Making imperfect policy for an imperfect world

There’s already been a lot of (virtual) ink spilled discussing the proposal in the Queen’s Speech to ban all ‘legal highs’.  Chris Snowdon and Ian Dunt have already neatly attacked the inconsistency and illiberalism of the proposals, and an article in the Guardian laid out the issues pretty clearly, so I’m not going to talk about the specifics.  (Though it’s worth noting the conundrum that if nutmeg is permitted as a foodstuff, couldn’t a flavoured herb that mimics cannabis also be considered a foodstuff if it could be argued that its primary function is to flavour the food?)

Despite the generally negative tone of commentary on the policy, I remain optimistic.  I’ve said before that ‘legal highs’, along with e-cigs, might provide a catalyst for a reviewed genuine debate on drugs policy, and that’s certainly the case if we just look at those articles by Chris and Ian.

The issue for me, though, is almost more fundamental than their questions of consistency or the Guardian’s worries about whether the proposals will ‘work’ – assuming for a moment that there is just one aim of drug policy: to reduce harm, rather than for government to be tough, or simply to be doing anything at all.

Of course the discussion of whether this approach has ‘worked’ in Ireland is important and interesting, but perhaps the most important point is the limited role evidence can play in this process.  ‘Head shops’ may have disappeared, but that might be simply driving the market underground, which may be more dangerous both in terms of product regulation and quality, and violence and disruption relating to the trade in the substances.  And if fewer people are attending treatment reporting ‘legal high’ use, that might be that they’ve substituted illegal substances (which may or may not be a good thing), or they might be simply more reluctant to report using these substances now their legal status has changed.  In fact, it’s conceivable that reporting use of legal highs specifically was attractive because it meant clients didn’t have to admit doing anything ‘wrong’ (or, more accurately, illegal).

If we try to get to a more direct measure of ‘harm’, we’re still scuppered.  It’s hard to measure chronic harm, like dependence or addiction, as it can take years to be reported or even to develop.  It’s also very difficult to identify acute harm from hospital stats, for example, because it’s unlikely that the data recording will be of sufficient quality to allow you to distinguish between poisonings from ‘legal’ intoxicants and those from other substances.

But that’s almost by-the-by.  All these difficulties with evidence and ‘what works’, along with the apparent inconsistency, highlight what this debate is – perfectly reasonably – about, and why exceptions are the rule.

That is, the key feature of this policy is that specific substances – alcohol, caffeine, nicotine etc – will have to be individually excluded from the ban on psychoactive substances.  This immediately raises the question why these substances?  But there is an answer to that: they are embedded in our society far more than the others.  We probably know more about the effects of these substances on humans than the effects of truly new psychoactive substances, but the real reason they’re legal and not others is an accident of history.

But I’ve read too much Burke and Oakeshott to think that we should be beating ourselves up for not having a ‘rational’ drugs policy.  As I’ve said on this site before, muddling through might actually be the most rational response to the issue of psychoactive substances.  Those accidents of history have happened, and we do have to make policy with all the baggage that comes with past policy decisions; we can’t simply make a clean break and decide on policy from first principles – not to mention the fact that if we’re talking about anything less than global policy then we’ll have to pay attention to what other countries and regions are doing on these issues.

But to say we’re muddling through, and perhaps being a bit irrational, isn’t quite the same as saying we must be unclear or (to use that performative word) obfuscating.  We can be open about the reasons alcohol, caffeine and nicotine are different – and maybe then think about what that means for taurine or e-cigs.

Perhaps there is some consistent principle here about food and drink as methods of delivery (which would say something about the discomfort politicians seem to feel about instrumental use of psychoactive substances), which would then exclude smoking tobacco.  Or perhaps it really is just muddling through with a ‘feel’ for what is right.

Either way, this sort of open debate would reject the fiction that policy decisions are made on the basis of immediate ‘harm’ from a substance; but it could lead to a more holistic discussion that acknowledged the social elements of intoxication and substance use: that different stimulants, for example, mean different things even if they have the same ostensible physiological effects, and so can be legitimately treated differently.  Drunken comportment is socially constructed, as anthropologists of alcohol never tire of observing, and we must make policy in that social setting.

Making policy for a perfect world doesn’t lead to perfect policy, and I would welcome a debate that is more honest and realistic as much as rational and evidence-based.

What is a drug?

Last Tuesday I gave a rather rambling lecture at LJMU about how although the big picture in substance misuse policy in terms of national and international developments is interesting and important, it’s also crucial to think about local decision-making.  (Of course, I’m bound to say this as I’m involved in that local decision-making, and I am of course terribly important…)

Rather than summarise the whole thing here, though, I wanted to reflect on points that arose in the discussion afterwards.  I was asked a very perceptive question about the nature of drug misuse and public perception, with particular reference to users of performance and image enhancing drugs (PIEDs) such as steroids.  The point is that such substances don’t fit neatly into standard understandings of drug misuse.

Of course, that isn’t news to harm reduction professionals, who’ve been grappling with this particular issue for decades (though maybe it’s got a new face with ‘smart’ drugs and things like injectable tanning enhancers).  And to some extent this is precisely the issue I’ve drawn attention to in my academic work, when I’ve tried to highlight that what we find problematic isn’t simply health harm, but intoxication, pleasure and disorder, combining in some kind of class and gender infused carnivalesque.

Writing that in that way makes it sound particularly pretentious, but the point is something more than the fact that society and users think and worry about PIEDs in a different way to substances where the attraction is ‘recreation’, ‘pleasure’ or ‘intoxication’.  I actually want to make a fundamental point: this difference actually undermines the very idea of what we mean by a drug.

What ties all these things together?  It’s not that they’re mind altering or intoxicating – tanning enhancers needn’t be.  And it’s not that everything that’s mind or body altering is a ‘drug’ according to this definition – nutmeg and various other unexpected substances are listed on Erowid.

So we often fall back on the terminology of ‘substance’ use/misuse/abuse.  But practically everything’s a substance – and this word makes me think back to my attempts to understand philosophy.

And this isn’t just a game of semantics.  These definitions and understandings, even if they’re only implicit, shape national and local policy.  There’s a drug treatment budget within local public health teams, but is this the right place for interventions to address PIED use?  Should separate facilities be provided for users of PIEDs?  These sorts of questions come down to our definitions of what a ‘drug’ is.

The facetious way out of this impasse is to say that (at least in this context, rather than a medical one) a drug is simply something that is disapproved of.  That is, ecstasy is a ‘drug’, but alcohol isn’t.  And people do often refer to the area I work in as being about ‘drugs and alcohol’, and now sometimes ‘alcohol, drugs and tobacco’.

And to be honest, perhaps this is the unspoken truth of drug policy: yes it’s an incoherent fudge, but would a coherent, solely evidence-based rational policy work any better?  It’s not just policymakers and the public who see PIEDs as different from other ‘drugs’ – it’s also the users themselves.

Not for the first time, I’m uncomfortably leaning towards a position the likes of Michael Oakeshott and Edmund Burke would be happy with, but I think I’d actually welcome a politician or policymaker – and perhaps especially an academic – who stepped forward and said, well it’s not perfect, and it’s not rational, but maybe this is makes as much sense as we can handle.

Markets for good? A response to Reform

For various reasons I’ve been thinking a lot about commissioning as a process lately.  Of course, you could say that’s my job, as a commissioner of substance misuse services, but actually the day-to-day work is precisely that – focusing on day-to-day issues, rather than the sorts of principles and models beloved of policy advisers and think tankers.

One of the reasons I’ve been mulling over these principles and models is a report published back in November by Reform, written by Andrew Haldenby, Richard Harries (no, not that one) and Jonty Olliff-Cooper.  The key message is that performance of ‘human’ public services isn’t great, and in a period of freefalling budgets reform is the only solution.  The reform proposed is, in broad brush terms, to stop either state provision or contracts won through tendering.  Instead, ‘licences’ to deliver services would be granted to any qualified provider.  Then, you’d get competition for services and a range of options so that each individual access an approach that suits them.

(As an aside, I should say that anyone interested in substance misuse services specifically should check out Russell Webster’s series of blogs on this report – though we differ in our views.)

I don’t want to go into a great deal of detail about the report (though I probably will anyway).  I’d take issue with a few specific points – particularly those criticising the field of substance misuse, given that this is miles ahead of most commissioning I’ve seen in local authorities or CCGs – but this is mostly defensive vanity.

As usual, there’s a few straw men in there, as when there’s a claim that people are seriously suggesting ‘salami slicing’ public services in the face of huge cuts (p.13).  It’s also odd for the authors to suggest that drug treatment should be opened up to ‘non-state providers’ (p.9) when this has been the case for decades.  I’d also suggest that this is true more widely in terms of ‘licensing’: there’s plenty of private provision of health and social care (think of residential rehabs for substance misuse, or BUPA for mainstream healthcare).  The issue could only be with the demand side, and ensuring that people have access to the range of providers.

I’m also not convinced that such a licensing system could work in an area like Dorset for the services being discussed.  You only just get competition in food suppliers (most towns don’t have a choice of genuine supermarket), and everyone buys food.  About 5 in every thousand people in Dorset use opiates.  I can’t see how villages and towns could realistically offer choice in drug treatment, or that you’d get a range of providers competing to provide services.  People can’t travel because there aren’t any decent transport services – and in any case, why should someone from Blandford have to travel to Weymouth to get choice in their healthcare?  But that’s all an argument for another day.

What I want to focus on in this post is a more fundamental point about the general conception of markets.  The report itself is called ‘Markets for Good’.  Apart from the fact that this sounds suspiciously like the title of an Ed Miliband speech, it concerns me that the potential clarity of ‘market’ as a concept, as an analogy or metaphor, has been lost.

The reason ‘markets’ are attractive as an idea is that we think we’re familiar with them – we buy our food and other groceries through them, and even if we don’t actually use a market in its traditional sense, we think of going to Tesco as participating in ‘the market’.  We talk about ‘the market’ for particular consumer products.

What Reform are describing, though, isn’t like those ‘markets’.  There’s elements of competition, but that in itself doesn’t make a ‘market’.  Most importantly, what’s described is an actively created structure in which companies might operate, that isn’t a replica of the ‘market’ for food or white goods, or any of those things we’re familiar with.  If we’re actively creating a particular environment to in some ways mimic a market, it’s important to work out why we consider ‘markets’ to be efficient and fair modes of allocating resources and fostering innovation, as it’s those bits we’d want to build into the pseudo-market being proposed.  One I don’t discuss here, but is worth thinking about, is that by virtue of the fact that ‘strong markets are characterised by vigorous competition’ (p.18), they’re also characterised by failure of providers.  Is this acceptable and manageable in public services?

However, back to the fundamentals.  The reason we get efficient services from providers like Tesco is that there’s widespread demand for food and clothes, and there are economies of scale in providing single products for people.  You might get some choice within a supermarket, but we don’t get ‘personalised’ services (p.11).  Most people buy their clothes ‘off the peg’, not tailored to them personally.

Moreover, the report talks about how providers should “address the ‘whole person’ by working on multiple outcomes with the same individual” (p.11).  This sort of knitting together of services is indeed crucial, as we know that recovery from substance misuse, for example, doesn’t depend on dealing with substance use in isolation from other factors such as housing, employment, relationships.

However, think again about whether markets we know as working efficiently actually provide this.  Even in a world of supermarkets, we tend not to find the needs for our ‘whole person’ from the same provider.  Even if we just think about food, the aim isn’t for a single shop to provide us with a hamper of all we need; it’s about making sure the consumer has access to all the best shops for those particular products.  Take the example of my lunch at work (and don’t judge my choices).  It could well feature a pork pie and an apple from Waitrose, but crisps and a sandwich from M&S.  (And this example tells you already the options available to me in Dorchester town centre: no Tesco, Sainsbury’s, Greggs, Morrison’s etc.)

(Weirdly, the report concludes by suggesting that it favours a model whereby a consumer has a different provider for each key ‘outcome’ (p.70).)

The whole report seems to be based on an odd, superficial reading of markets, seeing them as comprised simply of individuals and individual transactions.  We can’t really understand the purchase of green beans as a transaction between me and Tesco; there’s all sorts of other levels of transaction involved with providers, transporters, governments and so forth.  (Incidentally, the document piously claims that ‘aiming to pay no more than the raw unit cost of a service will kill the market’ (p.57).  Tell that to supermarket suppliers.)

You might think I’m being unfair by comparing providers of ‘human’ public services with supermarkets and food – but that’s precisely the analogy employed by the authors themselves (p.28).  I just can’t see that it’s helpful.  The whole principle of grocery shopping is that you can buy the products again tomorrow, and switch to an alternative provider without any serious long-term consequences.  That just not true of social care.  Moreover, the report actually rules out switching providers, as it would be ‘too complex to administer’ (p.69).

There’s also a strange view of providers as being uncooperative or unthinking, where ‘incentives’ (p.21) have to be actively created to make providers behave the way we’d expect them to.  By contrast, all the providers I’ve ever dealt with have been keen to make a difference.  Who works in the field of substance misuse unless they’re passionate about the cause?  Providers are constantly squeezing activity out of limited resources and finding new sources of funding within the community.  In fact, the providers are obliged to take this approach, and not just be motivated by financial incentives attached to contracts, because they tend to be charitable foundations, often founded by parents concerned about their loved ones’ substance use.

Crucially, the proposed structures don’t resemble the markets we’re familiar with either.  The report of course talks about ‘outcomes’ based commissioning.  I’m not opposed to this (though it’s much more complicated than a lot of people seem to think, as soon as the ‘outcome’ is anything more complex than the delivery of a vaccination).  However, the model proposed bears no relation to how markets actually work.

The classic example of an ‘outcome’ relates to a birthday cake.  You could buy ingredients, or a ready-made cake, but that’s only the ‘output’; the actual outcome is the smile on your child’s face and their full belly.  The Reform authors complain about ‘paying for process, not outcomes’, but that’s precisely how the markets we know of work.  We don’t walk out of a supermarket and say: “I’ll pay you if, and only if, my little boy is smiling once he’s eaten this cake”.  You might not buy next year’s birthday cake from Sainsbury’s if he didn’t like it, but in reality hardly anyone goes back to the supermarket saying they weren’t ‘completely satisfied’ with the product.  And in any case, there’s too many personal factors involved to blame the supermarket if your son isn’t smiling – but that’s the outcome you were looking for when you entered into the transaction.  It’s hard to see how ‘allow[ing] customers to pay by satisfaction’ (p.48) would be workable in practice, particularly in a field like substance misuse where the outcome is complex and long-term, as relapse is common.

More fundamentally, the report worries that prices can be set ‘too high or too low’(p.31) – but the key to a market providing efficient outcomes is the price mechanism.  What the report ends up describing is the sort of arrangement that would infuriate Hayek: central planners must very carefully set the price of a service at just the right level.  In fact, the level of bureaucracy (or perhaps technocracy) is striking: each individual consumer will have a ‘price’ attached to them for a successful outcome, based on their individual characteristics (p.39).

Shockingly, for a paper that’s supposedly singing the praises of markets, it’s suggested that ‘providers should not be permitted to compete on price, only on quality’ (p.54).  I can’t think how a purchasing process without price competition can helpfully be considered a market.

I worry that underneath some of this there’s a misunderstanding of the nature of choice and ‘price’.  When suggesting (quite reasonably) that customers should be able to ‘choose any licensed provider’, the comparison given is university choice (p.66).  But this is to be blind to the fact that the currency in the university ‘market’ for students is exam grades.  Those with ABB+ are much more attractive to universities (based on the funding structure created by the Coalition government); it’s naïve to suggest that students can ‘choose’ whatever ‘provider’ they want.  In fact, it’s unlikely this constraint would apply in a ‘market’ for public services, but not being able to see that the university analogy is inappropriate signals a wider problem with understanding the nature of the proposed system.

Crucially, much of the discussion at this point has nothing to do with commissioning structures or practices, but the quality of these: the system doesn’t mean that ‘providers are all too often chosen for being the cheapest, not the best’ (p.34); that’s just poor practice that can happen in any system where providers or prices are chosen by central planners.

And much of the suggestions are perfectly possible within the current system.  When the authors complain about ‘blink and you miss it’ starts to contracts, this isn’t a problem (p.43).  Dynamic purchasing systems (DPS) already exist perfectly happily within current regulations – but they suit particular types of services (like short one-off placements where there can be economies of scale).  And they’re not that new – here’s some guidance from 2008 that’s the top result on Google.  In fact, spot-purchasing systems have been in place for as long as I can think – residential rehabs don’t just survive on block contracts?

This is a secondary point, but it does link into my feeling on reading the paper that probably commissioners on the ground actually know more about this and how to do it than the authors.  The friends and family test, mentioned on p.50 as being used in A&E is already in widespread use across all sorts of services, and although this is my defensive vanity again, it’s galling to see this, like DPS or spot purchasing or mystery shopping, being promoted as something new and worth shouting about.

Fundamentally, there’s lots of ideas I value in the report, and (despite the tone of this blog post) plenty of food for thought and helpful challenge to the way I think about commissioning.  There are services where licensing would apply and could be helpful, and it’s not fair to criticise the principle on the basis that it wouldn’t work perfectly for everything.

However, my theoretical or conceptual concern is genuine.  Much sociological ink has been spilt on the issue of whether markets retain their hegemony in political discourse after the financial crisis, but this report shows that the term is perceived to have some value.  And how could it not, when we happily supply so many of our wants and needs through structures we understand as ‘markets’?  But I do think it’s important we understand what the merits of these ‘markets’ are.

I’d respond to Reform’s proposals, then, in exactly the same way they criticise current commissioning arrangements: ‘they are scarcely markets at all’ (p.8).  On my reading, the whole report is based on a faith in something different from markets specifically: competition.  It’s competition, not markets with the key feature of a price mechanism, which is understood to drive performance.

In that respect, I agree strongly with the thrust of the paper, but the fact that what is proposed is not a ‘market’ in any real sense highlights that there are myriad structures within which competition and a drive for excellence can be fostered.  I would suggest that it’s the job of commissioners to do this, and the market metaphor may close down the options we see.  Here’s hoping when I’m back at work on Monday morning I’m able to live up to this claim.

The continuing search for a big number

Wellbeing is big in politics at the moment – or perhaps it’s better known as the happiness agenda.  It’s a long time since David Cameron talked about replacing GDP as a metric with a happiness index, but it’s still a live issue in politics.  Last week the British Academy and Prospect hosted an event with some pretty eminent speakers including Gus O’Donnell and David Halpern.

As an agenda, wellbeing is meant to open out new ways of thinking about politics.  What I was struck by, though, was the how the debate was conducted in very much the same terms as any other.  Perhaps inevitably given the backgrounds of most of the speakers, this ended up being a very technocratic discussion.  The audience certainly didn’t seem to be at odds with this approach, with one comment from the floor stressing the need for a wellbeing ‘number’ to rival GDP.

It might seem that such a proposal seeks to fundamentally change how we approach and judge politics, but in fact it’s merely an echo of a well-established (and perhaps discredited?) mode of politics.  All through O’Donnell’s talk I was thinking about how much this was the worldview of a New Labour era technocrat.  He was talking about the importance of cost-benefit analysis, and how wellbeing ought to be included in such analyses, through approaches such as social return on investment tools.

My perspective is slightly different, having seen inside the sausage machine.  All those claims about how much £1 spent on drug treatment saves the public are reliant on locally-generated data and cost estimates.  These might be in right ballpark, but they make me question the ability of them to inform marginal decisions about what to fund or what policy to implement.

And GOD (as O’Donnell was known) seemed to realise this too, casting doubt on the figures used to calculate the savings HS2 will generate.

There have been well-documented issues with government by ‘numbers’, and I would have thought that the real potential opportunity the concept of ‘wellbeing’ offers is to rethink fundamentally how we approach political issues.  The problem with GDP as I see it is that it is a single number with little nuance.  To replace it with another single number would strike me as just as misguided.

And of course most politicians haven’t focused simply on GDP.  It’s certainly a useful figure, but inequality is often also discussed, as are unemployment figures.  The fact is that politicians will always be looking for a figure that strengthens their case and position.

Wellbeing in this world isn’t an opportunity to fundamentally remodel politics; it’s a conceptual device to promote existing opinions.  Nic Marks, for example, at this event used wellbeing to argue that localism and further devolution of power was a good idea.  Personally, I can’t see what wellbeing adds to this debate – and I certainly can’t see that being pro-wellbeing should make you a localist.  I can imagine lots of public health advocates claiming that they believe in the importance of wellbeing and also noting the importance of national and international policy decisions on issues like alcohol.  Minimum unit pricing only really makes sense as a national policy, for example.  I’m not sure O’Donnell, with his view of policymaking and desire for a national wellbeing index, would agree with Marks either.

The most frustrating element of the event for me, though, was the lack of discussion around the potential role of a technocratic elite in making these decisions about what wellbeing might be and how it should be promoted.  David Halpern, the founder of the Behavioural Insights Team (better known as the Nudge Unit) originally within the Cabinet Office, revealingly stated that we’re often not very good at predicting what will make use happy.  He seemed to suggest that with better analysis and data we could get advice on making all sorts of decisions.  But giving that kind of advice really does mean having an idea of ‘eudaimonia’ agreed by society.  If analysts are to advise us on what makes us fulfilled, they’d surely need some kind of assumption about what fulfilment means for people in Britain.

And here’s the rub, and the key point of why GDP isn’t so bad after all – or, actually, why thinking in terms of money isn’t so bad.  (And I’m in the uncomfortable position of having to agree with Chris Snowdon on this – see p.92 on the value of economic growth here.)

The attraction of money – unless you’re modelling yourself on Silas Marner prior to the arrival of Eppie – is that you can exchange it for things you want.  You might spend £20,000 on a car.  I would think that to be mad, but it might make you ‘happy’ and ‘fulfilled’, and increase your ‘wellbeing’.  Money is a means to the end of individual fulfilment; wellbeing is that end – but to try to work out what it is for everyone seems to me to be a little fruitless.

Moreover, one of the dangers of focusing on wellbeing is that it misses the important point that money is a form of power.  The panellists suggested that we needed to focus on people who didn’t have high wellbeing rather than people who weren’t well off, but that leads me to worry (and this isn’t a particularly original thought) that we would be ignoring legitimate questions about the justice of the distribution of society’s rewards.  Money might not be everything, but it is something worth talking about.

Of course, politics isn’t – and shouldn’t be – simply about improving people’s financial lot, but the vision proposed at Senate House last Wednesday didn’t strike me as being any better.  The idea of wellbeing foregrounds issues of values, and we shouldn’t duck debates about these by thinking we can somehow resolve issues with a new all-encompassing ‘number’.

The Centre for Social Justice and Res Rehab (again)

As readers of previous posts will know, I’m not the greatest fan of the work of the Centre for Social Justice on substance misuse.  This isn’t anything to do with my own politics, or theirs.  I don’t think the claims are actually political in the sense of left or right.  Rather, they are (apparently) more like managerialism: ‘what works’ to deal with ‘addiction’?

The most recent claim of the CSJ was that there’s not enough residential rehabilitation in this country.  I say recent, but it’s an ongoing claim, but with a new quick and dirty bit of analysis behind it.

The CSJ looked at the estimated number of opiate and/or crack users in each region of the country, and then divided this by the number of residential rehabs listed by Public Health England (PHE).

Today’s post is just a short response to this analysis, highlighting a few points that make this not just inaccurate but unhelpful.

Setting aside one issue that frustrated me – whether we should be calling all (or any?) users of crack and opiates ‘addicts’ – there’s a clear and straightforward issue with the analysis.

I’m assuming that fundamentally what we’re concerned with is whether people are able to access a particular mode of treatment, which the CSJ says is “the most effective means of helping someone fully recover from addiction”.  Location is not the same as access.  This is particularly the case for a type of treatment where people generally stay for 3-6 months, and part of the very point of it (as opposed to the community-based treatment the CSJ continually run down) is that it’s not in the service user’s own local area.

It is, at best unintentionally misleading to claim that these stats suggest rehab is the preserve of the ‘wealthy’.  That might be true, and there would be ways of assessing that, but this analysis certainly doesn’t offer that evidence.

And this brings me to the more fundamental point: the CSJ are still claiming that res rehab is “the most effective means of helping someone fully recover from addiction”, when there is no evidence to suggest this.

Again, I’m not saying this isn’t the case.  I’m concerned that despite the illusion NDTMS gives of there being plenty of quality and quantity of data related to treatment, we don’t actually have quite the information we’d want to identify if someone can be said to have ‘fully recover[ed] from addiction’.  The NTA admitted as much in 2012.  And this is quite apart from working out what it would mean to ‘fully recover’.  (It seems from the CSJ ‘2015 manifesto’ that cocaine users should never drink again, otherwise they shouldn’t be classed as ‘successfully completing’ treatment – see p.22.)

The statement about the effectiveness of res rehab is particularly difficult to sustain when Iain Duncan Smith’s own Department for Work and Pensions has just recently published research showing that if res rehab is more effective than standard community-based treatment that only applies to a small cohort of the most ‘complex’ clients, and even then it’s not clear it’s ‘cost effective’.  There’s a great summary of this work at findings.org.uk

(It might seem harsh to be discussing cost effectiveness, but at some level all policy decisions have to come down to this, particularly if we’re talking about funding one form of treatment in place of another.)

Why does this matter?  Well, if CSJ staff really want to make a difference, they should be looking at producing evidence and arguments that make the debate about substance misuse treatment clearer, not muddier.  We do need an open debate about how well currently-commissioned work, and what the aims of those services should be, but outlandish statements about the number of res rehabs in the North East doesn’t help that.  Perhaps those staff could benefit from some reflection on why they’re so attached to res rehab.  That or reply to my tweets asking how they can substantiate their bold claims – because if there’s something they know and I don’t, it would be helpful to pass it on.  Then maybe we could work together to make a difference.

What does a spiral look like?

The Daily Mail recently posted the headline: “Number of women drinkers treated in hospital for liver failure soars with teenage girls being treated for life-threatening condition”.  The article includes a statement from Andrew Langford of the Liver Trust, suggesting that that liver disease in the UK is ‘spiralling out of control’.  This is just the sort of claim that gets me interested, and it turns out to be an ideal topic to be discussed on this blog, if I’m to stick to my original intention of trying to bring clarity to debate.

So first to the Mail’s claim on the numbers of women being treated for liver failure.  I don’t actually know exactly where the stats come from that the Mail quotes, but they provide them and comment on them, so I’ll just do the same.

The claim is that they have ‘soared’ in recent years.  As you can see from the graph below, they’ve increased, and at a steady rate – it doesn’t look to me like they’re ‘soaring’.  In fact, it works out at a 3% rise each year, which isn’t so dramatic.  When adjusted (very crudely*) for population growth, this figure drops to around a 2% annual increase.  Still noticeable, but I’d be even less likely to see this as ‘soaring’.

So what about the claim that “Treatment for women aged under 30 has increased by an incredible 58 per cent since 2004”.  Well, that’s true if you’re just comparing the figure for 2004/05 (78) with 2013/15 (123) – that works out as a rise of 57.7%.

But, as we’ll see again in a second, looking at a single year – or in this case comparing just two – can be a little misleading.  If we look at all the data the Mail gives, we can see that it’s 2004/05 that looks like an anomaly, and since then the numbers have stayed pretty much constant.  When you look at the blue line it’s hard to see any real pattern over the years; it just seems to be dodging either side of the average.

And the green line gives some indication of whether the emphasis on young women is fair.  My judgement would be it isn’t really.  Despite last year’s uptick, the green line is generally falling – which tells us that if we’re concerned about liver disease amongst women, the younger age group is becoming less relevant, as it accounts for a smaller proportion of those cases.

There are variations in population over the period that could muddy this picture (the changes are a bit too complicated for me to take into account in a quick blog post) but the number of 15-30 year-old women has gone up and then down again over the 9 years so it’s not going to make a crucial difference.  (Just as an aside, I always find looking at the population pyramid fascinating, with the ever-repeating echo of the baby boom.)

So I’d struggle to identify a crisis with liver disease amongst women – and certainly amongst younger women.  Remember that the figure the Mail gives is 123 diagnoses for women under 30.  That’s under one person per local authority in the country.  Out of the thousands of young women in your local area, there probably isn’t even one who was diagnosed with liver disease last year.

Also, it’s worth noting that by focusing on women, the article is assuming there’s more of a problem for them than men.

Unfortunately I can’t easily get time series data that’s also divided by gender for liver disease hospital admissions, but I can get the death figures – which in some ways could be more powerful.  These stats show quite strikingly how men still dominate the figures, and also how the number of deaths amongst men or women from alcohol-related liver disease hasn’t really changed much since 2007, apart from a blip in 2011.  And that’s not even taking into account the growth in population, which would suggest the rate of liver disease deaths due to alcohol might actually have fallen in that period.

And it’s these death figures that are behind the Liver Trust claim that we’re seeing liver disease ‘spiral out control’ in this country.  As we’ve seen, there are rising rates of diagnosis.  My rough and ready calculations suggest that admissions have risen by about a third in the past decade, averaging 4% growth a year (not adjusting for population).

I’m still not sure that constitutes them ‘spiralling out of control’.  The key graph for this claim, as far as I can tell, is probably this one – which quite rightly gets shown a lot by concerned public health professionals (taken here from the Liver Trust’s own website):

It is indeed a shocking graph, and shows that liver disease is a serious and unusual issue for mortality rates.  The point about a spiral in this context is that it conveys things are getting higher and higher – over time.  And certainly the graph shows that.  The liver disease line rises and rises.

But if you look closely, you can see that the data stop at 2008.  This isn’t an old graph; it’s the one on the Liver Trust’s main ‘Facts about liver disease’ page, designed to inform journalists and others.  The data points are 1971, 1981, 1991, 2001 (spot a pattern here?) and… 2008.  The graph was probably put together then, but the data for 2011 and beyond are now out so it might be sensible to update the graph.

We can take the death figures since 2001 from the chart before, but standardise them to 2001 to continue the methodology of the Liver Trust chart.

Looking at the data like that, it’s suddenly clear that 2008 is an interesting year to pick as an ‘end point’ of a graph on liver disease deaths.  It’s the highest we’ve had in this country.  But we’re actually seeing at worst a static number of deaths from this cause (again, while we have an increasing population) and at best the numbers are actually declining.

All this doesn’t mean that I don’t think liver disease is a serious problem – and the rates we’re seeing are way beyond the immediate postwar period.  But there are lots of reasons for that, and we need to have a sensible debate about how best to address that.  I’m not convinced that alarmist rhetoric about rates ‘spiralling’ when they might at most be rising pretty steadily helps this debate.  But then I’m not having to play the political game of winning attention (and therefore funding) for my chosen issue.  I left that behind a few years ago.

*Methodological note:

Apart from the Daily Mail stats, all the liver disease figures I’ve quoted are from the 2014 ‘Statistics on Alcohol’ publication, which is here: http://www.hscic.gov.uk/catalogue/PUB15483 The time series data can be found in the csv zip file.

The population stats are taken from mid-year estimates, and are available here: http://www.ons.gov.uk/ons/rel/pop-estimate/population-estimates-for-uk--england-and-wales--scotland-and-northern-ireland/2013/index.html

If you’ve got any questions, just get in touch, but I think I’ve been clear and fair in what I’ve done.

Condemning the carnivalesque

This post, like a few before it, is about an academic article I’ve had published recently.  A version of this may or may not end up on the LSE British Politics and Policy blog, but in any case this version has a few things included that I couldn’t fit in with the word count – one of which is a few more words on the paradoxical semantic/pedantic point that when academics talk about a ‘new culture of intoxication’, this only makes sense because we’re talking about intoxication as drunkenness, rather than something pharmacological.  That’s the only point worth noting, really – otherwise I’d point you to the article itself, which is free to access and probably more clearly written (if in a more academic style).

Alcohol – and public policy in relation to it – seems to be a fascination in Britain not only for governments, but the media and academics.

A common academic view has been that British night-time high streets, and our drinking behaviour on them, have been shaped by a form of neoliberalism, exemplified by the perceived loosening of licensing laws – for example through the 2003 Licensing Act that supposedly ushered in 24-hour drinking.  This has taken place, it is suggested, as part of a broader trend for consumption such as drinking to replace productive work in importance to the UK economy and young people’s identities.

But this apparent liberalisation hasn’t meant that government has been indifferent to people’s drinking choices.  The neoliberal approach is characterised by its response to those drinking practices it considers undesirable: where governments with a different ‘mentality of government’ reshaped the drinking environment – for example through precisely those licensing laws that more recent UK governments dissolved – neoliberal governments have focused on the drinkers themselves, trying to change behaviour through education and social marketing such as the ‘Would You?’ and ‘Change for Life’ campaigns.

This means that governments don’t think each person’s way of laying out their own life is the best by definition, as some classical liberals might; neoliberal governments actually have strong ideas of ‘good’ and ‘bad’ drinking.  This distinction between ‘good’ and ‘bad’, though, isn’t inherent in the neoliberal approach to government.  A neoliberal approach could focus on health issues, or disorder, or indeed celebrate drinking as a valuable contribution to the economy; the difference would be in the programmes designed to educate consumers.

Both in the media and academic work it’s common to see discussions of how ‘good’ and ‘bad’ drinking are defined.  Often it’s suggested that the government has criminalised intoxication, or certain forms of pleasure.  In a recently published article I’ve argued that the concept of the carnivalesque is actually more helpful in understanding alcohol policy in England.

But what does the carnivalesque mean, if it’s to be of any use?  Carnival is a time when rituals turn the world ‘inside out’ – for example, when a peasant is made ‘carnival king’ for a day.  Much academic work on the carnivalesque has drawn on Mikhail Bakhtin.  His idea of the carnivalesque includes free and familiar contact between people, profane speech and grotesque realism, with an emphasis on the body, and attention drawn to its natural features and functions, such as sex and excretion.

One of most evocative descriptions of carnival is given by Mike Featherstone: ‘The popular tradition of carnivals, fairs and festivals provided symbolic inversions and transgressions of the official ‘civilized’ culture and favoured excitement, uncontrolled emotions and the direct and vulgar grotesque bodily pleasures of fattening food, intoxicating drink and sexual promiscuity.’  Parallels with the alcohol, excitement, (apparent) transgression, kebabs and sexual promiscuity of the night-time economy and its ‘binge’ drinking are immediately apparent.

Bakhtin in particular, though, has been criticised for taking a rose-tinted view of carnival – both in general and with specific reference to drinking.  However, he describes the way in which festivals and carnivalesque impulses were co-opted by institutions such as state and church and his analysis of Rabelais is centred on the ambivalence of profanity and carnival laughter, through which shame and triumph, death and life, are felt simultaneously.  Moreover, carnival has always been an event that has been commercialised and sanctioned by the state in some sense.  As Terry Eagleton put it, using Shakespeare’s words, ‘there is no slander in an allowed fool’.

But what’s the use of this concept in thinking about government alcohol policy specifically, as opposed to describing the night-time high street?  (And I wouldn’t be the first to do that.)  I’d argue that the strength of the concept of the carnivalesque is in this ambivalence: government’s toleration of but discomfort with certain practices.  And the carnivalesque takes us beyond ideas of pleasure and intoxication, which don’t quite capture what does actually make government uneasy.

There’s a strong case that in drug policy at least, what the government is condemning is indeed pleasure and/or intoxication.  The Observer recently published a ‘Drugs Uncovered’ special, and one article claimed that “the biggest taboo surrounding drugs today isn't taking drugs, but saying that they're fun”, while Adam Winstock has suggested that harm reduction policies would be much more effective if they acknowledged people’s pleasure in drug taking.

In a recent academic article in Addiction, Alison Ritter asked ‘Where is the pleasure?’ when thinking about drug regulation.  Fiona Measham – particularly in her work with Karenza Moore – has suggested that governments in Britain have made certain pleasures ‘impermissible’ and even ‘criminalised’ intoxication.

Measham, though, would be the first to point out how government policy has fostered ‘the new culture of intoxication’ in relation to alcohol.  Alcohol is something of a special case when it comes to drug policy – it’s one of the few recreational psychoactive substances actively endorsed by government.

Government does not accept that there is a fundamental problem inherent in alcohol, and it’s perfectly happy with people taking pleasure in its consumption.  Just think of David Cameron describing his family as having ‘a reasonable drinking habit’, or opposition from politicians from all parties to minimum unit pricing (MUP) on the basis that it would penalise people’s legitimate pleasure in drinking.

But then the standard academic position – for alcohol, at least, as opposed to other drugs – isn’t so much that no form of pleasure is permitted; it’s that certain forms of pleasure are ‘impermissible’.  And it can seem that it’s precisely an impermissible pleasure of intoxication that’s being condemned when successive alcohol strategies have defined ‘binge’ drinkers as those who ‘drink to get drunk’.

But although it might seem like a game of semantics, a genuine distinction can be made between intoxication and drunkenness.  The former implies something like a physiological change, and might be judged in the same way that impairment for driving is: by blood alcohol content.

Government concern is something more than this.  The 2004 Strategy worried about ‘the culture of drinking to get drunk’, where ‘there is little social control’.  It stated quite clearly ‘there is no direct relationship between the amounts or patterns of consumption and types or levels of harm caused or experienced’.  Counterintuitively, it’s actually this culture that is being condemned when academics have referred to ‘the new culture of intoxication’.

But it could still be argued that if it isn’t exactly pharmacological intoxication that government is condemning, perhaps it’s still a certain form of ‘impermissible’ pleasure.  However, there are two key problems with this.

First, drinkers aren’t necessarily experiencing ‘pleasure’ in the night-time economy.  As Barton and Husk have recently noted, preloading is often chosen over going straight out onto the night-time high street not simply because it’s cheaper, but because people find it more comfortable and pleasurable to drink at home in a more controlled environment and be able to have proper conversations.  But, crucially, those drinkers do still end up going out into that slightly uncomfortable world of altered social norms., attracted not by pleasure exactly but the ritual, communal, ‘controlled loss of control’ that I’d say is captured well by the idea of the carnivalesque.

But more importantly in this context, it’s not just that drinkers don’t necessarily experience this as pleasure; the government doesn’t think it’s pleasurable either.

This is best illustrated by looking at one government initiative specifically (admittedly from a few years ago).  We can see this clearly in the ‘Would You?’ social marketing campaign that ran in 2008.  Without going into great detail, the actions shown and the way in which they are portrayed are characteristic of the carnivalesque.  The world is quite clearly turned ‘inside out’, as a boy and a girl are depicted getting ready to start the night as they might end it, with plenty of illustrations of what Bakhtin would refer to as the ‘grotesque’ body complete with the flow of bodily fluids – urine, blood, vomit.

The appeal to the viewer is that ‘you wouldn’t start a night like this’, assuming not only that in everyday, sober life certain norms are shared between viewer and government, but also that such norms could and should apply to the NTE.  The adverts aren’t suggesting that drinkers should deny themselves the pleasure of this behaviour in favour of higher or deferred pleasures, or because the actions are selfish and impinge on others (the whole scene takes place within a private place where each actor is alone).  Instead, the aim is to highlight that these actions and consequences are specifically not pleasurable, and so behaving in a different way would be more pleasurable as well as sensible.

I’d like to think that, just like the distinction between intoxication and drunkenness, this idea of the carnivalesque isn’t simply a game of semantics, but has genuine implications for policy.  If we see this as the motive behind government policy, it opens out the question of whether this is an appropriate aim: should we be concerned about the carnivalesque culture, or actually should policy focus more directly on crimes and health harms?  Certainly there’s evidence that there’s a different approach developing in Scotland, and it might be worth thinking about how well that works.

Alternatively, if the problem really is the carnivalesque, we’d probably make better policy if the debate was clear and open about this being its aim.  It might also be a useful concept to use to think about illicit drug policy – or does the government only need to make this sort of distinction between responsible and irresponsible consumption when the substance is legal?

And given that my analysis is all of public documents and statements, it might be worth thinking about whether this is how government officials really think about alcohol policy: the concerns of policymakers and the reality of the process might be quite different from these statements designed for public consumption.  But all the same, I’d still say it’s useful to think about things in these terms.