Public Health and the power to persuade: Are we winning the argument?

I often write on this blog about evidence-based policy, but I want to write this week about how I feel torn in relation to this issue.

I was reminded of the ‘evidence-based’ phrase as I saw responses to the Government’s new drug strategy and the release of the latest drug-related death figures.  Transform, Release, Alex Stevens and others stated that the government was ‘ignoring’ evidence.

But on a quick Google search, I can’t see that Amber Rudd or Sarah Newton particularly used this phrase.  I’m not saying they didn’t use it at all, or that they wouldn’t want to make this claim – Sarah Newton did challenge the idea of decriminalisation on the basis that: ‘When you look at all the other available evidence, we just don't agree.’  I’d just suggest that they weren’t quite using the same ‘evidence based policy’ frame for their arguments.

On the Home Office webpage launching the strategy, the only reference to ‘evidence’ comes from Paul Hayes, which probably says more about the discourses of lobbyists and policy commentators than politicians.  As Alex Stevens’ own research would predict, the politicians were more interested in appearing ‘tough’ on ‘dangerous drugs’, as Sarah Newton put it in that article for DDN.

I should of course make my standard statement that when people cite evidence, it’s usually in relation to one ‘outcome’ of concern – in this case, drug-related deaths.  There is indeed good evidence that things like purity testing, drug consumption rooms, prescribed heroin, retention in treatment etc all reduce drug-related deaths (DRDs).  The problem of course comes when you acknowledge that DRDs aren’t the only outcome policymakers might be interested in (and they’re not the only drug-related outcome we should be interested in).

Regardless of our feelings about them, policymakers have other legitimate concerns: for example they worry that certain initiatives might undermine the fall in young people using substances.  That is, that decriminalisation or drug consumption rooms, or pill testing might send out the ‘wrong message’.  Giving them the benefit of the doubt, this could be genuine concern regarding harm reduction, as much as appearing ‘tough’.

(As an aside, it’s interesting that many of those who campaign on alcohol policy in the name of ‘public health’ would prefer to see fewer people using alcohol on the basis of the population model of alcohol-related harm, whereas those who campaign on policy relating to other drugs under the same banner often see no issue with more people using, and focus entirely on ‘harm’.)

But, more importantly, this isn’t just about harm reduction and drug-related deaths.  It’s also about morality.  You might think it shouldn’t be, but all politics is about morality.  Housing policy, inheritance tax, unemployment benefit – we can use ‘evidence’ in these arguments, and use economic theory to argue that putting a pound in the pocket of someone on £20,000 a year will benefit the economy more than putting it in the pocket of a millionaire, but that can’t be the end of the argument.  There will still be a discussion about whether that person ‘deserves’ that money.  And this is an important and necessary debate – because no matter which side of the political fence you sit, there are times when the ‘evidence’ for some perceived positive effect simply cannot outweigh the moral distaste you feel for a position.  And there’s the broader slippery slope argument: even if you don’t oppose this specific measure, it dilutes a point of principle that makes later distasteful initiatives more likely.

Here, we can see quite quickly how this applies to all parts of the political spectrum.  Peter Hitchens is quite open that his position on ‘drugs’ isn’t simply about the objective ‘harm’ they cause; it’s that taking intoxicants is somehow ‘wrong’.  And for all that left-liberals often like to think they’re wholly swayed by evidence, the ‘evidence’ would suggest otherwise and in fact ‘the Labour Party is a moral crusade or it is nothing’.  Finally, libertarians like Chris Snowdon often make use of the slippery slope argument.  For perfectly legitimate reasons, we don’t simply judge individual initiatives by their specific impacts on one outcome.

And most commentators on drug policy accept this – or at least are resigned to it.

Now here’s where I feel slightly torn.  My view on this blog is typically that we should acknowledge the complexity of policymaking and evaluation, and even then not discount the importance of moral or political positions; policymaking can’t simply be technocracy (even if we wanted it to be).

But then when it comes down to it, this can make me feel uncomfortable.  That is, the whole point of this blog is to encourage careful, nuanced thinking, and question black-and-white thinking, when most of life is more complicated than that.  Unfortunately, a critique of the ‘evidence-based’ position can somehow lead to an equally absolutist position of ‘anything goes’.  That is completely at odds with the aim of ‘thinking to some purpose’, as anything goes requires no thought at all.

What I mean is: even if the root cause of your position is irrational, or personal, you need to be able to articulate and explain it, maybe by saying that a certain policy is just a moral red line for you, or it just feels wrong, and describe why.  That isn’t to devalue the point; just to explain it.

And this this can sometimes be difficult and uncomfortable.  That thinking process shouldn’t simply be about saying ‘I think it so it’s reasonable’; it’s about reflecting on why you react in a particular way, and explaining it to someone else.

But when we acknowledge that, as the New Yorker article I linked to put it, ‘facts don’t change our minds’, this can open a can of worms.

As a response by a communications professional to a recent Guardian article put it: ‘telling people you’re wrong doesn’t work’.  This is generally true (although often not in a professional context, where in my experience we all seem much happier to look at evidence and change our minds), but the complexity is illustrated by the fact that the author – Nicky Hawkins – gives examples of successful campaigns that actually did exactly that: telling people they were wrong.  She explains how drink driving campaigns persuaded people that the issue wasn’t simply about ‘drunk’ drivers as much as the fact that anyone with a certain blood alcohol level will have slower reactions and poorer coordination.  That wasn’t just a way to justify the campaigns; it was the actual aim.  Deaths on the roads aren’t just caused by ‘alcoholics’.

But here’s where the difficulty arises.  The other example given is the justification for the smoking ban, where the villain of the piece became (apparently) second-hand smoke, not smokers themselves.  I don’t want to go into this in too much detail, partly because plenty of readers will know this example better than me.  But suffice to say…

(1) the timing of this campaign made it easier: there were fewer smokers, with rates particularly low amongst affluent/influential groups, so that even if smokers saw this as a personal attack they weren’t a majority or in a great position to make their voices heard.  (Of course the tobacco companies were in a strong position, but the argument wasn’t framed in relation to them, and their credibility amongst the general public was pretty low at this point.)

(2) The apparently desirable effects weren’t just about second-hand smoke; they were about persuading current smokers to give up.

So this wasn’t simply a brilliant campaign; the context is crucial, and there was some selective truth-telling (if that’s a phrase) in the accompanying justification.

There are lots of examples of this in politics in recent years (and actually, forever), so it’s a bit odd for a communications professional to offer this as a great insight.  Two recent classic examples prompted me to start this blog: drug treatment isn’t actually about crime and blood borne viruses, and tuition fees aren’t actually about getting students to pay their own way.  (The latter one is particularly egregious, because the burden to the taxpayer is not reduced, despite the popular narrative.)

I’m not saying the smoking ban was a bad idea, but I think it’s a classic case of not ‘thinking to some purpose’.  If the aim was to reduce passive smoking, then there are all sorts of options other than a ban that would have been workable.

And it’s much easier to ask people not to harm others than it is to suggest they should behave differently to stop harming themselves.  Interestingly, the same applies to the drink driving campaign: the most powerful point is that you could hurt someone else, who is innocent or your ‘vice’.

Most of the key public health debates today, though, are about people’s own decisions.  Perhaps the best way to frame these is, again, in terms of the structure that shapes these decisions: licensing, labelling, regulation, pricing.  But if the communications is designed for the general public, to directly change their decision-making, then unfortunately ideas of ‘passive drinking’ and the like have proved much less convincing; the argument is still about stopping people doing harm to themselves.

I know I’d be mistaken in hoping for some kind of Habermasian perfect communication and debate, and that kind of unrealistic aspiration is exactly what I try to critique on this blog.  My issue, as usual, is where to draw the line when you’re faced with a sea of grey, rather two clear camps of ‘good’ and ‘bad’.

The reason this has particularly resonated with me in the past couple of weeks isn’t just the fact that these three releases/articles have occurred; it’s also that I heard in my professional capacity that, pre-figuring the words of the breastfeeding article, public health professionals need to change the way they communicate with the public.  This sounds reasonable, and personally I’m not a fan of the preaching or evangelical approach – not because of its manner, but simply because I don’t share its view of the ‘good life’.  My objection isn’t the means, it’s the ends (although I don’t think you can separate them neatly).

I’m now going to draw on two people more experienced and intelligent than me.

I remember discussing with one academic a time that doubt crept into their mind about public health and the power to persuade.  If public health, in its attempts to compete with, say, the tobacco industry in trying to shape people’s beliefs and behaviour, adopts their principle of ‘persuade at almost any cost’, what makes it better than them?  That is, we have to be very careful about defining what makes ‘social’ marketing ‘good’, and ordinary marketing ‘evil’, as Gerard Hastings might put it.

This was a personal epiphany, but the general point isn’t a new insight, and it has some broader – moral – implications, to bring the discussion back to where it started: that policymaking can’t just be about technocracy.

And so to reference the other wiser head: James Nicholls (amongst others) has previously drawn attention to the role of alcohol in liberal political thought.  So let’s lookmat the nineteenth-century debate between John Stuart Mill and TH Green.  (And apologies if I oversimplify or misrepresent.  Go read James’ work if you want proper political theory.)  While Green felt it was illiberal to allow people to ‘enslave’ themselves to alcohol, and therefore recommended banning the substance, Mill rejected this argument – despite having used it to justify the abolition of slavery.  Mill suggested instead that if we’re really concerned with people’s moral behaviour, we shouldn’t use prohibition to shape it.  Someone who is only prevented from doing something immoral by the lack of opportunity isn’t showing moral character; they’re in fact behaving a lot like they’re a slave to the system.  The real show of moral character comes in making the ‘right’ choices.

And this position is further strengthened by Mill’s ‘harm principle’ that state intervention is justified when people’s actions impinge on others.  Of course in reality this is impossible to identify: no man is an island.  But the principle stands, even if the reality is more complicated.  (I can expand on this, but I think that’ll do for the moment.  Let’s just say if I do something, it potentially increases the likelihood that you will, so my decision isn’t entirely free of effects on others.)

So taking those two academic insights together, I feel uncomfortable if public health is somehow looking to change its approach.

Presenting facts is reasonable: if you drink too much you’re more likely to die earlier.  And actually evangelising is reasonable too: I believe that a longer life, full of physical activity and clean living is more rewarding and morally more valuable than other ways of living.  (I actually don’t.)

But mixing the two together, and persuading people to do something for one reason (‘you’ll love it’, ‘it’ll make you happier’) when your real reason is something else (‘the evidence suggests people will live longer and costs to the NHS will be reduced’) is distasteful to me.

And as I outlined right at the beginning, distaste can be a reasonable argument for rejecting a position, if explained.  So here’s my explanation: my distaste is that getting people to do the ‘right’ thing for the ‘wrong’ reasons is patronising and, at the risk of sounding like Chris Snowdon, a ‘slippery slope’.  If the current approach of public health professionals, with either evangelism or emphasis on ‘the evidence’ is considered patronising, wouldn’t this be even worse?

Of course you could ask: if there are two likely effects of an intervention why wouldn’t you emphasise the more powerful one?  And there might be some moments when the evidence and the emotion neatly intersect and provide powerful arguments.  But I suggest we should judge any such intervention by a crucial question: have you actually won the argument?  If you don’t care about that question, I’m not sure we’re on the same side in any debate.

Writing a drug strategy is just like choosing a suit

Over the past week or so, I’ve obviously read a lot about the new drug strategy.  Mostly short comments on Twitter, sometimes pulled into threads.  I’d also recommend reading the evaluation of the previous strategy and, if you’re interested in treatment specifically, the new Orange Book guidelines.  Or at the very least, Andrew Brown’s excellent summaries of them here and here!

(If you want a summary of my response, see this thread.  This blog post will try to make some bigger, broader points about policymaking and politics.)

My abiding impression is of a lot of sensible words, but without power or resources to back them up, I can’t see how anything will change.  This is a strategy that, in an environment of at least 20% cuts – and almost certainly more once the ringfence for public health comes off in the next couple of years – promises that quality and outcomes will improve, and a wider range of people will receive more tailored treatment.  I just can’t believe that.

I don’t want this post to simply be a rant against austerity, or an unreflective claim that any reduction in funding must equal a reduction in quality.  In Dorset we’ve been open in acknowledging that we can deliver treatment more efficiently and effectively than we have in the past by taking on the vision of ‘phased’ and ‘layered’ treatment from the Strang Report, and there is some truth in the idea that tightening resources can focus the mind and force people to work ‘better together’.

But that kind of approach depends on making some hard choices.

There is a certain efficiency in a Fordist approach to public services where everyone gets the same thing.  There will be some sweet spot of efficiency between that Fordist ‘any colour so long as it’s black’ approach and fully individualised, tailored services.  As usual, I’m going to suggest that compromise is a good solution.  Think of suits (as I often do).  For most people, it’s not ‘efficient’ to buy an expensive tailor made suit.  But that doesn’t mean we all have to wear the same suit.  There’s a nice sweet spot of buying ‘off the peg’, but being able to choose a range of sizes and styles from a range of providers.

But what’s the choice between Marks and Spencer and Moss Bros got to do with drug treatment?

Well, the point is that there should be some ‘tailoring’ of treatment, but within certain limits.  And certain styles or sizes are cheaper and more easily available than others.  So I might buy a tailored or more expensive suit for a special wedding, but have a few cheaper ones for work.  I would find it laughable if someone suggested that I should buy enough tailored suits to see me through the working week – unless of course they were about to massively increase my pay, or force me to reduce my mortgage, or how much I spend on food and drink.  The point is, I’d need to make some trade-offs.

Now, in this increasingly tortuous analogy, we can think of the commissioner as the suit-buyer, and treatment as the set of suits.  And this is when I haven’t even mentioned the ‘chinos’ of brief interventions (not to everyone’s taste, and not the full outfit, but cheaper than a suit) or the t-shirts of needle exchange (a good, cheap, reliable, low-level intervention).  Some interventions or moments are the ‘wedding’ occasion: it’s worth putting in that extra effort because of the reward of getting it right.  For others, it makes more sense just to have a decent, long-lasting M&S work suit.

The point is: someone needs to make this choice, and we can’t have a wedding-standard suit for every day of the week.

But the strategy seems to pretend that we can.  It describes having ‘a targeted approach for high priority groups’ (p.10), and then proceeds to list just about everyone who might have a ‘substance use disorder’ (or whatever you want to call it) or is at risk of one:

• Vulnerable young people
• Those not in education, employment or training
• Offenders
• Families
• Intimate partner violence or abuse
• Sex workers
• Homeless
• Veterans
• Older cohort
• Users of new psychoactive substances
• Participants in chemsex
• Users of image and performance enhancing drugs
• Those who misuse or are dependent on medicines (whether prescribed or over the counter)

I would struggle to think of someone who doesn’t tick one of these boxes.  I suppose it would be a single person in work, living on their own, who is neither young nor old, not using NPS, IPEDs, participating in chemsex or misusing any medicines, not engaged in crime or sex work, and has never been in the armed forces, and still has stable accommodation.

There could be a 35 year-old heroin user who fits the bill, but I think they’d be doing well to have stable accommodation on their own, be in employment, and not engaged in any form of criminal activity.  And in fact, I might even go so far as to suggest that, if they ticked all those boxes, by definition they don’t have a (severe) substance use disorder, because while they might have some form of dependence, it’s harder to see how their life is being affected by their use.

Maybe I’m being facetious, but I want to make a genuine broader point.  Policy discourses are filled with people talking about ‘targeted’ provision, or identifying ‘priority’ groups.  But a ‘target’ by definition means there’s some other place you don’t want to hit.  A priority can only be defined if there’s something you’re not prioritising.  Both locally and nationally, I fear that politicians and policymakers are reluctant to admit this trade-off and make the hard decisions.  But that should be what real leadership is about.

The sad thing is that this isn’t new.  Because I’m a slightly odd person, I’ve recently been spending my free time reading about the ‘new public management’.  The best book on this I’ve found is The Managerial State by John Clarke and Janet Newman.  This was published in 1997, and includes the following two sections that seem sadly resonant today:

Those working in public services are having to manage not just budgets and people in the pursuit of greater efficiency, but the tensions and dilemmas of rapid and unpredictable change.  The results are frequently high levels of stress and overload which tend to spill over into ‘personal’ life.  At the same time, however, these managers have engaged with the challenge of building more responsive, flexible and user-oriented public services. (p.x)

Dissent from the discourse is difficult to articulate – in the sense of having few pertinent vocabularies through which it can be spoken.  This does not mean it is absent.  On the contrary, it is clear that there continues to be a variety of sources and forms of dissent, ranging from defensive conservatism to marginalised radicalism both within and beyond the state.  But the scope of the discourse of change has meant that much of this exists in the form of passive dissent.  Familiar examples are the patterns of scepticism or cynicism that are a recurrent response to the inspirational language of organisational transformation.  This treats the discourse of change as ‘empty rhetoric’ – a dazzling imagery that conceals a grim reality of declining services, shrinking resources, and gung-ho managers following the latest big idea while the front line struggles on. (p.54)

I’m afraid that, in light of this strategy, the last sentence of this paragraph rings even more true to me.  I’m not optimistic we’ll see any change in favour of more realistic discussions and debates any time soon.

New Directions and the dangers of individualism

A few weeks ago I was at the annual conference of the wonderful New Directions in the Study of Alcohol Group (NDSAG), which also hosted the launch of the Addiction Theory Network, including such luminaries of the field as Nick Heather, Marc Lewis and David Best, amongst others.  I could highlight any number of speakers from the conference, from John Hill’s personal reflections on a career in the field to Marcantonio Spada’s discussion of metacognitive beliefs, or Lucy Rocca’s discussion of her own recovery story and the establishment of Soberistas, through to Reinout Weirs’ discussion of free will.

Throughout, I felt there was one core theme.  Whether we were talking about the experiences of commissioners, providers or service users, there was a real emphasis on people’s individuality.  We shouldn’t be searching for one single definition of problematic drinking, or one solution, or one structure for implementing this.  We need to, as other people put it, treat people as people with people.

Despite these continuities, this theme was expressed in a range of ways.  And so I argued that we sometimes focus too much on where or how to cut the commissioning ‘cake’ – should treatment be housed in the NHS, or local authorities, for example – when the best and most efficient thing to do is to accept the situation and focus on getting the right people in the right jobs to deliver the most effective and efficient service possible.  But this also led to discussions of what treatment itself should look like.

Lucy Rocca noted that lots of the people who engage with her site – notably middle-class women – wouldn’t feel comfortable or confident accessing ‘mainstream’ community treatment services.

Rowdy Yates noted that we should look at the particular assets an individual has in terms of ‘recovery capital’, and make sure that we’re topping them up at an appropriate rate – if we deal only with the ‘drug’ issue someone has, reducing cravings for example, but don’t deal with their social relationships, then we’ll be reducing their chances of recovery.

Marcantonio Spada emphasised that in applying a particular treatment (CBT), we have to be aware that people’s beliefs about their brain, body or ‘thinking’ will influence its effectiveness.  If we think ‘I need to control my thoughts at all times’, then this presents particular challenges.  We can’t simply apply a single programme and imagine it will work for everyone.

Similarly, Phil Harris noted the importance of the life course to argue that we need to ask of any approach to treatment not simply ‘does treatment work’, or even ‘does treatment work for this person’, but ‘at what moment’ does it work.

Sarah Wadd, with particular reference to older people, noted that there are many reasons for drinking, and therefore we shouldn’t imagine there could or should be one approach to engaging people or changing their behaviour.

This point was taken up by Doug Cameron in the Q&A after the session launching the Addiction Theory Network.  If, as the panellists had suggested, the ‘brain disease’ model of addiction is so flawed, why hold onto the idea of addiction at all?  The DSM definition of what it calls a substance use disorder lists a whole range of criteria for diagnosis – some or all of which may be present, suggesting something more akin to a spectrum.  And indeed that is the public health model of approaching substance (mis)use.  And of course a consequence of identifying a whole spectrum of issues is that a strong case can be made for making a available a whole spectrum of interventions.

But of course in reality there hasn’t been a spectrum of treatments for substance misuse – and some would argue that under the NTA, there was very little on offer for alcohol users at all, let alone tailored variety.  So in some senses it’s fair that this issue of variety and nuance should be raised.  However, thinking, as I often do, in a rather self-centred way, it felt a bit harsh on commissioners to be hearing these calls for accessible, tailored treatment at a time when funding for this service area is being cut by at least 20% in line with the public health budget – and that’s if addiction services have made their case strongly enough to local politicians ahead of the myriad of other things that could be badged ‘public health’ interventions.

I started to wonder what we’re hearing (and making) these calls now.  It would make sense if the cracks in the system were starting to show because sufficient money was no longer coming in to cover them up.  That is, as services are stretched, some people end up getting a less good deal than others.

Some would argue this is happening in relation to drug treatment, particularly with the recovery agenda, meaning that those with more complex needs, or who are less likely to make quick progress, are selected out of a system that is primarily interested in achieving ‘successful completion’.  Personally, I think there’s no need for this to happen, and I think it’s a mischaracterisation of most treatment systems.  But more importantly in the context of New Directions, this just doesn’t apply to alcohol.  As those who complain about alcohol treatment being the ‘poor relation’ to drug treatment make clear, alcohol treatment hasn’t had that level of funding to paper over any cracks.

In one or two instances, it’s possible that this increased focus genuinely represents a change in need.  Perhaps middle class women are drinking more, in greater numbers, than in previous generations, and that’s why Soberistas has found plenty of users.  And similarly, people in and approaching retirement today are drinking more than their counterparts 20 or 30 years ago, and so again it’s only fair that we consider whether current services match tis potential emerging need for treatment.

At the same time, there’s something about the timing of the investment and the research and policy positions now being developed and outlined.  We had a period of well-funded, clearly-defined, centrally-controlled treatment.  Now the NTA is no more, and there is more local autonomy, there is the opportunity to consider whether things could be done better – with a real prospect of actually implementing alternative approaches.  And this opportunity is further strengthened by the fact that there’s over a decade of data and experience of what that ‘monolithic’ approach delivered.

I’d suggest this idea of focusing on people as individuals is part of something bigger.  New Directions has always prided itself on ‘providing a safe environment for original thinkers and speakers since 1976’.  And this means an emphasis on careful thinking, as opposed to comforting but superficial beliefs.  Wulf Livingston highlighted issues around language in the field.  We talk about substance misuse, but not all substances are drugs, and of course as I’ve written before, the word ‘drugs’ is pretty meaningless in any case.  And what about that word ‘misuse’?  Is it misuse to use substances that are narcotic, psychoactive or in some way affect one’s brain, for precisely that reason: to alter one’s mental state?

So if you’re interested in looking at the detail and nuance that lies behind established orthodoxy, I’d recommend joining the New Directions group and coming along to the next event or conference.  The principle was wrapped up in Nick Heather’s point about the next stages of evaluation of apps and online interventions: let’s conduct research that’s designed not simply to find out if they ‘work’, but rather to identify the mechanisms behind any effect – why they work.  There’s plans for an event for early-career researchers later this year, and then next year’s conference is a one-day event in Sheffield.

But to finish by returning to my self-centred perspective, I want to ask again about that focus on individualised treatment in today’s environment.  I am still slightly worried by this focus: that it may become a stick to beat the sector with.  That it is a way of directing attention away from those who remain the most at risk, the most in need.

Of course it shouldn’t be, and this wasn’t the intention of those who were raising these important points at New Directions.  But it’s maybe a way of responding to the cuts.  It’s difficult to legitimately rage against the cuts that are hitting the sector under the guise of a neutral, research-led approach.  However, it’s perfectly possible and reasonable to point to how current provision isn’t universally effective, and doesn’t meet the needs of all groups in society.  And perhaps there’s something positive about focusing on groups that do have some political capital in society: older people and the middle class.  The current state of the sector is, of course, a political decision (at both a local and national level), and so it will require a political solution.  Maybe I should learn to stop worrying and love the criticism.

But the running theme of the conference was to emphasise complexity, or nuance, ahead of simple ideas.  To look at the individual nature of the people involved in treatment and commissioning, to think beyond orthodoxy, beyond the disease model of addiction to more complicated, entangled idea of choice within constraints.  And that’s why I’m not sure I can stop worrying and simply love this nuance.  Simple ideas are attractive and easily understood.  ‘It’s complicated’ is a much more difficult sell.

Tony Moss suggested that if the Addiction Theory Network wants to replace the disease model, then it needs something to replace it with.  If we trace the history of thinking about problems related to alcohol there is a tendency to see the problem as either within the ‘demon drink’ (as in much temperance narrative), or within people who have, as Mark Gilman has put it, have ‘got the spots’ – the people who fit the AA model of having the ‘disease’ of alcoholism.

If the model being presented instead emphasises that both structure and agency are implicated, then this is, unfortunately, quite simply a more difficult idea to communicate.

And therefore, as so often, we come back to that difficult conundrum in relation to policymaking and public engagement: how much to participate in what is effectively a game, where the ‘winning’ positions and answers are not necessarily the ‘best’ or ‘most true’.  And there, just as with the question ‘what is addiction’, I don’t have any easy answer.

Who can buy an alcohol service?

This is a slightly longer post than usual, as it’s (almost) the words I spoke at the recent New Directions conference in Weston-super-Mare.  For those who haven’t been to New Directions before, I strongly recommend it.  There’s always an excellent line up of speakers, this year including Marc Lewis, Nick Heather and Lucy Rocca to name just a few.  One of my favourites, who I hadn't seen before, was Marcantonio Spada, from London South Bank University, talking about how our beliefs about how we think and how our brains work actually affect the reality of how we think and what we do: metacognition.

I was asked to speak in a session called ‘Can we have traditional alcohol services?’, under the title ‘Who can buy an alcohol service?’  So here goes…

***

Morning everyone.  I feel like I should start this talk with something of a disclaimer, maybe get my apology in first. In fact, three apologies. First, I'm going to talk to this title of ‘Who can buy an alcohol service’, but I’m not entirely sure what it means, so I'm going to use it an opportunity to present some kind of ‘state of the nation’ reflections from my job as a commissioner of substance misuse services in Dorset

Second, I'm worried about the length of this. But I shouldn't be much more than 20 minutes.

Finally, I don't explain too much of the nuts and bolts of commissioning, or who does what - it's part of my shtick that it's complicated, so maybe I don't want to destroy the mystique. But equally, please stick your hand up or shout out if I'm talking about something you'd like explaining. In my job, it's an extremely unfunny running joke that we talk in acronyms we can't actually spell, left alone explain. Fundamentally, I'm a commissioner, which means my employer - Dorset County Council or Public Health Dorset - pays the NHS or charities to provide treatment for what, despite Wulf's powerful and persuasive points yesterday*, I'm going to simply call 'substance misuse'. And that should really be a fourth apology, before I've really started.

Oh, and a fifth: I'm talking only about my experience, which I'm aware is very English. It's not even British. The systems in Wales and Scotland - not to mention Northern Ireland - are notably different.

But back to that title. The simple answer to this title question is: loads of people.  I think it’s a truth universally acknowledged that at the moment commissioning responsibilities are hugely fractured within the public sector.

This diagram, which I showed when I spoke at New Directions last year, is meant to be a helpful explanation of the NHS in light of the Coalition Government’s reforms – which included the transfer of all commissioning funds for substance misuse treatment to local authorities.  I don’t find this helpful – apart from to illustrate the mind-boggling complexity of the current arrangements.  And it doesn’t even cover some crucial elements that potentially relate to substance misuse, such as housing, or employment.

And this is where we might think we could run into problems.

I’ve written and spoken before about how the shift of responsibilities for drug and alcohol treatment from the National Treatment Agency to Public Health England wasn’t just semantic; there is potentially a genuinely different worldview associated with these different organisations.  And the different commissioners might have very different ideas of what the ‘problem’ with alcohol is, who the relevant potential ‘clients’ are, and what a positive ‘outcome’ would be.

But my comment last year was that we shouldn’t see this chaos or complexity as necessarily a bad thing.  Perhaps it would be neater and easier for commissioners and providers if we had straightforward, simple structures for ‘alcohol’ services, but of course life – including addiction, or dependence, or problematic use – is more complicated than that.  I’m going to stick my neck out and say that it doesn’t make much sense to look at alcohol use, or addiction, as separate from other elements of a person’s life.

Once we’re thinking about a person’s life as a whole, are the problems, the clients, or outcomes really that different for different organisations?

And I’m not going to deny that this is an issue, particularly when resources feel scarce.  There are arguments about who should be funding alcohol liaison nurses in hospitals, for example.  The acute trust or CCG might state that this is surely about public health, but the local authority Public Health team is likely to reply by saying that it’s the hospital that will save money by having fewer admissions, so shouldn’t they be the ones investing to save?

But my point is to ask whether we’re really as far apart as it might seem.  Whenever I sit down with commissioners or providers – be it in relation to the police, housing, or mental health – it’s immediately clear that even if we’re not talking about exactly the same people (and we often are), then we’re talking about many of the same causes, symptoms and solutions: stable housing, strong personal relationships, stable employment, and so on.  All these things boost people’s chances of turning their lives around.

That is, when it gets down to serious discussion, we're actually pretty agreed about what a positive outcome is, and how to get it.

This is the attraction of a programme and slogan like ‘Jobs,Friends, Houses’ and the idea that addiction is simply an absence of social connection – an idea recently popularised by Johann Hari, citing the research of Bruce Alexander, who spoke at this conference last year.

And this is why I’m sometimes sceptical of the idea that there should be ‘alcohol’ services, or that we should think of ourselves as part of an ‘alcohol’ sector – or even a ‘substance misuse’ sector.  We need to make sure services are linked together and think about the ‘whole’ person, or the ‘whole family', to use the buzzwords of the moment.  As Nick Heather put it last year when discussing this, ‘addiction is a problem of living’.  You can’t separate it out from other aspects of life; it is part of life, part of living.

But one of the problems with that approach is that there isn’t a neat distinction between cause and effect, or symptom and disease, as there would be in an ideal medical/scientific model.  What I mean is: substance misuse can be both a cause of and caused by unstable housing, relationships and employment.  These are potentially part of a complex cycle (which may be vicious or virtuous).  So it might be that for some people, a housing first approach, or ensuring stable accommodation, starts them on the road to recovery.  But for someone else, this would be at best a harm reduction strategy, and no real change can be brought about without addressing alcohol use head on, and the primary problem.  Without being flippant, there isn’t one definition of an alcohol problem; there are myriad (in fact infinite) problems where alcohol is implicated.

All I’m trying to say here is that although different people and organisations might agree on outcomes, on a broad definition of what the ‘good life’ might be, this doesn’t mean that services can just be reduced to generic ‘life’ support.  There is a need for something alcohol specific.

So if there’s a need for alcohol services, that brings us back to that question of who can (or should) be buying them.

As I said at the beginning, there’s loads of organisations that can buy something that could be badged as an alcohol service.  And I’m not really precious about this.

But I want to make two critical observations or suggestions about the way things work at the moment.

First, I think debates about the perfect place to house budgets or responsibilities in relation to alcohol are a waste of time. (Though I still often engage in them!)

I might have a view that local authorities aren’t the best place to house commissioning of structured treatment that involves prescribing, but there it is, and to be honest it doesn’t make a great deal of difference what building I have to work in.  The politics and debates will be different, and the pressures and priorities might change, but they won’t go away.

I could complain about how it’s difficult to harmonise or integrate local authority commissioning with the CCG, or NHS England, or the Police, but fundamentally these barriers will always exist - and they even exist within organisations.  Even though Public Health is now nominally part of local authorities, this doesn’t mean that there is wonderful integrated commissioning with housing and homelessness support, or social care, or children’s services.  These things are pot luck, perhaps a ‘postcode lottery’.

And that’s the crucial bit.  They’re down to local decisions and working relationships.  That is, the fundamental issue isn’t the structure, but the people.  We know this in treatment: that potentially the single most important thing in your treatment is the therapeutic relationship with staff.

But we don’t talk about it so much in broader policy terms.  Politicians and broader policymakers and influencers such as think tanks seem to think that we’re justone grand reform away from having the perfect structure to address a problem.  If only we had truly ‘joint’ commissioning, or ‘integrated’ budgets.

But this is a fight with an imaginary enemy – or at least an eternal, elusive enemy.

We’re talking about substance misuse, or as I mentioned earlier, all aspects of life.  And that means that there can never be a single, perfect way to cut the cake, and equally you can’t just commission ‘life’ support services (if you’ll pardon the pun).  To take a simple example: first aid, x-rays, possibly surgery, casts, check ups and physiotherapy might all be part of healing a broken bone – but they’re not delivered or managed by the same person, or the same service, or in the same place.  The key is to make sure the different organisations and people talk to each other and work together, for the good of the patient.

And the same is true for commissioning or providing alcohol services.  The organisational boundaries will never be perfect; it’s about working to ensure whatever system is in place is as efficient and effective as possible.

So that’s the first point: let’s not imagine that there’s a perfect solution that we just have to reform for in terms of organisational boundaries or responsibilities.  In my experience, the reality is that pooling budgets and joint commissioning are a pipe dream in any case, even for relatively small areas or themes.  Any form of ‘joined up services’ is best implemented by simply getting on with it at the coal face and coordinating front line services in practice.

So there we go, that’s the first word of the title out of the way: the ‘who’.  The answer (or dodge) being that I don’t really mind, but at the moment there’s loads of people.

I promise I’ll get onto the other words.

And to be honest, I’ve already covered ‘alcohol service’.  It’s too narrow, but equally some type of service that’s specific to alcohol (or at least substance misuse) is necessary.

So what are we left with?

The key bit is that word ‘buy’.  There’s no doubt that we currently do ‘buy’ services from either the NHS or third sector organisations – or in fact in some cases, as in Bath and North East Somerset just up the road, from private providers like Virgin.  But I want to suggest that the word ‘buy’ in this context is misleading about what’s happening, or what perhaps could or should happen.

We think of commissioning as buying, and of buying as being something to do with this mythical idea of a ‘market’, or at the very least ‘competition’.  But the reality is nothing like buying breakfast cereal in a supermarket.

My job isn’t really about procurement or purchasing.  In fact, there’s a procurement team within the council who deal with the actual purchasing and contracting – which only happens every few years in any case.  My job is to help design services and work with managers to ensure the right sort of things are being done and we’re getting the outcomes we all want.  In fact, you’d probably best describe it as being either some kind of manager or a service design and development officer.  But I suppose we call it commissioner because that’s the popular or fashionable language.  And in reality, my actual official job title is the meaningless ‘Senior Health Programme Advisor’.

Commissioning, as defined by government, academics and think tanks, is about much more than buying, purchasing or procuring – however you want to label it.

If you look at the model of commissioning from the Institute of Public Care at Oxford Brookes (where I did my commissioning qualification), you’ll see that the actions of ‘analyse, plan, do, review’ could equally apply to any form of service delivery.  Maybe that inner circle wouldn’t apply, but if you just look at the outer ring relating to commissioning, it’s hard to imagine any sensible service not operating something along these lines: think about what you might do; do it; see how well it went.

So in some ways, this model of ‘commissioning’, where we emphasise procurement, isn’t actually that important.  In itself, it shouldn’t really change the assessment of need in the local community, or the design of services.  (I’m not making any comment here about how those things are shaped by local or organisational priorities, and the fickleness of politics in funding decisions.)  And as anyone who’s been through one of these processes knows, there’s a lot of discussion about transfer of staff from one provider to another, and you can often end up with much the same people doing much the same job, but perhaps under a different organisational banner.

But, based on a procurement process I’m in the middle of at the moment – and so can’t say too much about – I think there are potentially significant effects of this approach.  Fundamentally, a huge amount of my time over the past year has been spent:

• writing reports for committees to approve certain budgets and processes;
• writing service specifications for new contracts;
• writing evaluation questions for prospective providers; and then
• conducting evaluations;
• organising and marking interviews; and
• writing feedback.

There are positives to this: it means we can re-shape services, and we’re planning carefully for that.  But it comes at a cost – even if that cost is simply that we have to spend less time on the usual quality assurance or service development work.

And this is where the market analogy breaks down.  That just isn’t the same as any market I’ve ever shopped in.  You don’t buy years’ worth of Weetabix, find you don’t really like it or it’s leaving you hungry by mid-morning, and then just say: “well, I’ll just have to stick with it for another year or 18 months till I can buy something else”.

I know this is a flippant example, but it is actually relevant.  Within this model of procurement and commissioning, there is undoubtedly waste and miscommunication.  Some people have suggested to me that there would be much less stress and miscommunication if the whole process was less formalised.  In fact, if it was simply an ongoing conversation as it is outside of procurement periods.  And rather than setting up evaluations as a kind of exam, or jumping through hoops (“we’re not going to specify who our key partners are; it’s a test to see if they know”) commissioners and providers could just have a direct conversation.

And in fact we can run procurement more in that way.  There are ways we can do this whole thing called ‘commissioning’ better.  For example, the idea that local authorities must go out to tender every three years is a myth.  Commissioners can be more creative – particularly in the current climate where all bets are off about the future of local government funding and NHS commissioning practices.  The current regulatory framework allows for decision to be postponed in exceptional circumstances, and if the circumstances today in terms of changing budgets, shifting commissioning responsibilities, local government reform in many areas, and so on aren’t exceptional, I’m not sure what would be.

Moreover, decisions don't have to be made on the basis of price. We've set a budget, and we’re judging providers on how they're planning to spend that money (how much goes on ‘front line’ service delivery, for example), and how credible those plans are.

And this is my plea, then, to finish this rambling presentation.  Or rather, my two pleas.

First, we all need to campaign to make the system better, by which I simply mean ‘more efficient’ – which is ironic, given that commissioning and the supposed ‘market’ model is meant to be efficient by definition.

But as I said earlier, changing the system isn’t terribly useful in itself.  Usually the most efficient thing is to work within whatever is in place in the most sensible way possible – particularly given that what really matters is the people involved.  If you’ve got the right people, and they’re motivated, they can make good things happen.

And that’s the second plea.  We all – whether providers, commissioners, or interested observers – need to work in ways that make that system as close to optimal as it can be.  Let’s be pragmatic, canny, and calculating.  For example, why drive some charities out of business by competing in a zero-sum way?  Providers should be working in partnership, and not simply seeking to hoover up additional market share.  I know that’s easy for me to say, as I’m not a ‘business development’ officer whose salary is dependent on bringing in new contracts.  And I know commissioners have been guilty of setting up these conditions in which that kind of competition happens.  But both commissioners and providers can work differently.

And that brings me onto my final point, which I think the organisers of the conference were wanting to get at with this session, entitled: ‘Can we have traditional alcohol services?’  I think it’s getting harder to imagine, with the financial pressures as they are, that it would make sense to commission or provide a standalone alcohol service.  Increasingly, there are pressures to reduce transaction costs, which means commissioning one contract across an area, and let’s not forget that ‘joint commissioning’ is the flavour of the month.

But that doesn’t have to mean having just one agency.  It’s very possible that partnerships can exist, whereby a specific service or organisation with something to add provides the bit of the treatment system where they have expertise – say in club drugs, or perhaps alcohol, or even a specific element of alcohol – for example engaging increasing risk drinkers, rather than fully fledged dependent drinkers.  They might have specific expertise, or a local profile and reputation.  That could be what makes them particularly good at doing this on a relatively small, specialised scale.  And actually that specificity and expertise could be provided under a different banner or service, but by the same overarching organisation.  Wouldn’t that still be a dedicated ‘alcohol service’?  It’s not inevitable that specific or local expertise will be wiped out by ‘the market’.

So in conclusion, let’s not paint commissioning in simplistic terms as a form of magic market, or the devil’s work.  It’s just a word, and a broad set of principles that are reliant on people doing sensible things.

Of course, the context is the reduction of public sector budgets, and the idea that local authorities will be self-sufficient and fund all public health services (including substance misuse and sexual health) through business rates in a couple of years.  But that’s a tale for another day.  For the moment, I’d just answer the question: ‘can we have traditional alcohol services’ by saying, ‘Yes, if you actually want them enough.’  Whether we should – well, that’s a question for someone else.

Thank you.

* We talk about substance misuse, but not all substances are drugs, and the word ‘drugs’ is pretty meaningless, as Toby Seddon (amongst others) has pointed out.  And what about that word ‘misuse’?  Is it misuse to use substances that are narcotic, psychoactive or in some way affect one’s brain, for precisely that reason: to alter one’s mental state?

Reflections on the Psychoactive Substances Act one year on

One of the most interesting developments in UK drug policy in the last few years has been the introduction of the Psychoactive Substances Act (PSA), which came into force just over a year ago in response to the emergence of 'new psychoactive substances', often known as 'legal highs'.

As this anniversary has come round, there's been quite a bit of media and policy discussions about how well it's worked, and whether it can be viewed as a positive development.

I've been involved in several discussions about this.

First, there are several recorded interviews or snippets of mine that have been broadcast on BBC Radio Solent:

• This is a pre-recorded piece that sets the scene about what 'legal highs' are;
• This is a fuller interview with the excellent Steve Harris about the policy and public health perspective on whether anything's changed based on the Act;
• And finally, this is a neat little clip putting together some of my interview with the very reasonable points made by Dorset Police.

Second, I've commented on an excellent event, the Psychoactive Supper, held around the time of the introduction of the Act.  The organisers put together a short film describing what happened, and then asked me and the excellent Neil Woods of LEAP to comment on it.  You can find this if you scroll down a bit here.  What I try to do in this piece is describe how the supper highlights the inconsistencies in the Act, and reflect on how well the Act may have worked in practical terms.

But if you want a more complete outline of my personal (optimistic) opinion, please read my recent piece on VolteFace, which was itself prompted by the most recent meeting of that group of academics.  I set the scene for a discussion of the Act by suggesting that we're kidding ourselves if we think we can have a perfect, neat, objective drug policy based on reducing 'harm'.  Harm is a really complicated concept that we can't use to put a single value on a substance, and if we try to identify substances we're going to legislate as 'drugs' then we've already begged the question: what is a drug?

And so I think the PSA is a potentially positive development because it's more open and honest: substances are banned and controlled not on the basis of some objective idea of harm, but simply because they alter our mental state - because they are psychoactive.  That means there's much more scope for discussion and disagreement when compared with a debate about drugs and 'harm'.  It's hard to disagree that something scientifically decreed to be 'harmful' should be closely regulated, and even illegal, but it's not so clear that everything that alters our mental state can or should be outlawed as a matter of course.

I look forward to the possibility of that more open debate about the aims and effects of 'drug' policy, but being very aware that public debate doesn't always lead to the kind of clear and open discussions I'd prefer.

I hope some of this at least is of interest.  I think there's no doubt that in terms of policy relating to alcohol and other drugs - or whatever we're going to call psychoactive substances - we live in interesting times.

Is research really something special?

As I've mentioned before on this blog, I've been pretty busy over the past few months, as we've been re-procuring almost all of the substance misuse treatment services across Bournemouth, Poole and the rest of Dorset.  So I can only apologise that several of the posts I'm writing currently are responses to events held or pieces published some time ago.  But as I always say, with a historian's perspective, the fundamental issues related to alcohol and other drugs don't really change - and certainly not in a month or two.

So here goes with some reflections from the Alcohol Research UK conference a month or two ago.  Unlike its usual format of what I think of as a kind of 'state of the nation' set of presentations from big names in the field or simply those with significant findings that need communicating to the wider sector, this year it had a very specific focus: public involvement in research.  In some ways I missed the standard approach, getting my latest update on the state of research in relation to alcohol harm.  But there were clear strengths to this approach.

First, there's no doubt that involving service users and the wider public in research and service provision is too often a token exercise, and this is something we're acutely aware of in Dorset: although we've included service user panels in our recent procurement exercise, and there are service user reps are included contract review meetings and relevant decision-making boards, there's still more we can do, particularly in relation to day-to-day business.  And this conference was full of pointers about how to start thinking about this process, from philosophical insights to practical tips.

Second, there's simply something positive about being encouraged to look at an issue from a different perspective.  In this case, I started to think about the broader point of how we often divorce research from practice.  A key presentation came from Simon Denegri of the NIHR, which funds a considerable amount of health research in the UK.  He emphasised the increasing importance placed on service user – or patient – involvement in research in the UK.  This should help shape the entire process of research, right from the initial setting of priorities for researchers and funders.  One of his insights was that actually, most patients expect there to be research going on in relation to healthcare, and so wouldn't be surprised to be asked to be involved.

This is an important insight in terms of more than the culture around healthcare research.  The reason people wouldn't find this strange is that they expect there to be work going on to ascertain what treatments work, and how they can be improved.  This is partly because medicine is so closely related to science, and the model of drug trials, and Randomised Control Trials (RCTs) fits so well, but that's no reason why we shouldn't expect people to apply the principle more broadly – to the full range of substance misuse treatment services, for example.

If we think of research at its simplest level, it's just trying to answer questions, which is exactly what we spend a lot of time doing whether at work or home.  How can I put up these shelves?  What sort of meal can I make from these ingredients in the fridge?  How can I swim faster?  In each case, we probably have a think using the knowledge we've already got, maybe consult a book or the internet to see what other people have found, and maybe we just give something a go and see how it works out.  All of these are part of any 'research' process.  And most fundamentally, all those example questions I've given have an implicit purpose: someone wants to be able to store books, or eat some tasty food, or win a swimming competition.

Now think about 'alcohol research'.  If we take Alcohol Research UK's overarching mission, the aim is to reduce alcohol-related harm.  And research can't do this on its own.  In fact, it needs policy and practice to 'do' anything, to make any difference.

Let's return to those 'research questions', such as how to make something for dinner.  Those are precisely the kind of questions practitioners should – and do – ask of alcohol treatment.  How can we optimise treatment for this client?  And they'll be working on all those bits I outlined: knowledge/experience they have, consulting maybe findings.org.uk or similar resources to find out what others have done to achieve success, and maybe just trying something and reflecting on how it goes.

And this is precisely the same model as commissioners are encouraged to follow: analyse, plan, do, review.

Institute of Public Care, Oxford Brookes University.  See http://www.scie.org.uk/publications/guides/guide45/files/Workshop_Handout_1_IP__Commissioning_Framework[1].pdf?res=true 

And wouldn't people in treatment or out of it find it strange if we weren't doing this?  If we weren't reflecting on our current practice to find out who needs support, what we think works for different groups, and how well we're delivering this?

This might seem like a bizarre discussion.  Like I've set up some kind of straw man.  And perhaps I have, but if so then it's a straw man that I've genuinely believed in – or at least been scared of – and that seems to inform thinking in universities, the NHS, and wider treatment services.

I benefited from a grant to do a PhD at Bournemouth University, and the only reason that grant existed was Vice Chancellor Paul Curran’s idea to transform Bournemouth into a 'research led' university, where it had previously been seen as a teaching and training university, according to the established wisdom: our department in particular trained people to be nurses and social workers.  I was part of the grand vision to sweep away old experts in teaching with a new cadre of young researchers.

I won’t reflect on how well that worked out, or whether it was even a good idea in the first place, but I’m very grateful for the opportunity it gave me.  My point is simply that the division between teaching and practice on the one hand, and research on the other, was an unavoidable aspect of how this issue was framed, and how it played out.  And similarly, at conferences in this field it sometimes feels that academics and practitioners don’t just talk different languages, but are different species.

(I’m assured this wasn’t always the case; that addiction studies and conferences like New Directions in the Study of Alcohol used to be filled with research active clinical psychologists – and I believe it.  Flicking through the 2002 New Directions journal (another illustration of the fact that the key issues and dilemmas don’t go away) you can read reflections on practice by Doug Cameron and Richard Velleman, amongst others.)

But in fact, any practitioner worth their salt would have been asking those questions I just outlined, and developing their practice accordingly.  And any researcher worth their salt should have been trying to answer them.  That is, there is no great divide in philosophy, epistemology or anything else between practice and research.  Some of us just choose to get precious about – or frightened of – this word ‘research’.  In fact, it really just means finding out, and we shouldn’t be dividing it off from practice; we should be embedding it in practice.

As I say, this may mean nothing to some readers, or seem like a straw man argument, but I would argue that if we embed a culture of being curious, seeking knowledge and looking for innovation into our practice, then we are de facto ‘researchers’ – and this is an approach that isn’t typical of services and commissioners today.  And if providers and commissioners are de facto researchers, so should those accessing the service be.  Then, as in healthcare more broadly, it wouldn’t seem odd or unusual to ‘involve’ service users – in fact it would be strange not to.

Is drug policy about drugs?

This week, I’ve been at a mini-conference to discuss prohibition through different periods of history and across different countries and societies.  Although I did (part of) my first degree in history, anything I write now is more based on what ‘I reckon’ rather than any genuine knowledge, historic or current.  So it’s not clear what I was doing there, but they let me in anyway.

(I should say at this point, as I did when I wrote about the original conference, that this is an amazing group of academics, and there’s a load of fascinating work going on at Warwick University more broadly.)

My contribution was born a year ago as a response to the 2016 Psychoactive Substances Act.  Unsurprisingly, at that point (and now), it was hard to find too many academics in history or social policy prepared to defend the Act.  So, being the attention-seeking contrarian that I am, I saw my role (or my way of getting a paper accepted) as being to be a bit more positive about the Act.  I suggested that it could be a catalyst for change in drug policy, as it reframes the debate from being about harm to being about psychoactivity itself.  But that’s a post I’ve kind of already written (though I can write it much more clearly, and will do sometime).

So what I want to do here is to reflect on what we were trying to do as a whole.  The idea was – and is – that we can usefully say something about the idea of prohibition through the ages.

But I was constantly reminded of a paper I saw at the wonderful ADHS conference a few years ago.  There, Lauren Saxton talked about how alcohol was understood to lead to infertility amongst women in France in the nineteenth century (because that was their major national concern), whereas at the same time, with the same substance in Britain, we were concerned that alcohol was leading women to have more children than they should do.

The point being: alcohol (or any other ‘drug’) has a meaning and set of concerns that are hugely dependent on the wider context.

So what’s that got to do with prohibition?

Well, hearing these accounts from France, Indochina, Mexico, Russia, America, Portugal, as well as the UK and the international community more generally, I started to think about how alcohol or any other drug offers something of a lightning conductor for any other concerns the public might have, be they in relation to race, gender, class, nationality, religion, productivity, industry, modernity, or anything else.

In some ways, use of morphine in the late nineteenth and early twentieth century could be seen as rational, pure, clean and reasoned, with the use processed ‘white drugs’ (like heroin and cocaine, as well as morphine) administered with precise dosage using the technical innovation of the syringe.  This was what Christopher Hallam was telling us the ‘bright young things’ of the interwar period were doing – elite, well-educated, white aristocrats.  ‘Brown drugs’ were less processed substances like hashish and opium, perhaps seen as ‘dirty’ and were more associated with the working class or ‘foreigners’ like Chinese immigrants.  (The white/brown binary here really is pretty transparent.)

But others, like Susannah Wilson, noted that in some cultures and periods, that scientific/natural binary doesn’t always have ‘science’ on top.  Of course, doctors can use it to defend their own use, as they did in nineteenth century France, but the precision and technical approach to drug use can be seen as new and frightening.  Soon, you get onto a discussion of the optimism and fear that equally surrounded ‘modernity’.  Is change exciting, frightening, or both?  Are ‘natural’ ingredients better than chemically pure, processed ones?  You’re probably thinking that it depends on who you are, what you’re doing and what you’re trying to achieve.  And so it is with drug debates.

Similarly, the idea of prohibition can symbolise any number of things.  It can be, as Mark Lawrence Schrad argued, an opportunity for emerging nations (such as Turkey, even when ruled by heavy drinker Ataturk) to expel foreign industries and express a new anti-colonial identity.  Or it could be an opportunity for the Protestant Ethic to express itself.  (And I should reference the work of Henry Yeomans at this point, as I didn’t do in that post.)  Or, in the early twentieth century, it could be a way for a nation to show it was part of the international club, which Cecilia Autrique noted was part of Mexico’s motivation in developing drug policy in the early to mid twentieth century.

Alternatively, rather than being anti-colonial, prohibition has been justified by discourses of anti-orientalism (that drug use is somehow characteristic of ‘weak’ nations like the Chinese, or Arabs, or whatever culture is viewed as negative in the time and place in question).

But even here, things are complicated.  Aro Velmet explained that the same forms of drug use were seen as appropriate to French Indochina in the early 20^th century, because of the culture and climate – not just for people from that culture, but for French people living and working there – but inappropriate if they were continued on returning to France.

So amongst all this I started to wonder whether there was any coherence at all.  Notably, as James Nicholls has pointed out, there’s no straightforward position on the issue of ‘alcohol’ that can be produced by reference to even the relatively narrow definition of nineteenth century liberalism.  JS Mill argued that it wouldn’t be real freedom for us to abstain from alcohol if it was just what was required.  And yet TH Green maintained – invoking the same argument that led Mill to reject slavery, that we shouldn’t be given the opportunity to become dependent on alcohol – we’d be better off if alcohol was never available.

And as Mark pointed out, this is a more nuanced debate than we often acknowledge: the key organisation in the US was the Anti-Saloon League, rather than the Anti-Drinking-at-your-own-pace-at-home League.

So, given all our discussion, is really anything linking these themes at all?  I’m reminded of my concern about whether there is any point in trying to develop an ‘alcohol’ strategy.  ‘Alcohol’ or ‘drugs’ or ‘prohibition’ might be a lens through which to look at society, but what we end up actually looking at are the familiar themes of politics, identity, and so on.  It’s no surprise that a discussion of drug policy in the nineteenth and twentieth centuries ends up as simply a discussion of racism, anti-colonialism, nationalism, gender, class, and so on – the ‘fundamental’ issues of societies in that period.

So is there any point talking about ‘prohibition’ as a general concept (or more importantly as a useful academic concept)?

Well, only in as much as James Nicholls suggests alcohol is a useful lens through which to understand how people think of and enact liberalism (in principle and in practice).  But maybe what that means is that there’s not much point studying the phenomenon of prohibition in itself, or trying to understand what motivates people to ‘prohibit’.  Perhaps, just as with ‘alcohol’ and/or ‘drug’ strategies, the ‘take-home’ point should be that we need to think about what these substance-specific ideas tell us about life more broadly.

So, in answer to the title of this post, I’d say no, ‘drug policy’ isn't really about ‘drugs’.  But it's worth pointing that out. And as ever, I look forward to a more open, honest discussion.  And I’ll be writing again soon about how the 2016 Psychoactive Substances Act can be part of that more open and honest discussion.