This is the time of year we’re meant to reflect on our supposed over-indulgence over Christmas and New Year, perhaps committing to a Dry January without alcohol, or a new diet or exercise regime.
While some of the interest and publicity given to these campaigns might come from a public health perspective, it can often be more easily understood as a moral or ethical attack on certain forms of consumption or activity. Before Christmas, AC Grayling wrote a piece in the BMJ that, while mistaken on some points and original on none, was still worth noting ahead of the inevitable ‘new year, new you’ articles.
Perhaps, in fact, Grayling’s article – ‘Morality and non medical drug use’ – was all the more important precisely because it wasn’t new: debates about alcohol and other intoxicating substances, although they move in certain ways, still tend to be framed in the same terms they have been throughout history. As James Nicholls has observed, political debates about alcohol are almost invariably ‘questions about what it is to be human, the relationship between individual freedom and state intervention, about the points at which our experience of the world is reliable or unreliable, and whether that matters, and what our responsibilities should be in those different situations’. We might address those questions in different ways, but the fundamentals don’t really change that much.
One notable recent example of this has been the concern of the Coalition and Conservative Governments – and in particular Iain Duncan Smith – that families in the ‘deepest difficulties’ were not having their ‘basic needs’ because money was being spent on alcohol or other substances. This issue goes straight to the heart of that question of individual freedom and state intervention, and hangs on the concepts of free will and personal responsibility. Duncan Smith had previously suggested that people who didn’t access support for a substance misuse issue should have their benefits cut.
To see how these policies could be implemented in practice, the government commissioned Dame Carol Black to report on the challenges obesity and substance misuse posed for people trying to find employment.
The report, as well as being admirably clear, is thoughtful and comprehensive. There aren’t many government policy reports that include a quote from Sigmund Freud in the introduction. And although I’m not terribly happy with the use of the word ‘addictions’ throughout the report, or the use of the £21bn figure to represent the cost of alcohol to the UK, or the claim that 30% of opiate users left treatment successfully last year (p.8), those aren’t fundamental criticisms.
The report, though, by being thoughtful, is obliged to state (clearly) that ‘there are no easy solutions’ (p.7). The reason is that although substance use is common, dependency is less so – and usually linked to a wider set of problems (p.7).
Like the AC Grayling article, this is not news. The report cites a 2011 review of evidence between 1990 and 2010 to state that there is a ‘mutually reinforcing’ relationship between employment and recovery (p.9), but this is a chicken and egg situation. And in itself, as the report notes, treatment doesn’t really change someone’s employment prospects. This isn’t a surprise, as so many wider factors influence employment, from the wider economy to the individual’s previous skills and experience.
But more fundamentally, it isn’t a surprise if we’re talking about ‘addiction’, because this is by definition not just about substance use. Read a definition of ‘addiction’ or ‘substance use disorder’, and it will typically refer not simply to ‘heavy use’ of a substance, but criteria including work, relationships, housing and so on being affected by use. Look at the underlying ‘causes’ of addiction, and you’ll see substance misuse is strongly linked with ‘adverse childhood experiences’.
If you look at someone’s life as a whole, with all this in mind, it’s hard to identify whether the substance itself is the issue, or a symptom – the chicken, or the egg. In reality, of course, this is often a moot point by the time someone reaches treatment services: all these factors are interlinked, and often mutually reinforcing, and so need to be tackled together, not in isolation.
This means that there aren’t simple solutions to complex problems, and we can’t just get everyone who might benefit into substance misuse treatment and then sit back and watch ‘full employment’ arrive. And practical suggestions in the report are thin on the ground. The key recommendation is that ‘the Government should promote more integrated collaboration across the benefits and health systems, to improve employment outcomes for this group and for others with long-term health conditions’ (p.15).
As the report acknowledges, ‘this challenge of integrating services is not new’ (p.15), and when I’m in a negative mood, you can hear me talk about how all this working together is pie in the sky until we’re talking about shared budgets, joint commissioning so that we have genuinely shared services, and an approach to measuring the outcomes that acknowledges the contribution made by lots of different organisations to a range of outcomes.
Of course many treatment services already provide what could be described as ‘employment services’ through training and work placements. What I mean is that it’s hard to envisage a local council (which funds substance misuse treatment) genuinely focusing on employment outcomes if the organisation that reaps the benefit is the Department for Work and Pensions and there’s no chance of a high-performing local authority (or a service commissioned by it) getting its hands on that money.
The report is clear on this issue, lamenting the ‘fractured’ nature of commissioning responsibilities in this area (p.8). It’s music to my ears to hear the report talk about the need to ‘join up the benefits system with other services, particularly health, but also the full range of Local Authority services (including treatment and housing)’ (p.15).
And despite my pessimism there are ways of working together without yet sharing budgets: having both providers and commissioners of the full spectrum of services around the same table, talking to each other –as they do in Plymouth, with their system optimisation group. Although this sort of arrangement isn’t really discussed specifically in the report, the ideas about integration and co-location are related and welcome – and there’s no question that more can be done even within current frameworks.
And there are more practical recommendations too. The report rejects ‘mandated’ treatment for all benefit claimants with an identified substance misuse issue, but suggests that all those passing through JobCentre Plus should have a discussion with a healthcare professional about the barriers they’re facing in getting into work – which should identify any treatment needs. The report identifies a key problem of Jobcentre Plus not recording much health information – they list just one relevant condition, often copied from a GP’s fit note, which rarely mentions addiction. The report therefore, sensibly enough, recommends beefing up the collection of this data, and the support associated with it.
But for me, the report is strongest when it can be thought of as part of a broader project.
I had a sense, on reading the report, that it was trying to balance what some have seen as a stigmatising approach by Ian Duncan Smith and the DWP more broadly, with ideas of pre-paid cards for benefits, as recipients can’t be trusted with cash, for example. The report talks glowingly of the positive contribution peer mentors can make (p.10), how guidance for employers should be produced to encourage them to take on staff in recovery (p.12), and how work placement schemes can be about changing perceptions of employers as much as giving experience to potential employees.
And more than this, I see the report as having a wider role: to emphasise the complexity of society and social policy. It really hammers home the relatively simple point that all the factors of adverse childhood experiences, employment, mental and physical health, social relationships, substance use, and so on are interlinked and mutually reinforcing.
This isn’t a new insight, even if we might think of it in new terminology as a ‘wicked’ problem. The interlinked nature of such issues has been the standard fare of social policy for centuries. The Beveridge Report, for example, identified five interlinked ‘giants on the road to reconstruction’. But whatever the reason, we still seem to want single, magical solutions to human and social problems. In fact, citing Beveridge is instructive: his approach can be seen as part of a broader optimistic approach to social policy whereby fundamental ‘laws’ of society can be discovered, which can then inform policy.
A colleague of mine recently observed the strange paradox that victims of childhood abuse are seen as tragic and to be pitied in public and media debates, while ‘addicts’ are more often demonised – even though their issues are often a development of precisely that form of abuse. We like simplistic ideas of innocence and guilt; right and wrong.
And that brings me full circle back to AC Grayling and his unoriginal observations on drug policy. They are unoriginal and need repeating because at the same time as the problems in society are more complex than that, so is the policymaking process.
This is why, although I applaud the report for emphasising the complexity of the issues involved – and even more for the clear way in which it is written – I am sceptical of its value in the policy debate. Politics in 2016 should have reminded us that simple solutions to acknowledged complex problems are attractive: leave the EU or simply vote against ‘the establishment’.
Politicians, policymakers and commentators need to improve not only their analysis, but their communication and storytelling. The Black Report just isn’t a good story.
But that ‘storytelling’ is perhaps the role of all of us in ‘the sector’. How to transform analysis into a story that has impact not only on policymakers but the wider public. For me, it’s about emphasising adverse childhood experiences, and challenging that paradox that stigmatises subsequent substance misuse. In the meantime, though, there’s plenty of practical suggestions in the report that can and should be adopted sooner rather than later, without the wait for that ‘story’.
Dr Will Haydock is a Visiting Fellow in the Faculty of Health and Social Sciences at Bournemouth University, Senior Health Programme Advisor for Public Health Dorset, and writes regularly on drug and alcohol use on his blog Thinking to some purpose. Tweets @WilliamHaydock