine_2012.pdf">the ethics of
‘nudging’ people into different behaviours</a>, uncritically noting that certain
environments ‘work for us instead of against us’ (p.228).<span style="mso-spacerun: yes;"> </span>Who decides what’s ‘for’ us and what’s
‘against’?<span style="mso-spacerun: yes;"> </span>How?<o:p></o:p></div>
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At root, we have a view that emphasises the value of rationality.<span style="mso-spacerun: yes;"> </span>But there are two key problems with
that.<span style="mso-spacerun: yes;"> </span>First, there is no single
definition of a ‘rational’ decision.<span style="mso-spacerun: yes;"> </span>For
example, Courtwright states that when Zadie Smith gave up Facebook to help her
concentrate on writing a novel ‘She was wise to do so’ (p.209).<span style="mso-spacerun: yes;"> </span>Perhaps, but how can we know?<span style="mso-spacerun: yes;"> </span>And would we all be wise to do so?<span style="mso-spacerun: yes;"> </span>There are plenty of people who have been
inspired or supported by Facebook; even supported to give up their
‘addictions’.<span style="mso-spacerun: yes;"> </span>How can we develop a
general policy position on a medium like Facebook?<o:p></o:p></div>
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Second, constant rationality is not always productive –
either for individuals or societies.<span style="mso-spacerun: yes;">
</span>There is a reason that feasts and holidays were endorsed by rulers and
ruled alike.<o:p></o:p></div>
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Is it that ‘vices’ hold real risks, or are they somehow
imagined?<span style="mso-spacerun: yes;"> </span>It seems to me that
‘self-control’ is valued not because the consequences of uncontrolled behaviour
are risky, but simply because they are (in some people’s eyes at least) somehow
irrational.<span style="mso-spacerun: yes;"> </span>Well indeed, <a href="https://volteface.me/feature/carnivalesque-will-haydock/">that is
precisely the point</a>.<o:p></o:p></div>
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Perhaps it could be argued that so long as not too much harm
is involved, then activities could still be classed as ‘pleasures’ (or perhaps ‘vices’)
rather than ‘addictions’.<span style="mso-spacerun: yes;"> </span>And yet if
they are not rational, how can they still be classified in this way?<span style="mso-spacerun: yes;"> </span>How can we then draw appropriate lines
between them?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If this still sounds like an abstract and indulgent academic
argument, think of how we regulate e-cigarettes, the night-time economy or
alcohol more broadly.<span style="mso-spacerun: yes;"> </span>If vaping is
somehow seen as a vice, not to be encouraged, this has serious implications for
public health and smoking cessation<span style="mso-spacerun: yes;">
</span>policy.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If we are not able to define clearer boundaries between ‘vice’
and ‘addiction’, then we will struggle to support people who have issues with
heavy drinking. <span style="mso-spacerun: yes;"> </span>As health professionals wrestle
with the issue of why such a small percentage of people who drink heavily
access support, there are plenty of people suggesting that we need a more
nuanced approach to ideas of mental capacity and consent, arguing that, at a
certain stage, we can define heavy drinkers as acting so irrationally against
their best interests that they cannot sensibly be said to have mental capacity
to make informed, rational decisions about their own welfare.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Without clearer thinking and writing, we won’t get closer to
resolving these questions and developing policy solutions.<span style="mso-spacerun: yes;"> </span>David Courtwright has offered an interesting
and engaging contribution to the discussion, but for me he raised more questions than he answered.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-31801268665415985042019-08-30T13:07:00.003+01:002019-09-01T12:05:24.136+01:00Has substance misuse treatment been moved out of the NHS?<br />
<div class="MsoNormal">
I’ve been struck recently by the number of articles and
comments lamenting the state of substance misuse treatment in the UK (and
England specifically), and the fact that some of the problems and solutions
identified seem to be missing the point.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Two of the clearest pieces have actually been written by the
same person, <a href="https://www.southampton.ac.uk/warc/members/julia-sinclair.page">Julia
Sinclair</a>, for two different outlets – the <i><a href="https://blogs.bmj.com/bmj/2019/08/23/julia-sinclair-drastic-cuts-and-disconnected-services-are-fuelling-surge-in-drug-related-deaths/">BMJ
Online</a></i> and <i><a href="https://www.mentalhealthtoday.co.uk/blog/professionals/addiction">Mental
Health Today</a></i>.<span style="mso-spacerun: yes;"> </span>It’s not exactly a
torrent of articles, and although this post is a bit of a rant, I should be
clear that it’s not aimed at Julia; I have a lot of time for her critique of
the state we’re in.<span style="mso-spacerun: yes;"> </span>It’s more that her
comments have stirred up some frustrations I have with the wider debate about
the commissioning and provision of substance misuse treatment services.<span style="mso-spacerun: yes;"> </span>You’ll need to judge whether I’m missing the
point myself!<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Fundamentally, the argument runs that people who use drugs
are getting a poor service from treatment, and this is due not only to budget
cuts but also the separation of mental health services from substance misuse,
which is the result of local authority commissioning which has taken substance
misuse treatment out of the NHS.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
First off, I want to acknowledge that I actually agree with
a lot of the substance of this critique.<span style="mso-spacerun: yes;">
</span>Budgets have been cut substantially, treatment is often not as accessible
as it should be, provision of opioid substitution treatment isn’t always
delivered in line with guidelines, and links with mental health support can be
poor.<span style="mso-spacerun: yes;"> </span>And I don’t want to enter into an
argument about whether the NHS or third sector organisations are good or bad.<span style="mso-spacerun: yes;"> </span>Or whether substance misuse commissioning would
be somehow ‘safer’ in the NHS.<span style="mso-spacerun: yes;"> </span>That’s
been well covered before (see <a href="https://jimmcmanus.wordpress.com/2018/06/13/sending-public-health-back-to-the-nhs-the-comfort-of-false-counsel/">here</a>
and <a href="https://gregfellpublichealth.wordpress.com/2018/09/01/the-public-health-function-should-be-moved-back-to-the-nhs/">here</a>).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My point is simply that if we are going to try to improve
services, then we need to be able to diagnose the problem accurately, and that
means learning from the past, rather than idealising and misunderstanding the
arrangements that were in place.<span style="mso-spacerun: yes;"> </span><a href="https://thinking-to-some-purpose.blogspot.com/2017/06/new-directions-and-dangers-of.html">As
I often argue on this blog</a>, I think this is less about structures (where
budgets sit, which organisation commissions, which organisation provides) and
more about getting the right people doing the right work.<span style="mso-spacerun: yes;"> </span>That’s the hard bit.<span style="mso-spacerun: yes;"> </span>It’s pretty straightforward (and even neat,
logical and rewarding) to run a procurement process or take a position on a grand
policy issue, but it’s harder to actually ensure that staff are getting
appropriate clinical supervision and engaging in reflective practice, for
example.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So what about that history?<span style="mso-spacerun: yes;">
</span>What is it and why does it matter?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Well, the narrative from the articles (and plenty of other
people I encounter in person, from politicians to frontline practitioners) is
that before 2013 and the public health reforms, we lived in a world where there
was a budget held by the NHS, which was used to fund NHS organisations to deliver
high-quality, well-integrated substance misuse and mental health care.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I don’t want to speak for every person, organisation or
area, so I’ll just focus on my own experience.<span style="mso-spacerun: yes;">
</span>None of these points is accurate.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
Prior to 2013, in Dorset, Bournemouth and Poole we had one
PCT (though only recently – there had been several in the recent past, all with
different approaches to substance misuse which persisted).<span style="mso-spacerun: yes;"> </span>This did indeed fund the local community
health trust to deliver various bits of substance misuse treatment – an
inpatient detox unit in the east of the county, prescribing teams and shared
care nurses, as well as funding shared care arrangements with GPs who wanted to
be involved (which was a bit hit and miss).<span style="mso-spacerun: yes;">
</span>The provision available, though, wasn’t just about the ‘substance misuse’
commissioning; in the west, where there was no inpatient unit, we had use of
mental health beds for detoxes, though of course the input to that wasn’t quite
the same.<span style="mso-spacerun: yes;"> </span>(We lost the use of those beds
while the same trust provided both mental health and substance misuse services.<span style="mso-spacerun: yes;"> </span>Cuts to mental health budgets drove that,
independent of commissioning responsibilities or budgets in substance misuse.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But this NHS work wasn’t the only provision locally.<span style="mso-spacerun: yes;"> </span>And crucially the funding for that NHS
provision had nothing to do with the ‘pooled treatment budget’ (PTB) handed out
by the National Treatment Agency.<span style="mso-spacerun: yes;"> </span>Neither
did the social work input to those teams, provided directly by the local
authorities.<span style="mso-spacerun: yes;"> </span>Neither did the housing
provision or ‘supporting people’ work sometimes provided by organisations that
also delivered substance misuse support.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Setting aside data concerns, the NTA was part of the story through
the three Drug and Alcohol Action Teams (DAATs) locally that were hosted by the
three local authorities.<span style="mso-spacerun: yes;"> </span>These commissioned
various organisations (incidentally all third sector) to provide things like
harm reduction, group work, criminal justice interventions (DIP), and aftercare.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So we were doing local authority commissioning of the third sector
well before 2013.<span style="mso-spacerun: yes;"> </span>In fact, when people
talk about ‘the sector’, they’re generally talking about that era of 2001-2013
when there was increasing funding available – and organisations like CRI (as
was), Turning Point and Addaction grew dramatically.<span style="mso-spacerun: yes;"> </span>Not the NHS.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(If you’re interested in the history of the third sector in
providing substance misuse treatment, it’s worth looking at the work of <a href="https://www.lshtm.ac.uk/aboutus/people/mold.alex">Alex Mold</a>,
particularly <a href="https://www.vssn.org.uk/paper/from-the-alternative-society-to-the-big-society-voluntary-organisations-and-drug-services-in-britain-1960s-2010s/">this
article</a>.<span style="mso-spacerun: yes;"> </span>There’s a long history that
doesn’t start in 2013 or even 2001.<span style="mso-spacerun: yes;"> </span>And
the NTA’s successor, PHE, has actually written a good history of drug use and treatment
in England – see <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/586111/PHE_Evidence_review_of_drug_treatment_outcomes.pdf">chapter
1 here</a>.)<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
This patchwork provision, I’m afraid to say, was not seamless
and certainly not flawless.<span style="mso-spacerun: yes;"> </span>And the
issues weren’t simply with the third sector communicating with the NHS.<span style="mso-spacerun: yes;"> </span>Even within the same organisation there were
issues with ensuring people received the right care, at the right time, in a coordinated
way.<span style="mso-spacerun: yes;"> </span>Having had discussions with mental
health professionals in the last couple of years about how we can improve links
between the two services (now provided by different organisations), I have
heard some world-weary complaints about how ‘we’ve been talking about this for
20 years or more, and nothing ever changes’.<span style="mso-spacerun: yes;">
</span>So much for this being better when it was ‘all in the NHS’.<o:p></o:p></div>
<div class="MsoNormal">
<blockquote class="twitter-tweet"><p lang="en" dir="ltr">It was crap in 1982 and its still crap now. All you hear is people at conferences saying how the two need to work together. More like 40 years than 20, certainly more than 6.</p>— John Divney (@JohnDivney) <a href="https://twitter.com/JohnDivney/status/1164152361511772161?ref_src=twsrc%5Etfw">August 21, 2019</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script>
<br />
And in fact it is still, as much as it ever was, in
the NHS.<span style="mso-spacerun: yes;"> </span>The prescribing services may no
longer be provided by GPs or the local community health trust, but they are
provided by another NHS trust – in fact, one with a specialism in mental
health.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
But I’m overplaying the position taken in those particular
articles.<span style="mso-spacerun: yes;"> </span>Julia calls for a ‘return to
joint NHS and local authority commissioning of addiction services’; it’s just
the blunt phrase ‘addiction services were moved out of the NHS into local
authorities in 2013’ that gets my back up, as this suggests that everything
went wrong when things moved out of the NHS – only most things weren’t in the NHS
anyway, and those that were are still often delivered by the NHS.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We have some structures for joint commissioning still, but I’d
accept those could be more proactive in driving genuinely joined up work.<span style="mso-spacerun: yes;"> </span>But equally let’s not kid ourselves that DAATs
were some ideal world.<span style="mso-spacerun: yes;"> </span>My experience was
that they were seen as a decision-making body for the local authority element
(and we were generally able to get committee agreement for our proposals),
while the NHS (PCT) saw itself as being bound by its own processes, not the
DAAT Board.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For me, the issue isn’t that addiction services have been
taken out of the NHS.<span style="mso-spacerun: yes;"> </span>When Julia worries
that ‘addiction services are now often disconnected from wider health and care
services’ we’re more in agreement.<span style="mso-spacerun: yes;"> </span>That
word ‘care’ us crucial here, and highlights that the fundamental issue isn’t
about organisational boundaries and responsibilities.<span style="mso-spacerun: yes;"> </span>Despite nominally being part of local
authorities, my experience is that public health commissioning and social work
provision are more separated than they were before 2013.<span style="mso-spacerun: yes;"> </span>We’ve lost those embedded social workers
(though particularly in Dorset Council some of those staff are doing different,
but extremely valuable work related to substance use).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The loss of those embedded social workers, just like the
loss of the mental health beds, isn’t down to commissioning responsibilities.<span style="mso-spacerun: yes;"> </span>How could it be if hosting commissioning in one
organisation is a solution?<span style="mso-spacerun: yes;"> </span>It’s all
part of the local authority…<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
In reality, <a href="https://thepsychologist.bps.org.uk/volume-32/july-2019/threadbare-patchwork-support">it’s
down to all organisations being squeezed and choosing, as a result, to focus on
‘core business’</a>.<span style="mso-spacerun: yes;"> </span>And substance use
isn’t seen as core business by anyone but public health teams (<a href="https://thinking-to-some-purpose.blogspot.com/2013/08/addiction-medicine-and-local-public.html">and
even then it’s questionable</a>).<span style="mso-spacerun: yes;"> </span><a href="https://thinking-to-some-purpose.blogspot.com/2017/09/principles-and-pragmatism-we-need-to.html">Don’t
imagine it was seen as ‘core business’ and the budget didn’t get raided before
2013</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The challenge isn’t where these responsibilities sit; it’s
getting the right people to talk to each other, in the right way, at the right
time.<span style="mso-spacerun: yes;"> </span>As we all know, that can just as
hard within a single organisation as across them.<span style="mso-spacerun: yes;"> </span>Sometimes it’s actually easier across
organisations because people aren’t competing or jockeying for position.<span style="mso-spacerun: yes;"> </span>But that, like all of this, depends on
circumstances.<span style="mso-spacerun: yes;"> </span>Let’s not imagine we can
find a solution in structures.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-41070068001226177812019-07-09T12:32:00.002+01:002019-07-09T12:43:58.877+01:00Why secondhand drinking isn't like secondhand smoke<br />
<div class="MsoNormal">
<a href="https://www.theguardian.com/society/2019/jul/08/how-secondhand-drinking-ruins-lives-every-family-has-been-touched-by-this">This
week the Guardian have published a piece highlighting the indirect harms that
can arise from drinking</a>.<span style="mso-spacerun: yes;"> </span>This is
important stuff that should be more prominent in alcohol policy debates.<span style="mso-spacerun: yes;"> </span>Too often, issues around alcohol policy drift
into the classic libertarian territory of saying that it’s simply someone’s
individual choice what they put into their body.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This position neglects two key points.<span style="mso-spacerun: yes;"> </span>First, decisions are made in specific
contexts that have been designed, consciously or not, by policy.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Second, our decisions have impacts on other people; no man
is an island.<span style="mso-spacerun: yes;"> </span><a href="http://undercurrentphilosophy.com/long/philosophy-of-alcohol-in-conversation-with-dr-james-nicholls/">The
classical liberal debates about alcohol</a> aren’t simply about whether alcohol
enslaves the individual drinker, as JS Mill put it, but also in terms of his ‘harm
principle’: do your actions harm those around you?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The article in the Guardian lays out quite clearly some
potential harms from other people’s drinking: violence, drink driving, neglect,
abuse, and so on.<span style="mso-spacerun: yes;"> </span>And Ian Gilmore makes
what seems an obvious comparison with passive smoking.<span style="mso-spacerun: yes;"> </span>Indeed it’s referred to as ‘secondhand smoke’,
and the title of the article refers to secondhand drinking.<span style="mso-spacerun: yes;"> </span>We’ve been here before.<span style="mso-spacerun: yes;"> </span>In 2009 Liam Donaldson referred to ‘<a href="https://www.telegraph.co.uk/news/health/news/5000433/Passive-drinking-is-blighting-the-nation-Sir-Liam-Donaldson-warns.html">passive
drinking</a>’, though the concept didn’t get much traction.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I should be clear that I think discussing these very real
and serious harms is important, and can – indeed should – reshape our debates
about alcohol policy. <span style="mso-spacerun: yes;"> </span>However, this analogy
worries me, <a href="https://thinking-to-some-purpose.blogspot.com/2013/03/the-first-post.html">for
all the usual reasons I write about on this blog</a>.<span style="mso-spacerun: yes;"> </span>We need clarity and honesty from messengers on
this issue for two reasons.<span style="mso-spacerun: yes;"> </span>First, you
want to protect your reputation as a messenger for being open and truthful.<span style="mso-spacerun: yes;"> </span>Second, and much more importantly, you actually
want to generate the best policy solutions, which means being clear about what
exactly the problem is.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For ‘passive’ or ‘secondhand’ drinking, the problem is
qualitatively different from ‘passive’ or ‘secondhand’ smoke.<span style="mso-spacerun: yes;"> </span>If we base our solutions for alcohol simply on
analogy with tobacco, we’ll make some serious mistakes, as they’re quite
different drugs, perceived quite differently, that play different roles in our
society.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Crucially, the danger with passive smoking is in the
substance itself: someone else is exposed to the toxins in the smoke.<span style="mso-spacerun: yes;"> </span>This is the key justification for the smoking
ban: you physically need to separate non-smokers from smoke to reduce their risk
of developing certain health issues.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For alcohol, this does not happen.<span style="mso-spacerun: yes;"> </span>A child might access a parent’s alcohol, for
example, but this is not ‘passive drinking’; it’s actual drinking.<span style="mso-spacerun: yes;"> </span>The harm comes not directly from the substance,
but indirectly through the person using it.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As the Guardian piece points out, there are all sorts of
harms that are related to alcohol.<span style="mso-spacerun: yes;"> </span>However,
these are quite different to those related to tobacco.<span style="mso-spacerun: yes;"> </span>People in smoking areas tend not to start fights
after they’ve had just a few cigarettes.<span style="mso-spacerun: yes;">
</span>People tend not to fail to get the children to school because they’ve
been busy smoking too many cigars the night before.<span style="mso-spacerun: yes;"> </span>You don’t have a few pipes of tobacco and
become incapable of driving safely.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
To be fair, I think Ian Gilmore knows this.<span style="mso-spacerun: yes;"> </span>He explains that the smoking ban, which he
sees as a positive policy intervention, was only possible as a result of
increasing awareness amongst policymakers and the public that secondhand smoke
is bad for your health.<span style="mso-spacerun: yes;"> </span>But he then
recommends a completely different policy solution for ‘secondhand drinking’:
increasing duty, and therefore the price.<span style="mso-spacerun: yes;">
</span>This is genuinely analogous to tobacco – but analogous to an intervention
introduced to reduce harm to the smoker, not those around them.<span style="mso-spacerun: yes;"> </span>The idea is that higher taxes both reduce
consumption and enable society to pay for the treatment of health conditions of
those who do continue to smoke (though the cost-benefit analysis of the latter
point is much debated).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
What Gilmore is really doing is being disingenuous, or more
generously being a pragmatic lobbyist.<span style="mso-spacerun: yes;"> </span>He
states: “Secondhand smoking [as a concept] really changed public opinion and
paved the way for legislation to make bars and public places smoke-free.”<span style="mso-spacerun: yes;"> </span>Here he is stating his lobbying approach.<span style="mso-spacerun: yes;"> </span>He wants to establish secondhand drinking as
a concept in public opinion so that different policy solutions are contemplated.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And this is fine by me.<span style="mso-spacerun: yes;">
</span>If we define the problem differently (it’s not just about harm to the individual
drinker, but the people around them too) then it’s reasonable we should
consider different policies to address this.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The problem is that tobacco is a poor comparison because of
what causes problems and what it’s place in society is.<span style="mso-spacerun: yes;"> </span>And in pragmatic terms this is important not just
because we want to have accurate descriptions of reality, but because lobbyists
want to use the right tactics.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But for the moment let’s just focus on the reality.<span style="mso-spacerun: yes;"> </span>Most of the problems with tobacco are about
tobacco.<span style="mso-spacerun: yes;"> </span>If you replace the tobacco smoke
with other ways of getting the actual drug – nicotine – then <a href="https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update">suddenly
much of the harm (to others as well as the person using) disperses too</a>.<span style="mso-spacerun: yes;"> </span>When we’re talking about bans on e-cigs, we’re
in the slightly trickier territory of <a href="http://sqapo.com/mill.htm">JS
Mill’s use of the word ‘nuisance’ rather than his clearer idea of ‘harm’</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="https://thinking-to-some-purpose.blogspot.com/2019/07/local-substance-misuse-services-or.html">As
I wrote last week</a>, many of the problems related to alcohol are not neatly
about alcohol.<span style="mso-spacerun: yes;"> </span>We can take the substance
away and still not resolve the underlying issues.<span style="mso-spacerun: yes;"> </span>A reductive focus simply on price and
availability will not serve those who still end up drinking – and those around
them.<span style="mso-spacerun: yes;"> </span>When we discuss the harm of ‘secondhand
drinking’ we need to be thinking about treatment, culture, education, social
support, wider resources.<span style="mso-spacerun: yes;"> </span>I worry that
the analogy with tobacco leads people to a narrow set of ‘solutions’.<span style="mso-spacerun: yes;"> </span>Gilmore states: “[With cigarettes] we have
relentlessly pushed the price up. <span style="mso-spacerun: yes;"> </span>Quietly,
but relentlessly. <span style="mso-spacerun: yes;"> </span>And that’s made a huge
impact. <span style="mso-spacerun: yes;"> </span>The UK is the leading European
country in reducing smoking rates.”<span style="mso-spacerun: yes;"> </span>The analogy
remains and the conversation comes back to price.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
‘Passive drinking’ never caught on as a concept.<span style="mso-spacerun: yes;"> </span>Maybe ‘secondhand drinking’ will, but it needs
to mean something more than an analogy with smoking, otherwise the public and
policymakers will, quite rightly, see through it.<span style="mso-spacerun: yes;"> </span>We can do better than this.<span style="mso-spacerun: yes;"> </span>Let’s be open and honest about this issue (as
most of the Guardian piece is), and work from that to realistic, sensible policy
interventions.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com2tag:blogger.com,1999:blog-125653241615635488.post-59475890062169082792019-07-03T13:48:00.000+01:002019-07-03T13:48:22.943+01:00There but for the grace of God<br />
<div class="MsoNormal">
Over the past few weeks, and in <a href="http://thinking-to-some-purpose.blogspot.com/2019/07/local-substance-misuse-services-or.html" target="_blank">my previous blog post</a>, I’ve
been debating how we can best think about the support our sector tries to
offer.<span style="mso-spacerun: yes;"> </span>Sometimes this is about
structures of oversight and how different services are divided up, but I’m
frequently reminded of the possibly trickier issues of funding and stigma.<span style="mso-spacerun: yes;"> </span>In this post I want to suggest they’re all
potentially linked.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
As I say, I’ve been thinking about targeted support and
stigma a lot recently.<span style="mso-spacerun: yes;"> </span>It’s the old
issue of how you can offer targeted support to those who need it most, without
creating a perception of them somehow being less than ‘normal’ people – a
perception that will quite possibly make people less likely to seek out that
support, as doing so would identify them as ‘in need’ or ‘at risk’.<o:p></o:p></div>
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<br /></div>
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This is a standard social policy issue, applied to school
meals, university fees, child benefit, and so on.<span style="mso-spacerun: yes;"> </span>In general terms, the argument would be that
since the 1980s we have seen a move away from these approaches to something
more targeted.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
While there are potentially issues with this ‘targeting’ approach,
the logic makes sense, and to a certain extent it’s unavoidable.<span style="mso-spacerun: yes;"> </span>If we have limited resources, we have to ask
how we can prioritise different issues or individuals.<span style="mso-spacerun: yes;"> </span>This might seem to have become more severe
during a period of austerity, but it’s not an issue that goes away: if we get
an increase in funding, there will always be more worthy causes and good ideas
than it can support.<o:p></o:p></div>
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<br /></div>
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But I’ve been conflating two ideas here: targeting issues
and targeting people.<o:p></o:p></div>
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<br /></div>
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We will always have to balance up different initiatives or
issues.<span style="mso-spacerun: yes;"> For example, a</span>re we more concerned about TB
or measles as infectious diseases at the moment?<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
Think of this as comparable to when you move house.<span style="mso-spacerun: yes;"> </span>You might well debate whether to redo the
bathroom or kitchen first – or perhaps at the time it’s more of a priority to
repaint a few other rooms.<span style="mso-spacerun: yes;"> </span>Most of us
don’t have the time or money to do everything at once.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
That happens in all departments and policy areas.<span style="mso-spacerun: yes;"> </span>We live in a finite world.<o:p></o:p></div>
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<br /></div>
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So why am I worried about stigma?<o:p></o:p></div>
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<br /></div>
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Well, targeting issues is not the same as targeting people.<span style="mso-spacerun: yes;"> </span>(And even targeting issues can cause stigma
if we see those issues as only relating to certain people.)<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
Let’s compare the attitude to prevention for measles and
cervical cancer.<span style="mso-spacerun: yes;"> </span>Both are prevented
through vaccination, and there have been issues with ensuring coverage of both
– but for quite different reasons, I would suggest.<span style="mso-spacerun: yes;"> </span>The MMR scare has been well-documented.<span style="mso-spacerun: yes;"> </span>The issue there is seen as being in the
vaccination itself.<span style="mso-spacerun: yes;"> </span>Some people perceive
it as risky.<o:p></o:p></div>
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<br /></div>
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The issue with the HPV vaccine (though it doesn’t seem to be
talked about much anymore) was that this was a sexually transmitted virus and
so <a href="https://www.theguardian.com/science/blog/2016/jan/11/why-is-there-opposition-hpv-vaccine-cervical-cancer">there
was some concern</a> that admitting to needing it was an acknowledgement that
you, or perhaps more accurately your daughters, were likely to have unprotected
sex.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
The framing of this as a population issue helped get us over
this: the vaccination is just something that health professionals recommend for
everyone, to reduce our risk at a population level.<span style="mso-spacerun: yes;"> </span>This is framed as leading to ‘community
immunity’ as some people call it (to avoid thinking of people as a ‘herd’).<o:p></o:p></div>
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<br /></div>
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So what’s this got to do with alcohol?<span style="mso-spacerun: yes;"> </span>Well this is again that old issue of whether
‘the problem’ resides in the substance (alcohol is ‘no ordinary commodity’ – a
carcinogen, a toxin or a poison) or the person (‘I am an alcoholic’).<span style="mso-spacerun: yes;"> </span><a href="https://thinking-to-some-purpose.blogspot.com/2018/09/lets-have-end-to-tall-tales-about.html">I’ve
written about this before</a>, and my usual get-out is that there are as many
problems related to alcohol as there are individuals experiencing them.<span style="mso-spacerun: yes;"> </span>We therefore shouldn’t search for a single
diagnosis or solution.<o:p></o:p></div>
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<br /></div>
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But this doesn’t really help policymaking in lots of
contexts.<span style="mso-spacerun: yes;"> </span>Saying ‘it’s complicated’ (or
more likely in policymaking circles ‘complex’, ‘multifactorial’ or ‘wicked’)
doesn’t get us very far.<span style="mso-spacerun: yes;"> </span>What are we
going to actually do about that complexity?<span style="mso-spacerun: yes;">
</span>(Actions speak louder than words.<span style="mso-spacerun: yes;">
</span><a href="https://www.theage.com.au/national/victoria/you-talk-we-die-abbotsford-mural-calls-for-action-on-safe-injecting-rooms-20170822-gy1l16.html" target="_blank">You talk, we die</a>.)<o:p></o:p></div>
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<br /></div>
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This is particularly acute when we know that, <a href="https://alcoholchange.org.uk/publication/understanding-the-alcohol-harm-paradox">even
controlling for the total amount of alcohol consumed, different groups of
people experience different levels of harm</a>.<span style="mso-spacerun: yes;">
</span>This is partly due to certain protective factors and differences in patterns
of consumption, but it’s also because risks don’t seem to just add together,
they multiply.<span style="mso-spacerun: yes;"> </span>Drinking and smoking and
low levels of physical activity combine to make a particularly toxic
combination for a range of health risks.<o:p></o:p></div>
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<br /></div>
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I say ‘different’ groups of people.<span style="mso-spacerun: yes;"> </span>I mean class.<span style="mso-spacerun: yes;">
</span>People from more deprived areas face higher levels of alcohol-related
health harm even though, on average, they’re drinking less.<o:p></o:p></div>
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<br /></div>
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What can we do about this?<span style="mso-spacerun: yes;">
</span>And what can we do about the fact that dependent drinkers are not a particularly
popular group, and people find it hard to say ‘there but for the grace of God
go I’?<span style="mso-spacerun: yes;"> </span>Is this difficulty in
identifying with ‘alcoholics’ partly due to <a href="https://thinking-to-some-purpose.blogspot.com/2015/10/the-concept-of-addiction.html">the
Alcoholics Anonymous approach of defining ‘alcoholics’ as a distinct, tightly
defined group of people</a>?<span style="mso-spacerun: yes;"> </span>If we want public support for treatment or prevention, we need people to identify with those facing issues – unless we want to resort to <a href="https://thinking-to-some-purpose.blogspot.com/2018/05/changing-narrative-with-personal-stories.html">the
‘mad, bad and dangerous to know’ approach that justified funding drug treatment
in the 2000s</a>.<o:p></o:p></div>
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<br /></div>
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<a href="https://blogs.helsinki.fi/psulkune/files/2008/03/KBS-Melbourne-Bruun-Sulkunen-Warsell-published-version.-pdf1.pdf">Kettil
Bruun</a> and others solved this by suggesting that interventions should
address a whole population (the HPV and measles approach), whereas <a href="http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf">Michael
Marmot</a>, thinking about wider public health issues, proposed something
called ‘proportionate universalism’ in an attempt to square the circle: support
is universally available, but targeted and made accessible for those most in
need or traditionally least likely to make use of it.<span style="mso-spacerun: yes;"> </span>Both represent a response based on the
understanding that we live in a class society, which shapes both material
resources and status.<o:p></o:p></div>
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<br /></div>
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So what does this mean for us today?<span style="mso-spacerun: yes;"> </span>What are the burning issues in alcohol policy
where this is relevant?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Well I’ve been thinking recently about two popular
ideas.<span style="mso-spacerun: yes;"> </span>One is <a href="https://www.politicshome.com/news/uk/political-parties/labour-party/news/104677/labour-announces-plan-enforce-%E2%80%98strict%E2%80%99-alcohol">labelling
of alcoholic drinks</a>, and the other is their idea of improving funding for
alcohol treatment – perhaps through a ‘<a href="https://alcoholchange.org.uk/blog/2018/pay-3p-more-for-a-beer-save-lives-the-alcohol-treatment-levy">treatment
levy</a>’ as Alcohol Change have suggested: a specific addition to alcohol duty
that is ringfenced to support alcohol treatment in the UK, which is still in
some senses the ‘poor relation’ of drug treatment, which is not exactly
affluent itself.<o:p></o:p></div>
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<br /></div>
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I think these two approaches (albeit slightly tweaked) have
much in common, and can provide the best of the Marmot and Bruun approaches –
which in themselves are attempts to get round that knowledge that, yes, alcohol
is a potentially problematic substance for all, but perhaps we’re not all
equally at risk.<o:p></o:p></div>
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<br /></div>
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Labelling is not simply about individual level decision-making
on a specific occasion.<span style="mso-spacerun: yes;"> </span>If we model it
in that way, there’s a danger that (thinking about calories, for example)
someone might choose to have a few vodkas rather than just one glass of wine,
and end up drinking more alcohol.<span style="mso-spacerun: yes;"> </span>For
me, the point is more to create that general perception that for everyone
alcohol is no ordinary commodity, and has risks attached.<span style="mso-spacerun: yes;"> </span>That can then shape decision-making and
culture in the longer term, both at an individual and population level.<o:p></o:p></div>
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<br /></div>
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I don’t want to overstate the potential of this.<span style="mso-spacerun: yes;"> </span>More fundamentally you could ask the question
why this information is displayed on other drinks but not ones containing
alcohol.<span style="mso-spacerun: yes;"> </span>But there is a neat dovetailing
with the need for funding for alcohol treatment.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
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This levy is designed to specifically improve alcohol treatment, which
supports people with the most serious problems but perhaps doesn’t do as much
as we might hope.<span style="mso-spacerun: yes;"> </span>In England, <a href="https://www.gov.uk/government/collections/alcohol-and-drug-misuse-and-treatment-statistics">treatment
services engage more than 50% of all people estimated to be using heroin,
whereas they manage about 15% of people drinking dependently</a>, which itself
is a narrow definition of having a problem.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
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Specialist treatment, then, is focused on those most in
need.<span style="mso-spacerun: yes;"> </span>And here we return to the example
of HPV.<span style="mso-spacerun: yes;"> </span>If we think of the treatment of
cervical (or other) cancers, debate tends not to focus on the fact that many of
them are linked to ‘lifestyle’ factors such as smoking, drinking, diet,
exercise, sexual behaviour (in terms of virus transmission).<span style="mso-spacerun: yes;"> </span>Cancer is seen as a lottery and people should
be treated.<span style="mso-spacerun: yes;"> </span>Alcohol dependency is not
viewed in the same way.<span style="mso-spacerun: yes;"> </span>As in the HPV
example specifically, it was seen as being linked to individual personal
choices.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And this is where the idea of an alcohol levy, though
logical, has some challenges.<span style="mso-spacerun: yes;"> </span>It is an <i style="mso-bidi-font-style: normal;">addition</i> to alcohol duty, designed to
support services that only serve a minority of the population.<span style="mso-spacerun: yes;"> </span>I think that, rather than a levy, a more
achievable idea is a broader ‘rationalisation’ of alcohol duty.<span style="mso-spacerun: yes;"> </span>There is some appetite for this – and from <a href="https://www.ifs.org.uk/publications/9053">organisations like the IFS</a>,
not just alcohol specialists.<span style="mso-spacerun: yes;"> </span>From a
political perspective, as I’ve noted elsewhere, there’s an opportunity to frame
this kind of change as a positive of Brexit; something that I imagine
politicians will be keen on (if this ever goes ahead).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The other advantage of this framing is that it feels less
like a targeted tax <i style="mso-bidi-font-style: normal;">all</i> drinkers pay
for people who have problems they don’t.<span style="mso-spacerun: yes;">
</span>Of course this is the basic principle behind taxation and public
services, but that doesn’t mean it’s an easy sell when this discussion is only
about a particularly challenging issue.<span style="mso-spacerun: yes;">
</span>If this allocation is contained within broader alcohol taxation (and I
still support the idea of a hypothecated tax to produce a ringfenced budget)
then that debate about the principle of ‘who pays’ is less at the
forefront.<span style="mso-spacerun: yes;"> </span>This is potentially a
virtuous (or vicious) circle.<span style="mso-spacerun: yes;"> </span>If we
believe general taxation is for issues that affect us all, and alcohol
treatment is funded in this way, then perhaps we might start to see alcohol
treatment less as something that is for a special category of people.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And this links with the idea of labelling, which presents alcohol
as a substance that comes with certain risks.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Crucially, though, this is different from <a href="https://thinking-to-some-purpose.blogspot.com/2014/06/does-total-consumption-matter.html">the
total consumption / whole population model of alcohol harm</a>.<span style="mso-spacerun: yes;"> </span>It acknowledges that alcohol is not all about
risks adding up and leading to harmful health conditions, or even the slightly
more subtle point that if we all drink more at a population level there will be
more dependent drinkers.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The point is that there <u>is</u>, to some extent, a special
category of people who are facing bigger challenges than the rest of us.<span style="mso-spacerun: yes;"> </span>Their issues aren’t simply hangovers,
‘presenteeism’ at work and failing to fulfil some imagined potential.<span style="mso-spacerun: yes;"> </span>But also, as with most other health or social
issues, we can’t perfectly predict who they will be.<span style="mso-spacerun: yes;"> </span>The point is to generate not just sympathy
but empathy for those who need treatment.<span style="mso-spacerun: yes;">
</span>‘There but for the grace of God…’</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-36410215774970889112019-07-01T13:02:00.003+01:002019-07-01T13:02:43.845+01:00Local substance misuse services or national everything services<br />
<div class="MsoNormal">
Whether it’s in relation to alcohol or opioid treatment,
I’ve been thinking a lot recently about how people might need support
specifically in relation to certain substances (as opposed to ‘substance use
disorders’ or wider issues related to health or social care).<span style="mso-spacerun: yes;"> </span>That sounds a bit cryptic, so let me try to
explain.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As usual with this blog, it’s not an original or
mind-blowing insight, but something that keeps occurring to me that I think we
should remind ourselves of more often.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
When we discuss treatment or policy, we often do this by
substance.<span style="mso-spacerun: yes;"> </span>So there’s been discussions
of alcohol labelling recently, and a growth in personal testimonies of how
giving up alcohol makes people <span class="MsoHyperlink"><a href="https://thinking-to-some-purpose.blogspot.com/2017/10/fitter-no-happier-but-more-productive.html">fitter,
happier and more productive</a></span> (recently Megan Montague’s <span class="MsoHyperlink"><i style="mso-bidi-font-style: normal;"><a href="https://soberstory.co.uk/">Sober Story</a></i></span> caught my eye).<span style="mso-spacerun: yes;"> </span>And there’s discussions locally and
nationally of how we can specifically improve opioid substitution treatment
(OST).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But as we know, if ‘addiction’ is anything, it’s about more
than a substance.<span style="mso-spacerun: yes;"> </span>It’s about all those
things we label ‘recovery capital’ – health, housing, employment,
relationships, etc – whether for good or bad.<span style="mso-spacerun: yes;">
</span>To a certain extent, substance use becomes a ‘<a href="https://psychcentral.com/addictions/substance-use-disorder-symptoms/">substance
use disorder</a>’ when it starts to have negative effects on other aspects of a
person’s life.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And so it’s unsurprising that people find it hardest to
change their patterns of substance use when the challenges they’re facing – and
their reasons for using – are not just about the substance.<span style="mso-spacerun: yes;"> </span>It’s people with the least severe issues for
whom the substance is the primary problem, and it’s these people who are best
served by interventions that focus on the substance itself – like alcohol brief
interventions.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And yet when we talk about treatment services, we’re
generally thinking of things that are designed for those most in need of support.<span style="mso-spacerun: yes;"> </span><a href="https://thinking-to-some-purpose.blogspot.com/2018/09/lets-have-end-to-tall-tales-about.html">We
know that most people ‘spontaneously recover’</a> without formal support, as a
result of their own thinking and support from friends, family and the wider community.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And yet the services we provide – which should be
replicating those supporting factors like employment, housing, family,
community – are typically labelled ‘drug’ and/or ‘alcohol’ treatment
services.<span style="mso-spacerun: yes;"> </span>In fact it’s not just that
they’re labelled in this way; we commission and provide them separately from
housing, employment, and other health and social care services.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This doesn’t make sense to me.<span style="mso-spacerun: yes;"> </span>And in conversations and meetings over the
past few months and years I’m encouraged by the fact it doesn’t seem to make
sense to anyone.<span style="mso-spacerun: yes;"> </span>I’ve written before
about how substance misuse treatment can feel neither part of the ‘health
family’ or social care and other related services, and given the cross-cutting
nature of these issues there’s no point in searching for the ideal
institutional ‘home’ for this agenda.<span style="mso-spacerun: yes;"> </span>But
equally, it’s inefficient (and exhausting) for local areas to be reinventing
the wheel, and I think there are some structural and policy changes that could
make this easier.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This doesn’t just mean devolution of budgets, though that might
make collaborative work easier.<span style="mso-spacerun: yes;"> </span>I still
don’t think there’s a magical solution, and the key is to get relevant people
to work together better at a local level – not just on the frontline, but in
linking policies and planning.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This isn’t an endorsement of localism, though.<span style="mso-spacerun: yes;"> </span>Without some form of external prompt, when we’re
under pressure we often have a default of ‘tending our own garden’.<span style="mso-spacerun: yes;"> </span>It can seem not just comforting but a
priority to focus on what we can control ourselves and JFDI if we want to make
a genuine difference.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The problem is that <a href="https://thepsychologist.bps.org.uk/volume-32/july-2019/threadbare-patchwork-support">this
isn’t the most efficient way to deliver support to the people we’re most
concerned about</a>.<span style="mso-spacerun: yes;"> </span>There is a role for
national organisations like PHE to be that voice reminding us to look up and
think about the bigger picture.<span style="mso-spacerun: yes;"> </span>Actually,
it needs more than just a voice.<span style="mso-spacerun: yes;"> </span>Recommendations
are often disregarded, or considered to be stating the obvious – even if they’re
equally obviously unachievable.<span style="mso-spacerun: yes;">
</span>Requirements, from an agency with teeth, can drive these conversations,
particularly in the areas where collaboration is most challenging.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In searching back through this blog to see when I’ve written
about this before, I notice <a href="https://thinking-to-some-purpose.blogspot.com/2016/06/the-good-old-days-of-nta.html">a
striking, brief piece from several years ago</a>.<span style="mso-spacerun: yes;"> </span>Nothing has changed as yet, but the sheer weight
of reports and recommendations from organisations like the ACMD do genuinely
seem to be making a difference.<span style="mso-spacerun: yes;"> </span>More and
more people seem to be agreeing with the idea that strengthening national
guidance and oversight (even commissioning at a national level) would be a step
forward, and I get the feeling that key people with influence at a national
level are taking this on board.<span style="mso-spacerun: yes;"> </span>Here’s
hoping.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-91360590528443037342019-03-15T18:34:00.000+00:002019-03-15T18:34:00.637+00:00Can we build a more trusting, collaborative substance misuse treatment sector?<br />
<div class="MsoNormal">
I spent Friday in Manchester, at EXCO2019 – the annual
conference of <a href="http://www.expertfaculty.org/">the Expert Faculty on
Commissioning</a>.<span style="mso-spacerun: yes;"> </span>There were lots of fascinating
discussions throughout the day, and I’d recommend catching up by looking at the
hashtag on Twitter: <a href="https://twitter.com/hashtag/EXCO2019?src=hash&lang=en">#EXCO2019</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One of the key issues revolved around balancing ‘dusting off
the old vinyl’ and doing the basics well on the one hand, with the bright shiny
disco ball of ‘innovation’ on the other.<span style="mso-spacerun: yes;">
</span>Pete Burkinshaw from PHE kicked us off with this metaphor, but pretty
much everyone else used it thereafter – in fact Kate Hall had already
independently written it into her presentation!<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As Tony Mercer from PHE suggested (echoed by Paul Musgrave
later, who hadn’t heard Tony), we might sit down at home and listen to vinyl,
but it doesn’t work everywhere: you might play CDs in your car and listen to
MP3s on the train.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And this was the other key theme of the conference:
tailored, or personalised treatment.<span style="mso-spacerun: yes;">
</span>There’s an idea that I’ve written about before that although we hope tailored,
segmented, personalised treatment will be efficient as well as effective and fair,
but we shouldn’t take this for granted.<span style="mso-spacerun: yes;">
</span>Fordism, where every colour is available so long as it’s black, sometimes
has its place.<span style="mso-spacerun: yes;"> </span>The devil, as ever, is in
the detail, and the risk with this conference (as with most others) is that it becomes
a sequence of platitudes, soundbites and metaphors without taking us forward <u>in
practice</u>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There was much discussion of ‘optimal’ dosing, defined as
60mls-120mls of methadone per day, or equivalent.<span style="mso-spacerun: yes;"> </span>But <a href="https://twitter.com/Khudz6">Kerrie
Hudson</a> had earlier noted that, for her, being able to deal with cravings in
the morning with a relatively low dose of methadone (say 30mls) and then use at
other times, was a stabilising factor, meaning she could carry on working.<span style="mso-spacerun: yes;"> </span>It was appropriate for her particular
situation at that particular time.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The sensible way through this is to point out that (a) the
patterns of prescribing in our system don’t suggest that most people on 30mls
are ‘optimised’ even by their own definition, and the actual dosage of medication
someone receives shouldn’t be imposed (whether that’s through an increase or
reduction); it should be a joint decision between clinician and patient to achieve
a jointly agreed aim.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And that kind of approach, along with all sorts of other
initiatives that could be badged as ‘innovative’ or involving ‘segmentation’
were discussed on the day.<span style="mso-spacerun: yes;"> </span>But they
remain that: isolated examples of good practice.<span style="mso-spacerun: yes;"> </span>We don’t (yet) have a tool for segmentation that
could structure these kinds of conversations that keyworkers need to have.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In the session I participated in, I had been asked to
introduce a discussion of depot buprenorphine – a fact possibly not unrelated
to the fact the conference was made possible by funding from Camurus, who make
these devices.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I don’t object to this, though the Faculty needs to be
careful not to become reliant on one source of funding, and I think local authority
contributions would be more appropriate.<span style="mso-spacerun: yes;">
</span>I saw my role as being to ask some challenging questions and bring the
conversation back to those practical considerations, rather than thinking the
innovation will be useful in itself.<span style="mso-spacerun: yes;"> </span>Who
will this form of medication benefit?<span style="mso-spacerun: yes;">
</span>Where could it be implemented effectively and efficiently, given we’re living
in tough times financially?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I’m not sure I got my point across, but it didn’t matter
anyway, because the discussion, thanks to much more eloquent and passionate
commissioners than me, took a turn to be about commissioning and the ‘sector’
in general.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This was where the conversation got interesting.<span style="mso-spacerun: yes;"> </span>We talked about how certain metrics and
processes, previously centrally imposed (like TOPs and ‘successful completions’)
don’t have to be at the heart of local authority commissioning, but the point
was made that this doesn’t mean agencies and staff can disregard them even if
they wanted to.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As a provider, you can’t be sure that if your successful
completions are low in one area because you’re being honest and retaining
people in treatment, that you won’t be judged unfavourably when you tender for
a contract in another area.<span style="mso-spacerun: yes;"> </span>Not all
commissioners take this view.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And as a member of staff, if you stop recording people
(sometimes optimistically) as successfully completed, or don’t note that they
have apparently stopped using on top or committing crime on their latest TOP
form, then perhaps you’ll lose a sense of a job well done. <span style="mso-spacerun: yes;"> </span>And how will the service user themselves be
able to identify that they’re making progress?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It’s not as straightforward as a commissioner just telling a
provider to relax about metrics.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And what about length of contracts?<span style="mso-spacerun: yes;"> </span>There was agreement that long contracts were a
good idea, and local authorities seem to be increasingly open to these.<span style="mso-spacerun: yes;"> </span>But it’s not the case everywhere, and the
sector still feels competitive.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Nurses leave to work elsewhere in the NHS because there just
isn’t (felt to be) the same security in substance misuse.<span style="mso-spacerun: yes;"> </span>Locally, in each of the three acute hospitals
across Dorset there’s at least one nurse in the alcohol liaison/care team that
used to work in the Dorset substance misuse service, and we can’t seem to recruit
replacements.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Organisations feel they can’t reveal their ‘trade secrets’ (and
if anyone has indeed got the ‘solution’ to ‘addiction’ there certainly keeping
it secret), and the spectre of tendering can lead to tensions, fear and anger
on the ground.<span style="mso-spacerun: yes;"> </span>It’s hard to believe that
doesn’t then seep into consultations, affecting service user care.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And this isn’t the fault of those frontline staff or the
organisations that employ them.<span style="mso-spacerun: yes;"> </span>It’s
central and local government that have created and maintained these competitive
structures.<span style="mso-spacerun: yes;"> </span>And while <a href="https://twitter.com/WilliamHaydock/status/1106560796811816960">some
people in the room could be congratulated on creating different approaches in
their area</a>, this doesn’t change <a href="https://thinking-to-some-purpose.blogspot.com/2017/06/who-can-buy-alcohol-service.html">the
overall picture or culture as being one of competition and sometimes open
confrontation</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So I started to think about how, in practice we could make
this change.<span style="mso-spacerun: yes;"> </span>And all the themes we’d
been discussing seemed to coalesce.<span style="mso-spacerun: yes;"> </span>We
don’t have clear segmentation tools.<span style="mso-spacerun: yes;"> </span>Guidance
on ‘good practice’ tends to be relatively abstract (NICE, Orange Book) or just
a set of examples designed to show that local government is brilliant (the
Local Government Association).<span style="mso-spacerun: yes;"> </span>Approaches
to performance management vary considerably.<span style="mso-spacerun: yes;">
</span>Contract lengths vary wildly from 3 years to 10 or more.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This lack of consistency makes life difficult for providers,
who can’t tailor their approach to one commissioner, and commissioners, who end
up reinventing the wheel.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Last year, <a href="https://thinking-to-some-purpose.blogspot.com/2018/07/from-competition-to-partnership.html">I
wrote about how I could see a role for the Expert Faculty as a repository for
genuine, practical examples of ‘good practice’</a>, but this would need to be
distinct from the work of PHE or the LGA.<span style="mso-spacerun: yes;">
</span>Some of the work that could improve the situation is being coordinated by
PHE through their review of opiate substitution treatment, which I’m hoping
will produce some practical guidance on segmentation, enabling frontline
workers to put the ‘phasing and layering’ of treatment proposed by the Medications
in Recovery report into real-life practice in a straightforward way.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But there’s more that needs to be done to reshape the sector
and build trust.<span style="mso-spacerun: yes;"> </span>One thing I wondered
aloud about in the session of the conference I was directly involved in was
something like a charter or a kitemark for commissioning.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Providers want to feel confident they’re entering into an
arrangement with someone who’s reasonable, flexible and constructive, and where
they don’t have to worry about misleading metrics.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And commissioners, I’m sure, would embrace a set of principles
– particularly if they could take these to elected members or senior management
and explain that these (for example not re-procuring every 3 years) are
considered good (or even standard) practice in the field.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I’m not going to talk much more about this here, as it’s
only the most embryonic of ideas (and I wouldn’t claim that it’s original) but
I wonder if it’s worth exploring further.<span style="mso-spacerun: yes;">
</span>It would surely give both commissioners and providers the confidence to
break free from the shackles of successful completion metrics and 3-year
tendering cycles that occupied so much time and prompted so many sighs over the
course of the day.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I often ask for comments on this blog, and rarely get any,
despite hundreds of people reading it, supposedly, so I’m not expecting a great
debate in the comments.<span style="mso-spacerun: yes;"> </span>What I hope,
though, is that by EXCO2020 we’ll have a clearer sense of the practical,
tangible contribution of the Faculty, and whether this sort of initiative is
what it should be championing.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-53331909597924537792019-03-13T20:11:00.000+00:002019-03-14T10:24:09.293+00:00Consultations on drug policyA couple of days ago, I was asked by email for some comments on <a href="https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-and-social-care-committee/inquiries/parliament-2017/drugs-policy-inquiry-17-19/" target="_blank">the current health and social care select committee (HSCC) inquiry</a> and <a href="https://www.gov.uk/government/news/professor-dame-carol-black-announced-as-independent-reviewer-of-drugs" target="_blank">Black report consultations</a> on drug policy. Tonight, on my own time, I drafted some thoughts. I've copied these below and would welcome comments.<br />
<br />
Just to give some context, the questions in the Black report at this point are as follows:<br />
<br />
<br />
<div style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span style="color: black; font-family: "symbol"; font-size: 10pt; margin: 0px;"><span style="margin: 0px;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt "Times New Roman"; margin: 0px;">
</span></span></span><span style="color: black; font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">What are the demographics
and characteristics of drug users and drug suppliers and how have they changed?
</span></div>
<br />
<div style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span style="color: black; font-family: "symbol"; font-size: 10pt; margin: 0px;"><span style="margin: 0px;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt "Times New Roman"; margin: 0px;">
</span></span></span><span style="color: black; font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">What causes individuals to
become involved in drug use and/or drug supply? </span></div>
<br />
<div style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span style="color: black; font-family: "symbol"; font-size: 10pt; margin: 0px;"><span style="margin: 0px;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt "Times New Roman"; margin: 0px;">
</span></span></span><span style="color: black; font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">What are the evidence-based
approaches to preventing and reducing drug use and drug supply? </span></div>
<br />
<div style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span style="color: black; font-family: "symbol"; font-size: 10pt; margin: 0px;"><span style="margin: 0px;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt "Times New Roman"; margin: 0px;">
</span></span></span><span style="color: black; font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">What causes drug related
serious violence and how can it be prevented? </span></div>
<br />
<div style="margin-bottom: .0001pt; margin-bottom: 0cm; margin-left: 36.0pt; margin-right: 0cm; margin-top: 0cm; mso-list: l0 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;">
<span style="color: black; font-family: "symbol"; font-size: 10pt; margin: 0px;"><span style="margin: 0px;">·<span style="font-size-adjust: none; font-stretch: normal; font: 7pt "Times New Roman"; margin: 0px;">
</span></span></span><span style="color: black; font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">What are the most important
evidence gaps relating to drug use and drug supply and what further work would
be needed to address them? </span></div>
<b></b><i></i><u></u><sub></sub><sup></sup><strike></strike><br />
And those for the HSCC inquiry are:<br />
<br />
<br />
<div style="line-height: normal; margin: 0px;">
<span lang="EN" style="color: black; font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">Health and harms: </span></div>
<br />
<ul type="disc">
<li style="color: black; font-family: "Calibri",sans-serif; font-size: 11pt; font-style: normal; font-weight: 400; line-height: normal; margin: 0px;"><span lang="EN" style="font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">What is the extent of
health harms resulting from drug use? </span></li>
</ul>
<br />
<div style="line-height: normal; margin: 0px;">
<span lang="EN" style="color: black; font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">Prevention and early intervention: </span></div>
<br />
<ul type="disc">
<li style="color: black; font-family: "Calibri",sans-serif; font-size: 11pt; font-style: normal; font-weight: 400; line-height: normal; margin: 0px;"><span lang="EN" style="font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">What are the reasons for
both the initial and the continued, sustained use of drugs? This refers to
the wide spectrum of use, from high-risk use to the normalisation of
recreational use. </span></li>
<li style="color: black; font-family: "Calibri",sans-serif; font-size: 11pt; font-style: normal; font-weight: 400; line-height: normal; margin: 0px;"><span lang="EN" style="font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">How effective and
evidence-based are strategies for prevention and early intervention in
managing and countering the drivers of use? This includes whether a
whole-system approach is taken. </span></li>
</ul>
<br />
<div style="line-height: normal; margin: 0px;">
<span lang="EN" style="color: black; font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">Treatment and harm reduction: </span></div>
<br />
<ul type="disc">
<li style="color: black; font-family: "Calibri",sans-serif; font-size: 11pt; font-style: normal; font-weight: 400; line-height: normal; margin: 0px;"><span lang="EN" style="font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">How effective and
evidence-based is treatment provision? This refers to both healthcare
services and wider agencies, and the extent to which joined-up care
pathways operate. </span></li>
<li style="color: black; font-family: "Calibri",sans-serif; font-size: 11pt; font-style: normal; font-weight: 400; line-height: normal; margin: 0px;"><span lang="EN" style="font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">Is policy is sufficiently
geared towards treatment? This includes the extent to which health is
prioritised, in the context of the Government’s criminal justice-led
approach. </span></li>
</ul>
<div>
<span lang="EN" style="color: black; font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">Best practice: </span></div>
<br />
<ul type="disc">
<li style="color: black; font-family: "Calibri",sans-serif; font-size: 11pt; font-style: normal; font-weight: 400; line-height: normal; margin: 0px;"><span lang="EN" style="font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">What would a
high-quality, evidence-based response to drugs look like? </span></li>
<li style="color: black; font-family: "Calibri",sans-serif; font-size: 11pt; font-style: normal; font-weight: 400; line-height: normal; margin: 0px;"><span lang="EN" style="font-family: "calibri" , sans-serif; font-size: 11pt; margin: 0px;">What responses to drugs
internationally stand out as particularly innovative and / or relevant,
and what evidence is there of impact in these cases? </span></li>
</ul>
If you want to respond yourself - and I think this is something everyone with an interest should get involved in - the HSCC consultation closes on Monday.<br />
<br />
<span style="background-color: transparent; color: black; display: inline; float: none; font-family: "times new roman"; font-size: 16px; font-style: normal; font-variant: normal; font-weight: 400; letter-spacing: normal; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px;">So here goes my response. I should point out it's not a formal response; just some thoughts that have occurred to me over a glass of my favourite intoxicant.</span><br />
<b></b><i></i><u></u><sub></sub><sup></sup><strike></strike><br />
****<br />
<br />
<div style="margin: 0px;">
<span style="margin: 0px;"><span style="font-family: "calibri";">Having
read through this, I think the fundamental questions are relatively similar, so
here’s my stream of consciousness, which reflects the views of an academic rather
than a commissioner.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">Most
drugs in themselves carry relatively low risk to the individual concerned when
used in known dosages and purity, under safe conditions without forming
patterns of substance use disorders.<span style="margin: 0px;">
</span>Therefore the health harms resulting from drug use per se are relatively
low.<span style="margin: 0px;"> </span>Issues are most likely to arise
when purity and dosage are unknown and where people have poor information about
how to use more safely (or do not act on this information, sometimes due to the
stigma or fear associated with the illegality of certain substances).</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">People
come to use drugs initially due to a mixture of factors, with (anticipated)
pleasure of some kind linked to availability.<span style="margin: 0px;">
</span>What people find exciting, comfortable or pleasurable varies, and the
effects of different drugs varies and is affected by setting, and so the
reasons are as varied as people who use drugs themselves.<span style="margin: 0px;"> </span>In understanding why people continue to use
drugs, a functional approach is helpful: these substances serve a function for
the people who use them, whether that is to have new experiences (‘psychonauts’),
distance oneself from previous experiences or thoughts, or simply experience a ‘rush’.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span style="margin: 0px;"><span style="font-family: "calibri";">For most people, trauma and poverty / lack of
opportunities drive people towards <u>problematic</u> drug use and
dealing.<span style="margin: 0px;"> </span>Those involved in dealing are
getting younger.<span style="margin: 0px;"> </span>The violence associated
with the drug market is the consequence of the substances being illegal, and
violence increases when a gap in the market appears – i.e. when existing,
stable dealers are arrested and imprisoned.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span style="margin: 0px;"><span style="font-family: "calibri";">(But I understand the Black review has been
instructed not to consider the legal status of drugs.<span style="margin: 0px;"> </span>And in any case, the police will be more
expert than me on this.<span style="margin: 0px;"> </span>I hope Neil
Woods from LEAP will be submitting evidence.)</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span style="margin: 0px;"><span style="font-family: "calibri";">Prevention of pursuit of intoxication and use
of psychoactive substances per se is a somewhat futile task.<span style="margin: 0px;"> </span>All societies, to our knowledge, have made
some use of intoxicants or intoxicating practices.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">Evidence
suggests that the most effective approaches to prevent <u>harm</u> from
substance use is not to focus on substance use or dispense information and advice,
but to educate young people in relation to decision-making and safekeeping
strategies, and to discuss these issues with adults in terms of the effects on
their wider lives (e.g. improving parenting skills).<span style="margin: 0px;"> </span>Such work should be integrated into broader
process/practices, e.g. mainstream education, general healthcare and social
work practice.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">In
terms of treatment, while there is relatively strong evidence that high-quality
treatment and harm reduction initiatives can reduce crime and reduce the
transmission of blood-borne viruses, there is a lack of evidence regarding ‘what
works’ in fostering long-term recovery.<span style="margin: 0px;">
</span>Therefore a priority for government should be to commission and support
research that takes a robust, longitudinal approach to evaluate different
treatment options and approaches in terms of their effectiveness.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">As
to whether currently commissioned treatment services are provided in line with
this evidence, there are questions to be asked as to whether services engage
enough people to make a difference at a population level, and whether, once
people are engaged, they receive treatment in line with this evidence, much of
which is based on either lab-style settings in terms of talking therapies, or
US-style ‘methadone clinics’ in relation to opiate substitution treatment (OST).<span style="margin: 0px;"> </span>What evidence there is suggests that dosages
of medication dispensed as part of OST are not generally in line with evidence,
supervision regimes are not applied consistently, and talking therapies are not
delivered in line with tight guidelines.<span style="margin: 0px;">
</span>In most cases there is certainly not joined up health and social care
provision for the client group who have run into issues with substances, with
services commissioned and provided by separate organisations, operating to
different priorities and policies, and using different IT systems.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">This
is not to say that services are not appropriate and effective, given the
limited nature of the evidence base.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">The
biggest challenge to delivering quality services is currently capacity.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">Treatment
services have been more than decimated in recent years, with cuts in most areas
of at least 20% to budgets since 2013, and prevention work has become patchy
and hard to monitor with the change how schools are overseen.<span style="margin: 0px;"> </span>At the same time, resources expending on
addressing the supply of drug use, for example through ‘county lines’, have
increased in areas such as Dorset.<span style="margin: 0px;"> </span>This is
currently a ‘zero sum game’, and therefore it would appear that resources are
being focused at less effective points in people’s lives, given that we know
treatment can help reduce the burden problematic drug use and associated
acquisitive crime can place on the criminal justice system.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">A
high-quality, evidence-based response to ‘drugs’ would be regulate all
substances and therefore permit use that is in line with good harm reduction
advice: i.e. where people can know and control the dosage and purity of the
substance, and the manner in which they ingest their preferred intoxicant.<span style="margin: 0px;"> </span>There would be more accessible treatment, better
integrated with different elements of the health and social care system, a
better evidence base by which to judge the performance of this system, and more
resources to support the oversight of the system in relation to quality.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">As
for international comparisons, no country has this cracked, partly because opportunities
for innovation are hampered by international treaties and the position of the
UN and particularly the USA.<span style="margin: 0px;"> </span>In general,
we know that harm is not simply determined by a country’s regulatory or
treatment system, as confirmed by the Home Office report a few years ago.<span style="margin: 0px;"> </span>Each country should take a tailored approach
to each substance, based on its history and starting point today.<span style="margin: 0px;"> </span>Social and cultural context play a key role
in determining problems and appropriate solutions – just look at trends and
approaches to alcohol use in different countries around the world.<span style="margin: 0px;"> </span>An approach that is perfectly reasonable and
successful in one context can be destructive in another. <span style="margin: 0px;"> </span>However, to focus on specifics, the approaches
adopted by Uruguay and Canada for cannabis seem to me the best models for
effective regulation introduced so far, though they will need careful
monitoring to evaluate their impact, particularly in comparison with the various
alternative regimes in operation across the US.<span style="margin: 0px;">
</span>These initiatives could and should go further, however, and cover all intoxicating
substances – though with regimes tailored to the particular risks associated
with each drug.</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">As
you’ve probably guessed, I’m writing this on my own time, as it may not be what
you were looking for!</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">Best</span></span></div>
<br />
<div style="margin: 0px;">
<br /></div>
<br />
<div style="margin: 0px;">
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">Will.</span></span><br />
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";"><br /></span></span>
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">***</span></span><br />
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">UPDATE:</span></span><br />
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">This morning I was asked why I hadn't mentioned Portugal, and whether this would be a good idea.</span></span><br />
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";"><br /></span></span>
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">This was my response:</span></span><br />
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";"><br /></span></span>
<span lang="EN" style="color: black; margin: 0px;"><span style="font-family: "calibri";">
<br />
<div style="margin: 0px 0px 16px;">
<span style="color: black; font-family: "Arial",sans-serif; margin: 0px;">Personally, I think
we're not far off the Portugal model in the UK, with treatment offered for most
people who commit drug-related acquisitive crime and very few people (in the
grand scheme of things) imprisoned for possession. The greatest harms (DRDs,
child exploitation, cuckooing) wouldn't be solved by decriminalisation, but
only legalisation.</span></div>
<br />
<div style="margin: 0px 0px 16px;">
<span style="color: black; font-family: "Arial",sans-serif; margin: 0px;">But you're right that it
at least reflects an achievable step, and highlighting it could convince people
that change is possible.</span></div>
</span></span></div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-82801183664149244032019-01-11T16:33:00.002+00:002019-01-11T16:33:24.517+00:00The downside of Dry January<br />
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I’ve been thinking about <a href="https://alcoholchange.org.uk/get-involved/campaigns/dry-january">Dry
January</a> a lot recently.<span style="mso-spacerun: yes;"> </span>Well, it is
January.<span style="mso-spacerun: yes;"> </span>And like every year, there’s
been lots of views aired by journalists and professionals.<o:p></o:p></div>
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<br /></div>
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As usual on this issue, the person who comes closest to representing
my views is <a href="https://twitter.com/ian_hamilton_">Ian Hamilton</a>.<span style="mso-spacerun: yes;"> </span><a href="https://blogs.bmj.com/bmj/2019/01/04/ian-hamilton-dry-january-no-match-growing-harms-alcohol-consumption/?utm_campaign=shareaholic&utm_medium=twitter&utm_source=socialnetwork">He’s
argued</a> that while Dry January undoubtedly delivers some real positive
change for many drinkers, it’s less clear whether it’s effective for the people
who genuinely need to change their drinking behaviour, and it certainly isn’t
designed for dependent drinkers.<span style="mso-spacerun: yes;"> </span>He even
worries that it could benefit the alcohol industry, as it distracts from those
with more serious problems – who provide the bulk of the industry’s revenue.<o:p></o:p></div>
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<br /></div>
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I should start with a caveat I don’t think we make explicit
often enough in discussions about alcohol policy.<span style="mso-spacerun: yes;"> </span>People come with a personal agenda.<span style="mso-spacerun: yes;"> </span>I like drinking, and I like getting
drunk.<span style="mso-spacerun: yes;"> </span>As far as I am aware (and that’s
a very important point), this has very rarely had any impact on my professional
or personal life, and certainly not in a very long time.<span style="mso-spacerun: yes;"> </span>I like to think I’m pretty self-aware regarding
alcohol, and so I’m pretty good at planning any drinking occasion so it doesn’t
impact on other obligations.<o:p></o:p></div>
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<br /></div>
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I don’t have any problem admitting this enjoyment of
drinking and drunkenness, and I certainly don’t see it as any kind of weakness
or moral failing.<o:p></o:p></div>
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<br /></div>
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This fact that I enjoy drinking, and specifically the
feeling of intoxication, is important.<span style="mso-spacerun: yes;"> </span>Often,
those who advocate abstinence either don’t understand the attraction of
drunkenness, or, when they do acknowledge this, <a href="https://twitter.com/OliverStanding/status/1081616449750401025">see it as
somehow a less respectable or worthwhile pleasure than, say, reading a book or
doing yoga</a>.<span style="mso-spacerun: yes;"> </span>I just can’t sign up to
that idea of higher and lower pleasures, and would emphasise that <a href="https://thinking-to-some-purpose.blogspot.com/2015/11/the-pleasures-of-intoxication.html">a
case can be made that drug-induced pleasure is in fact the ‘purest’ kind of
pleasure</a> possible in a Kantian sense (modified by Bourdieu), as it’s not instrumental
or tied to pretentiousness; it’s a pleasure (for some people) simply in itself.<o:p></o:p></div>
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But sometimes it’s not just about pleasure; it’s part of
some ‘deferred pleasure’ or idea of self-control that’s inevitably tied to
respectability.<span style="mso-spacerun: yes;"> </span>(There’s loads of work
on class and drinking apart from <a href="https://scholar.google.co.uk/citations?user=YktlM5cAAAAJ&hl=en">my own</a>
– <a href="https://twitter.com/DrEmilyNicholls">Emily Nicholls</a> is
particularly on <a href="https://scholar.google.co.uk/citations?user=5FHg1IMAAAAJ&hl=en&oi=sra">how
this intersects with gender</a>.)<span style="mso-spacerun: yes;"> </span>Drinking
less to protect one’s health is a moral action in the sense that it says something
about the moral schema you use to weigh up different pleasures.<span style="mso-spacerun: yes;"> </span>For a range of reasons, at the moment I’m not
in a place to feel I want to drink less.<o:p></o:p></div>
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<br /></div>
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So I’m not doing Dry January.<span style="mso-spacerun: yes;"> </span>Conflict of interest declaration over.<o:p></o:p></div>
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<br /></div>
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If you want a clear summary of the issues with Dry January, <a href="https://blogs.bmj.com/bmj/2019/01/04/ian-hamilton-dry-january-no-match-growing-harms-alcohol-consumption/?utm_campaign=shareaholic&utm_medium=twitter&utm_source=socialnetwork">Ian’s
piece on the BMJ website is good</a>, and I don’t want to re-hash that
here.<span style="mso-spacerun: yes;"> </span>The main weakness is that, even
excluding dependent drinkers, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26690637">the evidence</a> suggests
that the people who would benefit most from modifying their drinking are exactly
the people least likely to start (and finish) Dry January.<span style="mso-spacerun: yes;"> </span>Of course, like attempts at recovery, this
doesn’t mean the effort was worthless.<span style="mso-spacerun: yes;"> </span>Several
unsuccessful attempts may have a cumulative impact and lead to success in the
end, but it’s still not exactly a ringing endorsement, given that we’re not
talking about anything approaching ‘addiction’.<o:p></o:p></div>
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<br /></div>
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And I always feel a bit sorry for the people I bump into who
discuss doing Dry January and reveal they were only drinking about 10 units a
week to start with.<span style="mso-spacerun: yes;"> </span>The benefits won’t
be significant, and the risks weren’t that high to start with – in fact you
could argue they’re forgoing pleasure for no clear reason.<span style="mso-spacerun: yes;"> </span>But then we’re back to the performance of
respectability and the fact that some people get a positive feeling from
self-denial.<span style="mso-spacerun: yes;"> </span>(<a href="https://www.facebook.com/thedailymash/videos/dry-january-the-mash-report/1429000623875768/">The
Daily Mash</a> is particularly good on this.)<o:p></o:p></div>
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<br /></div>
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But going back to Ian’s analysis, there’s just one point I’d
take issue with, or modify slightly.<span style="mso-spacerun: yes;">
</span>Resources aren’t particularly being found for Dry January, as far as I
know.<span style="mso-spacerun: yes;"> </span>The beauty of it (and actually the
danger) is that it doesn’t require any resource or major policy change.<o:p></o:p></div>
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<br /></div>
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Locally, we’re just<a href="https://twitter.com/HealthyDorset/status/1083634744447942656"> using
social media to encourage people to consider taking a break from alcohol, and
signposting them to the behaviour change support we already have in place</a>.<span style="mso-spacerun: yes;"> </span>Ideally it might lead to more people
accessing that support, but that’s not exactly us putting additional resources
towards Dry January.<o:p></o:p></div>
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<br /></div>
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The great value of the campaign, <a href="https://thinking-to-some-purpose.blogspot.com/2017/01/dry-january-and-sponsored-marathon.html">as
I’ve said before</a>, is that even for those of us not doing Dry January, it prompts
us to consider whether we might want to review our own relationship with alcohol.<span style="mso-spacerun: yes;"> </span>Perhaps the reason I have alcohol-free days
and keep alcohol-free beer in the house has something to do with Dry January?<span style="mso-spacerun: yes;"> </span>(Though personally I doubt it as I’ve been
trying to keep 2 days a week alcohol free for well over 10 years now – since I
started working on these issues and reading the health and policy guidance.)<o:p></o:p></div>
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This is why I’m so positive about the name and strategy of <a href="https://alcoholchange.org.uk/">Alcohol Change UK</a>.<span style="mso-spacerun: yes;"> </span>I’m totally on-board with any organisation
that aims to get people to reflect on their choices.<o:p></o:p></div>
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<br /></div>
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And, as I say, this is the beauty of the campaign: it’s not
requiring anything of producers, retailers, regulators or drinkers.<span style="mso-spacerun: yes;"> </span>It just prompts drinkers to think and maybe
modify their own drinking.<o:p></o:p></div>
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But this is also why it’s so problematic for me.<span style="mso-spacerun: yes;"> </span>We know that behaviour change isn’t simply
about education and people making free choices.<span style="mso-spacerun: yes;">
</span><a href="https://thinking-to-some-purpose.blogspot.com/2018/02/accepting-complexity-but-thinking-simply.html">Choices
are never made in a vacuum</a>; there’s social and economic context which makes
some choices more likely based on the time and place you find yourself in –
both on specific occasions and throughout your life.<span style="mso-spacerun: yes;"> </span>The more we present drinking and the
associated health and social issues as being the result of choices made by the
drinker, the less appetite there will be for other approaches, based on price
and availability and so forth.<span style="mso-spacerun: yes;"> </span>I’m not
saying more restrictive licensing, or minimum unit pricing should be introduced,
but, <a href="https://journals.sagepub.com/doi/abs/10.1177/0261018313514804?journalCode=cspa">as
I’ve written before</a>, it’s important that all potential approaches are considered
and fully assessed.<o:p></o:p></div>
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<br /></div>
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So I’m not doing Dry January, but I can see that many people
report positive effects.<span style="mso-spacerun: yes;"> </span>If you feel you
could be persuaded, read <a href="https://medium.com/@chelseyflood/is-it-time-for-your-first-dry-january-465cee5e216d">this
excellent, insightful piece</a> by <a href="https://twitter.com/cjflood_author">CJ
Flood</a>.<o:p></o:p></div>
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<br /></div>
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My only question is whether all this attention on individual
choices in early January is actually useful in reducing alcohol-related harm at
a population level. As Ian suggests, the jury’s still out on that one.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com2tag:blogger.com,1999:blog-125653241615635488.post-58372562244440592932018-11-24T17:16:00.001+00:002021-01-03T10:53:18.585+00:00The iron law of prohibition<br />
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<a href="https://thinking-to-some-purpose.blogspot.com/2018/10/are-compassion-and-connection-answer-to.html" target="_blank">I recently wrote</a> about <a href="https://twitter.com/johannhari101">Johann Hari</a>’s book <i style="mso-bidi-font-style: normal;"><a href="https://www.bloomsbury.com/uk/chasing-the-scream-9781408857830/">Chasing
the Scream</a></i>.<span style="mso-spacerun: yes;"> </span>It’s an unusual
thing for me to do to focus so much on another person’s work, and because I
enjoyed reading it and felt it had lots of important insights and stories, I
felt bad criticising it.<span style="mso-spacerun: yes;"> </span>But I’m about
to write about it again.<o:p></o:p></div>
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<br /></div>
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When I was reading the book, I folded down pages or
underlined sections that I thought were either interesting or misguided.<span style="mso-spacerun: yes;"> </span>Somehow, in my initial post, I missed one key
point, which I think is a slightly misleading claim about the potential of
legalisation of substances.<span style="mso-spacerun: yes;"> </span>I’m going to
analyse that, but then argue that nevertheless legalisation may be the right
policy.<o:p></o:p></div>
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<br /></div>
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So, what did I disagree with?<span style="mso-spacerun: yes;"> </span>Well, it’s not really Hari’s point; it’s a
commonly made claim about how prohibition increases the strength of the drugs.<span style="mso-spacerun: yes;"> </span>Hari refers to it as the ‘iron law’ of
prohibition.<span style="mso-spacerun: yes;"> </span>The point is that if you’re
having to smuggle things, then you want the most efficient way of doing it –
which in the case of alcohol means spirits rather than beer: a truckload of
whisky will satisfy more people than a truckload of beer.<span style="mso-spacerun: yes;"> </span>The same could be said of fentanyl today: it’s
so potent that it’s much easier to transport than heroin.<o:p></o:p></div>
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This argument is often trotted out by <a href="https://www.theguardian.com/commentisfree/2018/mar/01/skunk-criminalisation-drugs-reform">people
who want to legalise cannabis</a>, noting that today’s cannabis (often questionably
referred to as ‘skunk’) is stronger than what used to be available 20 or more
years ago.<o:p></o:p></div>
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And yet whisky wasn’t created by prohibition, and hasn’t become
obsolescent in societies where alcohol is legal.<span style="mso-spacerun: yes;"> </span>Moreover, people didn’t just drink these
things neat; <a href="https://www.absolutdrinks.com/en/prohibition-cocktails/">there
was a growth in cocktail recipes</a> as people sought to mask the taste.<span style="mso-spacerun: yes;"> </span>The transport was separate from the
consumption.<o:p></o:p></div>
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And the ‘gin craze’, however accurate as a description of
drinking in 18<sup>th</sup> century Britain, wasn’t driven by prohibition but by availability
and affordability.<span style="mso-spacerun: yes;"> </span>Hari would also say
it was driven by the misery and dislocation of rapid urbanisation.<span style="mso-spacerun: yes;"> </span>As I wrote previously, we don’t need to – in fact
we shouldn’t – look for a single universal cause of substance use issues.<span style="mso-spacerun: yes;"> </span>There isn’t one.<o:p></o:p></div>
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In my original piece, I questioned Hari’s claim that ‘relatively
few of us want to get totally shit-faced’ (p.230), given the phenomenon of ‘<a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395906000910https:/www.sciencedirect.com/science/article/abs/pii/S0955395906000910">determined
drunkenness</a>’.<span style="mso-spacerun: yes;"> </span>Here, I want to stress
that associating the level of ‘problem’ with the ‘strength’ of a drug is
misguided.<span style="mso-spacerun: yes;"> </span>Does whisky lead to more problems
than beer?<span style="mso-spacerun: yes;"> </span>It’s hard to say.<span style="mso-spacerun: yes;"> </span>Certainly not everyone who drinks whisky gets
drunk, and it’s perfectly possible to get ‘shit-faced’ drinking only beer – I’m
living proof.<o:p></o:p></div>
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<br /></div>
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And if you’re looking for an efficient way to get ‘shit-faced’,
it’s not necessarily the ‘strongest’ drink that you choose, but often the
cheapest – like white cider, which is a creation not of prohibition, but <a href="https://twitter.com/VictimOfMaths/status/1056990289422925826">our slightly
arcane tax system</a>.<o:p></o:p></div>
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A clearer ‘iron law’ of prohibition for me wouldn’t be that
it creates the strongest or most dangerous drugs (tobacco and alcohol companies
are perfectly competent at that); it’s that the strength and general composition
of the drugs is uncertain.<o:p></o:p></div>
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<br /></div>
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I’m not saying that prohibition doesn’t sometimes increase
the strength of drugs, or at least limit our choices, but it’s not an absolute ‘law’
– whereas lack of information (which is a key cause of overdose) is.<o:p></o:p></div>
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Also, strength is not the only determinant of problems.<span style="mso-spacerun: yes;"> </span>If we’re talking drunkenness we can’t only blame
spirits.<span style="mso-spacerun: yes;"> </span>And if we’re talking violence, beer
is again often to blame.<span style="mso-spacerun: yes;"> </span>And we could
probably blame wine for a good number of ‘alcohol-related’ illnesses where
there has perhaps been very little violence or drunkenness, but the health
harms of alcohol have come home to roost.<o:p></o:p></div>
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<br /></div>
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And this gets us to something of a choice about prohibition
or legalisation.<span style="mso-spacerun: yes;"> </span>I don’t want to get
into the detail of the debate, partly because a lot of it is supposition, and
depends so much on what regime is introduced to regulate substances, what the
prior culture of the area is, and so on.<span style="mso-spacerun: yes;">
</span>Not all countries that allow alcohol have the same levels of
alcohol-related harm – even if they have the same pricing and availability.<o:p></o:p></div>
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<br /></div>
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As always, I could focus not so much on how legalisation
would reduce harm for consumers, but for how it would be game-changing for
people involved in the production and distribution of drugs, where violence is
endemic and whole states have lost their <a href="https://en.wikipedia.org/wiki/Politics_as_a_Vocation#Summary">monopoly on
the legitimate use of force</a>.<o:p></o:p></div>
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<br /></div>
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And looking at the consumer side of things too, <a href="https://thinking-to-some-purpose.blogspot.com/2018/09/lets-have-end-to-tall-tales-about.html">taking
the example of alcohol</a>, we can suggest that there might be higher rates of drug-related
illnesses in the long term for consumers, but there would be less crime and
violence.<span style="mso-spacerun: yes;"> </span>Alcohol-related crime is
generally because people are drunk, but most drugs don’t tend to encourage this
– or there’s no reason they should.<span style="mso-spacerun: yes;"> </span>The
crime on the consumer side for these substances tends to be acquisitive to fund
drug use, but this doesn’t happen so much in relation to alcohol (particularly
not any more) now alcohol is, in relative terms, so cheap.<o:p></o:p></div>
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<a href="http://theconversation.com/legal-cannabis-vs-black-market-can-it-compete-104915">As
others have outlined</a>, in order to ensure there is no black market, the legal
price for drugs needs to be relatively low, and of course a potential consequence
of that is use increasing, along with associated harm.<span style="mso-spacerun: yes;"> </span>That’s what we can see with the growth in
alcohol consumption in the UK from the 1960s to 2004.<span style="mso-spacerun: yes;"> </span><a href="http://www.bbc.com/future/story/20151102-why-do-the-british-drink-so-much">Various
factors combined to make alcohol consumption increase</a> as it became more
acceptable, more affordable, and more available.<o:p></o:p></div>
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So is the price worth paying?<span style="mso-spacerun: yes;"> </span>Well, for me, as I’ve said, the benefits for
producer countries and those involved in the drug trade are clear.<span style="mso-spacerun: yes;"> </span>But for consumers and those around them it’s
potentially more of a mixed bag.<span style="mso-spacerun: yes;"> </span>But I’m
still prepared to say it’s worth it – just not because of the ‘iron law’.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
Again, without going into the detail (<a href="https://www.tdpf.org.uk/sites/default/files/Use-report-2016.pdf">other
people can do that better than me</a>), I see this as a question of whether we
would prefer the situation today where for consumers and producers life is (to
quote another political theorist) <a href="https://en.wikipedia.org/wiki/Thomas_Hobbes#Leviathan">nasty, brutish and
short</a>, to the situation under legalisation where we’d probably see some
higher rates of chronic conditions such as cancer (which we’ve seen with increased
alcohol use).<span style="mso-spacerun: yes;"> </span>I’d prefer the latter.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
That life is nasty, brutish and short for some people isn’t
the result of particular substances, even when they’ve been strengthened and
adulterated by prohibition.<span style="mso-spacerun: yes;"> </span>The nastiness
is the result of the wider structures, which can be changed.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-85422109906863873012018-11-23T11:50:00.001+00:002018-11-23T17:05:19.191+00:00In praise of fellowship<br />
<div class="MsoNormal">
Last night I went to my first ever Alcoholics Anonymous (AA)
meeting.<span style="mso-spacerun: yes;"> </span>It was an open meeting,
specially put on for Alcohol Awareness Week.<span style="mso-spacerun: yes;">
</span>I’ve been meaning to go to an open meeting for years, and there are
opportunities every month, but (like so many things) it’s only getting a date
in the diary that made me do it.<span style="mso-spacerun: yes;"> </span>I was
encouraged that a number of other professionals were there too, representing local
support and care organisations from midwifery to probation.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I found the meeting genuinely moving – but of course I
would.<span style="mso-spacerun: yes;"> </span>Who wouldn’t, hearing stories
being shared not only from two regular meeting attendees, but also someone who
attends Al-Anon – the sister organisation of AA that supports people whose
loved ones have issues with alcohol.<span style="mso-spacerun: yes;"> </span>The
moving thing wasn’t simply those testimonies, but something about bringing home
the human side of my job.<span style="mso-spacerun: yes;"> </span>I don’t mean
this in the way we often do: slightly patronising, remembering there are ‘service
users’ not just numbers in spreadsheets.<span style="mso-spacerun: yes;">
</span>I mean something about real human connection.<span style="mso-spacerun: yes;"> </span>One person who is alive speaking to
another.<span style="mso-spacerun: yes;"> </span>I know this sounds both cryptic
and trite, so I’ve tried to write something here that explains what I mean.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Sitting in the room, I felt like I was somehow back in the
past.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Writing that on its own makes me feel like I’m perpetuating a
stereotype of AA, of people sitting in a cold, damp church hall, wearing unfashionable
clothes, drinking flavourless coffee.<span style="mso-spacerun: yes;"> </span>My
experience was far from that.<span style="mso-spacerun: yes;"> </span>The coffee
was decent, the room was warm, modern and comfortable – and I’m certainly in no
position to comment on anyone’s dress sense.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
What I mean is that the kindness, community and somehow ordinariness
reminded me of the stability and community of my childhood.<span style="mso-spacerun: yes;"> </span>I felt like a weight had been lifted.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I tried to explain this afterwards to someone else there,
but failed.<span style="mso-spacerun: yes;"> </span>I said that sitting there,
listening to people’s stories, made me think (as I have about social work in
the past) that, done well, this kind of fellowship and community and the
genuinely <u>mutual</u> aid it offers would be of benefit to most people.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Of course, the person I was speaking to reasonably and
carefully explained two things.<span style="mso-spacerun: yes;"> </span>First,
that these groups were open to and designed for people who had issues with alcohol.<span style="mso-spacerun: yes;"> </span>Second, that these ‘issues’ were of a
particular kind – as a doctor quoted in the ‘Big Book’ that I picked up there
stated: ‘the action of alcohol on these chronic alcoholics is a manifestation
of an allergy; that the phenomenon of craving is limited to this class … These
allergic types can never safely use alcohol in any format at all’ (p.xxviii).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I hope I’ve always been respectful to this point of
view.<span style="mso-spacerun: yes;"> </span>To praise the general principle of
mutual aid isn’t to deny the special nature of ‘alcoholism’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But here’s where I may have been slightly less respectful.<span style="mso-spacerun: yes;"> </span>I get caught up in intellectual games and the
pleasure of having a neat (ideally slightly unexpected) position when I write
about alcohol and other drugs – though I nearly always end up sitting on the
fence somehow.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The intellectual game that fascinates me is the classic
discussion of structure versus agency, as sociologists would put it.<span style="mso-spacerun: yes;"> </span>Or in terms of alcohol problems, <a href="https://thinking-to-some-purpose.blogspot.com/2018/09/lets-have-end-to-tall-tales-about.html">does
the issue lie in the person or in the bottle</a> – and I like to say that
things are complex, nuanced, <a href="https://thinking-to-some-purpose.blogspot.com/2018/11/the-disease-of-black-and-white-thinking.html">shades
of grey</a>.<span style="mso-spacerun: yes;"> </span>(In work, by contrast, I
generally tend to want to know ‘the answer’ and get on to ‘do something’.)<span style="mso-spacerun: yes;"> </span>This interest in nuance (or fence-sitting)
has led me in the past <a href="https://thinking-to-some-purpose.blogspot.com/2015/10/the-concept-of-addiction.html">to
question whether ‘addiction’ really exists</a>, and to emphasise that <a href="https://thinking-to-some-purpose.blogspot.com/2017/08/are-we-all-alcoholics-now-or-is-none-of.html">if
‘alcoholics’ exist then they are a small sub-section of the group of people who
have problems with alcohol</a>, and if we get too caught up in defining ‘addiction’
we’ll fail to pay attention to the whole range of people who are struggling.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So I’ve not really had too much time for this concept of a
particular ‘class’ of ‘alcoholics’, as the quote in the ‘Big Book’ puts
it.<span style="mso-spacerun: yes;"> </span>(Though re-reading some of my old
pieces this morning, maybe my love of ‘nuance’ has meant <a href="https://thinking-to-some-purpose.blogspot.com/2016/04/addiction-or-false-consciousness.html">I’m
more reasonable than I think</a>.)<span style="mso-spacerun: yes;"> </span><a href="https://twitter.com/jamesmorris24/status/1064980373548007425">There are
certainly those</a> who see the use of terminology like ‘alcoholic’ as not only
stigmatising but limiting people’s autonomy and potential for recovery.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Having now been to a meeting, though, I feel I’ve been a bit
too cold and detached in my assessment.<span style="mso-spacerun: yes;">
</span>It’s the same way I feel, on reflection, about the <a href="https://thinking-to-some-purpose.blogspot.com/2016/04/what-do-we-mean-by-drugs.html">things
I’ve written</a> saying that the 2016 Psychoactive Substances Act could, in the
long term, be helpful for UK drug policy debates.<span style="mso-spacerun: yes;"> </span>The problem with intellectual games, <i style="mso-bidi-font-style: normal;">abstract</i> principles and ‘long term’
policy debates is that they’re not human, they don’t <i style="mso-bidi-font-style: normal;">feel</i>.<span style="mso-spacerun: yes;"> </span>(<a href="https://www.simontaylorsblog.com/2013/05/05/the-true-meaning-of-in-the-long-run-we-are-all-dead/">In
the long run, we are all dead</a>.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The most revealing moment in the meeting was, for me, when
various people spoke about ideas of ‘God’ and a ‘higher power’.<span style="mso-spacerun: yes;"> </span>This is one of the most debated features of
AA, and the one many sceptics leap upon to discredit or disengage with it.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One person explained that, sitting in a church, he wouldn’t
feel like he was surrounded by people who understood him, whereas in AA he knew
‘these were my people’.<span style="mso-spacerun: yes;"> </span>This is a bit
like a phrase I remember Mark Gilman using a few years ago when he came to
speak in Dorset, describing an ‘alcoholic’ as someone who has ‘got the spots’ –
but it’s also something more.<span style="mso-spacerun: yes;"> </span>It’s not
just sitting in a room with people who have the same condition or ‘illness’ (many
of us have done that at one time or another, and it’s not always useful or
fulfilling); it’s about the sense of fellowship.<span style="mso-spacerun: yes;"> </span>As someone else explained, for her the ‘higher
power’ was something outside of, beyond, herself: the other people in the room.<span style="mso-spacerun: yes;"> </span>This is the human, feeling element that I am
somehow too easily able to switch off when analysing or writing.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The term ‘alcoholic’ is used in this context without shame
or judgement.<span style="mso-spacerun: yes;"> </span>It’s seen as a description
of a ‘class’ of people, and this ‘class’ isn’t simply defined by alcohol
consumed.<span style="mso-spacerun: yes;"> </span>It’s a class for whom, as one
person put it to me afterwards, just stopping drinking isn’t the solution – in fact,
without some wider support, that can often make things worse.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Of course, such people are not the only people who suffer
harm from alcohol.<span style="mso-spacerun: yes;"> </span>And we need to be
flexible in our idea of ‘rock bottom’ (and whether someone actually has to hit
it to find recovery).<span style="mso-spacerun: yes;"> </span>But it’s hard to
sit in that room and feel anything but warmth and admiration for what this
fellowship – these people – have done and continue to do.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So going to the meeting helped me remember another way of
being in the world.<span style="mso-spacerun: yes;"> </span>Somehow more
relaxed, more grateful, more structured.<span style="mso-spacerun: yes;">
</span>There are various reasons I feel I’ve lost that recently.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But it also made me consider my own drinking.<span style="mso-spacerun: yes;"> </span>I’ve not got very far in reading the ‘Big
Book’, and so I keep coming back to that section at the beginning by a doctor –
William D Silkworth.<span style="mso-spacerun: yes;"> </span>There’s a revealing
sentence that opens a paragraph describing the nature of ‘the alcoholic’: ‘Men
and women drink essentially because they like the effect produced by alcohol’
(p.xxviii).<span style="mso-spacerun: yes;"> </span>I certainly do.<span style="mso-spacerun: yes;"> </span>I drafted this post last night, and was
already envisaging the train back from London on Friday night where I’d enjoy a
couple of cans of ‘train beer’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I’m not suggesting my drinking is ‘alcoholic’, but two
things in the past week have made me question my relationship with alcohol.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
One was meeting staff and PhD students when I went back to
Bournemouth University last Friday to teach a session on ‘controversial
cultures’.<span style="mso-spacerun: yes;"> </span>Discussing ‘binge’ drinking
culture as potentially controversial, I was asked if there was something in the
British psyche that means we can’t drink sensibly.<span style="mso-spacerun: yes;"> </span>Thinking of <a href="https://www.historytoday.com/james-nicholls/drink-british-disease">James
Nicholls</a>, I argued that there isn’t a single, fixed British drinking
culture and, anticipating this week’s Alcohol Awareness theme, I emphasised
that ‘<a href="https://alcoholchange.org.uk/get-involved/campaigns/alcohol-awareness-week">change</a>’
is possible at a population as well as an individual level.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And the second moment was last night at the AA meeting.<span style="mso-spacerun: yes;"> </span>The description of how drinking, for some people,
was a way of avoiding the discomfort of living, the anxiety of navigating the
world, the awkwardness of being oneself.<span style="mso-spacerun: yes;">
</span>(These are all poor phrases to represent what people actually
described.<span style="mso-spacerun: yes;"> </span>I can’t represent their eloquence
in my writing.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is why I drink too.<span style="mso-spacerun: yes;">
</span>It takes the edge off.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And this, generally, is why people use any drug.<span style="mso-spacerun: yes;"> </span>As I remember <a href="https://thinking-to-some-purpose.blogspot.com/2017/06/new-directions-and-dangers-of.html">Wulf
Livingston arguing persuasively at NDSAG</a>, much drug use can be seen as
functional in some way, even when it’s part of what would generally be labelled
‘misuse’: if the drugs weren’t serving some purpose, people wouldn’t use them.<span style="mso-spacerun: yes;"> </span>Perhaps in the long term there’s a better
solution, but drugs, too, are a solution of sorts.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Most of us just don’t reach the point described by several people
at the meeting, where they were so tired of the repeated pattern of using/drinking
that they no longer wanted that life (and therefore no longer wanted a drink
because they knew how that ended).<span style="mso-spacerun: yes;"> </span>For those
of us still drinking, we’ve decided at some level that the benefits still outweigh
the costs.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And I don’t just mean a small glass of wine over
dinner.<span style="mso-spacerun: yes;"> </span>I haven’t tried many drugs, but
for the moment I can certainly say that alcohol is ‘my’ drug.<span style="mso-spacerun: yes;"> </span>I respect that this isn’t true for everyone
(or even most people), but fundamentally I struggle to genuinely understand why
people wouldn’t like the feeling of drunkenness.<span style="mso-spacerun: yes;"> </span>Why, if there were no commitments tomorrow,
wouldn’t people always say yes to another drink?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But sitting in that room, I wondered about that.<span style="mso-spacerun: yes;"> </span>Is it a healthy, happy approach to life: when
I can, I try not to be fully conscious or present?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Just like my writing, I wonder if my drinking is an attempt
to show off, to be special.<span style="mso-spacerun: yes;"> </span>Am I trying
to be one of Steve Earnshaw’s intellectual, ‘<a href="http://www.manchesteruniversitypress.co.uk/9780719099618/">existential
alcoholics</a>’?<span style="mso-spacerun: yes;"> </span>(Just without the
courage of their convictions to be truly destructive.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And that brings me back to that starting point, which could
be seen as simultaneously undermining and celebrating the principles and practices
of AA.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
(Wait for it, but just so you’re warned, this is the
supposedly clever conclusion bit I always aim for when writing a piece like
this.<span style="mso-spacerun: yes;"> </span>In this case part of me is
thinking that it’s particularly clever because I’m being self-referential and
self-critical given that <a href="https://thinking-to-some-purpose.blogspot.com/2018/10/are-compassion-and-connection-answer-to.html">I’ve
recently been questioning Johann Hari’s claim that the opposite of addiction is
connection</a>, and yet here I am praising connection as a solution to
addiction.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The value of AA, to me, is this reminder of the ‘miracle’ of
an ‘ordinary’ life, and the benefits of ‘fellowship’.<span style="mso-spacerun: yes;"> </span>These are amazingly special things, affirming
the value of AA – and yet they are also surely universal (as much as anything
can be), which leads me to question how ‘special’ this approach really is.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But although we could all perhaps learn from AA, and despite
the fact that this ‘class’ of ‘alcoholics’ aren’t solely defined by their
drinking habits, there remains something unique: fortunately most of us are
never placed in situations so extreme that we have to think in this way.<span style="mso-spacerun: yes;"> </span>And this is perhaps where all of us can take
a moment to express what was so fundamental for so many people in the room last
night: gratitude.</div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com1tag:blogger.com,1999:blog-125653241615635488.post-47649751139597224382018-11-20T22:47:00.002+00:002018-11-22T09:58:04.232+00:00The disease of black and white thinking about addiction<br />
<div class="MsoNormal">
Today (<span class="MsoHyperlink"><a href="https://twitter.com/hashtag/OurDay?src=hash">#OurDay</a></span>) I was at
an event in Bournemouth where we were discussing how we could get the different
services to work efficiently and effectively together, when there’s <i style="mso-bidi-font-style: normal;">decreasing</i> resources at the same time as
many of the people who need support are facing <i style="mso-bidi-font-style: normal;">increasing</i> challenges, such as unstable housing, complicating
health conditions, unemployment, benefits cuts and so on.<span style="mso-spacerun: yes;"> </span>As one person described it, it’s a ‘perfect
storm’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This isn’t news, and although the suggestions made by staff
were excellent, I want to focus on some conversations I had outside the main
discussions – over lunch.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The first thing to note is that despite the astonishing
passion and dedication of these staff, who are quite simply not paid enough, the
environment they are working in is taking its toll: those decreasing funds and
increasing challenges mean people are struggling to see that they’re genuinely
making a difference.<span style="mso-spacerun: yes;"> </span>Is it just pushing
water uphill?<span style="mso-spacerun: yes;"> </span>At one point do you decide
to stop propping up a system you don’t believe in?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And that brings me onto a bigger point about beliefs that I
want to focus on here.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I was surprised that there was still considerable passion not
just in the delivery of treatment, but in the recovery / harm reduction
debate.<span style="mso-spacerun: yes;"> </span>I had naively thought we’d
buried the hatchet, but it’s very much alive in terms of how people see the
decisions that different organisations and clinicians make.<span style="mso-spacerun: yes;"> </span>In a sense, that’s not surprising, though, and
it’s partly the fault of commissioners (and politicians) for doing one of two
things.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
First (and this is my own typical failing) we’ve sometimes
been guilty of ducking the issue, of imagining that just saying things like ‘<span class="MsoHyperlink"><a href="https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/policy%20research/public%20and%20population%20health/evidence-based-interventions-for-managing-illicit-drug-dependence.pdf?la=en">evidence
based</a></span>’ or ‘<span class="MsoHyperlink"><a href="https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk-guidelines-on-clinical-management">Orange
Book</a></span>’ will dissolve any conflict.<span style="mso-spacerun: yes;">
</span>It won’t.<span style="mso-spacerun: yes;"> </span>We should be savvy
enough to know that there’s plenty of wiggle room in <span class="MsoHyperlink"><a href="https://www.nice.org.uk/guidance/ta114">NICE</a></span> and <span class="MsoHyperlink"><a href="https://www.gov.uk/government/publications/drug-misuse-treatment-in-england-evidence-review-of-outcomes">PHE</a></span>
guidelines, and there’s always that black box of ‘clinical judgement’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Second, and conversely, we’ve sometimes been <u>too</u>
definite.<span style="mso-spacerun: yes;"> </span>Sometimes issues have been
presented as ‘black and white’, with a proposal being ‘right’ and all other
options ‘wrong’.<span style="mso-spacerun: yes;"> </span>No wonder, then, that
as the goalposts seem to be moved staff feel betrayed or lied to: if the
previous policy was ‘right’, surely this one is ‘wrong – or vice versa.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We should all be a little more cautious when ‘selling’
policies, and open and honest about our motivations and the limits of our
knowledge.<span style="mso-spacerun: yes;"> </span>(We should also obviously be
careful not to introduce any genuinely ‘wrong’ policies in the first place.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The problem is that when someone is presenting something as
a black and white issue, and you’re not sure you agree with their position,
it’s easy to get caught in that same binary way of thinking – when what I’d
prefer with most of this is to suggest that there isn’t a single right
approach, and if we want to talk about services that are tailored to the
client, we need to genuinely listen to them.<span style="mso-spacerun: yes;">
</span>A one-size fits all approach, whether from a self-proclaimed ‘recovery’
or ‘harm reduction’ perspective is likely to be unhelpful for a number of
people.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If this all sounds a bit cryptic, that’s fine.<span style="mso-spacerun: yes;"> </span>My real point is something almost trivial
about the theory of addiction.<span style="mso-spacerun: yes;"> </span>(Which of
course is never cryptic.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In my experience of discussions about ‘addiction’, certain
high-minded academics <span class="MsoHyperlink"><a href="https://www.tandfonline.com/doi/full/10.1080/16066359.2017.1399659">critique
the ‘disease model’ of addiction</a></span>, and possibly even <span class="MsoHyperlink"><a href="https://academic.oup.com/alcalc/article/48/6/633/444152">the whole
concept</a></span>.<span style="mso-spacerun: yes;"> </span>Then they are
advised that the disease model, <span class="MsoHyperlink"><a href="https://www.drugabuse.gov/news-events/news-releases/2015/07/nida-niaaa-commentary-strongly-supports-brain-disease-model-addiction">as
championed by NIDA</a></span>, is valuable because it helps stop addiction
being stigmatised.<span style="mso-spacerun: yes;"> </span>If people are ‘ill’
rather than ‘bad’, then surely there’s no reason to marginalise them and not
offer reasonable healthcare and support?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It always feels to me that critiques of the disease model
are therefore labelled as abstract, idealistic, and not in touch with ‘real’
politics or treatment.<span style="mso-spacerun: yes;"> </span>This is brought
home even more by <span class="MsoHyperlink"><a href="http://www.williamwhitepapers.com/pr/Dr.%20Ernie%20Kurtz%20on%20AA%20%26%20the%20Disease%20Concept%2C%202002.pdf">the
close links between the disease model and the ideas of fellowships like
Alcoholics Anonymous</a></span>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Of course this is naïve on two counts.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
First, academics can also have lived experience.<span style="mso-spacerun: yes;"> </span><span class="MsoHyperlink"><a href="http://www.memoirsofanaddictedbrain.com/authors-bio/">Marc Lewis</a></span>,
who co-wrote one of the pieces linked to above, makes no secret of his.<span style="mso-spacerun: yes;"> </span>Indeed, it’s his experience that led him to a
different perspective on the issue.<span style="mso-spacerun: yes;"> </span>And
more broadly, these aren’t simply abstract, academic debates; they can shape
policy and treatment.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Second, the idea that being ‘ill’ isn’t stigmatising is
absurd.<span style="mso-spacerun: yes;"> </span>Any number of diseases and
illnesses have been considered moral failings, or simply dangerous and
therefore stigmatising, from leprosy to cerebral palsy, to HIV to name just a
few.<span style="mso-spacerun: yes;"> </span>We don’t manage to treat everyone
who is ill with dignity.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Is the disease contagious?<span style="mso-spacerun: yes;">
</span>Is it somehow caused by someone’s ‘lifestyle’ (or that of their
parents)?<span style="mso-spacerun: yes;"> </span>These are key questions not
just for the stigma surrounding addiction, but many other illnesses.<span style="mso-spacerun: yes;"> </span>And they’re not easy to answer.<span style="mso-spacerun: yes;"> </span>(<span class="MsoHyperlink"><a href="http://www.williamwhitepapers.com/pr/2010%20Recovery%20is%20Contagious.pdf">If
recovery is contagious, then isn’t addiction?</a></span>)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But it seems to me that this remains the frame of the debate:
brain disease a realistic, pragmatic, stigma-reducing idea; critiques perhaps
well-intentioned, but abstract and academic.<span style="mso-spacerun: yes;">
</span>Criticising the disease model is seen as a hobby of abstract academic
thinkers not grounded in the real world.<span style="mso-spacerun: yes;">
</span>(Maybe that’s me being oversensitive, but stick with me.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
That’s why I was surprised to hear critics of ‘harm
reduction’ (self-confessed advocates of ‘recovery’) also criticising the
disease model.<span style="mso-spacerun: yes;"> </span>But of course this made
perfect sense.<span style="mso-spacerun: yes;"> </span>For them, the reliance on
methadone (and an emphasis on ‘optimal dose’ in the Orange Book that is
relatively high compared to much practice) represented a medicalising of
addiction based on a disease model.<span style="mso-spacerun: yes;"> </span>If
you diagnose a disease, our standard medical approach is to prescribe, well, a
medicine – in this case methadone.<span style="mso-spacerun: yes;"> </span>But
methadone is nothing like an antibiotic, or steroid.<span style="mso-spacerun: yes;"> </span>It doesn’t <u>in itself</u> fight an
infection or reduce swelling; it feeds a physiological dependency.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I don’t really want to get drawn into the details of this
debate.<span style="mso-spacerun: yes;"> </span>It would take too long and the
evidence isn’t always perfectly clear.<span style="mso-spacerun: yes;">
</span>It would also mean conducting a debate in ‘<span class="MsoHyperlink"><a href="http://thinking-to-some-purpose.blogspot.com/2014/11/on-irrationality-of-drug-policy.html">bright
lines</a></span>’ when <span class="MsoHyperlink"><a href="https://thinking-to-some-purpose.blogspot.com/2016/09/when-clear-thinking-can-be-muddy.html">the
reality is a little more muddy</a></span>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I just want to pause on this point: recovery advocates can
also be critics of the disease model.<span style="mso-spacerun: yes;">
</span>This is of course completely coherent, and maybe it’s only me who’s
intrigued, but it highlights that these debates aren’t simply black and
white.<span style="mso-spacerun: yes;"> </span>If we had to choose a ‘side’
between ‘harm reduction’ or ‘recovery’ we might find ourselves alongside
with some people we don’t agree with regarding the very nature of ‘addiction’.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
An overly prescriptive idea of ‘right’ and ‘wrong’
approaches to treatment actually contains the seeds of its own downfall.<span style="mso-spacerun: yes;"> </span>If your enemy’s enemy is your friend, you’ll
find that, actually, we’re all friends.<span style="mso-spacerun: yes;">
</span>We shouldn’t be choosing sides.<span style="mso-spacerun: yes;">
</span>Not when there’s bigger battles to fight – like that perfect storm.<o:p></o:p></div>
<br />Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com2tag:blogger.com,1999:blog-125653241615635488.post-89921084769072151082018-11-19T16:22:00.000+00:002018-11-19T16:22:03.440+00:00Alcohol Change: The Voice of Moderation?<div class="MsoNormal">
Today the new charity formed out of the merger of Alcohol
Concern and Alcohol Research UK has been launched. You might remember that when this merger was
first announced <a href="https://thinking-to-some-purpose.blogspot.com/2016/12/concern-isnt-research-and-reducing-harm.html">I
was pretty sceptical that it could work</a>.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I felt that fundamentally the two organisations had different
visions that were basically at odds with each other. Alcohol Research UK sought to improve
knowledge and information to help reduce alcohol-related harm, while Alcohol
Concern sought to eliminate alcohol-related harm altogether.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
These might only be seen as matters of degree, but the idea
of a world free from alcohol harm is as utopian as the UN’s claim that we
should create a ‘drug free world’. Given
what we know about alcohol, the only way to guarantee you won’t suffer any harm
related to it is not only for you not to drink, but for no-one around you to
drink. A world free from alcohol harm
means, in reality, a world free from alcohol.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The new organisation – Alcohol Change – defines its vision
as being a society where there is an end to ‘serious alcohol harm’, and
envisages bringing this about by improving knowledge, policy and treatment, and
therefore changing cultural norms and drinking behaviours.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
You can read about Alcohol Change’s proposed approach in <a href="https://alcoholchange.org.uk/get-involved/campaigns/alcohol-awareness-week/the-alcohol-change-report">a
kind of ‘state of the nation’ report</a> released to coincide with Alcohol
Awareness Week. I just want to pick out
a few gems and talking points from this that have made me eat humble pie: I
think that maybe the staff and Trustees at Alcohol Change have managed to do
what I thought was if not impossible then certainly highly challenging.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
First, there’s a paragraph in Alan Maryon-Davis’
introduction that I think should be shared with every journalist and political
commentator ever considering discussing alcohol policy:<o:p></o:p></div>
<blockquote class="tr_bq" style="margin-left: 36.0pt;">
There is nothing inevitable about
the way we drink, how we behave when drinking or how difficult it is to access
the support that can help turn lives around. Research shows that the majority
of dependent drinkers recover, that heavy drinkers can make new choices, and
that the social and cultural environment in which people drink can and does
change. Change is possible for individuals, and it is possible for society.
(p.1)</blockquote>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<o:p></o:p></div>
<div class="MsoNormal">
Far too often we view drinking habits as unchanging and unchangeable:
we’ve been drinking too much as a nation since well before William the
Conqueror arrived.<o:p></o:p></div>
<blockquote class="tr_bq" style="margin-left: 36.0pt;">
‘Drinking in particular was a
universal practice in which occupation they passed entire nights as well as
days. They consumed their whole sustenance in mean and despicable houses, unlike
the Normans and French, who in noble and splendid mansions lived in frugality …
They were accustomed to eat till they became surfeited and to drink till they
were sick. The latter qualities they imparted to their conquerors.’ William of
Malmesbury, 12th century</blockquote>
<div class="MsoNormal" style="margin-left: 36.0pt;">
<o:p></o:p></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTD9OZziJjomgnrOYE_YufresL13JHtAs3iMiDa0p8BPcNB4ToD9iP9UsF89cckrDrXPC1SVWz-bhBX-BKfu5Y8HZ6AibaEod2_yeCnSc5FqYLNG62gapBtkMsz062WUoTA_IO5NkVVXYl/s1600/Drinking+over+time.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="596" data-original-width="1043" height="182" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTD9OZziJjomgnrOYE_YufresL13JHtAs3iMiDa0p8BPcNB4ToD9iP9UsF89cckrDrXPC1SVWz-bhBX-BKfu5Y8HZ6AibaEod2_yeCnSc5FqYLNG62gapBtkMsz062WUoTA_IO5NkVVXYl/s320/Drinking+over+time.PNG" width="320" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYCP_TmXjE1w7jge1r2qNhgkDLkIN_s6EvAR4LFGzj-KqAo-eYVdkWzeD8ffOOGwyevrJdzAofG3kHPEZ6_ERBDtn8w7_b5t_1qXFVmKunewVJFMeQQ7cS_busZRq3lfKNqzmxw2kpe8lm/s1600/Liver+disease+in+Europe.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="568" data-original-width="998" height="182" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYCP_TmXjE1w7jge1r2qNhgkDLkIN_s6EvAR4LFGzj-KqAo-eYVdkWzeD8ffOOGwyevrJdzAofG3kHPEZ6_ERBDtn8w7_b5t_1qXFVmKunewVJFMeQQ7cS_busZRq3lfKNqzmxw2kpe8lm/s320/Liver+disease+in+Europe.PNG" width="320" /></a></div>
<div class="MsoNormal" style="text-align: center;">
<i>Taken from <a href="https://publications.parliament.uk/pa/cm200910/cmselect/cmhealth/151/15102.htm" target="_blank">House of Commons Health Committee report 2009</a></i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But that raises the inevitable question: if change happens,
and we can shape it, what sort of culture should we be aiming for? And this is where the ideas of knowledge,
information and choice come through strongly and, for me, positively in the
Alcohol Change document.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I’m generally sceptical about health and behaviour change programmes
based around ‘choice’ because they tend to ignore (or at least downplay) the
level to which people’s choices are structured by the situation they find
themselves in: who their parents are; where they live; how much money they
have; the job they have; the personal relationships surrounding them; and so on.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But this document <u>doesn’t</u> duck this issue; it notes
the importance of culture and norms in shaping our preferences and
expectations, and how these in turn can be shaped by policy levers.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The changes in alcohol consumption shown in the graph above
were partly down to some short and medium terms factors – both conscious policy
decisions and the simple fact of a dire economic situation – but they cast a
very long shadow, with alcohol consumption for most the twentieth century
remaining at historically low levels.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And the policy point is made with a bit of nuance too. <a href="https://www.emeraldinsight.com/doi/full/10.1108/DAT-02-2015-0006">As I’ve
argued elsewhere</a>, too often policy discussions focus on exciting new
initiatives – such as minimum unit pricing – at the national or even
international level. In reality, there’s
massive variety and impact generated by local decision-making – but somehow
Town Halls are seen as less interesting than Whitehall. It’s refreshing, therefore, to read a
strategic document that emphasises the importance of engaging with ‘local
government … commissioners of treatment services [that’s me!], the police,
local planning, and all the other local stakeholders with a role in reducing
alcohol harms’ (p.11).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For me, this document seems to have got the approach just
right.<o:p></o:p></div>
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<br /></div>
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There will of course be campaigners who feel that ‘serious’
is a weasel word that dilutes the utopian aspiration of a world completely free
from alcohol harm, and the focus on knowledge and information is a naïve concession
to the evil industry of ‘big alcohol’. And
conversely there will be libertarians who see the emphasis on culture change as
beyond the scope of reasonable activities, which should allow people to pursue
their own choices.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For me, that’s the ideal position for a new charity like
this to be in. <a href="https://thinking-to-some-purpose.blogspot.com/2013/06/public-health-realpolitik.html">I’ve
complained before</a> about the polarised, adversarial approach that often
characterises alcohol policy debates – ‘public health’ versus ‘the industry’ –
where both sides have some valid points but neither is listening to the other.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
There will always be these voices at either end of the
spectrum, and there’s little value in duplicating one or the other – a simple approach
to balance will mean both are heard (or at least given the opportunity to shout
over each other).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The value of Alcohol Change should rest in being a different
voice, not associated with a partisan position but as a trusted messenger and ‘truth
teller’. And in playing that role –
rather than simply being a vocal, idealistic (even utopian) campaigning
organisation – it may find its ideas and proposals are listened to more
seriously than either of the two extremes.
As so many alcohol researchers and lobbyists have noted, there is great
power in being able to define what the ‘moderation’ is. Alcohol Change can position itself as the
voice of moderation in more ways than one.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
The last time I wrote about this merger, I summed up my
scepticism with a reflection on my personal feelings – valuable because so
often (as drinkers, professionals or campaigners) our views on alcohol are
shaped by personal experiences and beliefs.
I said that while I would be keen to work for Alcohol Research UK, I
just couldn’t see myself being a good fit with Alcohol Concern, given its hardline,
lobbying approach. I don’t know whether
it’s praise or not, but I can honestly say that Alcohol Change looks like the
sort of organisation I’d enjoy working for.<o:p></o:p></div>
Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-30693441628076312962018-10-29T16:57:00.003+00:002018-10-30T11:32:40.298+00:00Are compassion and connection the answer to drug policy debates?<br />
<div class="MsoNormal" style="tab-stops: 112.5pt;">
Two people I have a huge amount of
respect for – Suzi Gage and Harry Sumnall – have <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/add.14481">just published
a paper</a> encouraging us all to have a bit more restraint when discussing the
implications of <a href="https://theoutline.com/post/2205/this-38-year-old-study-is-still-spreading-bad-ideas-about-addiction?zd=1&zi=el3ouklp">the
Rat Park experiment</a>.<span style="mso-spacerun: yes;"> </span>Just like the original
author, Bruce Alexander, did, in actual fact.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
I was familiar with the experiment
somewhere back in the mists of time, but (setting aside Bruce Alexander’s
appearance at the 2016 New Directions in the Study of Alcohol conference) the
reason it’s on my radar now is that Johann Hari and others have used it to
campaign for the legalisation and regulation of drugs.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
For those of you who are
interested in finding out more about the experiment, I’d recommend Suzi and
Harry’s article.<span style="mso-spacerun: yes;"> </span>Basically, the study is
typically seen as showing that a rat’s propensity to get ‘addicted’ to a drug (morphine
in the case of Bruce Alexander’s work, but others have used cocaine) is not
simply dependent on the drug, but their environment.<span style="mso-spacerun: yes;"> </span>Put rats in bare, individual cages and they’ll
use intoxicating drugs to the point of incapacitation or even death; put them together
in a ‘Rat Park’ with other rats and entertainment and they’ll pretty much
ignore the drugs.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
The problem is, of course, that it’s
more complicated than that, and in any case it’s hard to extrapolate from a
small animal study to a global policy for humans.<span style="mso-spacerun: yes;"> </span>It’s often overplayed because it’s an eye-catching
story.<span style="mso-spacerun: yes;"> </span>In itself, the research isn’t
miles from the general consensus about what causes issues like addiction: a
mixture of the substance, the person and wider circumstances.<span style="mso-spacerun: yes;"> </span>The ‘biopsychosocial’ model, if you like.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
The point of all this discussion
is that reading the article reminded me I had recently made the effort to read
Johann Hari’s <i style="mso-bidi-font-style: normal;"><a href="https://www.bloomsbury.com/uk/chasing-the-scream-9781408857830/">Chasing
the Scream</a></i> in full.<span style="mso-spacerun: yes;"> </span>I felt
guilty at criticising him on the basis of TED talks or newspaper articles
without actually having read the whole book.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
I’m not particularly negative
about the book.<span style="mso-spacerun: yes;"> </span>It’s well written and
the interviews and storytelling are engaging.<span style="mso-spacerun: yes;">
</span>I also want to believe the conclusions, and I like the way he writes
about how he reached them, and the uncertainty about whether they hang
together.<span style="mso-spacerun: yes;"> </span>I largely agree with the
conclusions.<span style="mso-spacerun: yes;"> </span>I think the world would be
a safer place if more drugs were regulated and available through legal routes,
whether prescribed or sold.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
Unfortunately, Hari was right to
be concerned: the conclusions don’t actually hang together.<span style="mso-spacerun: yes;"> </span>I know the book isn’t new, and other people
have analysed it before me, but I it’s been a useful exercise for me to think
all this through, and it’s important for our debates about drug policy.<span style="mso-spacerun: yes;"> </span>It can feel like we’re at a fork in the road
at the moment, not just seeing possibilities for change, but real change
itself.<span style="mso-spacerun: yes;"> </span>Cannabis is legal for recreational
use in countries around the world, and more and more places are operating decriminalisation,
either in theory or practice.<span style="mso-spacerun: yes;"> </span>The
arguments and claims we make for these policies, are important.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
So just noting a few of the issues
with Johann Hari’s claims, he can’t seem to decide whether drug use is exciting
or boring – and he sees this as crucial to the solution.<span style="mso-spacerun: yes;"> </span>So he quotes John Marks, who prescribed
injectable heroin on the Wirral in the 1980s, as saying: ‘I try to make my
clients realise that what they’re doing is boring, boring, boring.’<span style="mso-spacerun: yes;"> </span>Except that’s not (always) the case.<span style="mso-spacerun: yes;"> </span>And it’s not what Hari says elsewhere in the
book.<span style="mso-spacerun: yes;"> </span>Using heroin can be exciting – and
not just in terms of the chemical ‘high’.<span style="mso-spacerun: yes;">
</span>As <a href="https://link.springer.com/article/10.1007%2Fs10612-015-9312-5">Steve Wakeman
has powerfully described</a>, the routine of getting together enough money,
making the deal and using the drugs provides a focus and some excitement to the
day, and also offers people a sense of expertise and achievement.<span style="mso-spacerun: yes;"> </span>It can also provide a community.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
As I say, Johann Hari knows
this.<span style="mso-spacerun: yes;"> </span>When he quotes John Marks on
p.211, he has already quoted Bruce Alexander on p.176 saying that when the life
of a heroin user is compared with what might happen if they got a ‘McJob’ or
became a janitor, it seems ‘really exciting’.<span style="mso-spacerun: yes;">
</span>Hari doesn’t have to agree with everyone he quotes, but he does need to
balance different perspectives up against each other.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
Of course it’s possible that,
following the idea that people ‘<a href="http://geneheyman.com/wordpress/wp-content/uploads/2013/11/HeymanAnnRevClinPsych13QuitDrugs.pdf">grow
out</a>’ of most patterns of substance use, heroin use is exciting to start with,
and maybe for many years, but at a certain point there comes a time when it
seems ‘boring, boring, boring’.<span style="mso-spacerun: yes;"> </span>But as
the Bruce Alexander point shows, this depends on what else is on offer.<span style="mso-spacerun: yes;"> </span>It also means that one approach won’t make
sense for everyone.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
This has important consequences
for policy. <span style="mso-spacerun: yes;"> </span>Heroin assisted treatment
(HAT) is more likely to work if the alternative isn’t seen as exciting –
because HAT will never be exciting in that way, as <a href="http://journals.sagepub.com/doi/10.1177/1748895815575617">Steve Wakeman
has again described so well</a>.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
So we’re not clear from this book
what treatment we should be offering people, but perhaps that isn’t much of a
criticism.<span style="mso-spacerun: yes;"> </span>This is really a book about
the global ‘war on drugs’.<span style="mso-spacerun: yes;"> </span>So let’s
think about drug policy more broadly.<span style="mso-spacerun: yes;">
</span>Hari suggests that use of substances isn’t down to access, but in fact there’s
plenty of evidence that use of alcohol (and in fact other drugs) goes up and
down depending on how accessible it is.<span style="mso-spacerun: yes;"> </span>Some
might argue that overall levels of substance use stay the same, people just switch
from one substance to another (even across legal boundaries).<span style="mso-spacerun: yes;"> </span>However, we know that overall substance use
varies over time, and this is partly about access and affordability.<span style="mso-spacerun: yes;"> </span>In many countries, <a href="http://geneheyman.com/wordpress/wp-content/uploads/2013/11/HeymanAnnRevClinPsych13QuitDrugs.pdf">the
interwar years saw slumps in alcohol use</a> not because everyone was switching
to other drugs, but because money was tight and <a href="http://www.manchesteruniversitypress.co.uk/9780719086373/">it was harder
to get hold of a drink because of stricter controls or even prohibition</a>.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
But citing Bruce Alexander again, Hari
states: ‘The answer doesn’t lie in access.<span style="mso-spacerun: yes;">
</span>It lies in agony.<span style="mso-spacerun: yes;"> </span>Outbreaks of
addiction have always taken place … when there was a sudden rise in isolation
and distress – from the gin-soaked slums of London in the eighteenth century to
the terrified troops in Vietnam’ (p.228).<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
There are two problems with this
approach.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
First, it’s not clear that high
levels of substance use are associated with agony so much as affluence.<span style="mso-spacerun: yes;"> </span>Perhaps affluence comes at times of change
and upheaval, but the relationship is more complicated than that.<span style="mso-spacerun: yes;"> </span>Of course, ‘addiction’ is a problematic
concept, and it might be that if we define it tightly enough then we can see
that instances increase at times of ‘agony’.<span style="mso-spacerun: yes;">
</span>There’s certainly no doubt that difficult experiences can drive people
to substance use.<span style="mso-spacerun: yes;"> </span>But dealing only with ‘agony’
– or even seeking the prevention of ‘agony’ would leave us with a pretty narrow,
ineffective drugs policy.<span style="mso-spacerun: yes;"> </span>Too often, the
book slides into describing drug use as inherently problematic (e.g. pp.241-2) –
and then moments later talking about the inevitable human desire for
intoxication.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
Second, availability <u>is</u> a
key factor that is part of the mix.<span style="mso-spacerun: yes;"> </span>The ‘gin
crisis’ (or rather the perception of a crisis) occurs not simply because of an
increase in agony, but also because of availability of a particular product,
which has been developed through technological innovations and the confluence of
foreign policy (gin as a patriotic Protestant alternative to French brandy).<span style="mso-spacerun: yes;"> </span>Use of heroin amongst American troops in Vietnam
was partly the result of it being available.<span style="mso-spacerun: yes;">
</span>Why not other substances?<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
The response to this is that the
substance is secondary: whatever is affordable and available will be used to
soothe the pain.<span style="mso-spacerun: yes;"> </span>But was there less pain
in the ‘dark ages’?<span style="mso-spacerun: yes;"> </span>During the English
Civil War?<span style="mso-spacerun: yes;"> </span>During the World Wars of the
twentieth century?<span style="mso-spacerun: yes;"> </span>We’re drinking more
now.<span style="mso-spacerun: yes;"> </span>If drinking follows pain, that
simply wouldn’t be true.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
And, crucially, we do drink
despite it being legal.<span style="mso-spacerun: yes;"> </span>Campaigners
might see legalisation as ‘a drama reduction programme’ (p.263), but the most
important bit of drama relates to the murderous crime drama that is the
production and distribution of drugs.<span style="mso-spacerun: yes;"> </span>There’s
plenty of drama in consumption even when substances are legal.<span style="mso-spacerun: yes;"> </span>If the ‘fun’ were taken out of drug use,
wouldn’t people move onto something else (like the ‘<a href="https://www.theguardian.com/education/2009/aug/20/obituary-mike-presdee">carnival
of crime</a>’) to get it?<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
These might seem like flippant
points, but they have important implications for policy.<span style="mso-spacerun: yes;"> </span>‘Addiction’ is not the only problem related
to substance use, and it doesn’t only relate to ‘agony’, though this can be an important
factor.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
To challenge this ‘agony’, Hari’s
rallying cry is that the opposite of addiction isn’t sobriety, but ‘connection’
(p.293).<span style="mso-spacerun: yes;"> </span>‘A compassionate approach <i style="mso-bidi-font-style: normal;">leads</i> to less addiction’ (p.252).<span style="mso-spacerun: yes;"> </span>His hope is that people and politicians of
all stripes will begin to see that drug policy ‘isn’t a debate about values’
but rather a debate about harm.<span style="mso-spacerun: yes;"> </span>‘We all
want to protect children from drugs’ (p.252), for example; we just disagree
about how best to do this.<span style="mso-spacerun: yes;"> </span><a href="https://thinking-to-some-purpose.blogspot.com/2016/04/what-do-we-mean-by-drugs.html">I’ve
written before</a> about how ‘harm’ is extremely hard to define.<span style="mso-spacerun: yes;"> </span>In fact, it’s a weasel word that makes us
think we agree when we don’t.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
I don’t want to downplay the
importance of Hari’s claims with these criticisms.<span style="mso-spacerun: yes;"> </span>When he describes the issues surrounding the
criminalisation of drugs and the broader social and economic deprivation that often
goes with them (p.238), we could be talking about many areas of the UK today:
if we take away the drugs, what is a person potentially left with?<span style="mso-spacerun: yes;"> </span>No job, or realistic prospect of getting
one.<span style="mso-spacerun: yes;"> </span>No stable, safe, warm and dry
accommodation.<span style="mso-spacerun: yes;"> </span>No supportive personal relationships.<span style="mso-spacerun: yes;"> </span>Of course this is a particularly negative view,
and everyone carries assets with (and within) them, but the reality is that ‘recovery
capital’, just like all other forms of capital, is not evenly distributed
across society.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
But the general point regarding legalisation
is that it would reduce stigma.<span style="mso-spacerun: yes;"> </span>Hari
quotes Joao Figueira who suggests that people who’ve got into problems with
alcohol were always treated as ‘friends’ and given support, and now the same
humanity and sympathy are offered to people who use illicit drugs (p.250).<span style="mso-spacerun: yes;"> </span>But I don’t recognise that in our approach to
people in the UK today.<span style="mso-spacerun: yes;"> </span>Public debate, and
even plenty of private interactions, often don’t show humanity and compassion
to people who run into issues with any substance, including alcohol.<span style="mso-spacerun: yes;"> </span>(If you doubt my position, take a look at the
articles and comments on <a href="https://www.dorsetecho.co.uk/news/16964324.more-needs-to-be-done-to-tackle-weymouths-drink-and-drugs-problem-council-hears/">the
<i style="mso-bidi-font-style: normal;">Dorset Echo</i> website</a> from time to
time.)<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
Legalisation is not an easy answer
to reducing stigma.<span style="mso-spacerun: yes;"> </span>In fact, as
substances become more available, and more people use them without problems,
the potential judgement might become more harsh.<span style="mso-spacerun: yes;"> </span>At the moment, many people have
misconceptions that illegal drugs are immediately addictive.<span style="mso-spacerun: yes;"> </span>If they were disabused of this notion by
seeing plenty of people using them recreationally, perhaps they would identify
the problem as residing not in the substance but the individual.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
I agree that compassion could
reduce problems surrounding drugs, or at least help us deal more effectively
with them.<span style="mso-spacerun: yes;"> </span>The issue is that compassion,
and the approach Hari sees as compassionate, need some serious work to make
them politically acceptable.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
Understandably, Hari seems to be
writing for the people who are going to read his book: bluntly, middle-class,
liberal, intellectuals.<span style="mso-spacerun: yes;"> </span>When he claims
that we all want to reduce harm, I don’t recognise that in our political
culture today.<span style="mso-spacerun: yes;"> </span>There are plenty of
people who see punishment not as a form of rehabilitation that may be more or
less effective, but as something that has a moral purpose of its own.<span style="mso-spacerun: yes;"> </span>When Hari suggests that ‘most of us don’t
object to drug use in and of itself.<span style="mso-spacerun: yes;"> </span>We
worry about the harms caused by drug use’ (p.266), I think he underestimates
the public opinion challenge surrounding legalisation.<span style="mso-spacerun: yes;"> </span>Even drinking to intoxication is condemned in
our society, and that’s making use of a legal drug.<span style="mso-spacerun: yes;"> </span>Use of illicit intoxicants is far from acceptable.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
I know this is changing, and there
are organisations like <a href="http://volteface.me/">VolteFace</a> who are
making waves in changing the terms of debate, but this is hard work that needs
to be done carefully, and it can’t be done simply by calling for compassion or
believing that intoxication is acceptable.<o:p></o:p></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
<br /></div>
<div class="MsoNormal" style="tab-stops: 112.5pt;">
Reading the book reminded me of
why I find this kind of line on drugs policy disappointing: <a href="https://thinking-to-some-purpose.blogspot.com/2018/09/lets-have-end-to-tall-tales-about.html">it’s
looking for a magic solution to a multifaceted issue (or, more accurately, a
whole range of issues) and overplaying its hand</a>.<span style="mso-spacerun: yes;"> </span>That’s why the article by Suzi and Harry
reminded me of my thoughts on the book, which I’ve meaning to write down for a
while: we need to be really careful about what we’re promising, and the
problems we’re trying to solve, otherwise we could end up in a worse position
than we’re starting from.<o:p></o:p></div>
<br />Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com4tag:blogger.com,1999:blog-125653241615635488.post-47493090820304247682018-09-11T22:07:00.001+01:002018-10-27T19:35:41.106+01:00Let's have an end to tall tales about addiction<br />
<div class="MsoNormal">
I’ve talked about addiction on this blog before.<span style="mso-spacerun: yes;"> </span>I’m not being flippant, given basically the
whole thing is about alcohol and other drugs.<span style="mso-spacerun: yes;">
</span>I mean <span class="MsoHyperlink"><a href="http://thinking-to-some-purpose.blogspot.com/2015/10/the-concept-of-addiction.html">I’ve
written about the nature of addiction</a></span>, and whether it’s useful as a
term.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I think I’ve always been honest that I’m not an expert on
this.<span style="mso-spacerun: yes;"> </span>I’m not a clinician or a technical
researcher.<span style="mso-spacerun: yes;"> </span>I’m a council worker who’s
done a bit of academic work – in sociology!<span style="mso-spacerun: yes;">
</span>I’m not entirely sure why, but I’ve started thinking about this
again.<span style="mso-spacerun: yes;"> </span>Well, I know why – I’ve been
passed some fascinating reading – but I’m not sure what started this or why
I’ve found it particularly engaging.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Anyway, onto the meat of the thing.<span style="mso-spacerun: yes;"> </span>I’ve written before about <span class="MsoHyperlink"><a href="https://thinking-to-some-purpose.blogspot.com/search?q=grey">how we’re
generally attracted to black and white, binary thinking</a></span>.<span style="mso-spacerun: yes;"> </span>In addiction debates, this often plays out as
a choice as to whether ‘the problem’ lies in the person or the substance.<span style="mso-spacerun: yes;"> </span>For example, is it that certain people are
unable to drink alcohol in a controlled fashion (‘I am an alcoholic’ – but
other people aren’t) or that there is something inherently problematic about
the substance itself (we should control or even ban alcohol because it is ‘<span class="MsoHyperlink"><a href="http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780199551149.001.0001/acprof-9780199551149">no
ordinary commodity</a></span>’)?<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
Of course I’m bound to say, being the person I am, that
‘it’s a bit of both’, but often that nuance means sacrificing clarity, and the
action that tends to go along with it.<span style="mso-spacerun: yes;">
</span>As academics (and in fact civil servants) are told so often: it’s hard
to prompt the implementation of an initiative if you don’t have a clear ‘narrative’
to explain it.<span style="mso-spacerun: yes;"> </span>I’m not sure we have a
clear narrative on substances and addiction.<span style="mso-spacerun: yes;">
</span>Or maybe we do, but it’s not stable: it’s clear for a few years, then it
changes.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
Because then along came <span class="MsoHyperlink"><a href="http://chasingthescream.com/">Johann Hari</a></span>, re-popularising <span class="MsoHyperlink"><a href="http://www.brucekalexander.com/articles-speeches/rat-park">Bruce
Alexander’s Rat Park</a></span>, explaining that the key to understanding
addiction is social connection: if you put rats not in bare cages, but an open
‘park’ with company and plenty of fun activities, they don’t want to use morphine/cocaine.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So we have a third explanation: addiction is about social
context.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
That’s not a new insight; Rat Park isn’t a new
experiment.<span style="mso-spacerun: yes;"> </span>But what is new (to me,
though still predating Johann Hari’s interest) is <span class="MsoHyperlink"><a href="http://geneheyman.com/wordpress/wp-content/uploads/2013/11/HeymanAnnRevClinPsych13QuitDrugs.pdf">an
article by Gene Heyman</a></span> (shared with me by <span class="MsoHyperlink"><a href="https://twitter.com/geerai">Gary Wallace</a></span>, a wonderful
commissioner doing <span class="MsoHyperlink"><a href="https://www.plymouth.gov.uk/sites/default/files/IntegratedCommissioningSystem.pdf">wonderful
things in Plymouth</a></span>).<span style="mso-spacerun: yes;"> </span>Heyman
looks at big datasets from the USA to assess hypotheses like whether addiction
is related to the substance, the individual, their social context (e.g.
education) etc.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It felt particularly timely reading this as issues around
decriminalisation, regulation etc seem to be more on the political agenda than
they have been for years, and the sector (in the UK) is increasingly operating
under a new organising framework: no longer crime or employment, but ‘<span class="MsoHyperlink"><a href="https://publichealthmatters.blog.gov.uk/2018/02/08/public-health-and-upholding-the-law/">adverse
childhood experiences</a></span>’.<span style="mso-spacerun: yes;"> </span>That
is, substance use is often a response to trauma.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I have a lot of time for this explanation (for a more
academic exploration, see <span class="MsoHyperlink"><a href="https://www.hannapickard.com/">Hanna Pickard’s work</a></span>).<span style="mso-spacerun: yes;"> </span>However, not every heroin user is a victim of
abuse, or a survivor or trauma, and this must be more widespread than we care
to admit if we were to include all dependent drinkers in this category.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Of course, that raises two questions: first, is dependence
the same as a ‘substance use disorder’ or ‘addiction’; and second, what does
this mean for the claim that addiction is an ‘equal opportunities’ disorder?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I would respond by saying that this is political, and Gene
Hyeman can help us with this.<span style="mso-spacerun: yes;"> </span>It’s
political because the choice of what narrative or ‘story’ to tell about
addiction affects the policy solutions we come up with (and how likely these
are to be implemented).<span style="mso-spacerun: yes;"> </span>(Think <span class="MsoHyperlink"><a href="http://journals.sagepub.com/doi/pdf/10.2478/v10199-012-0015-x">Kettil
Bruun choosing to emphasise the population-level issues associated with
alcohol, partly in order to avoid stigmatising ‘alcoholics’</a></span>.)<span style="mso-spacerun: yes;"> </span>Gene Heyman helps because his way of
conceptualising the issue cuts through some of this.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Heyman notes that we have a definition issue: what is
addiction, and how does it relate to dependency?<span style="mso-spacerun: yes;"> </span>He notes that discussions often become
circular: if you don’t behave in a certain way (including relapsing or needing
treatment) then you weren’t ‘really addicted’ in the first place.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But he points out that so long as we’re reasonably
consistent in how we apply it, DSM (IV) definitions are pretty reliable.<span style="mso-spacerun: yes;"> </span>These count symptoms, and if you have enough
then you count as having a substance use disorder (dependent on terminology at
the time).<span style="mso-spacerun: yes;"> </span>(I’m going to ask properly
knowledgeable professionals to cut me some slack here.<span style="mso-spacerun: yes;"> </span>I’m no expert, as I’ve said, but I’m also
trying to make this simple and straightforward.)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
We need to be careful whether we’re seeing recovery as
meaning you’ve still got ‘symptoms’, but below the threshold number, or in fact
you’re now not using at all (you’ve got no symptoms).<span style="mso-spacerun: yes;"> </span>But there are ways of controlling for this,
and basically, once we get beyond this, we can see something of a standard
distribution of misuse, just with varying levels of duration.<span style="mso-spacerun: yes;"> </span>(You’ll need to read the whole article if you
want a proper, reasoned explanation of this conclusion.)<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
And we need to remember that the people we see in treatment
are a small section of those who use substances, and even of those who run into
issues with substances.<span style="mso-spacerun: yes;"> </span>I’m perfectly
happy with that.<span style="mso-spacerun: yes;"> </span>In treatment
discourses, we often talk about ‘<span class="MsoHyperlink"><a href="https://www.thersa.org/discover/publications-and-articles/reports/the-potential-of-recovery-capital">recovery
capital</a></span>’, meaning the stock of factors that support people to
improve their situation.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Generally, people have a much better chance of recovery: if
they have some kind of financial safety net and stable accommodation (physical
capital); if their wider health is pretty good and they have some life and
employment skills they can draw on (human capital); if they have a particular
set of values that fit with the life they’re trying to form (cultural capital);
and if they’re surrounded by supportive, like-minded people (social capital).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
For lots of people who drink too much, they have a good
stock of this recovery capital, and if they can break the habit of drinking
heavily then they will quickly improve their health and wider social
situation.<span style="mso-spacerun: yes;"> </span>For these people, for
example, a GP-led detox might be perfectly sufficient for them to maintain
their recovery for a long time.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Or think of the memoirs and <span class="MsoHyperlink"><a href="https://girlandtonic.co.uk/">blogs</a></span> that seem to have
multiplied in recent years, describing how once the author jettisons alcohol
they become <span class="MsoHyperlink"><a href="http://thinking-to-some-purpose.blogspot.com/2017/10/fitter-no-happier-but-more-productive.html">fitter,
happier and more productive</a></span>.<span style="mso-spacerun: yes;">
</span>I know that’s a simplification of the narratives, but it can sometimes
feel that there’s assumption that the other elements of someone’s life are
ready to fall into place if someone stops drinking, even if this takes some
work.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I think it’s important to remember that’s not so easy if
there’s no stable accommodation that’s accessible to you, if your personal
relationships are destructive, with little chance of escape, there’s no jobs
locally and your employment prospects aren’t great because your education and
CV don’t look too great to people who are looking at you for the first time.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It’s people facing these more challenging circumstances – with
less ‘recovery capital’ – who are most likely (or should be most likely) to
benefit from treatment services.<span style="mso-spacerun: yes;"> </span>They’re
also – for precisely that reason – the people most likely to relapse, and to
struggle to recover long term.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I know I’m telling people what they already know.<span style="mso-spacerun: yes;"> </span>I know this could be seen as a straw man.<span style="mso-spacerun: yes;"> </span>(Even Peter Hitchens, a vocal opponent of
intoxication and substance use generally, can’t decide if it’s the substances
that are evil, or the people using them who are flawed – he probably thinks
it’s a bit of both!)<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But first I would recommend that anyone who hasn’t reads
through <span class="MsoHyperlink"><a href="http://geneheyman.com/wordpress/wp-content/uploads/2013/11/HeymanAnnRevClinPsych13QuitDrugs.pdf">the
article</a></span>.<span style="mso-spacerun: yes;"> </span>It has interesting
points to make about inequalities, prohibition, and what treatment can and should
offer.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Second, I want to ask (or just wonder aloud) whether it’s
possible to break away from the soundbite approach of ‘addiction is about
social connection’ or ‘addiction is a response to trauma’ or ‘addiction is
based on genetic predispositions’ or ‘addiction is the result of using an
addictive substance’.<span style="mso-spacerun: yes;"> </span>It’s all and none
of these things, for a whole number of people.<span style="mso-spacerun: yes;">
</span>How can we talk about ‘<span class="MsoHyperlink"><a href="https://www.gov.uk/government/news/phe-launches-opioid-treatment-quality-improvement-programme">tailored
treatment</a></span>’ and ‘<span class="MsoHyperlink"><a href="https://www.nationalelfservice.net/populations-and-settings/patient-safety/what-happened-to-you-trauma-informed-approaches-to-mental-health-care/">trauma-informed
care</a></span>’ if we can’t even see the nuances in the disorder we’re trying
to treat?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I know the attraction of a big idea.<span style="mso-spacerun: yes;"> </span>I know the attraction of a simple
‘story’.<span style="mso-spacerun: yes;"> </span>But attractive as that is, it
often leads to the wrong solutions, and all interpretations are time-limited:
with falling crime rates, we don’t talk so much about heroin users committing
acquisitive crime now; it’s more about breaking the cycle of ‘adverse childhood
experiences’.<span style="mso-spacerun: yes;"> </span>If the symptoms and
‘disease’ have stayed the same, why should we be changing what we do?<span style="mso-spacerun: yes;"> </span>Or do we just say we’re doing different
things, and carry on regardless?<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Perhaps a more sustainable approach would to be to admit that
we’re dealing with a spectrum of issues, with a range of causes and factors.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Providers in the sector are often told to diversify and not
be reliant simply on one large contract.<span style="mso-spacerun: yes;">
</span>Perhaps commissioners, lobbyists and policymakers could follow the same
advice and not be reliant on one big ‘story’?<o:p></o:p></div>
<br />Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0tag:blogger.com,1999:blog-125653241615635488.post-13145334279942836742018-09-10T11:24:00.002+01:002018-09-10T11:24:37.689+01:00You can't be an expert on your own<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{152}" paraid="945339370" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">After attending</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> EXCO 2018 a couple of weeks ago, </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">I don’t have the answers to what </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">Excellence in </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">the </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">Commissioning of Opioid Use Disorder</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">s looks like. But then I wouldn’t expect to. In fact, I think I’m giving the conference the highest praise possible when I say that it got me thinking in depth about commissioning and how we do it.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{169}" paraid="1730831961" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{171}" paraid="1034241280" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">Any conference has, almost by definition, some element of ‘broadcasting’; people telling a room what they’ve done</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">,</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> and ideally reflecting on what they’ve learned. But sometimes the most useful part of a conference is the human contact, the genuine sharing of ideas. In simple terms, a conversation rather than a lecture.</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> It’s this that sets a conference apart from reading a book or an article, or even watching a webinar.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{181}" paraid="171397149" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{183}" paraid="646224851" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">EXCO was no exception. For me, some of the most interesting and useful moments were in conversations over coffee or lunch.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{187}" paraid="1571515515" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{189}" paraid="1397522813" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">And I think this applies more widely: there’s a real need for genuine conversations in commissioning. </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">I don’</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">t necessarily mean </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">sitting over coffee and chatting things through. This kind of exchange of ideas could be virtual, through online communities (I’ve just joined an interesting group on </span><a class="Hyperlink SCXW42264582" href="https://khub.net/" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; cursor: text; margin: 0px; padding: 0px; text-decoration-line: none; user-select: text;" target="_blank"><span class="TextRun Underlined SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; color: #0563c1; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; text-decoration-line: underline; user-select: text;" xml:lang="EN-GB"><span class="NormalTextRun SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: inherit; margin: 0px; padding: 0px; user-select: text;">Knowledge Hub</span></span></a><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">, generally used by local government staff).</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{204}" paraid="48969615" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{206}" paraid="1188072927" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">And in fact it’s not just about actual conversations, whether virtual or ‘IRL’. I’m thinking more of an exchange of ideas. It was in some ways a point from Annemarie Ward about our sector being in competition that got me thinking again about how we might approach things differently – and that wasn’t part of a conversation</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> so much as her</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> point percolating through my mind on the (long!) drive home from Manchester.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{216}" paraid="1148584592" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">But writing about how we need ‘an exchange of ideas’ is exactly the sort of thing that generally winds me up. It’s no wonder that when commissioners like me use this kind of phrase we get told, quite rightly, ‘</span><a class="Hyperlink SCXW42264582" href="https://twitter.com/JohnDivney/status/1010122302716088321" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; cursor: text; margin: 0px; padding: 0px; text-decoration-line: none; user-select: text;" target="_blank"><span class="TextRun Underlined SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; color: #0563c1; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; text-decoration-line: underline; user-select: text;" xml:lang="EN-GB"><span class="NormalTextRun SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: inherit; margin: 0px; padding: 0px; user-select: text;">you talk, we die</span></span></a><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">’.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{227}" paraid="255035391" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">But I think it’s important. It’s about the way we approach our jobs – and without doing this in the right way, we really are in danger of pointless talk.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{233}" paraid="1253044534" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">What do I mean by pointless talk? Well, the kind of ‘broadcasting’ I talked about earlier. Too often, when a group of professionals come together to share ‘best practice’, it turns into a bragging session. Too often, when an organisation like Public Health England </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">(PHE) </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">or the Local Government Association</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> (LGA)</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> release a guide to something it’s full of ‘case studies’ that are simply puff pieces – opportunities for people to boast about how wonderful their organisation (and, by implication, their own work) is.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{245}" paraid="1923339244" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{247}" paraid="186735011" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">My fear about an ‘expert’ faculty is precisely that: it will become an opportunity for those involved to broadcast information that confirms their status as ‘experts’.</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> We don’t need another organisation like that.</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> Instead, we should be more honest and collaborative. Perhaps if, instead of talking, we made more of an effort to listen, share and cooperate, then fewer people would die.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{7fb41cdc-3295-4462-8743-6d146ddb0d0a}{255}" paraid="218862605" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{2}" paraid="1165964091" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">I know this sounds rich coming from someone who actively </span><a class="Hyperlink SCXW42264582" href="http://thinking-to-some-purpose.blogspot.com/" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; cursor: text; margin: 0px; padding: 0px; text-decoration-line: none; user-select: text;" target="_blank"><span class="TextRun Underlined SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; color: #0563c1; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; text-decoration-line: underline; user-select: text;" xml:lang="EN-GB"><span class="NormalTextRun SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: inherit; margin: 0px; padding: 0px; user-select: text;">blogs</span></span></a><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">, </span><a class="Hyperlink SCXW42264582" href="https://twitter.com/WilliamHaydock" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; cursor: text; margin: 0px; padding: 0px; text-decoration-line: none; user-select: text;" target="_blank"><span class="TextRun Underlined SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; color: #0563c1; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; text-decoration-line: underline; user-select: text;" xml:lang="EN-GB"><span class="NormalTextRun SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: inherit; margin: 0px; padding: 0px; user-select: text;">tweets</span></span></a><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> and </span><a class="Hyperlink SCXW42264582" href="https://scholar.google.co.uk/citations?user=YktlM5cAAAAJ&hl=en&oi=sra" rel="noreferrer" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; cursor: text; margin: 0px; padding: 0px; text-decoration-line: none; user-select: text;" target="_blank"><span class="TextRun Underlined SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; color: #0563c1; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; text-decoration-line: underline; user-select: text;" xml:lang="EN-GB"><span class="NormalTextRun SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: inherit; margin: 0px; padding: 0px; user-select: text;">writes</span></span></a><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">, sharing his own views, but maybe it takes one to know one. I like a bit of attention, and I find it rewarding to feel like an expert, but on lots of things – </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">actually,</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> everything – the attention shouldn’t be paid to me, and I’m not the ‘expert’ voice you should be listenin</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">g to.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{27}" paraid="237481994" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{29}" paraid="1814364627" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">But</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> what does this mean in practice? It means that I think the </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">F</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">aculty could be a great vehicle for these conversations. But I would suggest we need to approach these conversations differently to lots of interactions I see (and participate in!) at the moment.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{39}" paraid="1611013708" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{41}" paraid="1991917268" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">(I appreciate it’s slightly odd that I’m stating a definitive opinion at the same time as I’m denying expertise or that anyone has the answer. I’m afraid you’ll have to live with that.)</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{45}" paraid="1156251036" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{47}" paraid="1420080790" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">So l</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">et’s turn a management platitude on its head: don’t come to me with solutions, come with problems. If you come to a group with a problem, there’s instantly a conversation. If you come with a solution, you’re often just grandstanding.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="OutlineElement Ltr SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: white; clear: both; cursor: text; direction: ltr; font-family: "Segoe UI", "Segoe UI Web", Arial, Verdana, sans-serif; font-size: 12px; margin: 0px; overflow: visible; padding: 0px; position: relative; user-select: text;">
<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{55}" paraid="1815744042" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">You might have thought PHE could play</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> this role as a facilitator of conversations, but it’s clear it’s not</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> quite managing it</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"><span class="NormalTextRun SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: inherit; margin: 0px; padding: 0px; user-select: text;"> </span></span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">at the moment</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">. Having heard Rosanna O’Connor speak at EXCO, I wonder if we – local commissioners – are part of the problem. (Of course we are.) She made the point (though not in these words) that the sector can look a bit like it’s crying wolf about funding cuts when all the stats still look rosy, because no-one wants to admit that things aren’t going well in their team, their organisation, their local authority.</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> And i</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">f we don’t want to tell them things aren’t working, how can they host open, honest conversations?</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{73}" paraid="1039058537" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
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<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{75}" paraid="3127812" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">So I think there </span><span class="TextRun Underlined SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; text-decoration-line: underline; user-select: text;" xml:lang="EN-GB"><span class="NormalTextRun SCXW42264582" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: inherit; margin: 0px; padding: 0px; user-select: text;">is</span></span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> a potential role for a Faculty of Commissioning, but while I’d love to be an expert, a person can’t be one on their own.</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> Perhaps this faculty could b</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">e a place</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> to share mistakes and problems</span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB"> as much as </span><span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">ready-made expertise.</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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<div class="Paragraph SCXW42264582" paraeid="{f5ab12fa-713d-4d2d-acb8-2b1aabb0f3ac}{95}" paraid="1894606352" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; background-color: transparent; color: windowtext; padding: 0px; user-select: text; vertical-align: baseline; word-wrap: break-word;">
<span class="TextRun SCXW42264582" lang="EN-GB" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; font-variant-ligatures: none !important; line-height: 18px; margin: 0px; padding: 0px; user-select: text;" xml:lang="EN-GB">It’s this slightly pessimistic vision that could make me optimistic. How about you?</span><span class="EOP SCXW42264582" data-ccp-props="{"201341983":0,"335559739":0,"335559740":240}" style="-webkit-tap-highlight-color: transparent; -webkit-user-drag: none; font-family: Calibri, Calibri_MSFontService, sans-serif; font-size: 11pt; line-height: 18px; margin: 0px; padding: 0px; user-select: text;"> </span></div>
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Will Haydockhttp://www.blogger.com/profile/00623145846257433457noreply@blogger.com0