Recovery capital and specialist treatment services

I’ve written about the issues surrounding the move of substance misuse treatment to Public Health before, but this week I’ve come back to thinking about it – and not because of anything to do with Dorset Public Health, I should point out.

I don’t have a neat conclusion to this post, and to some it will seem like either stating the obvious or a self-interested defence of the status quo.  However, I still think it’s important to make the case for existing forms of substance misuse treatment, and I do so unapologetically.

Although it’s some months old now, this week I read this article suggesting that social policy research, due to the background of researchers, can often focus on what might be called middle-class problems.  And on the same day, there was this article on the Guardian website, suggesting that Public Health has neglected middle-class, middle-aged alcohol consumption.

The incongruence immediately struck me – not least because thinking about the people substance misuse treatment might have missed has been high on our agenda in Dorset.

Then, I saw this work from Drug & Alcohol Findings reminding me of how recovery is possible – even more common – without formal treatment.

Given that I work as part of a team that commissions substance misuse treatment, it’s no surprise that I’m sceptical of these challenges to its efficacy.  However, I want to leave aside the self-promotion work of the (former) NTA.  Particularly when taken together, these various sources raise some fundamental issues about the nature and aims of treatment.

To be fair to Hannah Fearn, who was writing in the Guardian, her main point was that middle-class drinking can get neglected in public debates around alcohol, when the focus is almost invariably on ‘binge’ drinkers within the night-time economy.  I’d agree with this to a certain extent – there’s a plethora of ‘problems’ related to alcohol, and in order to put in place effective, targeted interventions (whether that’s minimum unit pricing, licensing conditions or access to residential rehab) we need to define the problem we’re concerned with.  Solutions to the ‘problem’ of ‘binge’ drinking (and apologies for all the quotation marks, but I think they’re necessary) won’t necessarily be solutions to the ‘problems’ of older people’s drinking.

So, before we consider what Public Health has or hasn’t been targeting – and it’s a bit odd to blame them for substance misuse services when this has been the responsibility of DAATs in England until April 2013 – it’s worth considering what the problems associated might be.

The role of Public Health is, as I mentioned in my previous post, pretty bold: “to protect and improve the nation’s health and to address inequalities”.  This idea of addressing inequalities (presumably in health, though that’s not exactly spelt out) is absolutely crucial in this context of determining priorities.

As I’ve suggested, there’s any number of possible policy concerns regarding alcohol: health harms (which might be acute or chronic), drink driving, disorder, crime, antisocial behaviour, and – as I’ve argued elsewhere – a general fear or dislike of intoxication, to name just a few.  There aren’t many people who argue that drinking over your daily recommended limit is wrong in itself; the point is more that you are felt to be risking your health.

But we know that not all people face the same risks.  For whatever reason, despite the fact that people from higher socio-economic groups seem to drink the most, it’s those from the lower socio-economic groups who suffer disproportionate harm.  Mark Bellis and his team are conducting some fascinating research investigating this ‘alcohol harm paradox’.  It might turn out that it’s less of a paradox than it first appears because of the way consumption is estimated through self-reporting – that is, it might only seem that the richest drink the most.  However, whether or not it is a paradox, the point remains that the health harm related to alcohol falls disproportionately on those at the lower end of the socio-economic spectrum.

So, let’s assume that alcohol consumption isn’t considered an evil in itself, but only a problem because of the effects on health and so forth.  Then, if we were to target provision where there is greatest need (a pretty core principle of good service commissioning), we wouldn’t focus on middle-class wine drinkers.*

Now, this position can be interpreted politically in two ways.  First, it could be argued that I am demonising working-class drinking, suggesting that middle-class drinking is OK.  Alternatively, I could say that I am defending services from being reconfigured to serve middle-class interests.  It’s really up to you to decide.

This is where the Findings analysis comes in.  Plenty of people recover from alcohol (or drug) dependence/addiction/misuse without accessing specialist treatment (as I was forcefully reminded by Keith Humphreys, talking to him after the Alcohol Research UK conference, when I suggested that DIP work could be successful in addressing issues of addiction and crime – he disagreed).

However, it seems to be the case that some people are better placed to achieve recovery than others.  In contemporary terminology, picked up on in the 2010 Drug Strategy, there are resources called ‘recovery capital’ – social, physical, human and cultural.  Some people might see these as a twist on Pierre Bourdieu’s forms of capital, which he actually uses to effectively define class.  That is, the distribution of these sorts of resources affects all sorts of life chances, and thus can be considered as something broader than the sum of their parts: class.

This isn’t just an issue of dependence or addiction.  As I wrote in my previous post, the insight of public health analysis is that all sorts of elements of social life are interlinked: educational attainment, health, employment, housing, and so on.  That’s exactly what Bourdieu was trying to get at with his broader notion of class – or EP Thompson, Raymond Williams or whoever you prefer.

By this logic, not only are the middle classes less likely to suffer alcohol-related harm, but also if they do they’re more likely to have access to the resources you tend to need to overcome alcohol issues.

Looking at what specialist treatment services tend to provide, it’s precisely these elements of recovery capital: social capital by providing a network of support; physical capital by helping someone into safe, stable accommodation; human capital by providing education and mental health treatment; cultural capital by analysing values and aspirations.  This is unsurprising when that’s exactly what the government wants its money spent on.  However, it doesn’t change the fact that these are resources that help to foster recovery – and the need for this support isn’t equal across the population.

Of course, none of this should detract from the fundamental point underlying that Guardian article: that alcohol issues shouldn’t solely be seen as the preserve of ‘binge’ drinkers, and we should have a public debate about drinking that tries to look at the whole spectrum of problems that might exist.  However, that doesn’t mean they all need the same levels of resource or attention.

*There is one caveat to this position, however.  It is possible that although most such drinkers aren’t facing issues now, they might be storing up problems for the future.  Some time in the not-too-distant future I plan to write a post about ageing and alcohol, and one of the core issues with this is how people are now drinking at very different levels as they hit retirement compared to those in previous generations.  Given that our ability to process alcohol decreases as we age, and some of these drinkers may have longstanding patterns or habits of drinking above general guidelines that may be hard to break, this may pose an increasing issue for services.  The truth at this stage, though, is that we simply don’t know – and that’s not a question of ‘only time will tell’; there simply hasn’t been enough good research looking at this issue.

Public Health and bedtime stories

Although I ended up rambling about municipal pubs, my last post was prompted by my enthusiasm after going to a public health conference hosted by the LGA.  As I’ve said before, I see real opportunity for public health to make a difference to a wide range of policies in local government, not necessarily through spending, but by being a voice around the table – or, given the discussions in London the other day, embedding that voice into the decision-making process by winning over other stakeholders, whether they’re within the council – say in the transport department – or outside, like pharmacists and dentists.

On the other hand, though, I’ve sometimes been wary of a public health approach.  Because the approach increasingly focuses on ‘lifestyle’ illnesses there’s a tendency to understand public health in individualistic terms where people are felt to be making bad ‘choices’.

There are two key problems with this approach.  First, there’s the liberal JS Mill argument that someone’s own way of living their life is the best almost by definition.  Second, there’s a question as to whether this model of individual free choices actually reflects reality, where certain choices are easier than others and people’s options and the relative attractiveness of them will be affected by structural factors, such as wealth, environment and so on.  (This point was made by several speakers at the LGA conference.)

On this front, say on smoking policy, the first point would question whether the state should have any role in trying to reduce smoking prevalence, as that’s just the expression of individuals’ decisions, balancing up the costs and benefits of smoking and deciding that the pleasures are worth the risks.  The second point (which would only be relevant if you didn’t accept the first) would note that people’s propensity to smoke seems to be affected by their background and other factors, so you’d need to do more than address individuals; you’d need to change those background factors.

Certainly I’ve made both of these criticisms in the past.  Why shouldn’t someone drink if they want to?  Who defines too much?  And let’s not, from ivory towers, guilt trip people about the joys of an abstemious life.  Sometimes, reading something like the Marmot Review, given what we know about how wealth and income inequality determine health, it can seem like the only way to achieve its objectives is a shift in political culture – instituting communism.*

However, this wasn’t the way I felt on Tuesday.  As I say, I felt enthused.

But I was reminded of these questions about the scope of public health when I heard about a public health initiative to ensure that children are told bedtime stories.**

This is in some ways exactly the sort of thing I was enthused about – public health looking at the broader determinants of health.   But it also raises the question as to whether this is really a public health intervention when its influence on health is so indirect.

In fact, because of the interlinks, such an intervention is best understood not as a health intervention, but as part of a broader project to foster fulfilment, and possibly the development of ‘good citizens’.

The principle of the bedtime story reading in its relevance to health is the same as the Good Behaviour Game, for example: strengthening what is sometimes called resilience.  To some extent, this idea of resilience could be seen as an attempt to combine the individual and the structural perspectives on public health.  One of its key defining features is the ability to make choices.

The vision of a resilient individual is one who makes wise, considered choices.  To some extent, this sort of intervention could be seen as neoliberal: an attempt to make people self-governing, rather than reshaping the structures around them.  I don’t want to discuss here whether I agree with this mode of governance or not; simply to acknowledge that there are other ways to ensure public health – more direct interventions, that focus less on individual choice, might be at least as effective.

Also – and this is what distinguishes neoliberalism from classical liberalism – the government has clear ideas of what ‘good’ choices are; it doesn’t really sign up to the Millian point that everyone’s own way of living their lives is by definition the best (within certain limits).

To some extent, the elements that constitute this new public health approach are not controversial, or specific to left or right wing agendas.  Equally, they are not aims that are specific to public health.  I was enthused by the discussion of initiatives within Wigan and Hertfordshire at the conference not because they would enhance people’s health, but because they are more than this – in the case of Wigan the campaign was explicitly about community and aspiration in general: “Believe in Wigan”.

As I said previously, when writing about Brighton’s public health report, I’m more engaged when education or community are invoked as, if not goods in their own right, then contributing to something like eudaimonia or fulfilment – rather than being ways of protecting one’s health.

And here’s the rub.  I was enthused by the projects described on Tuesday because they were about fostering wider fulfilment, happiness, eudaimonia – whatever term you prefer.  You might choose the term wellbeing – and indeed health and wellbeing boards are part of the governance for public health teams.  But this is not public health in itself.

I would like to think that the idea that local government should put in place conditions that allow people to flourish is uncontroversial.  However, what we mean by flourishing is certainly up for debate.  In Mill’s view, you wouldn’t want too many restrictions as people become fulfilled humans actually by the process of reasoning and choosing.  (You aren’t a moral person if the choice to behave in a certain way is made for you.)

This could bring us onto a discussion of liberalism and nudging – appropriate, as nudging was a theme of the conference – but the point I want to make here focuses on public health specifically.  I was uncomfortable with the idea of happiness in the Brighton report, where it seemed to be either a meaningless proxy for health or a means to achieve health.  Similarly, community, or education, or bedtime stories shouldn’t be justified as good things on the basis of public health.  This is not why we want these things.  Scientific evidence continually emerges, and we might find that there is some drug that ensures health and longevity better and more efficiently than any amount of green space, or bedtime stories, or cycle paths.  Would this mean that we should abandon encouraging these things?

Public health is at the moment a good strapline under which to group all sorts of concerns that are not directly financial.  Given that the overriding dynamic in local government policymaking at the moment is saving money, having such an emphasis can be helpful, and that’s why I found the discussions positive.  However, it’s attractive to embed these ideas across local government departments precisely because they are not specific to public health; they simply amount to good government.

Maybe, for the moment, public health teams are a useful tool to remind local authorities that there’s more to life than short-term balance sheets.  However, it’s helpful sometimes not to take too instrumental a view.  The language of price and value is embedded in social mobility discussions, with Alan Milburn stating a few days ago:

“When 2.3 million children are officially classified as poor it exacts a high social price. There is an economic price too in wasted potential and lower growth.”

Just as equality shouldn’t be justified on the basis of economic growth, there’s a danger in suggesting parents should tell bedtime stories to boost their children’s health and resilience.

*The way PHE’s aims are stated, it’s actually as if the core task is reducing inequality of any kind: ”Our mission is to protect and improve the nation’s health and to address inequalities”

**I should confess at this point that I know next to nothing about this specific intervention and how it’s delivered.  The points I’m making here, though, should still be valid as I’m talking about the general principles.

Working with the alcohol industry locally?

I was at an LGA event on Tuesday called ‘Changing behaviours in Public Health – to nudge or to shove?’  (See #LGAcwb on Twitter.)  It certainly sparked my enthusiasm by showing how public health has been embraced by local authorities around the country, and how areas like Wigan and Hertfordshire seem to have successfully engaged wider partners, such as dentists and pharmacists, as well as getting councillors and council officers on board with the wider public health agenda.  These are all things I feel we could do much better in Dorset.

However, as usually happens with me, I saw things very much in light of what I’ve been reading and thinking about recently.

Claire McDonald spoke persuasively and openly about mobilising private interests to advance public health causes – mentioning Unilever’s initiative to boost handwashing (and/or use of Lifebuoy soap?) and her own initiative to prompt women to tell their GP ASAP (As Soon As You’re Pregnant).

I could feel myself bristling, simply because I have a natural suspicion of the profit motive.  However, given that we don’t have a nationalised food industry (although many public health professionals certainly aren’t comfortable with private food companies), I can’t help but accept that the market is perfectly capable of providing good things, and often efficiently.  If we want to wash our hands more often, and this is a good thing, what’s wrong with a company finding a niche (and some money) in this?

The workshop discussion on alcohol policy also raised the same issues of whether industry has a legitimate role to play, featuring Emily Robinson from Alcohol Concern alongside Elaine Hindal from Drinkaware (funded by the industry) and (much more open about his industry links) Henry Ashworth from the Portman Group.*

This discussion didn’t quite lead to the clear argument I experienced at last year’s DrugScope conference (perhaps an indication that Henry and Elaine pitched their message better to the audience than Mark Baird did there), but there was certainly some scepticism from those in the room as to whether the industry could really foster a healthier drinking culture (a straw poll revealed almost unanimous support for ‘shoves’ over ‘nudges’).

Now here’s my hobby horse (for this week).  I’ve been thinking about neoliberalism (resubmitting an academic article) – the point being that certain policy options around alcohol seem unthinkable because of the dominance of this ‘mentality of government’, when in fact they’ve been in place at various times and places in history.  Reading Intoxication and Society I was struck by the example from James Brown of schemes that pre-date the Central Control Board or Gothenburg System by hundreds of years – where government took the profit motive away from those running drinking venues, so that they didn’t have a reason to sell people more alcohol.**

Given that very few councils have introduced Early Morning Restriction Orders (EMROs) or Late Night Levies, it’s no surprise municipal pubs aren’t on the agenda.

But this isn’t all about the need to abolish the profit motive surrounding something that is ‘no ordinary commodity’.  Canada also had a comparable system of retail regulation, analysed in a new book by Dan Malleck: Try to Control Yourself.  Unfortunately, I haven’t read it yet (but consider this me proposing myself as a reviewer to any journal that will have me).  However, I have read the (free) review in Brewery History by Matthew Bellamy.  The review questions Dan’s argument that the regulation was a key element in reshaping Canada’s drinking culture such that, in Bellamy’s words, ‘Controlling oneself and drinking moderately continues to define an important part of what it means to be Canadian’ – in contrast with the situation before Prohibition in 1916, when ‘It seemed as though there were only two types of Canadians . . . those who drank to excess and those who did not touch a drop’.

Let’s set aside for the moment the point that immediately occurs to me, which is that, unhelpfully, we often have a similar (but mistaken) understanding of alcohol consumption in the UK today.

Bellamy’s critique of Try to Control Yourself is that actually the culture change isn’t all about the regulation.  It’s also about the brewers.  (He’s writing in a journal called Brewery History, after all.)  Having an (economic, profit-based) interest in temperance not winning the day, they found that they could embrace the model of the responsible ‘citizen-drinker’ the Liquor Control Board of Ontario envisaged.

You can see the same sort of motive operating in other times and places – Chris Routledge makes the point that the creation of the fantastic Philharmonic Dining Rooms (and other Cain’s pubs) in Liverpool was a deliberate move to generate a sense of respectability around drinking, enhancing its social, cultural – and therefore political and economic – capital.

And there are lessons in this commercial dynamic for us today.  Not only is the industry a legitimate stakeholder in alcohol policy formulation, but it’s not a monolith.  In the debate around MUP, some organisations were in favour, others opposed – the divisions weren’t always neatly predictable, and some companies shifted their positions.

In Bellamy’s interpretation, it’s the brewers who put the pressure on the hotel [pub] managers to run things smoothly.  However, this needn’t be the dynamic today.

To bring us back to the LGA conference, in the alcohol workshop discussion, there was little mention of on-licensees.  Where retailers were concerned, ASDA was mentioned, but most of the discussion was implicitly focused on the producers that fund the Portman Group – perhaps because this organisation is more open about its industry links, whereas Drinkaware is less directly the CSR arm of its myriad of funders (including plenty of organisations with on-trade interests, such as Admiral Taverns, JD Wetherspoon’s, Punch Taverns and Marston’s, for example).

To be fair, Henry mentioned schemes such as Best Bar None, and there’s plenty of work local authorities and public health teams have already done with such initiatives and more, working with the on-trade.  However, I’d suggest that if we’re looking for innovative ways to change drinking cultures, there’s more that can be done.***  There is serious mileage in Henry’s proposal for encouraging the ‘nudge’ of house wines being weaker, for example.  And in the context of Claire’s enthusiastic (or pragmatic?) embrace of Unilever and Merck/MSD as partners for public health change, the idea of having to shove the industry seemed dispiriting.  (Of course, we could come back to the idea that, unlike Lifebuoy soap, alcohol is no ordinary commodity, but then neither are pharmaceuticals.)

Thinking about culture change locally, the alcohol policy options that have been pursued in the past, and the possibility of harnessing private enterprise to benefit public health, it’s not so much the producers who are worth targeting as the retailers – and, I would argue, the on trade specifically.  This is particularly the case in the LGA context, when licensing (as opposed to MUP or taxation) is in the hands of local authorities.

The reason I think there’s more opportunity to engage the on-trade, if we’re interested in changing cultures around alcohol, is that the on-trade is no longer overwhelmingly reliant on the trade in alcohol.  That is, to some extent the situation produced by state regulation in Carlisle or Gothenburg has come about organically.  Although it’s an unusual case, I believe the majority of the turnover these days in student unions such as Bournemouth’s is on food and soft drinks including coffee and tea, rather than alcoholic drinks.

In the case of handwashing, Unilever have an interest in selling soap, but public health professionals want to encourage people to use soap, so working together seems plausible.  In the case of the on-licensed trade, the mix today is such that the interest in profit doesn’t need to be an interest in selling (only) alcohol – and so there may be a potential overlap between the licensee’s interests and public health.

There are of course several issues with this claim.  Most importantly, not all venues have the same model, and it’s those which are the most dominated by selling alcohol at the moment that are most likely to worry public health teams – and they’ll also be the least likely to have common ground.  However, the converse point is to look at research like this (by Adrian Barton) and see that ‘pre-loading’ often happens in part because drinkers don’t like the option they’re being provided with by such venues, particularly early in the evening.  And yet drinking at home isn’t always the best idea either from the perspective of government and public health, as an uncontrolled environment with little precision around units.  Might one potentially beneficial outcome for both public health professionals and local licensees be to encourage people it’s better down the pub – or at least certain pubs?

There are also wider challenges in shaping the policymaking context.  The argument that the brewers in Canada were in favour of the responsible ‘citizen drinker’ depends to some extent on the spectre of temperance and prohibition, when, as Brian Harrison put it, the world of temperance can seem a long way away, with ‘unfamiliar arguments and forgotten attitudes’.  And yet for such a faraway movement it provided the policymaking context for the drinking laws that were in operation when Harrison was writing and, in slightly altered form, for the rest of the 20^th century.  One can trace the influence of such campaigning even if none of the key demands are met.

Similarly, organisations like Alcohol Concern can see themselves as providing a counterbalance to the drinks industry, and helping to shape the terms of the debate and possibilities seen by government, merely by being part of public discussions.  Andrew Barr suggests that the formation of the Portman Group itself was a response to an emergent neo-temperance movement.

Thinking of Alcohol Concern as a counterbalance as a positive development sits somewhat at odds with my previous complaint of the zero-sum, realpolitik of the two apparently opposing sides in alcohol policy debates – though to be fair I did talk about the ideal dream world where different stakeholders come together for open and honest debate with their different perspectives...

But rather than this pessimism, I’d rather end in the same vein as I began: extolling another potential opportunity for innovative, helpful public health work.  Now would seem as good a time as any to think about how the on-trade could be encouraging public health.  Although there’s been good work so far, the opportunities for development are plentiful: as well as offering an alternative to pre-loading in city centres, the idea of the pub as the hub will resonate in more rural areas, enhancing social capital (and therefore health).  In such a world, the industry doesn’t sound an amoral product of the profit motive.  Maybe I am converted to public-private partnership…  (Well, not quite yet.)

If you’re aware of interesting, effective work already going on please let me know.  As far as I'm aware, the sort of development I'm proposing doesn't seem to have been a feature of Community Alcohol Partnerships, for example, but if things are happening that would keep the fire of my enthusiasm (and envy) burning a little longer...

*In a shameless act of self-promotion, here’s the link to my previous post on this issue – and here it is in a more public forum.

**For those who don’t know about these schemes, I can’t recommend highly enough reading about them in, for example, James Nicholls’ The Politics of Alcohol or Paul Jennings’ The Local.

***This raises the question of whether we actually want to change drinking cultures, and whether this is a legitimate aim of public policy.  I’m not actually sure, but for this article it’s taken as read because it’s clearly a current public health aim.  And, as I mention, there is something to be said for the industry representing its own interests and public health representing its own.  They might sometimes overlap, but they won’t always and that’s why it’s useful and interesting to hear both perspectives.

Breathalysers and drunk tanks

This morning I saw a story about breathalysers having been used in Norwich city centre to test people entering nightclubs.  I wasn’t excited or outraged by this, just confused.  I couldn’t see how it could be helpful.  However, it’s been bouncing around in my head, and after some helpful Twitter responses, I seem to have come round to thinking that it might be worthwhile after all.

Most of my posts on this blog are somewhat reactive and negative – talking about something that’s annoyed me, whether it’s Brighton’s focus on happiness in their Public Health strategy, the government’s decision to move substance misuse services into local authority Public Health teams, or the tactics of both the alcohol industry and public health campaigners.  The list could go on.  So it’s nice to actually write something vaguely positive for a change – and to feel that I’ve listened and had a think and changed my mind.

In the Norwich example, one of the points that made me initially sceptical was that as far as I could tell (and I watched the video through twice to try to make sure), there was no limit at which people would be turned away.  It seems more likely that bouncers would focus on the usual techniques of judging whether someone is drunk by their behaviour.

This raises all sorts of questions about the adequacy of breath tests.  First, there’s the claim that they are not an accurate indication of pharmacological intoxication.  Then, there’s the issue of whether a test that measures one’s blood alcohol concentration (BAC) gives us an accurate idea of what we might call ‘drunkenness’.  Although some previous research (thanks Matt Hennessey) has found a pretty decent match between BAC readings and subjective judgements of drunkenness, it’s clear from the approach taken here that, as entry will still be based on observed behaviour, there’s something of a PR exercise going on here.

As I’ve been reminded several times, we shouldn’t overstate the rationality or calculated nature of policy.  Sometimes, policymakers are as keen to be seen to be doing something as to actually do something effective.

However, let’s assume that it’s possible there’s something more to this initiative.  Even if it only runs for one weekend, it has still gained some press coverage and might highlight the issue of venues serving intoxicated customers, and the possibility of them being turned away at the front door.  As James Nicholls points out, clubs would have an interest in turning people away not just to please the police but if it changed people’s expectations about how much they could drink before going out while still getting into a club: the clubs will have an interest in initiatives that reduce pre-loading and push people to go out earlier and/or wanting more alcohol to get to their desired level of drunkenness.*

That is, the aim is that people will change their behaviour, seeing that they’re likely to get turned away if they arrive drunk, but I fail to see how this is likely unless there’s a fundamental change in the admission/serving process – which seems unlikely when bouncers are to rely on the same tried and tested observation techniques.

Moreover, drunkenness is seen as desirable by many in the night-time economy.**  That study that showed how observations of how drunk people seemed generally matched BAC figures also noted that for most people knowing their BAC would be irrelevant to their drinking levels over the rest of the night.  Where it would change people’s behaviour, it would be mostly for them to drink more (24.7% of those surveyed), rather than less (just 3.5%).

However, it’s possible that this might reduce drinking levels amongst those going out, as with observational assessments there’s always the feeling that you can beat the bouncers, pretending to be more sober than you are.  People are likely to think it’s more difficult to fool a bouncer who’s liable to breathalyse them.

So by this logic the point of breathalysing people isn’t to actually change their immediate desires for drunkenness; it’s to push them to arrive at the club more sober.

At the same time, this doesn’t undermine the initiative.  We know that interventions that deal with immediate desires can in the end reshape culture as different drinking practices just become normal.  Think of licensing restrictions originating in the First World War that seem to have had a long influence on this country and what forms of drinking were considered normal.  And the current context for policymaking is arguably one in which we’re more likely to accept that people are irrational, and so changing the ‘choice architecture’ that affects their decisions is sensible.

At first sight it would be easier if there were a clear line of BAC that would be unacceptable, as this would reduce the opportunity for just taking a chance with drinking beforehand, assuming that your level won’t be too high, or the bouncer won’t check you, or you’ll be able to explain away a high reading.  However, there are issues with this in practice.  Just to give a couple of examples, the same BAC won’t imply the same effects for all in terms of intoxication, affecting coordination, reasoning and so forth – those things that make it undesirable for a club to let in people who are very drunk.  Second, drunkenness is learned, social behaviour, so even the same level of strictly defined ‘intoxication’ might produce more or less problematic behaviour in different people.

So, having begun the day thinking this was a pointless PR exercise, I’m wondering if there might be some mileage in it after all.

Thinking in this way about an idea that initially seemed unhelpful prompted me to look again at drunk tanks.  (This was also of course so I could end the post on a typically negative note.)

‘Drunk tanks’ as I refer to them here are distinct from triage style units that take the heat off emergency departments because, according to the ACPO proposal, the individual drinker pays for their confinement.

Such a scheme can have two possible aims (which may be connected).  First, to recoup the costs associated with drunkenness.  In this sense, as I discussed in my previous post, the responsibility for drunkenness lies almost entirely with the individual.  This shouldn’t be taken for granted, particularly if we are in this new policymaking world of understanding individuals as inherently irrational.

In this sense, the drunk tanks would work perfectly well if run efficiently.  However, ideas such as a late-night levy, or (in order to capture the off-trade’s role in this issue) simply funding these initiatives through taxation on alcoholic drinks would seem perfectly reasonable.  Such approaches would acknowledge the role of availability of wider structures in shaping culture and desires.

One concern of mine is the involvement of private companies, implying the addition of a profit incentive.  Even if one accepts that an individual should pay for the cost of their care, it’s another step to suggest that they should generate profit.  Of course the argument would run that the private company could provide the care and the profit at a cheaper rate than the existing state institutions, but I’d be baffled as to why that couldn’t already be done within the current system***, or why a third sector provider wouldn’t be able to provide the same or a cheaper service than the private sector.

However, there’s a second possible aim of the drunk tank, and that’s to re-shape behaviour.  It’s here that I think other approaches are likely to be more effective.

The drunk tank as deterrent relies on people reacting to the spectre of having to pay for their care by being more careful about their behaviour.  However, such attempts to re-shape people’s decision-making are not always effective.  Women in particular are frequently reminded of the importance of safekeeping strategies.  You might think of articles like this or campaigns like this, this or this.  However, research (not just mine) suggests that often what is the more likely consequence is ‘safety talk’.  One example in my research was a young woman who took a fixed amount of cash out with her, and no debit or credit card, so she couldn’t drink more than she felt was good for her.  She also took out an extra tenner, hidden in a ‘secret pocket’ so that if she lost her bag, or drank the full amount she had with her, she’d still have the money for a cab home.  Only, in practice, she knew that money was there and her drunken self would end up spending it on alcohol and deciding to walk home.  Regularly.

This highlights Harry Sumnall’s issue with the idea of the participants in the research cited above who said they’d drink more if they were given a BAC reading: “at time of interview subjects had drunk 10-16 units. I dont trust their answers”.  It’s a good point: we are different when we’ve had 10 units or so.

And that’s why I’m not sure about drunk tanks changing behaviour.  They might, as a spectre, but we’re also very capable of explaining away our drinking and underestimating our risk when we’re thinking of things we like.  Moreover, it’s unlikely to seem such a frightening prospect when we’re getting out that ‘secret tenner’.  At this point, we maybe do need some ‘nudging’ rather than an appeal to our rational, better natures.

If we’re serious about changing behaviour, I’d be interested in more structural solutions – and that could include initiatives like the Late Night Levy, even – or perhaps especially – if the costs are passed on to the consumer.  Certainly there are problems with how this would apply if it only affects the premises that are open late at night, ignoring the role of the off-trade; that’s one of the reasons MUP is attractive.  At the moment, though, I remain fascinated by the Gothenburg model of alcohol retail, largely removing the profit motive from the trade.

*This doesn’t necessarily mean they’d be keen on a strict definition of who they should be letting in and serving and agree with the police.  In a 2008 study, only around 60% of staff surveyed knew it was illegal to serve drunk people alcohol, and even of those who did know, over 8% of those still felt it was part of their job.

**There’s loads of stuff on this, but as well as my work, these two articles are particularly useful.

***For example, if it’s expensive because the police/ambulance staff are overqualified for the role they’re performing, a solution like the Cardiff triage centre solves precisely this problem by employing people and resources to fit the precise issue.

Drunk tanks, free school meals and universalism

In the past week, a couple of stories caught my eye, as they sparked considerable media attention.  Nick Clegg promised free school meals for all children in their first three years of primary school, and the Association of Chief Police Officers (ACPO) proposed ‘drunk tanks’ for those who were so drunk they were ‘incapable of looking after themselves’.

At first sight, you might think there’s little to connect the two policies, but I’d suggest they’re two sides of the same argument, regarding universalism.  This sparked me thinking about the ideas I'll ramble about in this post.

Daniel Sage has talked about this (relatively) recently over at his blog Knowledge is Porridge.  His argument was that Labour seemed to be moving away from the idea of universal benefits, and suggested that it’s universal services that command support and engage people – think of the NHS, most obviously, but also schools and public transport (especially for pensioners).

Nick Clegg’s free school meals, and Labour’s recent announcement on childcare, can be understood in this light: providing universal services to all children.

However, there’s immediately a potential problem with this initiative being classified as ‘universal’: if we take the unit of analysis as an adult (rather than all children) then it could be argued that the service only immediately benefits those who have children.

I have heard this same argument advanced in all sorts of contexts.  For example, people sometimes complain that their union does nothing for them – which can often be seen as a positive thing if this is because they’ve never had cause to draw on legal support, other funds or the helplines provided.

The idea in the back of people’s minds when they say this is that people should pay for what they use – and this is not the principle behind the NHS or union services.

Examples of this idea in practice might include the suggestion that those who consume particular amounts of alcohol or fatty foods should pay for their own medical treatment, rather than relying on the NHS, because they have caused their own illness.  This is what distinguishes ACPO’s proposed ‘drunk tanks’ from triage models already in place in town and city centres which mean that drinkers aren’t admitted to hospital emergency departments at great cost: the drinkers themselves would face fines to pay for the service they have received.

However, it’s hard to draw the line as to where someone is at fault for their illness.  Thinking of alcohol-related issues specifically, alcohol is understood to distort reasoning through its effects as both an intoxicant and an addictive substance.  For centuries the British legal system has struggled with the issue of how alcohol affects a person’s responsibility, and we still don’t have an entirely satisfactory answer.*

On the other hand, there’s the suggestion that actually addiction isn’t so opposed to rationality as we might sometimes think.

One response to this issue, particularly for those on the left, is to argue that, yes, people are rational and they should take some responsibility for their actions, but they don’t start from equal positions in the game of life.  This can mean in practice an emphasis on cultural or wider structural factors that affect people’s propensity to behave in certain ways.  ‘Lifestyle’ might be a class issue.

This doesn’t in itself undermine the agency or rationality of those who do behave in ways that might be deemed damaging to their health.  The link above about addiction and rationality points to an interview with Carl Hart from Colombia University (I’d also recommend the Q&A on his own website).  His train of thought isn’t to say that crack addicts, being rational, therefore have themselves to blame because they could theoretically make different decisions.  Rather, he suggests: “If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure”.  The whole point is that his experimental work presented crack users with genuine choices – which meant that they often chose something other than crack.

However, these arguments are unlikely to persuade those who have a worldview that emphasises personal autonomy and responsibility – precisely those who are most likely to be opposed to the idea of universalism in the first place.**  Such a worldview, with an emphasis on the market, tends to take something of a moral or natural selection view of life: people sink or swim, win or lose, live or die by their own merits and luck.

And indeed, those on the right may be as tempted as those on the left to argue that ‘lifestyle’ is a class issue – class (or more accurately groupings of people, say chavs, the underclass, the mass) can be mobilised as a negative concept, as much condemning as explaining.

What I want to suggest here is an alternative way of addressing this criticism of universalism.***

In the end, we come back to some ideas from my previous post about risk and population health.

A focus on personal responsibility tends also to mean an opposition to population-wide measures, as these are seen as hurting the ‘responsible majority’.  A targeted approach, according to this ‘consequentialist’ view, seems much fairer.  We should be left to get on with our own decision-making, with the attention directed at those whose actions produce negative outcomes – the doughnut eaters who end up with diabetes.

However, it’s revealing that a standard alternative offered to universal health care is an insurance-based system.  Such an approach highlights the importance of the concept of ‘risk’ in understanding alcohol harm.  Just like those union dues, we pay insurance because we don’t know how likely we are to suffer some form of misfortune.  And in fact, at our individual level, neither does the insurance company – rather, it aggregates the risk in the same way that a government would do in formulating a total consumption model of alcohol harm.

This idea of risk is generally accepted by liberals/libertarians – note Chris Snowdon’s comment on my last post: the government shouldn’t be intervening because the risks are ‘trivial’ at an individual level for the levels of consumption we’re talking about.

But inherent in risk is a lack of certainty.  And such a lack of certainty is hard to manage if you’re a rational actor.  This would be fine if you could be given probabilities of your actions: you pays you money, you takes your choice.  But we’re also told that the advice offered by medical practitioners regarding alcohol consumption is unreliable, with recommended daily consumption guidelines having been ‘plucked out of the air’.  That is, there are no reliable estimates at an individual level for the risks associated with drinking.  It’s precisely this point – that we’re not really able to assess our own level of individual risk – that lies behind population-wide interventions.

Of course one instant response is to say that such theoretical nuances don’t really apply to the reality of serious ‘lifestyle’ related illnesses – the alcoholic or the doughnut eater.  But thinking again of alcohol it’s not that easy to say that there are clear-cut cases.  Not all heavy drinkers suffer from alcohol-related liver disease, for example, – and certainly not cirrhosis – and on the other hand genetic or other compounding factors can increase your risk.  Moreover, there might be no outward warning signs until the liver has been extensively damaged.

That makes rational decision-making about one’s alcohol consumption pretty tough – especially if we are to disregard government recommended limits – which makes it harder to place the responsibility for an individual’s alcohol-related illness entirely at their door.  The alternative, I’d have thought, would be to accept some idea of reasonable risk metrics – and that’s something the temperance movement could perhaps help us with.  Though I’m not sure that would go down too well those opposed to universalism and population-wide alcohol control.

(This argument might apply more to the longer-term health effects of alcohol rather than the immediate ending up in a triage unit at 1am on a Saturday morning, but I’d like to think it’s still worth thinking about in alcohol policy discussions.)

*There are great chapters covering this issue here: http://www.palgrave.com/products/title.aspx?pid=550243

**Notably, the articles I link to above that mention people paying for care related to ‘lifestyle’ decisions are based on comments from individuals associated with Policy Exchange and the IEA, both of which advocate free market solutions to public policy issues – i.e. have considerable faith in models based on an individual rational actor.

***It should also be noted that rational-choice models can acknowledge the importance of context, just like Carl Hart’s model of crack users.  Iain Duncan Smith sees it as his mission to make work pay., his model could be understood as suggesting that people are simply taking rational advantage of an apparently warped system.

What are we arguing about?

Up to this point, I haven't used this blog for short, sweet pieces that simply point people to other articles, but there's always a first time.

This article in The Guardian outlines how we can end up talking at cross purposes when we haven't actually agreed the terms of the debate - or what we're arguing about.  (Reminding me of the social science injunction to 'define your terms'.)

In policy discussions this happens all the time, and is exactly what I try to use this blog to address - most recently in my exchange with Chris Snowdon about the utility of the total consumption model of alcohol-related or harm.  (Or were we talking about population level policy interventions?)

I can't think of a better short, sweet link to leave on a blog called 'Thinking to Some Purpose'.

Population approaches to alcohol

I’ve seen some discussion about the total consumption model of alcohol harm in the past few weeks, mostly from Chris Snowdon – both in a blog post for the IEA and on his own blog.  This discussion prompted me to think a bit more about the various ways consumption of alcohol is understood, and the various interventions that might be employed to address it.  I’m not going to add anything particular original here, but maybe point to some issues that sometimes get overlooked – and certainly have done in the recent discussions I’ve seen.

I’ve written before about how public health approaches tend to focus on population-wide problems, and population-level consumption of alcohol might be one of these issues.  Chris Snowdon suggests that the total consumption model is all about targeting heavy drinkers with something of a blunderbuss approach.  The theory, he states, runs that the consumption of the heaviest - and therefore problematic - drinkers moves in step with overall population consumption.  Policies designed to reduce population-wide consumption are in fact aimed at targeting these heaviest drinkers.

As John Holmes has pointed out, this needn’t be in quite the way that Chris Snowdon criticises; the Sheffield MUP modelling isn’t actually based on population averages, but rather targeted groups.

But there’s something more too.  Snowdon’s point is that this is a theory that isn’t held up by evidence, but as he’d probably be the first to point out, evidence and policymaking isn’t as straightforward as all that.  There’s a suggestion that Kettil Bruun, one of the lead advocates of this kind of policy, proposed it on the basis of politics – that a universal policy would be less stigmatising than measures targeted at particular ‘problem’ drinkers.

And also the evidence Snowdon sees as undermining this model is questionable – at least in the way he understands and marshals it.  First, I’m always slightly questioning of hospital episode statistics, and how they have changed over time, as this relates to accuracies of coding.  Second, even if these were accepted as measures of alcohol-related harm, it shouldn’t be surprising if they don’t march in step with current consumption figures.  Apart from the fact that consumption figures themselves can be questioned*, one can expect a lag before the health effects are felt of any increased consumption.

There’s a more important point here, though, about the idea of population level interventions.  One is that such universal interventions don’t have to imply equal effects on all individuals or groups within society, as John Holmes points out.  (Of course, as I’ve pointed out before, in many of the arguments surrounding MUP these apparently targeted effects may be as much a political claim as a genuine aim.)

Another, often overlooked point is that in fact MUP can be understood as a genuinely universal measure that does not rely on the total consumption model as outlined by Snowdon.  I often reference James Morris’ article about MUP on this blog, and unsurprisingly I’m going to do so again here.  The point is: alcohol harm is all about risk.  Not all alcoholics necessarily get liver disease, for example.  Your risk is affected by the amount of alcohol you consume, but it’s hard to predict on an individual basis.  The population model doesn’t face this issue because it’s aggregating so many risks that the broad relationship holds.  That is, if we all reduce our drinking marginally, then the individual change in risk levels is barely noticeable.  However, when all these slight reductions in risk are aggregated at a population level, the difference becomes noticeable in terms of mortality figures.

The important point here is the contrast with Chris Snowdon’s position that alcohol problems are located in a small section of society – ‘those who have a genuine drinking problem’.  It’s certainly true that there are groups of people who have particular alcohol problems, but there’s a whole host of issues relating to alcohol consumption that could be deemed problematic.  It’s the very fact that there are genuine issues relating to the wider population that means I’m concerned about how resources will be targeted in the future to meet public health aims.

And I don’t think this idea that ‘problems’ are confined to a small section of society is helpful.

First, as Alastair Campbell has pointed out this week, the seriousness of someone’s alcohol issues might not be immediately apparent to those around them.  People can be very resourceful in hiding their problems.

Second, people are able to hide such problems from themselves.  I don’t just mean the ‘denial’ of addiction.  We like to think that there are safe (even beneficial) levels of alcohol consumption, but in fact the analogy is more like driving a car: there are safer ways to drive, and it can be beneficial to your mental and physical health as well as quality of life, through many knock-on effect such as sociability, but there are risks in any level of consumption/driving.  The question is about the management of those risks.

Government discussions of alcohol policy haven’t always been helpful in this respect, as concepts such as ‘binge’ and ‘responsible’ are very malleable, and allow people to bend them to fit their own definitions of normal or acceptable – as in this research study which showed that older people tend to define acceptable drinking with reference to ‘propriety’ rather than ‘health’.  I found the same thing in my own research with younger drinkers, where people were perhaps surprisingly able to draw distinctions between themselves and the ‘other’, ‘irresponsible’ drinkers.  This isn’t to say that health should always be the number one priority in someone’s decision whether or not to drink; but it is illuminating to think about how it might be being disregarded.

This doesn’t mean I’m advocating MUP, or other policies that address total consumption across a population.  It simply means that the arguments for these interventions can’t be undermined by a narrow consideration of ideas around total consumption, and it may be unhelpful to characterise alcohol-related ‘problems’ as confined to a small group within society.

*The Mark Bellis et al research I link to is particularly relevant for Chris Snowdon’s point about harm not following consumption across socio-economic groupings.  This research, though not yet concluded, does suggest that there are all sorts of reasons for this pattern – not least that the consumption estimates may be out by differing amounts for different socio-economic groups.