Government of the people, by PHE, for PHE?

What is Public Health?  And what are Public Health directorates in local authorities for?

These are questions that have been behind a few posts on this blog (here’s one, two, three, for example).

These questions occurred to me again today by the coincidence of a discussion at work and seeing a post on the Dick Puddlecote blog (via a Chris Snowdon tweet).  Both were prompted (in part) by this week’s Health Select Committee report on Public Health England (PHE), which I acknowledged in my previous post I should probably be writing about.*

A key point in the Select Committee report is that PHE should “campaign on behalf of those public health objectives and policies which it believes can improve the nation’s health”.  This is a point Dick Puddlecote puts in bold as something shocking.

The odd bit is how what is effectively part of government could be a campaigning organisation.

Dick Puddlecote sees this as particularly frustrating because PHE is at odds with public opinion on issues like standardised packaging.

These are two separate issues, really: (i) whether the fact that government (or in fact, just one government department) is at odds with public opinion is an issue, and (ii) whether the idea of a ‘campaigning’ department makes any sense.

On the first point, without wanting to sound too much like Robespierre, representative democracy doesn’t imply that issues should be determined by the popular will.  The reason I couldn’t do what Owen Jones does, for example, is that I have no idea about the details of many policy issues.  I find it hard enough coming to a view on substance use policy – something I know a bit about – let alone something like social security, which I should be well-informed about, but don’t have any expertise in.  There’s also a neat point that (academic) policy commentators expect more coherence from politicians than they manage themselves.  Quite possibly true of me – it’s much easier to criticise than offer definite solutions.  (Look how I wimp out in the conclusion of this article.)

I’m also painfully aware that policy decisions should combine considerations of effectiveness and ideology (as well as politics).  But as I’ve said before, effectiveness can only be measured if we have an aim.  And no policy issue has just one aim.  So policy debates are about priorities as much as evidence.  And we know that in reality policy-making is a messy business, with horse-trading and competing agendas.

This highlights the importance of the second issue: should PHE be a lobbying organisation within government?

This isn’t exactly a new development.  PHE isn’t so much a new organisation as a rather odd agglomeration of preceding organisations that made sense, such as the Health Protection Agency (HPA) and the National [substance misuse] Treatment Agency (NTA) – and for the period from 2010 to when PHE was established, the NTA was clearly making the case within Whitehall for substance misuse.

But this isn’t a new or unusual development.  The NTA was a part of the Department of Health that had responsibility.  You don’t have to subscribe to some Weberian theory of bureaucratization** to see that this might be an everyday part of government.

Government is not a single impartial observer or decision-maker, sitting above the fray; it is a complex organisation, with various interests and ideologies operating within it.  (And here I don’t mean government as in the cabinet, so much as the machinery of government, of which PHE and local Public Health teams are a part.)

Thinking back to another policy issue I have had some knowledge and experience of, the same pattern can be seen in Higher Education.  When it came to budget time, the Department for Business, Innovation and Skills (BIS) and the HE sector had very similar hopes: for the science budget to be protected, and so forth, to help the HE sector.  Of course, the Treasury had different priorities – hence the bizarre student loans arrangement that really is just an accounting trick.

This doesn’t make BIS a quango or Trojan Horse (or sock puppet as Chris Snowdon would put it).

PHE might be finding its way, and honing what it can do best as a national organisation when much of its remit has been taken on by local authorities – but it certainly does have a remit, and if public health is a government funding stream (which it is), then there’s a need for some kind of body to represent that area of activity within central government – even if final responsibility is mostly devolved to local government.

It might be that some liberals think the new public health shouldn’t be a part of government, but that’s not the same thing as thinking that government shouldn’t be comprised of bodies representing different perspectives.  It’s quite right that the Health Committee should recommend PHE ‘campaign’ for a policy if it can be demonstrated to be beneficial to public health.  You might find that the Treasury, or BIS, or the Department for Culture, Media and Sport might disagree, but that’s how the decision has to be made: by all the potential interests putting their points of view across.

That’s how I see local public health teams making the most worthwhile contribution: by being a voice round the table as much as a direct commissioning or spending department, and informing planning, highways and transport and education, for example, to make them more conducive to healthy living.  Of course every time a decision is made in any of these areas it will be a compromise, and other interests might win, but that’s what a healthy debate is, if you’ll excuse the pun.

*I was going to write about older people and alcohol again, in light of the DrugScope report, but there’s not any real discussion points in that – apart from their suggestion that services for older people with substance misuse issues are at threat, which in my experience couldn’t be further from the truth.  I see that as the future of substance misuse services in Dorset, for better or worse.  At least it might be evidence-based, as we’ve just commissioned Alcohol Concern to conduct a project for us on that very topic.

**Dan Malleck has written brilliantly about bureaucratization within the field of alcohol policy.

Binge drinking as a 21st-century phenomenon

This week I know I should probably be writing about the Select Committee report on Public Health England, but sadly I haven't got time to craft something new and insightful (or even to read the report in full - though the section on MUP is interesting, and chimes with my feelings about the relative roles of industry and public health).

Instead, given that I've been thinking about the history of alcohol policy a lot lately, I thought I'd post an academc piece I wrote on a quiet afternoon at work 3 years ago, and so far haven't found a home for.  It's a bit short to be a proper social policy academic article, but I haven't had the time or inclination to work it up into something more significant.  If anyone has any comments or thoughts, I'd love to hear them.

“They’re buggering off with the bloody port-wine!”  Binge drinking as a 21^st-century phenomenon

The term ‘binge’ refers to a problematic form of drinking, rather than an attractive one, as Mass Observation noted in 1943 (p.342).  However, there is little clarity regarding what the term means in current discussions, beyond the general sense that it is new, and worrying.

The most striking discussions of binge drinking are in the media, both in newspapers and on TV.  Ladette to Lady and Booze Britain are prime examples on the TV, while headlines such as “Binge Britain’s Night of Shame” are common in newsprint.  In these discussions, ‘binge’ drinkers are generally understood to be young people who drink large quantities of alcohol in city centres before behaving in out of the ordinary ways considered unacceptable – perhaps anti-socially or even criminally.

The same picture emerges from an analysis of government approaches to alcohol policy.  ‘Binge’ drinking is a term that has been deliberately used by both the Labour and Coalition governments, and although quantity of alcohol consumed is often employed as a proxy, the key concern appears to be the altered state of norms that accompany such drinking, which is characterised by a particular approach: drinking to get drunk.

There has been a recently growing corpus of academic research on the topic of ‘binge’ drinking, which generally shares the focus on motivation in defining the phenomenon, stressing that this drinking to get drunk is a new development.  Quite what new features are of interest varies, but the contrast is drawn with a period – usually understood to have included the 20^th century prior to the 1980s – when ‘traditional’ drinking, a masculine, working-class culture centred on local community pubs, was the dominant form of public drinking (Gofton 1990).  In this environment, it is argued, intoxication was incidental to drinkers’ motivations, and drinking interactions formed part of a larger congery of social practices, including work, family, locality and other forms of leisure.  In these nostalgic academic accounts, the focus of research tends to be current young people’s drinking practices and their wider lives.  The historical comparison, though central to the argument that something is new and distinctive about ‘binge’ drinking, is often discussed only in passing, however.

The conception that ‘binge’ drinking is a new phenomenon is questionable on two levels.  First, and most obviously, does it exist at all – and if so, what does it mean in practice?  The burgeoning body of academic research referred to above suggests that many young people – though certainly not all, even of those who drink in city centres at weekends – often understand themselves to be drinking to get drunk and many consider unusual behaviour to be a desirable feature of a night out – even something that should be actively sought out.  Although it remains the case, as it was in 1943, that drinkers tend not to describe their practices as a ‘binge’, this academic picture has notable similarities with that painted by government and the media – though also considerable complexities (Griffin et al. 2009; Haydock 2009; Hollands 2002).

The second problem with these academic accounts, however, is that they claim that such practices are new.  As I suggested, exactly what is considered new varies.  In Measham and Brain’s (2005) account, for example, ‘determined drunkenness’ (a deliberate, almost calculating attempt to get drunk) is the key feature of the ‘culture of intoxication’.  In Hall and Winlow’s (2006) account, it is the broader friendship groupings, which are now the necessary means to the end of going out, rather than the drinking being the means to the end of spending time with one’s friends and cementing these relationships as was apparently the case in ‘traditional’ drinking.

Much research – including these two prominent examples – notes the importance of the wider environment to the emergence of this ‘culture of intoxication’.  Most obviously, licensing laws have changed, but alongside this there have been changes in the design of venues, the drinks available (and their prices) and the marketing of these products.  The role of the 1980s/1990s ‘rave’ culture in prompting this approach from the alcohol industry is often noted.

That there have been changes in the regulatory and broader environment regarding alcohol in the UK is undeniable, and it is certainly plausible that certain of these factors will influence drinking behaviour.  The affordability of alcohol, the licensing laws and the design of venues may all be important factors in affecting drinking cultures – and indeed, as I have argued elsewhere, government might be well-advised to think more broadly about the policy options open to it.

Nevertheless, to address the broader point first, it is not at all clear that friendship groupings and their relationship to consumption of alcohol have changed fundamentally over the past 100 to 150 years.  To begin with, it is unclear when this apparent golden age of pub friendship should be placed.  By the 1930s there is no question that, in “Worktown” at least, many drinkers felt the age of community pubs had passed, and the number that had closed was certainly notable.

It has been suggested that the tax changes introduced with the First World War fundamentally altered the nature of pub drinking, changing the affordability of alcohol, along with the more restrictive licensing laws.  This suggests that, if anything, any heyday of the British pub and ‘traditional’ drinking would be prior to this period.  On the other hand, in the nineteenth and early twentieth centuries, at the time when the Victorian and Edwardian pubs described by Hayward and Hobbs (2007) were springing up, there was concern that the influx of labour into cities had destroyed traditional rural forms of community, and there was considerable movement of people in search of work within an economy constantly in flux.  The stable communities, dominated by and centred around a single large employer, of Nottingham with its Raleigh factory* and “Ashton” as described in Coal is Our Life (Dennis et al. 1969), were always the exception.  It is hard to believe in the face of the evidence that the majority of lives – particularly for those without security of income or residence, the working class – were at any point stable and predictable in the way that the vision of the ‘traditional’ pub seems to convey.

In terms of how these relationships compare to today’s, if all that is meant by the idea of community is the ‘congeries of interests’ and ‘social experiences’ described by EP Thompson (1968: 939), then it is hard to argue that these have disappeared.  As I have argued elsewhere (Haydock 2010), class distinctions and communities, cemented by cultural practices, are alive and well within the night-time economy (see also Hollands 2002), and indeed the work of Hall and Winlow themselves is filled with acknowledgements of the importance of class in determining people’s social options and the prevalence of cultural distinctions within the night-time economy.

However, the argument of change is deeper than this; it is about the instrumental nature of friendship within today’s economy.  Hall and Winlow argue that today’s young people know less about each other than their predecessors did, and interact primarily through signifiers of consumption rather than production, with long-term relationships through work no longer being commonplace.  Although, as I have suggested, there is an element of nostalgia to these claims – friendships in the past were deeper and today’s social interactions are a “theatrical simulation of traditional forms of communality” (Winlow and Hall 2006: 186) – my aim here is not claim whether one form of social interaction or friendship is better, or to be longed for; I simply wish to consider whether or not two such different forms can realistically be posited.  Fellow drinkers in the pub, whether in the 1930s or the 1880s, did not necessarily work for the same company or in the same trade.  The community that existed and can be understood in terms of class was cemented through shared situations and practices, rather than strictly shared occupations or workplaces themselves, and such shared backgrounds are common amongst groups of drinkers today.  Moreover, although debates abound regarding the changing nature of work and leisure time in industrial and advanced deindustrialised economies, a holistic view of relationships, friendships and class as expounded by EP Thompson or Pierre Bourdieu (1984), for example, acknowledges the importance of practices that can broadly be considered consumption throughout, at the very least, the nineteenth and twentieth centuries.

Of course, it could be argued that the nature of communities and the centrality of production relations meant that leisure in the pub was not so separated from work as it is today, in a ‘binge’ drinking culture where the aim is understood to be getting ‘annihilated’ (Griffin et al. 2009) – away from everyday relations and relationships, especially those related to work and family.  As Winlow and Hall (2009), following the pop song and the advertisement for the lager Carling, put it, drinkers are ‘living for the weekend’.  The paying of wages might be cited as one prime example of the way in which pub life was tied to work.  It cannot be denied that this practice at the very least has died out, more or less, but the apparently new opposition between drinking and work relates to the second, broader point of what is new regarding ‘binge’ drinking: drinkers’ motivations.  Do current ‘binge’ drinkers approach alcohol in a fundamentally different way to those from the past?

The historical work on drinking cultures in Britain is perhaps surprisingly thin, when considering the nineteenth and twentieth centuries.  Brian Harrison’s (1971) landmark study, despite its broad title – Drink and the Victorians – analysed the Temperance movement specifically, while more recently John Greenaway (2003) has analysed political discussions of alcohol since 1830, and James Nicholls (2009) has looked at broader public discourses surrounding alcohol and drunkenness.  There is much less material considering how those who were actually engaged in the apparently problematic drinking thought of alcohol and themselves.  There are excellent historical sources, of a variety of types, that refer to alcohol consumption, but these have not been synthesised, and there is no identifiable single source.  As with issues of the carnival and carnivalesque more broadly, it is difficult to access accounts from drinkers themselves rather than observers (see Easton et al. 1988; Stallybrass and White 1986).

However, this material from observers is valuable.  Although government states that one of the key features of ‘binge’ drinking is that those involved drink to get drunk, such drinking is also defined by its consequences; not only health damage, but more notably behaviour.  This behaviour is understood to be out-of-control, violent, irrational and dangerous to both the drinker and others.  This sort of behaviour, and the idea that alcohol offers ‘time out’ from normal everyday requirements, is not confined to twenty-first century Britain (see, for example, MacAndrew and Edgerton 1970).  A cursory read of The Pub and the People will reveal that such ‘breakdown’, festival or carnivalesque behaviour was certainly not unknown to “Worktowners”.  If the concerns with ‘binge’ drinking are sex, violence, irrationality, public disorder and incapability due to alcohol, Christmas Eve in the late 1930s before World War II can illustrate these as well as any Saturday night in a city centre in 2011.

Therefore, I strongly challenge the assumption that ‘binge’ drinking is a new phenomenon.  While the economy may be organised along different lines from the late-nineteenth or early-twentieth centuries, and the design of pubs, licensing laws and alcohol advertising may all have changed, it is highly questionable that young people’s approach to alcohol is fundamentally altered, or that their formation of friendships is conducted on a different basis.  Further, more detailed research would be required to assess nineteenth- and twentieth-century drinking cultures in more detail, but at first sight at least it seems that the appreciation of ‘fuddled joy’ (Smith 1983) of drinking alcohol and the temporary ‘breakdown’ (Mass Observation 1943) offered by weekend nights out in the pub, accompanied by music and hot fast food, with the possibility of sex, are not new.

*I'm referring here to Alan Sillitoe's brilliant novel Saturday Night, Sunday Morning, from which Rob Hollands' Friday Night, Saturday Night takes its name (I assume!).

Here are some fun sections from The Pub and the People - I assume I'm not in breach of copyright by posting them, but let me know if so.  Do go and buy the book - it's not expensive and it's entertaining and informative: http://www.faber.co.uk/catalog/the-pub-and-the-people/9780571250950

 

 

  

 

"In a litter of broken glass and bottles, a woman sits by herself, being noisily sick" made me think of these two famous photos (though neither of them features a women actually being sick)

References

Bourdieu, P., 1984. Distinction: A Social Critique of the Judgement of Taste. Nice, R., Trans. London: Routledge.

Dennis, N., Henriques, F., and Slaughter, C., 1969. Coal is our Life: An analysis of a Yorkshire mining community. London: Tavistock.

Easton, S., Howkins, A., Laing, S., Merricks, L., and Walker, H., 1988. Disorder and Discipline: Popular Culture from 1550 to the Present. Aldershot: Temple Smith.

Gofton, L., 1990. On the Town; Drink and the 'New Lawlessness'. Youth and Policy, 29, 33-39.

Greenaway, J., 2003. Drink and British Politics since 1830: AStudy in Policy-Making. Basingstoke: Palgrave.

Griffin, C., Bengry-Howell, A., Hackley, C., Mistral, W., and Szmigin, I., 2009. 'Every Time I Do It I Annihilate Myself': Loss of (Self-)Consciousness and Loss of Memory in Young People's Drinking Narratives. Sociology, 43 (3), 457-476.

Harrison, B., 1971. Drink and the Victorians: The Temperance Question in England, 1815-1872. London: Faber and Faber.

Haydock, W., 2009. Gender, Class and 'Binge' Drinking: An ethnography of drinkers in Bournemouth's night-time economy.  Thesis (PhD). Bournemouth University, Poole.

Haydock, W., 2010. "Everything is different": Drinking and Distinction in Bournemouth. In: Wellard, I., and Weed, M. eds. Wellbeing, Health and Leisure. Eastbourne: Leisure Studies Association, 67-84.

Hayward, K., and Hobbs, D., 2007. Beyond the binge in "booze Britain": market-led liminalization and the spectacle of binge drinking. The British Journal of Sociology, 58 (3), 437-456.

Hollands, R., 2002. Divisions in the Dark: Youth Cultures, Transitions and Segemented Consumption Spaces in the Night-Time Economy. Journal of Youth Studies, 5 (2), 153-171.

MacAndrew, C., and Edgerton, R. B., 1970. Drunken Comportment: A Social Explanation. London: Thomas Nelson and Sons.

Mass Observation. 1943. The Pub and the People: A Worktown Study. London: Faber and Faber.

Measham, F., and Brain, K., 2005. "Binge" drinking, British alcohol policy and the new culture of intoxication. Crime, Media, Culture, 1 (3), 262-283.

Nicholls, J., 2009. The Politics of Alcohol: a History of the Drink Question in England. Manchester: Manchester University Press.

Smith, M. A., 1983. Social usages of the public drinking house: changing aspects of class and leisure. The British Journal of Sociology, XXXIV (3), 367-385.

Stallybrass, P., and White, A., 1986. The Politics and Poetics of Transgression. Ithaca, NY: Cornell University Press.

Thompson, E. P., 1968. The Making of the English Working Class. Harmondsworth: Penguin.

Winlow, S., and Hall, S., 2006. Violent Night: Urban Leisure and Contemporary Culture. Oxford: Berg.

Winlow, S., and Hall, S., 2009. Living for the weekend: Youth identities in northeast England. Ethnography, 10 (1), 91-113. 

A future of compromise and the long shadow of temperance

I’ve been thinking about compromise in alcohol policy a lot recently.  There’s two main reasons for this.

First, I’ve been reading Robert Duncan’s Pubs and Patriots, in which he paints a picture of late-nineteenth and early-twentieth century debates as characterised by ‘antagonistic squabbling’ between the trade and the temperance movement.

This adversarial approach has something in common with the second reason I’ve been thinking about compromise.  As I’ve discussed before on this blog, I think the current policy debate is unhelpfully adversarial between health and industry.

One of the remarkable things about most of the twentieth century (merely coincidentally the period before I started drinking), is that alcohol wasn’t a huge or controversial public policy issue in the way it is today.  Indeed, although there was concern about lager louts and something of ‘binge’ drinking, James Nicholls’ work suggests that the panic (not necessarily a moral panic) really sprang up in light of the Labour government’s proposals to expand licensing hours with the 2003 Licensing Act.

There’s all sorts of reasons behind this change – and public health campaigners would point out that the increased panic fits reasonably neatly with consumption and harm figures going up, and these have largely followed affordability indices.  There are serious questions to be asked about the reliability and validity of the figures used, but it’s reasonable to think that alcohol is more affordable for most people than it used to be, and affordability affects consumption.

However, there isn’t an inevitable direct linear relationship here.  Over history people have tended to consume more alcohol during boom times, but this doesn’t always hold and consumption doesn’t always keep heading up.

The key thing I was reminded of when finishing Pubs and Patriots was the comparison that can be made with the Second World War, when alcohol was not such a prominent political issue.  Robert Duncan would probably argue that policymakers had come to their senses and freed themselves from temperance prejudices.  However, you could also point out that actual consumption per head was much lower in 1939 than 1914.  That is, objectively the ‘problem’ had been dealt with.

I’ll stick my neck out and take the classic sensible historian’s approach of suggesting that in reality it was a bit of both.

It’s not simply that affordability and availability changed; more than that the WW1 reforms helped shape the culture around alcohol – and the industry arguably played a crucial role in that, or at least in how this was taken forward in the inter-war period.

David Gutzke has written about ‘Progressives’ reforming the pub in the inter-war years to make it more respectable and reduce the blight of drunkenness.  I don’t want to get into the debate of whether this was done out of moral conviction or rather sensible positioning for both economic and reputational reasons; I just want to suggest that similar ideas are circulating today, with the idea that the retail trade at least could be encouraged to develop a food offer and the sort of ‘upmarket’ environment that fosters what would a hundred years ago have been called ‘respectable’ drinking.

In some work, attention has been drawn to the ways in which ‘traditional’ pubs might have a role to play in toning down young people’s drinking by offering a more supervised environment than either drinking at home or in ‘vertical drinking’ style establishments.  Similar ideas about the value of the pub to local community have been promoted by the BBPA, linked to the idea of ‘the pub is the hub’.  In fact fostering cohesive communities can be seen as something that could promote public health.

That is, pubs could have a role in promoting public health.

I’ve written before about the idea of engaging the industry (especially at a local level), and I get the feeling that the same ideas of collaboration and dilution of principles are being played out today as 100 years ago when state purchase of the industry was mooted.  This was seen as something like a partnership with the devil by some temperance campaigners, much as legalization of drugs today might be viewed.

All policy is of course compromise, as there are many competing objectives, and so for my money this doesn’t sound like such a bad idea – especially as it’s not clear that the adversarial approach has led to better policymaking

Looking at the local area I’ve researched, however, the opportunity for this sort of compromise vision is somewhat limited.  You could argue that Bournemouth’s very reputation as somewhere that has moved from ‘blue rinse to hedonism’ illustrates the problem.

Part of the town’s construction and appeal as a ‘respectable’ nineteenth-century resort was that it didn’t have pubs and licences generally in the town centre.  The train station was even deliberately placed far from the beach in the hope that this would deter day trippers and those who couldn’t afford the cost of a carriage ride into town.

This made it, in a sense, an ideal location for the growth of the night-time economy – it wasn’t a question of remodelling pubs; this was almost a tabula rasa.  As a tourist resort, this worked, and the prevalence of (arguably bland) chain pubs, bars and clubs makes sense when you realise that a key part of the customer base is people who are just coming for the one night: people feel more comfortable going into a venue where they know what they’re going to get, rather than a gamble on a local variant.

My research has drawn attention to how this apparently bland, homogenised high street is in fact anything but in the eyes of the customers themselves: they have very clear ideas about the differences between venues, drinking practices and people.  However, there’s no denying that in academic and policy circles there’s an interest in moving away from what is seen as a concentration of binge-oriented venues.  Academics, consultants, local authority officials and elected council members all talk about ‘diversity’ and ‘food-led’ venues – and even the value of the traditional pub.

But Bournemouth town centre doesn’t really have any ‘traditional’ pubs – and certainly none with a real heritage feel.  And that’s where there’s a potential sharedinterest between tourism, leisure and public health – selling a resort as aplace of wellness.

So Bournemouth’s selling point of the nineteenth century – of a place of moderation, wellbeing and health – might actually limit its ability to move away from the ‘binge’ economy of the late 20^th and early 21^st centuries.  Now there’s an interesting legacy of temperance and apparent moderation.  Perhaps moderation in all things should have included a few pubs too – and in the spirit of moderation, maybe working together in the future wouldn’t be such a bad idea?

Disclaimer (20/02/2014):
Just to clarify, I'm not suggesting here that I support the idea of wellbeing in tourism, or that I think Bournemouth should go down this route as a way of 'selling' itself as a resort.  In fact, I've written an academic paper somewhat criticising the aspiration of 'civilising' the town that local members seem to have.

I'm more interested in the ways that pubs could be mobilised to support what is sometimes seen as a neo-temperance approach to pleasure and tourism - and how nineteenth century temperance and respectability has perhaps made that idea more difficult in Bournemouth.

Beyond a ratchet model of drug policymaking

Today I read a ‘for debate’ academic article published in Addiction: Alex Stevens and Fiona Measham arguing that current British drug policy operates according to a ‘ratchet’ process, whereby the tendency is for restrictions and controls to be applied, and this is a one-way street as the restrictions are (almost) never downgraded.

Stevens and Measham obviously feel the need to justify the article, as they acknowledge that many people will feel the argument is so obvious it doesn’t need an article dedicated to it.  However, it might seem necessary in light of the reclassification of cannabis downwards (before it came back up) and the coverage of Peter Hitchens in the media arguing that there has been no war on drugs.

The analogy of the ratchet is chosen because (in general) the argument is that once action is taken, it’s unlikely that it will be scaled back later.  However, in itself this is not negative – or perhaps even worthy of comment.  If we believe in a particular approach or action that is being ratcheted up, we can see this as progress in a consistent (and positive) direction.

The reason Stevens and Measham see the ratchet as a critique is the direction policy is heading in: towards control and prohibition.  This, they suggest, is not an effective evidence-based approach for reducing drug-related harm.  That is, the ratchet trend direction is more important than evidence, which is only used (through ‘absorption’) when it fits the pre-determined narrative and policy direction.

This direction of travel is towards something Stevens calls ‘toughness’.  It is more important for policymakers to be seen as ‘tough’ than for them to demonstrably reduce harm.

There are two key elements to the article, then.  First, the ratchet model of policy development.  Second, the idea of ‘toughness’.

Importantly, neither of these implies or explains the other, so while this might be an accurate description of UK drug policy I’d suggest it doesn’t get us any closer to understanding why the policies are developed in the way they are.  (To be fair to the authors, they don’t suggest they’re trying to do this in what is of necessity a very brief article.)

Answering this question of why UK drug policy formation follows this process would, like the distinction between ratcheting and toughness, probably require two sorts of approaches.

First, on the ratchet concept one would need to think through ideas of policy competition.  Maybe there’s some inflation-style model of policymaking, whereby political parties outbid each other and find it hard to step out of the terms of debate.  I don’t know much about these sorts of models of policymaking – that’s something I’d leave to the likes of Paul Cairney and Vittal Katikireddi.

But as I suggested, I don’t find the ratchet model something that would necessarily need changing in itself; it’s what we’re progressing towards that might be questionable – and in the field of drug policy this seems to be an emphasis on policy methods (prohibition, restrictions, criminalisation of new psychoactive substances) rather than policy aims.*

So we need to think about why these policy methods are attractive, even if they’re not really reducing harm.  And here we get to the bit of policy analysis that I find fascinating: attitudes to drugs, pleasure and health.  I would suggest that the fundamental principle driving the direction of travel is the view that substances seen to alter mind or body are considered suspect and unnatural – particularly when they relate to sensory pleasures.  This, I should point out, is something I think Stevens and Measham would agree with – Fiona Measham has actually written a book chapter entitled ‘The criminalisation of intoxication’ and Stevens has blogged about the morality underlying Peter Hitchens' claims regarding evidence.

Of course there are other elements to this trend – and there may be mileage in thinking about what Stevens and Measham refer to as the ‘thoughtworld’ of policymakers.  Civil servants, it could be argued, are likely to recommend policy approaches that have a significant role for government (and thus civil servants), whether through conscious calculation or, perhaps more likely, simply familiarity.  Control or prohibition might be such approaches – but then it would be hard to argue that legalisation and regulation of drugs like alcohol and tobacco doesn’t provide significant employment and funding to the state.

So, I’d suggest the ratchet framework doesn’t actually get us that much closer to the stated aim of the article: to ‘help us to use evidence and public deliberation to fit drug policies more effectively to the prospects of reducing harms’.

The key battleground is really over the definition of these ‘harms’.  Peter Hitchens might see himself as a lone voice, but there remains an assumption – at least in terms of what it is acceptable for politicians to say and do publicly – that intoxication in itself is harmful.  Until that position is challenged head-on I can’t see the ratchet mechanism changing.

*This isn’t to say that governments are genuinely committed to enforcing prohibitionist policies.  Peter Hitchens could be said to have a point that much of drug policy is more about rhetoric than effects – and in fact that’s something Stevens and Measham might agree with.

MUP as a lightning conductor

New year, same old alcohol politics.

Just as I was thinking I hadn’t posted for a while, as this blog is generally responsive and there hadn’t been many alcohol news stories worth thinking about (I’m not touching Dry January – read Pete Brown if you want anyone’s opinion), we all start talking about minimum unit pricing again.

I can’t quite bring myself to address the points people have been making, whether it’s Sarah Wollaston in the Telegraph, Anne Perkins on the Guardian website, or the Dick Puddlecote blog.  There’s a ridiculous claim that the Sheffield modelling is ‘deliberately contrived junk science’, and on the other side it’s suggested that Diageo shouldn’t sponsor a cocktail lounge at the Tory party conference – as if having a free drink might make a serious politician beholden to the alcohol industry.

Being the academic I (like to think I) am, I’m more interested in the fact that, yet again, we’ve focused on MUP.  This particular policy seems to have been the lightning conductor for all the concerns and debates around alcohol policy in the last few years.  After an interesting discussion on Twitter a few months ago, thinking about how the coverage and debate around MUP has been different in Scotland as opposed to England, I thought I might post something on here about why MUP has been so important and divisive in the public policy debate.

The first and most obvious point as to why it has caught the imagination is that the idea of a single, relatively straightforward solution is always attractive.  MUP has managed to capture the imagination as the solution to the alcohol ‘problem’.

Of course, it can’t be the single universal solution, and there isn’t actually an ‘alcohol problem’ – if there is any problem, there’s certainly more than one: crime, nuisance, acute health harm, chronic health harm, addiction, and the list goes on.

In fact, each one of these issues isn’t a single ‘problem’ in any case.  Along with others, I’m sometimes guilty of suggesting that addiction is no respecter of class and background.  This is certainly questionable when we look at what factors might make us think of particular forms of substance use as substance use disorders, and who might be most likely to achieve recovery, but more than this, not everyone’s ‘addiction’ is driven by the same factors, and some people (like it or not) may not feel they will always be an alcoholic – and may even feel comfortable enough to drink again.

MUP raises all those old issues around addiction, health, drunkenness and so on, but without them being explicitly named – and that’s why the debate focuses so much on this initiative, because it somehow is able to channel whatever concern about policy any person has.

As I’ve said any number of times before, public health tends to operate at a population level, and MUP can be seen as a policy that does this: it is (ostensibly) universal, rather than being targeted at particularly problematic individuals.

Although MUP can also be seen as targeted – David Cameron was keen to say it was an initiative to address ‘binge’ drinking, while the Sheffield research suggests it will hit (or benefit) the hardest drinkers hardest – the key point is that it targets the substance, not individuals.  This is one of the key reasons it excites public health campaigners and worries those whose business it is to sell alcohol.  ‘Alcohol is no ordinary commodity’ is a mantra of the public health community, and challenges the more free market view that alcohol is just another consumer product.

Thus the initiative gets straight to the two fundamental points that alcohol policy is based on: individuals’ current behaviour is irrational, and the state has a role in correcting this.

The way this is understood in England in relation to MUP can be seen as different to two relevant comparisons: Scotland, and Licensing.

It was the Scotland comparison that first interested me: I was told that in Scotland the policy debate hadn’t revolved so completely around MUP.

Although this might be the case, an analysis of the arguments for and against MUP in the media suggested that advocates for MUP didn’t often present it as part of a broader package of alcohol policy initiatives.  More importantly, though, the key context was statements regarding ‘Scotland’s heavy drinking culture’.

The article, along with other work by the same team, suggests that for MUP to be seen as appropriate, the concept of problematic drinking at a population level needs to be conveyed, rather than the current emphasis on ‘binge’ and youth drinking (which is what David Cameron did in England).

That is, the context for MUP discussions is possibly already more focused on population consumption in Scotland than it is in England.  Alcohol is possibly more acknowledged as problematic for all (Scots).

Where discussions around alcohol misuse are broadened out in England, the reference point tends to be simply an alternative problematic group – most recently the baby boomers, but at other times middle-class professionals.  The problem is not alcohol, but those drinking it: the middle classes who dare to ‘think they know better than health experts’.

The other difference is with licensing debates.  MUP quite clearly isn’t simply focused on the visible, night-time economy that so dominates media coverage (‘bench girl’ ends up illustrating almost every article on alcohol, or her neighbour in patterned tights – until the 2013 fashion for ‘nose in glass’).  Licensing can be – and is – framed in terms of nuisance to others, crime and disorder (and also the inconvenience to police shift patterns).  These are all factors that relate to someone’s drinking harming other people.

This is why MUP is so controversial: it’s not just about stopping me hurting other people; it’s apparently about stopping me hurting myself.

This is where the argument is attacked in terms that state either it’s my right to drink myself to death.  However, this is to look at alcohol as an individual rather than a population issue.

This isn’t just about aggregating risk – the point that not everyone is harmed by alcohol in the same way, so we shouldn’t target the alcohol, but the at-risk individuals (or nobody, as the health consequences are something of a lottery).

If I hurt myself, that doesn’t happen entirely without effects on others, however indirect.  People do not exist in isolation from a wider drinking culture, and that drinking culture does not exist in isolation from regulatory structures.

It is revealing that discussions of licensing often place emphasis on the 1915 reforms that are seen as forming the basis for the regulations that were in place until 2005.  These reforms were justified not so much in terms of reducing nuisance as ensuring that people didn’t drink so much as to be ineffective workers – and therefore hamper the common endeavour of the war effort.  That is, licensing needn’t always be a tool focused on a narrow definition of ‘harm’.  North of the border public health is now a licensing objective alongside the issues of nuisance and crime.

It could be argued that in relation to drinking public health is a misnomer: this is all about private health, and we’re not engaged in a war effort, so the comparison is irrelevant.

However, there seems little doubt that drinking styles are communicable, so perhaps rather than working with ideas of ‘passive drinking’ to suggest that drinking harms others around us in ways we don’t always see, public health campaigners might be better starting from the point that drinking is social, and that’s actually why it’s a public policy issue.  Maybe substance misuse isn’t such a non-communicable disease after all.  (Though that isn’t an original thought.)

That’s a bigger argument for another day – about the very question of whether one man is an island – but the point is that it’s not an argument that can be solved by looking at MUP as an issue in isolation.  There are broader political, philosophical and ideological questions distilled into this policy proposal, and they can’t be resolved simply by re-hashing the same old complaints about the nature of the alcohol industry or the fallibility of econometric modelling.  First off, it’d be nice to have some clarity about what problem MUP might be trying to solve.  To be honest, I’m not sure what that BMJ investigation adds…