On the politics of compromise

I don’t often write directly about party politics on this blog, because mostly I’m talking more about the process of policymaking than its moral positions.  And perhaps that’s true of this post too, but it is written in direct response to the way the Labour leadership debate has been conducted.  It’s not a direct commentary on particular candidates or other public figures, and it could be seen as a call for all of them to up their game.

I’ve often said on this blog that policymaking is about compromise, and the same must be true of politics more generally – for even when it seems that nothing’s being done, that’s a policy in itself.

But compromise, particularly at the moment, seems to be a dirty word – or at least one that’s probably misleading for what I want to try to say.  Really, the point is that all policies are (even if not consciously) a weighing up of inevitably competing positions and priorities.  There will be trade-offs.

Some of these trade-offs might involve cost (how much can we spend on crash barriers, medicines, school buildings, or how much do we want to prioritise the environment over economic growth), but for others it’s simply about balancing one legitimate priority against (many) others.  To take an example from a field I know something about, how can prescribing methadone to reduce the harm from injecting illicit drugs be balanced against the desire to support people to ‘recover’ as fully as possible from substance use issues?

What I’m trying to say is that by talking about ‘trade offs’ I don’t mean that Jeremy Corbyn’s policies – or those of Kendall, Cooper or Burnham for that matter – are ‘unrealistic’, as some Labour grandees seem to want to do.  I just want to point out that they will involve a trade off with some other potential priority, whether that’s conscious and spelled out or not.  Of course that potential priority might be written off as unimportant, but that’s easier for a big picture discussion of growth versus climate change than it is for the detail of adult social care policy, for example.

But there’s a bigger point about compromise and politics.  I see it as inevitable that not all people agree on the ends of politics, let alone the means.  Otherwise, we might have found a unifying political theory by now, but not even liberalism has managed that with its attempt to bypass any attempt at unity.

So no policy will please everyone.  Of course some views would disregard popularity, but some concept of popular appeal is important if you’re interested in power, which is the only reason a person is interested in politics (even if they, quite reasonably, think power doesn’t entirely reside in government).  It’s revealing that the campaign teams of both Andy Burnham and Jeremy Corbyn have been desperate to point out that their candidate has widespread popularity and electability.  Despite what some Labourites might think, the Corbyn campaign isn’t simply an attempt to sit aside from the mainstream of political debate and feel self-righteous.

And here’s my point: the Labour Party is itself, inevitably, a compromise.  It is an electoral coalition for the purpose of forming governments.  This isn’t its only function, but it’s the key reason it exists as a political party as separate from – or alongside – ‘the labour movement’.  The Conservative Party is a compromise too, for that matter.

Just as we haven’t got one unifying political theory we can all agree on, neither have the major parties.  They can’t be neatly categorised according to the classic axes of political theory.

Alcohol and drug policy is one area where we can see this clearly.  The Labour Party can’t decide whether minimum unit pricing of alcohol (MUP) is a progressive measure that will reduce alcohol-related harm amongst the most vulnerable, or whether it’s a way of targeting some people’s pleasures while leaving richer people’s untouched.

And the Conservative Party can’t decide whether liberalising alcohol licensing or drug laws is the right thing to do because it’s economically and socially liberal, or whether intoxication and visible carnivalesque behaviour are undesirable and therefore should be cracked down on as part of a socially conservative agenda.

These aren’t new problems.  James Nicholls has written very clearly about how the politics of alcohol highlights these liberal dilemmas, and the issue of alcohol for Labour Party politicians was laid out clearly in The Ragged Trousered Philanthropists over 100 years ago.

And yet, so far, these parties have tended to hold together.  Yes, there has been the SDP, and Douglas Carswell has chosen to see UKIP as a genuine libertarian alternative to the Conservatives (though I’m sure plenty of UKIP voters and party members would disagree).

Politics involves trade offs at some stage.  Our political and electoral system tends to place these at specific stages, but they’re still there.  In some other countries the compromise is made after an election, when a programme for government is put together by several parties accepting portions of each other’s manifestos.  We had our own experience of this after the 2010 election, and it didn’t end well for one of the compromisers.

(You could argue that 2015, with the exception of Scotland – or perhaps particularly in Scotland – was a turn back to clear two party government, rather than an endorsement of coalition or a further fracturing of political loyalties.)

The British electorate largely know they are voting for a compromise rather than their perfect party – but (under current electoral arrangements) they prefer to know what compromise they’re likely to get before they vote.  The compromise is effectively put to them as the programme of the two biggest parties, which are already ‘coalitions’.

There are other ways to conduct politics, of course.  We could vote for our ‘perfect’ party and spell out our compromise option through an alternative vote system.  We could have many parties with more coherent and tightly defined programmes for government, and then see negotiations set in after the election.

But I would suggest that parties, as a collection of people, and the expression of a collective will, cannot be wholly of one mind.  Those compromise manifestos not only cannot satisfy every voter, or even just the voters of that party; they cannot fully satisfy anyone.  Its policies will be a series of trade-offs, and the selection of policies will be a compromise rather than a perfect, complete vision of one mind.  That is the nature of living with other people.  (Unless, of course, you’ve found you’re living in a society where you never disagree with anybody – that would be interesting to know about, but it certainly wouldn’t be interesting to live in, or even human.)

Even smaller, ‘purer’ parties can’t achieve perfect agreement on a programme for government.  (I would argue that even an individual human being isn’t capable of that level of coherence and consistency, but that’s an argument for another day.)

So let’s not have one politician written off as a compromise candidate or another as an unrealistic idealist.  Compromise does not inevitably mean Tony Blair or David Cameron, any more than purity of principle and thought means Jeremy Corbyn.  There are compromises other than those made by the 1994-2010 Labour Party – but they will be compromises.  The trade-offs are made by everyone, or will be later.  The question is about the relative priority given to certain principles or priorities.

To paint compromise – as particular Labour members of all backgrounds and preferences have done during this campaign – as being one specific thing, infantilises political debate.  Reasoned, balanced, publicly-supported policies are not a bad thing – and they could come from any of these candidates or none.

Not a single candidate is ‘perfect’, but then there never will be a single ‘perfect’ candidate or policy platform for everyone, so let’s stop pretending this is a battle for head or heart, realism or perfection, and get on with some proper discussion.  Blairites don’t have a monopoly on realism, and Corbynites don’t have a monopoly on leftwing morality.  My ideals, my compromise, my realism are quite different from anything I’ve seen so far.

It seems a travesty to argue that what we could call consensus politics should be defined by Tony Blair, when the period called by that name is precisely what he was most keen to distance himself from.

Now what are the candidates’ positions on minimum unit pricing anyway?  That might actually be illuminating about their principles and priorities…

Drugs, harm and sceptical conservatism

I do occasionally stop thinking about the concept of evidence-based policy, but at the moment I seem to keep coming back to it.

With a certain arrogance, my aim in setting up this blog was to contribute to an open and honest debate on various policy issues, but particularly those relating to drugs and alcohol.

Regular readers will know that I don’t have much time for the idea that there is a single unquestionably ‘right’ answer to any policy problem, as every decision is necessarily a compromise.  I’m more interested in ensuring that when we’re making those compromises we’re going into them with our eyes open.

On the walk to work last Friday morning I was thinking about NPSs (novel psychoactive substances or ‘legal highs’) and nudging – and, oddly, but not unusually, sceptical conservatism.

My thought was that both nudging and this form of conservatism are based on a view of the world as being irrational, but functional.  It’s just that where sceptical conservatism thinks our ostensibly ‘irrational’ society has huge strengths, nudgers want to change our actions to make them more ‘rational’.

But what’s that got to do with NPS?

Well, I don’t think there’s any serious argument that our overarching policy approach to intoxicating substances is ‘rational’ – though perhaps that would be an oxymoron in any case.  Certainly there’s an inconsistency laid bare by the new Psychoactive Substances Bill in relation to caffeine, alcohol, nicotine and certain other substances.

As I’ve written before, I was optimistic that NPS and e-cigs might disrupt the status quo and get people to question current arrangements.  Others were more sceptical – and possibly more accurate.

But here’s the link between conservatism and nudging.  There are serious ethical debates around nudging, based on the fact that it operates on your unconscious ‘thinking’ – System 1.  But we are able to override this system (to some extent) with conscious thought (System 2).

So what if a ‘nudge’ lost (some of) its effectiveness if its aims and methods were broadcast?

That is, what if you told everyone that you were placing the doughnuts in a particular location in the café in order to reduce their consumption – and telling people this meant they didn’t react to that move?  The whole approach potentially depends on us being in blissful ignorance.

And it’s the same with sceptical conservatism.  Society is too complex for us to understand, and it works reasonably well.  We shouldn’t think too hard about how it’s working and try to tweak things to make them more rational – that way lie the horrors of the French Revolution.

But then what’s all this irrationality and unconscious stuff got to do with NPS?

Well, as I said before, there’s a view that our drug policy isn’t strictly ‘rational’, but it isn’t disastrous, and a complete revamp would be hugely risky.  Alcohol and tobacco might not be so different from banned substances in terms of their pharmacology, but their unique histories mean they’re understood quite differently, so it could be argued that the ‘irrationality’ is perfectly ‘rational’ given the irrational place we find ourselves in.

I’d suggest that the Psychoactive Substances Bill is an attempt to support the status quo, and there’s no mention of ‘harm’ because to frame the debate in this way would highlight the inconsistency of this current approach.

So this is where sceptical conservatism, nudging and drug policy interact: we don’t talk about the irrationality of policy for fear that would destroy the illusion – and if we thought too carefully about alcohol and drugs, maybe the (arguably) functional arrangement we currently have would fall apart.

So is it possible that one way to keep harm from drugs down is to not talk about harm?  And is that a policy compromise worth making?

Yes, it's politely political

I’ve been thinking and talking about evidence-based policy a lot lately.  Conversations at work with Public Health colleagues; the conference of the New Directions in the Study of Alcohol Group (NDSAG); various blogs and Twitter discussions.

After the NDSAG conference, I flippantly reduced much of the content to be being the sentiments of this song:

But it’s actually more than being flippant.  At the conference, which focused on the nature of addiction and pathological behaviour from alcohol use through other drugs to behavioural addictions such as gambling, many of the debates boiled down to the old political and sociological chestnuts of structure/agency; pleasure/harm; individual/society; freedom/safety.

As Jim Orford powerfully argued, at root these come down to issues of power, but I was reminded of my basic undergraduate paper on political sociology when the likes of Steven Lukes were being quoted.  Really, power, like addiction, is just another word or concept (and really a set of concepts) through which to think about all these problems.  In itself, a conceptual lens doesn’t resolve a problem; it provides a way to think about it.  (With the exception, of course, of the concept of the carnivalesque, which resolves all our issues with alcohol policy – of which more in a week or so.)

What thinking of these issues in terms of power reveals, though, is the seriousness of Skunk Anansie’s point.  (I don’t know if this is a better or worse use of musical analogy than Billy Joel.)  Issues of power are political, and when we talk about addiction, or indeed any form of substance use, we are talking about power – in fact it’s revealed in the 12 step programme very clearly, when AA members are instructed to recognise their ‘powerlessness’ in the face of alcohol, or when someone like Gerard Hastings complains about the role international companies play in providing choices for consumers.

This isn’t actually much of an insight, and it’s certainly not original.  At the NDSAG conference, James Nicholls made again the point that comes across so powerfully in The Politics of Alcohol: that alcohol is partly such an interesting topic for the sociologist or historian because it illuminates wider debates about freedom, ideology and so forth.  If we’re defining ‘good’ drinking, we’re saying something about what we think a ‘good’ human being or citizen looks like.

This marks a point that’s more fundamental than my immediate response to Robin Davidson’s presentation at the NDSAG conference about evidence-based policy, or a colleague’s comments about the role of evidence in policymaking in town halls and Whitehall.  I’m not just saying things are political in terms of competing priorities, or politicians having to be popular.  I’m saying issues of addiction and substance use, in a sense, aren’t special at all.  They’re about power, sure, but then so are all questions, if you want them to be: ‘everything, political’.

Policymaking isn’t a case of making ‘good’ or ‘bad’, ‘right’ or ‘wrong’ decisions; it’s about values and principles.  The sooner public health and addiction professionals realise this, the sooner they’ll make an impact on decision-making.

Making imperfect policy for an imperfect world

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

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

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

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

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

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

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

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

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

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

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

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

What is a drug?

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

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

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

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

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

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

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

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

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

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

Markets for good? A response to Reform

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The continuing search for a big number

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

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

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

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

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

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

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

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

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

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

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

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

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