Principles and pragmatism: We need to talk about commissioning

Yesterday the ACMD released a report on the commissioning of substance misuse, and this sort of thing is really the bread and butter of this blog, so I feel like I should overcome my lethargy and comment on it.  And it is worth commenting on, because it makes some important points – but obviously I’m going to challenge a few of its claims and assumptions, otherwise this would be a pretty short and uninteresting post.

I’m going to do this in a format that’s pretty unusual for this blog, which is to go through several of its conclusions and recommendations in turn and assess them.  This is partly to be clear and systematic, and partly because I don’t have any other clever ideas about how to tackle it.

First, then, it’s hard to argue with its statement that ‘reductions in local funding are the single biggest threat to drug misuse treatment recovery outcomes being achieved in local areas’.  Fundamentally, we know that the relationship with a client is crucial to good outcomes, and the less money there is the more thinly spread staff time is and the less training investment and time the staff will receive.

However, I’m less sold on the idea that the commissioning of treatment should be housed within the NHS.  There were good (pragmatic) reasons why substance misuse treatment responsibilities ended up with local authorities – not least because it was felt this agenda would get swallowed up within the behemoth that is the NHS.

A lot of the document (particularly given that it starts with a kind of history lesson on the funding of treatment since 1998) feels like a lament for the glory days of the NTA.  Maybe this isn’t fair, but I can certainly say that placing commissioning within the NHS would not be anything like those days.

My experience of NHS commissioning is that – partly because of the sheer scale of contracts – it’s not as detailed and hands-on as either substance misuse work under the NTA or local authority commissioning more generally.  Let’s assume, for example, that you were commissioning your local community health trust to deliver at least the prescribing element of the treatment system.  If you were sitting with the CCG, that would likely (for ‘efficiency’) be embedded as just one element of a much bigger contract covering all kinds of services – just have a look at the website of Dorset HealthCare (DHC).  At one stage, as a commissioner, there were three levels of meetings at which the Dorset prescribing would be considered: the overall CCG-DHC contract review; a specific substance misuse CCG-DHC contract review sub-group so that some people with direct knowledge of this service were in the room; and a DAAT-DHC meeting where we actually discussed activity and performance.  I wouldn’t want to go back to that, but I can see how it would be justified on paper as managing the contract more ‘efficiently’.

And the idea that the budget wouldn’t get raided as much as in local authorities is, to me, laughable.  NHS organisations, in my experience, find it much more difficult – quite understandably, because of their size and the range of services they’re providing – to give definite, accurate figures for staff time and costs of specific elements of service (like substance misuse) than (small) dedicated third sector agencies do.  It requires inventing quasi-market calculations like internal rents and charges.  Sure, this is a consequence of the slightly odd commissioning system – but that would make for an argument for getting rid of the whole system, not simply shifting responsibility from one silo to another.

Next, the report suggests clearer and more transparent financial reporting.  And you can already predict my issue with this: it’s really like looking inside the sausage factory.  At a national level, aggregating figures, I can believe this is helpful.  I’d be much more worried about doing this where comparisons are made at local authority level, comparing one year with another.  Huge elements of local budgets – like res rehab, inpatient detox, drug costs, dispensing fees – will not only vary significantly based on a few coincidences, but bills can come at all sorts of times with all sorts of delays that skew the figures from one year to the next.  And would it be timely?  You often don’t get a bill for the drugs you’ve prescribed for months, and then that bill might have to be passed from the CCG or provider to the commissioner to pay, so the actual spend on a crucial element of the budget would just be either forecasted or missed off – particularly where prescribing arrangements have changed in a year (which we’re told later in the document happens with worrying frequency).  I worry that there’d be some kind of league table of spend per head, which I just wouldn’t trust and could certainly be manipulated.

However, other measures referred to sound sensible (and some have already been mentioned in the Drug Strategy).  It’s a good idea to try to assess what proportion of the people with substance misuse issues living in an area have recently been engaged in treatment – but then this is something that we already do, and have done for years, based on information provided by PHE and before them the NTA.

The second conclusion of the report is very similar to the first: ‘The quality and effectiveness of drug misuse treatment is being compromised by under-resourcing’.  Again, it’s all about the money.  And again, I agree, but I don’t entirely sign up to the recommendations.  I’m not sure how national bodies developing ‘clear standards’ would prevent a ‘drive to the bottom’, unless there is actually more money in the system.

And I’m a bit uncomfortable with the phrasing in the report that seems to suggest that everyone apart from nurses, doctors and psychologists (and presumably psychiatrists?!) are ‘unqualified’.  (Interesting also that social workers aren’t name-checked.)  They’re unregistered, perhaps, but that’s quite a dichotomy to draw.  My view is very clear that there shouldn’t be this kind of dichotomy in a treatment system, because (without sounding too trite) different people and professions have different jobs and contributions to make.  Those registered staff should be focused on the functions that they are uniquely well-placed to deliver.

But perhaps I’m being unfair.  The report is saying that the Drug Strategy Implementation Board should be defining what an appropriate balance of these (supposed) two groups should be, and obviously I’d hope any final figure would be reasonable and reflect this reality.

I’m still a little worried, though, that the implication is that there aren’t enough registered professionals in the system at the moment, and the proportion needs to be higher.  Whether we like it or not, raising the proportion of these professionals will (in a world of even fixed, let alone reducing budgets) result in fewer frontline staff.  That is a trade-off that commissioners and providers are having to deal with all the time in service design.

The next conclusion is that there’s a disconnect between treatment services and wider health structures.  I don’t know what I think about this.  Personally, I’d be happy for treatment commissioning to be part of the NHS, and there do need to be strong connections with services.  But the reference is made to CCGs and STPs when plenty of crucial elements aren’t currently the responsibility of CCGs – for example custody healthcare and mental health liaison and diversion services sit with NHS England.  And that’s not to mention that better links with wider criminal justice services like probation would be helpful.

Perhaps treatment commissioners aren’t managing it currently, but given the wider needs of many service users, being commissioned by the same organisation as social care, safeguarding, family services, sexual health and housing shouldn’t be a bad thing.  Based on my experience, I’m pretty sure you’d find local authorities and the LGA quickly complaining about the lack of connections with safeguarding and family services if commissioning moved over to the NHS.

This isn’t to say that links to wider health services can’t or shouldn’t be improved, but reading this does make me want to re-emphasise the complexity of public services.  Does the recommendation really amount to anything more than the platitude that partnership is good?

The fourth conclusion is that ‘frequent re-procurement of drug misuse treatment is costly, disruptive and mitigates treatment recovery outcomes’.  I couldn’t agree more, and I’d point interested readers to my long and hard-to-read commentary on exactly this from a few months ago.

But again I wonder how realistic and sensible the recommendation is.  It is suggested that commissioning should be undertaken in cycles of 5 to 10 years.  This would certainly remove some of the churn, and it would basically mean there wasn’t commissioning.  I think this is fine, and it certainly fits with the direction of travel to accountable care organisations, where the commissioners just hand responsibility over to a single provider along with a budget for them to manage directly.

However, given the system at the moment, it would be an odd thing to do.  Imagine having written a 10 year contract in 2006.  You’d have given more money to the provider as budgets increased for a few years, and then in the last four years or so you’d be reducing it by about 5% a year.  There are reasons commissioners tend to go for three year periods (as we’ve just done in Dorset), and it’s not just some blind adherence to a (largely mythical) requirement of procurement regulations.  The reality is that it’s risky to promise something for a long period, and there’s something to be said – for both providers and commissioners – in offering certainty and security for a relatively short period, rather than guaranteed uncertainty for a longer period.

And actually, given that however you wrap it up the impending budget challenges will mean significant service re-design if not now then very soon, and possibly again in a few years, it’s not immediately obvious that one long contract with a stable provider (or group of providers) is the easiest or best way to do that.  You might find (perhaps based on that ‘balance’ of different types of staff) that the organisation that’s best at providing a service in stable times of relative plenty is not the same organisation you’d want at a time of tight budgets and political upheaval.  And perhaps there’s something to be said for the idea that a new broom sweeps clean, when big changes are required.

And that’s kind of what the document is getting at when it warns that ‘a system that has been seen nationally and internationally as highly successful is at risk of being undermined’.  The new broom will be sweeping out a system that’s good.

But to quote the irritating cliché, ‘we are where we are’.  I sometimes wonder when I read commentaries on commissioning whether people really understand that – particularly in relation to substance misuse – this really isn’t about people maliciously or naively reducing the budget.  The overall public health grant is being reduced, as is the broader grant to local authorities, and there’s no indication that either will exist in a few years, at which point local authorities will magically become ‘self sufficient’.

In reality, I’m not sure it would be responsible or sensible to start a commissioning cycle in 2017 based on a ten year (or even five year) period.  The broader context is that there is (a) ‘no money’ and (b) there are no reliable predictions on the wider political or economic context.

To think about practical solutions, there is (as I’ve written before) too much ‘churn’, and re-procuring services is often hugely wasteful.  But as well as extending contract periods, there are other things that can be done to reduce that churn, through having open, sensible processes, encouraging partnership working, designing the procurement process to offer a range of opportunities, and so on.  In fact, all the bits of good practice that commissioners have been being told and taught about for decades.

The final recommendation (and a bit of a tangent for this blog post) is about research.  The ACMD seems to be concerned that third sector providers aren’t as well linked into structures for clinical research as NHS providers.  Research is a good thing, and it’s probably just my sensitivity that makes this feel like another plea to commission NHS providers or house commissioning within the NHS, but I do want to offer an alternative perspective.

When we commissioned some research locally, it was actually those NHS structures that meant the staff and service users within our NHS provider found it far more difficult to engage in the process than those involved with our third sector partners.  There were so many hoops to jump through for what was an innocuous piece of research asking service users what they thought of services and how they felt their recovery could be strengthened.

Perhaps what the ACMD mean is that the NHS is better at jumping through those hoops.  But it’s interesting that it’s only at this point, in relation to research governance within the NHS, that the ACMD chooses to make its recommendation on the basis of the world as it is currently, rather than recommending a change to that world, as it does with budget constraints and political and economic uncertainty.

Overall, there’s a lot of sense in this report, and it’s hard to disagree with most of the conclusions, or indeed the principles behind the recommendations, but fundamentally I’d suggest things are a lot more complicated than they might seem.  Of course that’s partly my need to be contrarian and find something to disagree with.  (And citing ‘complexity’ is always a good way to do that.)  And it’s also simply the inevitable result of writing a clear report with definite conclusions.  This is a policy report, not a nuanced academic thesis about the challenges of commissioning drug services in 2017.

But most of all, I think it just highlights that we need to talk about commissioning, particularly of substance misuse treatment services.  If you caught me at another moment, feeling less defensive, you’d hear me say our team should sit within the CCG, so I certainly complain at this suggestion.

But as in my presentation to New Directions this year, I’d end by emphasising that the most important thing in commissioning or providing a service is the people.  Let’s not get too hung up on structures, or where a desk sits.  We can do most of this stuff from within local authorities or the NHS, and there will be strengths and weaknesses either way.  More important is just to get on a do good stuff on the ground, and try to ignore – or maybe even engage constructively with – the inevitable ‘churn’ around you.

But if we do need to talk about commissioning, this report certainly isn’t a bad place to start.  I just think as we conduct this conversation we need to be clear about how much we’re focusing on pragmatism or principles, and, probably because of the job I do, that seems to be where I depart from the ACMD approach.

Are we all alcoholics now, or is none of us?

This post is really a reflection on a recent article by Nick Cohen in Prospect, prompted by an exchange on Twitter between Andrew Brown and James Morris about whether the use of word ‘alcoholic’ is accurate or helpful.

So before I launch into something of a critique, I should say that the article itself is definitely worth reading.  It’s brilliant at identifying how drinkers are so adept at deflecting criticism of their own drinking (though they’re not unique in this – think of how we all seem to think we’re above-average drivers).

But he’s also great at conveying the emotions linked into drinking with a more personal perspective.  I’m going to quote at length here, which I hope isn’t a breach of copyright:

At the end of January 2017, I could not find a good enough reason to start drinking again. I still remembered the allure of alcohol, its promise of comradeship, love and simple pleasure. For me the most romantic lines in English poetry are from Edward Fitzgerald’s Rubaiyat of Omar Khayyam:

“Here with a Loaf of Bread beneath the Bough,

A Flask of Wine, a Book of Verse—and Thou

Beside me singing in the Wilderness—

And Wilderness is Paradise enow.”

But after too many years and too many flasks, neuroticism replaces romance. No one who hasn’t experienced it can appreciate the obsessiveness of the determined drinker. Questions build up as the evening approaches. Where am I going to drink? Who can I hassle into a pub? Can I sneak another one in without anyone noticing?

By the time you wake up in the morning, obsessiveness has metamorphosed into paranoia. What did I do? Why can’t I remember? Who did I offend? How did I get home?

If you find yourself asking these questions too often, the best answer is: “I give up.” How best to give up is, like everything else to do with alcoholism, infuriatingly hard to pin down.

All of that resonates probably a little too much with me.  I feel that ‘allure of alcohol’ and its ‘promise of comradeship’, but equally feel that these are, in reality, pretty illusory.  From a personal perspective I have asked all those questions at various times – though more recently I’ve decided that I don’t mind if anyone notices I’m having another drink; it’s no longer a question of ‘sneaking’ it in.

But from a professional perspective, one point is particularly resonant – perhaps without Cohen realising it.  He suggests that if we’re asking those questions too often we should just ‘give up’.  And I’d respond in the same way: if ‘everything to do with alcoholism [is] infuriatingly hard to pin down’ then I suggest we ‘give up’ using the word too.  It can’t possibly be helping, given that the purpose of a concept like this is to make sense of world – or at least create some useful questions – not simply ‘infuriate’ the interested thinker.

This is particularly odd when Cohen goes on to critique the disease model, emphasising that this is really a problem of behaviour (at which point I should plug the New Directions group and the (even ‘newer’) Addiction Theory Network, as well as this excellent blogpost on the disease model of mental health.

He challenges the idea that ‘alcoholics’ are this special breed, easily identifiable – because we are so bad at pointing the finger at the other easily identifiable groups: “The true alcoholic is always someone else. The old man in the park no one wants to know, the young woman sprawled on the pavement. Anyone and everyone, except you.”

And yet he goes on – just after criticising industry involvement in alcohol policy – to write that “Most drinkers are fine and healthy and good luck to them. Public policy needs to concentrate on helping alcoholics” – a line straight out of the industry playbook.

Of course, as I’ve written many times before, simply because something is said by an industry spokesperson, doesn’t make it untrue.  But as Cohen’s just pointed out, “the line between the heavy drinker and the terminal drunk is as blurred as your vision after a “good” night out.”  And if that’s the case, aren’t we really better talking about ‘heavy drinkers’ in general?  That would catch the attention of the right people without the risk they’ll ignore the message.

Of course the case could be made – as Andrew Brown did – that ‘alcoholism’ is a good way to grab attention for an important issue.  This is more about journalism than technical accuracy.

But again, he’s just told us that ‘alcoholic Calibans always see someone else’s face in the mirror’, so if someone talks to us about ‘alcoholism’ then we won’t be thinking of ourselves.  I just don’t think trying to redefine and re-purpose an ‘infuriating’ and indefinable concept is a good marketing or communications tactic.

The article seems to be trying to have its cake and eat it: we define ‘alcoholic’ too narrowly, seeing them as a special breed when in fact lots of us have problems and don’t acknowledge it; but equally most people drink safely and happily and we just need to focus on that special problematic group of ‘alcoholics’.

I think the biggest problem in this argument is that concept of alcoholism, which takes us down blind alleys of trying to define it in an effective way when, as I suggested at the beginning, we’d be much better off if we just gave it up.

The most important insight in the piece is perhaps about moving forward from problems.  Cohen writes, “The best guess is that drinkers stop when they have the usual prospects of happiness to fight for: a life worth living and the love of others.”

The problem, and therefore the solution, lies in a broader understanding of what makes life worth living – and although there are similarities, we all have our unique challenges and issues with this.  To go back to that lengthy section I quoted at the beginning, that’s why it’s an ‘infuriating’ task to define exactly how best to give up: each person is unique.  ‘Alcoholism’ as a concept, for me, just skims over these differences and challenges and encourages us to think only about the booze.  As Cohen would surely agree, there’s a lot more to life than that.

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.