The ACMD Report on Drugs Commissioning: Back to the Future?

This week the Advisory Council on the Misuse of Drugs published its report on the Drug and Alcohol Commissioning system in England.   Government hasn’t responded yet, and to be honest much of the trade press and media gave it very little coverage.   A good and thoughtful blog piece on this report and some of the issues it raises by Will Haydock rewards reading.

This report is a mixed bag but we shouldn’t ignore it

I’ve heard a number of policymakers and thought leaders be frankly dismissive of this report.  And I think that’s a shame.

There are some real mixed aspects of this report. First what I think are the downsides:

  • It feels like an approach of suspicion towards local authorities. They more or less ignore the joint Public Health England, Local Government Association and Association of Directors of Public Health report on drugs commissioning. Were the findings of that report, that actually a number of things which needed to change were being changed, just inconvenient to their narrative, one wonders? Picking one set of what’s gone before (back to pre-2012) while ignoring the other (the ADPH/PHE/LGA Report) just makes it easier to dismiss your report, without looking to see if there’s anything salvagable of value in it.
  • The report doesn’t engage with the substance of the Government’s new strategy other than demanding that it does several things they want. It doesn’t welcome what’s good in the Strategy and doesn’t really critique what’s problematic.  How can we take seriously a report about commissioning which doesn’t engage with a strategy whose impact on that commissioning system will be wide-ranging? On any view, that’s a mistake. And it makes it even easier to dismiss this report.
  • The report doesn’t engage really with the financial climate for the public sector, preferring to take an uncritical and somewhat rose-tinted view that everything will be better if we just hand drugs back to the NHS. This is naïve in the extreme given where NHS finances are now.
  • A nostalgia for the pre-2013 days which is not only unrealistic but shows some convenient amnesia of some of the things before 2013 which were not good. Putting drugs services back into the NHS is not going to protect them, that is a completely false hope in my view.  The report feels like it wants to hark back to a presumed Golden age when the National Treatment Agency  (remember them) ran things, and the NHS had control of drug and alcohol commission. Oh it was so much better, then. Except it wasn’t

In addition, there are two things in particular I regret about this report.  The first is it’s a pity they don’t mention any of the cuts to Local Authority budgets really, except some mention of the Public Health Budget and I think they take an overly selective reading of their own 2015 survey.

The second is that this is yet another report, giving yet another – sometimes overly partial – narrative.  Some have said this is really a narrative on behalf of the provider sector.  Writing reports feels like a rather dated tactic these days.  Getting together and discussing constructively issues between commissioners, providers and researchers is the approach that’s needed. Writing disgruntled reports back and forth seems to slightly miss the point in a system that needs us, more than ever, to work together.

Finally, I think they don’t sufficiently factor in the significant changes in demographics, use and epidemiology since 2012.  The drug and alcohol world is a different one in terms of trends, users, evidence and policy.  Going back to 2012 is not the answer. Arguing for the best funding and best commissioning and provision we can get now, is.

The report more or less lacks the nuanced and balanced understanding we have a right to expect from an organisation which should know better, and which should have done its job better.

So, we have a report which, given what I’ve said above, would be easy to dismiss, lends itself in the way it has been put together to not being taken seriously, and looks to some people as naive and partial. I think we need to look beyond all that and really think through this report.

The signals in the noise: Some good points

In the midst of what feels like a great deal of noise and lament, there are some good things and some sensible points. They do point out some areas where the system needs to work better.

They acknowledge some good things about the changes since 2013 – but spend little time telling us what they are before proceeding almost straight away to say everything else has more or less gone downhill.  I can’t help thinking they’re making a selective and overly rose-tinted reading of recent history.

My own view of where we are is rather more nuanced than this report. Some things are better, some things are more challenging, and some challenges endure – we didn’t have research right in 2012, for example, We still don’t have it right now.  The idea that the drug treatment system was ideal or even “really great” before 2013 is an unsupportably revisionist view of history.

Worth looking at the key conclusions and recommendations

It’s worth looking at their key conclusions and recommendations because while there are some things in here I find really problematic, there are some areas where they have a point and we need to listen.  It’s just a shame that rather than talk to commissioners, they feel it’s more appropriate to shout at them.

ACMD Report Conclusions and Recommendations

My take on these

Conclusion 1

Despite the continuation of the ring-fenced Public Health Grant to local authorities until April 2019, reductions in local funding are the single biggest threat to drug misuse treatment recovery outcomes being achieved in local areas.

 

 

This is the only point where they really acknowledge reductions in funding, but their point is reductions by commissioners, not reductions by government.

More and more people are saying that the government needs to reverse the cuts to public health, and these cuts are increasingly damaging. It would be good is ACMD felt able to join that call. They didn’t. I think that’s a mistake.

Recommendations

National and local government should give serious consideration to how current levels of investment can be protected, including mandating drug and alcohol misuse services within local authority budgets and/or placing the commissioning of drug and alcohol treatment within NHS commissioning structures.

 

Mandation of services seems to be everyone’s knee-jerk solution to this, so we mandate more and more of a smaller and smaller pot of money. All that does is make the job of running a public health system undoable.

Mandation is not the answer to this, reversing the cuts is the answer. Government has decided to impose cuts across the public sector, the drugs sector is no more special than any other part and cannot be exempt. Are drugs services more important than safeguarding children?  The more you mandate, frankly the more you pass the problem elsewhere to the rest of the system. More and more mandation is an appealing, but ultimately false, solution.

National government’s commitment to develop a range of measures which will deliver greater transparency on local performance, outcomes and spend should include a review of key performance indicators for drug misuse treatment, particularly those in the Public Health Outcomes Framework (PHOF), to provide levers to maintain drug treatment penetration and the quality of treatment and achieve reductions in drug-related deaths.

 

 

 

 

This recommendation doesn’t feel well thought through, which suggests the authors don’t understand the reporting which exists.

Reporting is already transparent with lines explicitly on drug misuse within the reporting on the ring fenced grant. The Public Health grant already has 26 lines of reporting, including substance misuse, for around £50m in my Authority’s grant. By comparison social care reporting lines are less than 10 for £300m . Benchmarking service costs is already done by CIPFA and can be publicly gained from government data on the Public Health grant. This recommendation completely misses the point.

The local health and wellbeing board or local drugs board and local authority are the places to consider and address “falls in treatment penetration”. This recommendation seems to want to re-instate the performance management of the old National Treatment agency.

There is enough transparency in the PHOF and other indicators, combined with the new strategy and guidance. We don’t need yet another additional range of measurements.

Conclusion 2

The quality and effectiveness of drug misuse treatment is being compromised by under-resourcing.

 

This is too sweeping, even if they have a point. Resourcing is not the only issue, even though it is an issue. Models of care, changes in demographic patterns and population need get very simplistic analysis in this report in some places.

The PHE and LGA report identified that commissioners have said in a number of places services needed reconfiguration to meet changed need and changed models of service. This conclusion just ignores the joint PHE, LGA and ADPH work on drugs commissioning.

There is another opportunity for ACMD to argue that the public health cuts need to be reversed here.

Recommendations

National bodies should develop clear standards, setting out benchmarks for service costs and staffing to prevent a ‘drive to the bottom’ and potentially under-resourced and ineffective services.

 

 

What do they actually mean by this? I don’t know. I’m not sure they do either.

This isn’t benchmarking, this feels like an attempt to set a national tariff or a minimum payment or go back to the market management arrangements of the old National Treatment Agency. That could have some merit, or it might not. But this recommendation should have been clearer and more focused about what mechanisms and structures they feel will help.

The Government’s new Drug Strategy Implementation Board should ask PHE and the Care Quality Commission to lead or commission a national review of the drug misuse treatment workforce. This should establish the optimal balance of qualified staff (including nurses, doctors and psychologists) and unqualified staff and volunteers required for effective drug misuse treatment services. This review should also benchmark the situation in England against other comparable EU countries. This is a helpful recommendation. Most commissioners I know would welcome a workforce review of skills and workforce needed for the future including workforce redesign. Simply basing workforce on models of workforce pre-2013 is not the answer to the changed epidemiology, policy and financial climate
Conclusion 3

There is an increasing disconnection between drug misuse treatment and other health structures, resulting in fragmentation of drug treatment pathways (particularly for those with more complex needs).

 

This is nothing new, and was recognised long before the new system came into place. We need to do something about it though, and they do us a service by reminding us.

The new drugs strategy, The 2017 revision of the Orange book clinical guidelines and the recent PHE guidance on co-existing morbidities actually provides opportunity to advance this agenda, as does the mental health crisis care concordat.  Much of this disconnection is because the system as a whole is fragmented. Putting treatment services back in the NHS won’t solve that.

Recommendation

Local and national government should consider strengthening links between local health systems and drug misuse treatment. In particular, drug misuse treatment should be included in clinical commissioning group commissioning and planning initiatives, such as local Sustainability and Transformation Plans (STPs).

This is a mostly sensible and welcome recommendation. Inclusion in STPs and strengthening links good, and making links with CCG and other plans. But has ACMD forgotten we have Health and Wellbeing Boards? (Ok, they’re not always wonderful either, but please, don’t just ignore an entire sector.
Conclusion 4

Frequent re-procurement of drug misuse treatment is costly, disruptive and mitigates drug treatment recovery outcomes.

 

 

Procurement can be a two-edged sword, if not done well and purposively. It can be a great tool for developing quality, and it can be a disrupter. The key thing here is to do it well and sensitively.

This conclusion could have been more nuanced, and identify in much better detail some of the ideas and suggestions for making this happen. There are numerous reports of places where re-procurement has been necessary to secure service improvement.

Recommendation

Commissioners should ensure that recommissioning drug misuse treatment services is normally undertaken in cycles of five to ten years, with longer contracts (longer than three years) and careful consideration of the unintended consequences of recommissioning. PHE and the Local Government Association (LGA) should consider the mechanisms by which they can enable local authorities to avoid re-procurement before contracts end in systems that are meeting quality and performance indicators.

 

In and of itself this isn’t the answer. Long contracts with a complacent provider don’t help anyone. I think the report though is calling for some kind of stability and relationship, and that makes sense. A key issue for us as commissioners is how we work well with the rest of the system to do that. To my mind this is a call for better system leadership and commissioning, and seen in that light we should give it serious thought.

Procurement is part and parcel of the legal framework of commissioning and providing services, many other areas have used it to improve outcomes and there is evidence that this has happened since 2013 on a range of public health services.

Procurement conducted well can remove unintended consequences and be a tool for improving quality, cost and outcomes. Done badly it can have the effects the report laments.

Systematically seeking to avoid re-procurement is both unlawful and seeks to thwart the intentions of value for money and effectiveness that procurement can, used well, address.

Conclusion 5

The ACMD is concerned that the current commissioning practice is having a negative impact on clinical research into drug misuse treatment across NHS and third (voluntary) sector providers. Many treatment providers are third sector and current research structures are not designed to recognise them. System churn due to recommissioning and reduced resources mitigates the stability and infrastructure required for research.

 

This is not new. Drug treatment services in many places have long been outside the NHS, and issues of research capacity, research structures and even things like provision and management of Specialist Registrars and Speciaist Trainees have been issues. We do need to ensure these issues are addressed constructively.

 

 

 

Recommendation             

The Government’s new Drug Strategy Implementation Board should address research infrastructure and capacity within the drugs misuse field. Any group set up to work on this should include:

·       government departments;

·       research bodies such as the Medical Research Council (MRC) and the National Institute for Health Research (NIHR); and

·       other stakeholders.

A sensible recommendation which we should support , but it should also include commissioners.  The lack of mention of local authority commissioners, once again, feels sadly like distrust.

 

 

 

 

 

 

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Chemsex: Why should it be a Public Health issue?

 

I don’t know about anybody else, but I can’t help thinking that the issue of chemsex is one we are still not really getting our act together on.  I claim no specific expertise here, but what I do know is this issue is impacting on the health of our population, and an already vulnerable one at that, so we need to act. And I have several friends and colleagues from across the country -the youngest 24 and a student, the oldest 50 and a professional in the City, whose processes of getting out of the harm they’ve come to I have helped with.

We seem to have depressingly little in the way of national leadership or action on this from the Public Health community, with the work of some dedicated individual clinicians and community activist -step forward David Stuart and 56 Dean Street, Greg Owen, Matthew Hodson, GMFA , James Wharton, MenRUs, Burrell Street Clinic for their Safer Chemsex Kit and a few others being most visible. I have provided links to several pieces of this work in the footnotes, but let me also direct you to  London Friend’s work on LGBT drug use and recommendations for treatment services .  I hope anyone I have missed off will forgive me.

It is simply unacceptable for the skills and resources of the Public Health profession to be absent from this issue.

I was discussing this today at another meeting. I said to a colleague from another agency “people say we don’t have a problem locally” and before I could continue to say “and they’re wrong” he interjected, “they should just open grindr, it’s everywhere.”

The use of some kind of substance to enhance sex is known and common throughout history (drinks while dating?) And if people are fine about that and use without harm, then I don’t feel it’s my business.  But recently the phenomenon of chemsex has become a bit better known than it was. A search of MEDLINE and PSYCARTICLES when I was doing a quick review to inform this blog, after removing duplicates, found in 2014 3 papers, a search for 2017 found 48 papers so far in the health and psychological literature.

Chemsex is a term for a complex of behaviours – use of dating apps to have parties where sustained group use of drugs happens, particularly drugs like cocaine, crack, GHB (gamma hydroxybutyrate) and crystal methamphetamine. Sex is often but not always a given at some of these parties. Slamming – injection of drugs for quicker highs, sometimes happens, and with it sometimes sharing needles.

While it may be more of a scene for gay men, bisexual men and heterosexuals do it too. What will that pattern will be in two years time? We know that trends started by gay men sooner or later get picked up by the wider heterosexual world, or am I just remembering disco through rose tinted (glitter encrusted) spectacles? (Showing my age there.)

Increasingly, use of chems or drugs is reported by men using dating apps for 1-1 encounters too. Recent work has shed more light on the multiple motivations and issues at play.  From the many paper available, I have a few which I think resonate. Weatherburn et al[1] identify a range of motivations linked to “enhancing the qualities valued in sex” including enhancing attraction, heightening sensation, intensifying intimacy and connection and, for some men, overcoming lack of libido. Media attention[2] and the interest of the scientific press[3] seems to have been somewhat limited to date.

The increasing intelligence from reporting by clinicians and community groups of problems presenting from chemsex is concerning. From understandable motives – socialising, feeling good, enjoying sex and coping with life pressures are reported as factors, certainly in GHB use for some time[4] , the drug use is primarily intended as a facilitator of these. But clinicians are reporting a range of harms including addiction and other sequelae.

Dedicated professionals like David Stuart and others working on this issue[5],[6] have brought greater light on chemsex. The publication by James Wharton of his chemsex experiences[7] in Something for the Weekend and the associated meda reporting[8],[9]have gone some way to cast some light on this as an issue which needs addressing.

Parties are not the only places, however, where chemsex is becoming an issue. Increasing use of chems with sexual hook ups means some men may rarely have sex sober. It’s not just physical risk, but psychological. Intimacy may become associated with being high, and for some, dependent on it.

Prevalence

A 2014 BMJ editorial suggested a minority of men engage in chemsex[10] but community reports suggest this is growing and becoming more prevalent. There are as yet no robust epidemiological estimates. Weatherburn et al report up to 18% of men from three London Boroughs uses cocaine and 10.5% GHB compared to 4.8% and 1.6% respectively of men elsewhere in England[11].

Wharton quotes estimates that a gay man dies in London from GHB overdose every 12 days but very few have been high profile[12]. Estimates of prevalence vary in recent reports[13] but what is clear is that this is becoming an increasingly prevalent presenting problem in sexual health clinics, and few services as yet seem prepared to address it effectively.

Harm

There are also some people who seem to be able to use drugs regularly without seeming to come to harm. If people genuinely can do that safely, and we can help them successfully avoid harm, then my interest ends there. But many do come to harm, and it’s those who experience harm in any form I’m interested in here. And the harms from chemsex can be wide.

Whether or not this is a minority phenomenon in terms of the population, the harms to some users are significant and the barriers to accessing services also important disablers of helping men deal with harms arising from chemsex[14].

What we don’t know reliably is how many men engage in chemsex without coming to some form of harm. Most data from clinics and the small amount of research to date identifies some kind of harm. A spectrum of harms across physical, psychological and social health is possible. Some of the documented and reported harms are shown in Table 1 below. But this isn’t exhaustive.

Table 1: Harms from chemsex

Physical Health ·      STIs, HIV and other Blood borne viruses

·      Physical effects of comedowns

·      Risks to circulatory system from injection

·      Respiratory risk from frequent use

·      Risk of death from overdose

·      Disrupted sleep patterns, anorexia, weight loss

·      Impaired immune function

 

Psychological/Mental Health ·      Use of chemsex to facilitate social contact and overcome loneliness, isolation

·      Coping mechanism for stigma and homophobia

·      Impact on coping skills, sleep, employment, cognitive functioning

·      Impact on relationships of becoming habituated on having sex while using drugs

·      Psychological impact of financial problems from financing habit

·      Impact on identity integration and acceptance

·      Bereavement from people in social networks dying as a result of G

Social health ·      Group identification

·      Coping with stigma

·      Holding down a job and responsibilities

·      Risk of debt and homelessness

·      Criminalisation for possession of drugs and sometimes dealing

 

Public Health Issues

Chemsex is not just a drugs or an HIV or a sexual health issue. For most men it seems to be linked to a complex manifold of issues. From the physical risks to health, to the psychological risks and impact on lifecourse development, there are significant issues which impact on the populations and individuals who use it.

I have spoken, written and presented elsewhere on how the need to ensure LGBT populations are able to live happily and successfully across the lifecourse must be a public health issue[15],[16]. So I won’t repeat that here. One of my worries is that chemsex for some can hamper or impair that process.

The mental health impact of being unable to have sex or be intimate unless high presents a number of challenges. But there is another set of issues. If some gay men use chemsex to cope with stigma or feelings about being gay, that must be seen as potentially problematic. It is a commonplace in psychology of LGBT populations that a key task is identity integration and acceptance[17]. Theory and evidence assumes that identity integration and assimilation is crucial to health and wellbeing outcomes for gay men across the lifecourse[18],[19],[20]. It is assumed to be especially important to ensure inclusion for LGBT people in education and employment. If chemsex disrupts such processes, or means a population or sub-population of gay men can only feel good enough about themselves where mediated through drug use (either individual or in groups), there may be significant avoidable psychological morbidity as a result. If what Wharton says about younger gay men finding it easy to get into this scene is true, then that has worrying implications about the ability of those men to form attachments and integrate their identity as they grow, with potential maladaptation and poor coping and mental health across the lifecourse[21].

Policy frameworks and action

While chemsex is mentioned in the new UK Drugs Strategy, there has been much criticism of the lack of commitment on what to do about it[22]. There remains no coherent public health response. Community harm reduction approaches[23] including safer injecting kits[24] are most visible interventions with the best available frameworks for clinical response being those developed by David Stuart[25] There is as yet no clear national policy framework or consensus guideline on what can or should be done. Community intelligence is still crucial to developing action on this, and we need to find ways of making sure we capture and factor that into response planning, on a more agile basis than we sometimes do.

What can be done?

A range of action is needed, and this needs to be revised as we know more. I group suggested actions under domains here.

Domain 1: Establishing prevalence and incidence

  1. We need as clear a picture of prevalence, service use, harm, morbidity and mortality as can be compiled, nationally and locally
  2. Including and using community intelligence in this development will be crucial
  3. Asking about chemsex use should become a routine question in sexual health services on the electronic patient record

Domain 2 : Harm Reduction strategies

  1. We need to work with providers of dating and sex hook-up apps to target information on harm reduction to users engaging in chemsex
  2. The current good practice (chemsex care plan and harm reduction information and kits) should be rolled out to those areas who identify they have a developing issue
  3. Support harm reduction including continued information and kits to reduce harm
  4. Agencies could consider safer chemsex courses as a way of helping reduce harm including teaching people skills of what to do about GHB overdoses
  5. Agencies should combine efforts to make available a single reliable source of information on reducing harm from chemsex and where to get help
  6. Sex venues should consider placing information on chemsex and where users can get help.

Domain 3: Service response and readiness

  1. Most chemsex users don’t find drugs services resonate with them on the whole. We need to identify what drugs services and sexual health services can to do address this and roll it out
  2. Sexual health and drugs services should identify what they can to do ask gay men about, identify and respond to chemsex issues, and develop collaborative approaches to sharing skills
  3. Those services should become skilled in particular identity and lifecourse issues facing gay men
  4. Services should consider whether they can recruit people recovering from chemsex harm to work with those seeking support
  5. Drug services should consider as part of this work both the LGBT supplementary guidance of the NEPTUNE programme work on NPS ,the London Friend work on drugs services and LGBT populations and the work of David Stuart

Domain 4: Developing consensus on interventions

  1. Agencies working on this should convene with experts on drug use, sexual health and LGBT development to develop some consensus guidelines on harms and issues, and intervention strategies, and keep this under review.
  2. Learn from the work being developed by the London Chemsex Network as part of this

Domain 5: Community resilience

  1. LGBT community groups who provide social groups or counselling facilities should consider what they can do to continue to support gay men with lifecourse identity development
  2. Employers with large numbers of gay men in population centres likely to be affected should consider what resilience and support packages they can put in place for employees with performance issues arising from chemsex

 

[1] http://sti.bmj.com/content/93/3/203

[2] http://www.newstatesman.com/politics/health/2016/04/what-chemsex-and-how-worried-should-we-be

[3] https://www.newscientist.com/article/2140756-what-is-chemsex-and-why-is-the-uk-government-worried-about-it/

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3611333/

[5] https://gregowenblog.wordpress.com/2015/10/17/chemsex-the-film/

[6] http://www.davidstuart.org/

[7] Wharton, James (2017) Something for the Weekend: London : Biteback Publishing

[8] http://attitude.co.uk/exclusive-former-british-soldier-james-wharton-opens-up-about-addiction-chemsex-culture-is-now-gay-culture/

[9] http://www.telegraph.co.uk/men/the-filter/11942081/Nine-things-you-should-know-about-GHB.html

[10] http://www.bmj.com/content/351/bmj.h5790

[11] http://sigmaresearch.org.uk/files/report2014b.pdf

[12] http://www.bbc.co.uk/news/magazine-35976705

[13] https://www.lambeth.gov.uk/sites/default/files/ssh-chemsex-study-final-main-report.pdf

[14][14] http://www.bmj.com/content/351/bmj.h5790

[15] https://www.slideshare.net/jamesgmcmanus/british-psychological-society-sexuality-and-wellbeing-symposium-a-public-health-perspective-on-lgb-populations

[16] https://www.slideshare.net/jamesgmcmanus/lgbt-public-health-agenda-idahot-2016

[17] https://msu.edu/~renn/BilodeauRennNDSS.pdf

[18] https://pcilab.ucsc.edu/wp-content/uploads/sites/472/2017/06/Hammack-et-al-2017.pdf

[19] Hammack, P.L (2009) The Story of Sexual Identity: Narrative Perspectives on the Gay and Lesbian Life Course New York: Oxford University Press

[20] https://www.ncbi.nlm.nih.gov/pubmed/12666737

[21] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215279/

[22] http://www.independent.co.uk/news/uk/home-news/drugs-treatment-strategy-government-criticism-problems-campaigners-a7841986.html

[23] https://www.gmfa.org.uk/Pages/Category/safer-chems

[24] https://www.menrus.co.uk/drugs/introduction/

[25] http://www.davidstuart.org/care-plan

New Government Drugs Strategy for England; One and a half Cheers

The Government has released a new Drugs Strategy for England, along with one or two other documents . This strategy needs close reading by commissioners and a range of stakeholders. There is some good stuff in it, but also some disappointments. This is my take. Right now I’m feeling  8/10 for aspiration, 6/10 for clarity and 5/10 for action.

Government says that the economic and social cost and changing population drug trends means a new strategy needed. Fewer drug users are coming into treatment and those under 25 who use opiates entering treatment for first time has fallen substantially. By contrast they say, there are more adults leaving treatment successfully but rates vary between best and poorest performing local authorities, and rates have levelled off in recent years with a decline in opiate users leaving treatment successfully.  The increase in drug related deaths requires action, but some are still working out what.

The aim is “to reduce all illicit and other harmful drug use, and increase the rate of individuals recovering from their dependence” and  they will be “taking a smarter, coordinated partnership approach;“  What’s not to like?  Well, this is a mixed document. Some great and welcome stuff, some areas where it remains to be seen what will change and some areas where, frankly, they could have done much better, even without funding. The question I have had in my mind throughout is “will this strategy serve people better?”  In some cases, undoubtedly yes. In other cases, much more could have been done.

The logic model of this strategy is an implicit one.  Joined up responses and local stakeholders with greater transparency. It is a massive missed opportunity that that significant and positive logic remains poorly, if at all, articulated across this document.

The legitimate role of the state in drugs

There is a debate to be had on what the interest of the state in drugs is. Indeed, there are lots of people who think they’re having that debate. Some of them though, seem to be longer on rhetoric than evidence. The influence of this debate, including the recent (and for my money patchy and inconsistent) report by FPH and RSPH on drugs is conspicuous by its absence.  My interest is harm. Where there is harm or potential for harm to people or communities, then we need to act. Where there isn’t, I’m not sure I, personally, have a role.  If people are using drugs without any harm or potential for harm, then that’s much less of a priority for me than those who really are harming themselves and others. I’m aware that this varies across government; customs and police have different as well as shared interests to me, and reducing supply remains important even if we only see that as a way of reducing crime. It’s important. But this strategy could have done a basic network analysis of those to guide us all on what we should focus on. That is left to local areas, if it is done at all. And that’s an omission.  All of that suggests to me that the policy agenda on this continues to remain short on the joined-up thinking we need to be mirrored at national, regional and local levels.

Responses from the people who will end up doing the work

The Association of Directors of Public Health (ADPH) and the Local Government Association (LGA) have both responded to the strategy.  The ADPH statement points out:

  • “The local response will require Directors of Public Health to continue to play a central role and we can no longer avoid the fact that cuts to the Public Health Grant are damaging to government’s ambitions. There is no long-term vision in this strategy to ensure services are adequately funded.”
  • “The pressure on Directors of Public Health and Local Authorities could have been easily addressed by reversing the cut to the Public Health Grant; the announced cuts total £531M while additional expectations continue to be created.”

Meanwhile the LGA response, while affirming that “Local government will continue to play its part in working with national government to deliver on our shared ambition to support those individuals and their families devastated by the harm caused by drug misuse” points out that  “we have long argued that reductions by central government to the public health grant in local government that is used to fund drug and alcohol prevention and treatment services is a short-term approach and one that will only compound acute pressures for criminal justice and NHS services further down the line.

It concludes “Leaving councils to pick up the bill for new national policies while being handed further spending reductions cannot be an option. Pressure will be placed on already stretched local services if the Government fails to fully assess the impact of their funding decisions.”

Key things for a Director of Public Health to do

For all the lack of mention of Directors of Public Health (not once in over fifty pages), there are numerous mentions of Local Authorities, and the document implies the system role we have will continue. The key challenge is to turn this strategy from paper to opportunity. That is just not going to happen without Directors of Public Health, local authorities more widely, police, voluntary sector and a range of other stakeholders working together locally. So the lack of even a basic acknowledgement of this beyond the repeated use of the word partnerships is at best, disappointing.  At worst, it suggests a lack of ability to think about systems approaches, despite the fact the strategy implies – and here I fully support it – we need whole systems approaches on this.

The key action for DsPH is to identify what we need to do to build effective local partnerships across reducing demand, supply and building recovery and work on this.  We should welcome the focus on partnership, evidence and transparency, as well as the lifecourse approach.

We should also recognise that no single agency will in reality be well placed to deliver most of this, it requires comprehensive action by a range of stakeholders.  But the role of local authorities and Directors of Public Health needed a somewhat better elucidation than is in the strategy, and to be honest, the role of national government gets little explanation. This document is long on ambition, short on conceptualisation and patchy on action. It will be important for local leaders to fill in these gaps if the ambition and opportunity the document rightly tries to set us towards is to be realised.

At best this document is welcome clarity and focus with very little specific commitment.  PHE will face new demands to support. We need to hold PHE to account to deliver this well and effectively, and to add value in the system. That varies by region and Centre, if PHE’s own stakeholder survey views are anything to go by.

Drug related deaths, lifecourse approach, recovery, prescription drug use, chemsex, NPS, working with police, better offender management, drug testing on arrest and more are all on my agenda. Some of this document helps, some of it still leaves us on our own to sort it out. It’s a shame that the leadership role of local authorities in this is mentioned more implicitly than explicitly.

Background

The strategy is owned by the Home Office, but it’s clear this has been significantly influenced by Public Health England.

There is no new money but several re-announcements of existing or previous money. While there is not a single mention of the Director of Public Health, it seems existing funding through Public Health Grant (until 2019) and the commissioning responsibilities of the Director of Public Health will remain.

There are lots of good intentions on partnerships which seem to boil down to a national strategy board to hold local areas and other work to account.  While one can see where concerns of different stakeholders have sometimes got through, this strategy feels written close to the chest of government, and what feels like lack of concrete commitments in some places, vague promises of support and work in others shows that. In a time of austerity, why did we not get the system together to work out what we could do without money. I think we would have had a better product.There are a number of things to be welcomed but this could have been a much better document with that approach.

The commitments on Families, for example, are spread across the document but beyond saying PHE will work with drug and alcohol family courts , produce a toolkit for local authorities and an exhortation that “evidence based psychological interventions which involve family members” should be available, there is often not much to go on.

Much of this gives PHE a significantly enhanced role of support or guidance, though some will argue that this is what they should have been doing anyway, and there is little in the way of detail on what will actually happen. The use of “support” occurs 150 times throughout the strategy and “work with” 17. But there is precious little detail and some will wonder about PHE’s ability to deliver.

The strategy seems to verge between a deficit approach “local areas need support” while recognising and exhorting local partnerships to do better at other times. This feels like it could have been better thought through.  Its really good they want local areas to be more effective but the relationship set out in here feels extremely one sided.  Will local commissioners have representation on the new national Board? If not, why not?

For all their talk on partnership and integration, the model still feels like it veers towards national doing to local and holding them to account.

Measuring outcomes gets various mentions with, on page 36, its strongest statement, a framework of measures and outcomes from treatment to recovery. A homelessness and housing measure, and measures for crime, mental health and employment will be added.  Without the impetus or requirements for agencies to work together though (and this never gets beyond exhortation in the strategy), this will be more difficult to achieve if local relationships and co-ordination don’t prioritise this. Good idea by government, but have they really thought through how to make this drive change?

A section on governance is perhaps most disappointing of all.  Given everything that could be done locally to address some of the aspirations of this strategy, there is only a commitment to a national strategy board (fair enough, that will be useful) which will “ use greater transparency and data on performance to support action by local services to deliver the best possible outcomes and monitor progress.” The old National Treatment Agency’s obsession with performance management by another name perhaps?

There will be a National Recovery Champion who will sit on the Board, provide leadership, support collaboration, seek to address stigma and act as a ministerial envoy. Well, as a change tool, this has mixed reviews. Has government learned little from the mixed experience of Tsars, Czars and Tzars across clinical areas, public sector transformation and drugs among other areas since 1994?

The statement that “the Care Quality Commission will play a vital role in assuring quality” is very welcome, provided CQC does better at understanding what it is we are all trying to achieve. The document talks about quality in an encouraging way. That’s good. But we need to work together to recognise it, and there is little concrete here to go on. Take for example what good looks like for specific populations. There are sections on specific populations across the document. These range from really welcome but could be stronger (dual diagnosis issues) to tokenistic and feels like government doesn’t actually know what to do (chemsex.)  The phrases “good practice” appear throughout. What this looks like across any area remains to be seen.

I’m not going to cover the global action chapter which feels more like its relevant to people other than local commissioners.

 

Reducing Demand – adopting a lifecourse universal approach

I count at least 20 commitments in this and other chapters on this:

  1. PHE will help local areas by providing professional guidance for midwives, health visitirs and school nurses under health child programme
  2. Providing support and guidance to LAs including systems to support integrated commissioning and delivery from 0 to 5
  3. Supporting school nurses, youth workers and community services to work together
  4. Providing information through child health profiles
  5. Encouraging schools and teachers to “develop their practice”
  6. Encourage prevention strategies in schools
  7. Develop resources and share them, and monitor existing programmes
  8. Specialist substance misuse services should link with wider childrens’ services
  9. Govt says they will support youth offending team to work with individuals
  10. Action on families : PHE will wotk with Family Drug and Alcohol Courts and local public health teams to improve outcomes and the existing Troubled Families programme. No mention of Family Safeguarding. The strategy later commits that PHE will develop a toolkit for LAs to support response to parental substance user
  11. Vague and unsatisfactory commitment on intimate partner abuse (page 12)
  12. In depth research on sex work
  13. Homelessness work will be done through the Homeless Prevention Programme (but nothing specific on drugs)
  14. Expectation to continue to work together on veterans drugs issues nothing concrete other than provide tailored pathways
  15. On Older People Advisory Council on Misuse of drugs looking at evidence on older people
  16. On new threats they talk about novel psychoactive substances (NPS) and will establish a new clinical network of experts and clinicians.
  17. In prisons NHS England has carried out a review of its commissioned provision and will increase focus on NPS
  18. Neptune II – an NPS programme, will be promoted more widely across the field
  19. Chemsex – PHE will support areas by providing guidance on close collaboration between sexual health services and community groups
  20. Misuse of prescription medicines – “we will support local authorities and CCGS so people dependent on medicines can access suitable treatment”

Some of this is good, some feels like a litany of “things we must mention” rather than a coherent set of strategically thought through concentrations of effort. Little of this seems to have much in the way of strong evidence base and the strategy seems to assume beyond pilot areas mentioned that it isn’t happening already. Some of this may be useful but this feels like doing for the sake of doing. Phrases like “encouraging” schools, seems to have little in the way of teeth given how government feels this is urgent. Some encouraging noise about universities’ role are given, for example, but no clear action. There is an incredibly weak statement on prescription medicine use especially given what others are doing about it

Restricting Supply Chapter

There are some new actions but mostly targeted at national level.  Some specific commitments to be welcomed include:

  1. Govt will look at options to make improvements to drug driving regime including remedial courses
  2. Look at how anti social behaviour legislation can be used to tackle drug related offending

Sub chapter on Drug Related Offending

This section  is mixed. There are some good things in here and if we work on them we could make the system work better. Some things need greater elucidation, though.

  1. Encouraging wider user of drug testing on arrest.
  2. push for drug testing to be more consistently available in the community so it can be part of a community or suspended sentence (feels like a backwards move for some areas)
  3. Early intervention for offenders through “better integration” with community mental health and substance misuse services
  4. Increase use of treatment as part of a community sentence including a protocol for drg rehabilitation
  5. Considering what to do following the pilots on out of court disposals
  6. Against the background of prison reforms, do more to restrict supply in prisons including testing and treatment. A specific list of actions and committments
  7. Some vague statements about local partnerships
  8. They will work with integrated offender management arrangements to share practice
  9. Continue to support heroin and crack action areas

We need to turn some of the very vague statements like “we will work with” into concrete actions. This section of the strategy seems strongest on the national enforcement and supply restriction work and work in prisons.  Buzzwords like better integration and vague words about local partnerships are welcome signs of intention but we need to turn these into action. The National Strategy Board will not achieve this unless it develops strong local relationships.

Building Recovery

This is, sadly,  probably the weakest chapter, even given the welcome but weak  lifecourse section.  There is a very welcome reminder of support after people finish treatment and a useful (page 31) and a list of points on things to enhance recovery. I like this checklist.   A good highlight is an emphasis on working from custody to community and actions to reduce drug related deaths.

But other than one or two pieces of action, it feels largely like most local commissioners are left on their own with the promise of PHE “support.”  All in all a missed opportunity for government to play its part much more synergistically with local commissioners.

A section on commissioning starts by saying nobody should be left behind, confirms the extension of the ringfenced public health grant to 2019 and says there will be greater transparency through building on the Public Health Outcomes Framework to “hold local areas to account” and then talks up the £30m Life Chances Fund and £10m payments to homelessness prevention programme. While the latter is very welcome, this section seems to say little of any use.  Again, some useful pointers but it’s up to local areas to make of this language of intention what they can.

Later in the strategy they commit to expanding the measurements of outcomes and treatment indicators (page 36), which could be very useful for commissioners and local stakeholders. Transparency is good.

I support recovery as part of response to drug and alcohol use. I really do. But evidence for recovery approaches is still building and in some areas is patchy, so the statement that  ACMD has been looking at the commissioning of drug treatment and recovery services and the impact this can have on recovery outcomes for individuals and communities is really welcome.  We need much more evidence and improving practice. But they could have recognised here that actually some of the providers around the country are doing amazing work. The commitment to “carefully consider any recommendations to inform future policy” from this while welcome, feels a let down given how important this area is. We need to be even more dynamic as a field on building and implementing evidence of what is effective.  Government’s leadership role in this alongside the rest of us is not well articulated here.

Commissioning

A re-iteration of need for local partnerships contains no specific commitments on doing anything to support them.  The 2007 guidelines on commissioning have, however, been updated, which is welcome.  PHE will support and share guidance and there will be a broader set of indicators (feels like they’ve already said this several pages earlier.) Commissioners “should” develop quality governance structures for drug treatment linked to safeguarding procedures for children and adults. (page 30.) The advice that we address quality in rehabilitation and detoxification is welcome .  But there is no indication of what quality looks like and this strategy is not going to give us it.  The proof will be in how agencies work together.

Workforce

This is a major issue in our field. There is a welcome statement on ensuring we continue to have the right workforce including working with HEE and Royal Colleges.  What will the National Strategy Board to do support this is my question back?

In particular I welcome the statement that Government will “work with Health Education England and other stakeholders, in line with the Five Year Forward View for Mental Health recommendation, to support development of an appropriately trained and competent workforce to meet the needs of people with co-occurring substance misuse and mental health conditions. “

If these commitments happen, it will be all to the good and it’s good the strategy recognises that.

Perhaps one of the most long awaited announcements has been the outcome of the Dame Carol Black work on drug use and employment.  Nothing really new here. Universal Credit will still roll out, JobCentres will have a “transfored roled” and a new “Work and Health Programme” will provide support to people who are long term unemployed and give early access to people with drug issues.

Finally, I strongly welcome the recognition of user engagement but this could have been better phrased. The section on peer-led recovery, by contrast, feels weak and beyond a mutual aid toolkit for peer support exhorts local areas to “support community based initiatives which promote and sustain recovery”

 

 

 

 

 

 

The Strategy Question

It feels like strategy is flavour of the month. (That’s not a bad thing.)  Our own second Public Health Strategy for Hertfordshire is in consultation right now, and I have been asked to help with Strategy development for two national voluntary agencies I work with and a major local charity. Meanwhile the County Council’s Corprorate Management Team had a strategy afternoon (always useful) and the Prevention workstream of the STP has to deliver its prevention workplan.  Strategy is ever present.  It must be the end of the financial year!

Yesterday a very enjoyable and enlightening twitter conversation was started by J Thompson-McCormick on public health strategy, which prompted a range of folk I respect and whose views I learn from to tweet their take on strategy. What struck me was the variety of takes, but some ever present common themes.

That prompted me to do a bit of reflective learning.  I produced my first strategy in 1990 as a new local government officer.  Since then I have lost count of the number of strategies I have led, had a hand in or simply advised on.

When I came to Hertfordshire I led the process of our Public Health Strategy in 2013.  I learned that Hertfordshire likes a “plan on a page”  – whatever you do a graphic representation helps. This year I had nothing of value to add when my team did the work with others and did it brilliantly. To me that’s success. They get it. Actually being able to let them do it and clear the space for them was my most useful contribution.  What that showed me was that there probably isnt enough space to put a cigarette paper between my ambitions and those of my team. I couldn’t be happier about that.

Some folk think our first Herts Strategy was too detailed ( to be honest. it’s somewhere between a strategy and a business plan) but it does have a strategy on a page. And it was detailed for a reason – Public Health was new to local government and I had to both set out our stall and get permission to do things. I don’t need to make it so complex now. Strategies and our approach to them should adapt and change with circumstances. Now I have to work out how we deliver public health in a very straitened set of financial circumstances and a different partnership and governance world. Some fundamental drivers for our strategy (money, partnerships) have changed. Our approach to what the strategy looks like must too.

The absolute fundamentals

What nearly thirty years of doing strategy has taught me is that there are multiple ways to do strategy, and the acid test is whether it gets you to where you need to be as an organisation.

When I worked in the private sector we had people who used the Strategic Planning Society knowledge and people who used Operational Research techniques, and indeed these can be crucial in the mix of doing good strategy.

I’m convinced that the private sector remains better at intersectoral collaboration – read partnership – than much of the public sector.  In my experience private sector partnerships are driven by constantly articulating and driving out the value to each partner, however that is expressed, rather than having a competition about who can fit the biggest pile of caring-sharing management speak into strategies. We could learn an awful lot from that.

The fundamentals of strategy

I think there are only seven fundamentals of Strategy, and those given below are mine. I don’t expect anyone else to agree. I still find a Harvard Business Review article from 2010 on the Five Questions of Strategy hugely useful. That piece begins with the sage advice that “People make strategy more than it needs to be.” There’s a fairly similar piece in Forbes I like to refer voluntary groups to. NCVO produces four extremely good and short videos on strategic planning for the knock down cost of £8.99. These are brilliant and I have used them many times with groups. So use what works for you, don’t assume any single person has THE formula.

1. Does it get you to where you need to be given the context you face? (And no, let’s not analyse that to the nth degree right now.)

2. Does it deliver the value you need, however you conceive that? (partnerships, outcomes, services, income)

3. How do you do it with the least cumbersome set of paperwork and processes?  If you have to read across nine documents to work out what you need to be doing, you’ve probably got something wrong.  Anyone who tells you rigidly you must have a strategy, a business plan, a delivery plan and a suite of strategic action plans may have it right for them, that doesn’t mean it’s right for you. There is NO hard and fast rule here. A strategy should ideally be a simple high level document with a “how will we get there” plan underneath. But if you combine the two, then that’s fine. That doesnt make it bad strategy. Failure to get results makes bad strategy.

4. Do the science (information, data, numbers, evidence), the art (influencing, leadership, stakeholder views and values) and your instincts (this feels and looks right given the issues we face) chime to tell you across all three of those domains this is right?

5. Strategies live and breathe and change, so expect to be in a different place by the time you get there. The key is whether you adapt as you go.

6. At a glance – can you graphically summarise and represent your strategy on a page?  No?  Then it’s too complicated.

7. Leadership and culture. The English public sector context is now such that leadership across distributed functions and responsibilities is the key to outcomes. Running empires is a dead leadership tactic for a passed financial era. (That doesn’t mean you let others control you or your budgets. Be a strategic dealer, not a doormat.)  Writing a business plan entirely on your own without any reference to anyone else (step forward several bodies we could all name) shows a signal lack of understanding this.  Leadership which is about getting my organisation somewhere without reference to others is folly.  Leadership which is about ensuring my organisation and others get to where they need to be is hard work, frustrating but essential. Producing a strategy in secret then expecting stakeholders to sign up (the early STP process) is just about the worst way possible to develop strategy and doom it to failure. Do the exact opposite of what NHS England did in directing Sustainability and Transformation Plans in their first six months and I suggest you won’t go very far wrong.

An example

I still think the best strategy I ever worked on was the Catholic Church’s national strategy on influencing healthcare. (As background, in case you’re wondering, over 200 care homes and facilities like counselling centres, with 3,500 projects are run from over 300 Catholic agencies in England and Wales, contributing an estimated £1.2bn of value to health and social care. Recent analysis of ONS data suggests that, compared to their size in the population, Catholics are eight times over-represented in the health and social care workforce in England. )

We had three priorities, suggested by Anthony Levy (an atheist, incidentally) , a man who’s done more strategy than I’ve had coffee, and whose style, take and modus operandi I just love:

  • Gathering – bringing people together to support each other and influence others;
  • Guiding – articulating why based on ONS data, Catholics are eight times overrepresented in the health and social care professions compared to the general population, the values behind that and why a belief in human dignity drives us to work in health and social care
  • Giving voice – Showcasing work, celebrating good practice, sharing what we do

Those three priorities, three years on, spurred action at national and local level with over 200  projects. And we monitor progress and impact under those three themes.  Consultant clinicians, bishops, domestics and policymakers worked together to produce it. We start the next strategy process in April 2017.

Getting to a good strategy

So, if those are the fundamentals, how do you get there?  In reality, there are multiple ways, and I don’t think I’ve ever stuck exactly to any single formula. The only must do is include people who are relevant – people who will deliver it, stakeholders, end users of this, politicians, leaders, anyone you expect to have on board.  I once started a strategy process by gathering people who couldn’t agree round a blank flipchart, said “what do we want to achieve? And we’re not leaving the room till we get agreement” and they produced a very clear set of five strategems within two hours, with some robust facilitation!

On another occasion I got buy in from a group that I would produce an initial rough position paper that they would rip apart and put back together again. And they did.  Usually I like to start with someone describing the situation and context, mutually identifying some principles of what will get us through, and then getting the group to articulate and produce a broad framework.  And then, usually, you have to have a small group work up the detail and come back for validation, amendment and augmentation.  Strategy by committee is painful. Strategy by whole town meeting is impossible.

Where on earth do I start?

Why not start with reading the Farnam Street Blog piece A primer on strategy and then some of the links below?  You may or may not then wish to read Richard Rumelt’s book Good Strategy, Bad Strategy if you have the time and inclination.  Then you need to decide on i) what you want to achieve and ii) a process to get there (but one you can change if you need to, in order to get the outcome right.)

The Process of Process

I think however you do it, you need a process to get a strategy.  That means you need to understand, get folk to agree, and then steward the process you’re using.  I like to answer the questions below (and adapt as I go along) so we get a good strategy.  You might find the wickedly helpful Dummies.com strategic planning toolkit for dummies helps. And I know people in private, public and third sectors who’ve used this at my suggestion and say it works.  I’ve adapted some of these principles from a book by Aubrey Malphurs first published in 1999. Others are my own

  1. Who are we?
  2. Why do we do what we do? (Values)
  3. What kind of world are we facing?
  4. What are we supposed to be doing in that world? (Mission)
    1. What are our must dos?
    2. What are our would like to achieves?
  5. What kind of organisation do we need to be to survive? (Vision) What values do we need?
  6. What will success look like? (Outcomes)
    1. How do we measure progress?
  7. How will we get there? (Priorities)
  8. What tools, resources, skills, processes and partnerships do we need? (Leadership, Culture, Skills, Deliverables.)
  9. Who do we need to engage to get a strategy out of this which people own?
  10. How do we make sure we adapt as we go along, and deal with pleasant and unpleasant surprises?

If I had a top tip

If I had a top tip on strategy, it is this. Everyone sweeps and looks forward to the future. Very few when they’ve done that then sweep backwards from the future to today, to see if the plan falls apart, which it often will. Sweeping forwards, then backwards, then forwards to correct is essential in my view.

Stewardship

The role of anyone leading a strategy process is one of stewardship. This isn’t “your” baby. It’s a process you are holding to get a group of people or agencies to a strategy that they can own and invest in. “This ain’t about you, princess.” If you can get folk to buy into this, and it feels right, then you’ve done your job.

Reading and learning

There are multiple tools and books out there. There are expensive courses and Master’s degrees and for some agencies these are useful.  For our purposes they’re probably overkill. I’ve tried to point you as I go along to the cheap and the free and the valuable above. In addition to the resources above, some people find the On strategy stuff useful. Bear in mind though they are trying to sell you their strategy and performance software.  Roger Darlington has a beautifully simple take.  HBR’s 10 must reads on strategy is good.

You don’t need massive sets of books and consultancies on strategy for most purposes.  Business plans and project plans and delivery plans or whatever you call them need detail in them.  Strategies need to blend high level and detail to do them well. In my view this is better produced by the people who will own it with a person or people leading process. Externals, if you use them, are often best to facilitate agreement and ownership rather than write it.

Happy Planning!

Behavioural Sciences for Public Health webinar: the rough guide. 27th April 2017 registration open

Registration is now open for this webinar for busy public health people who want to know  whether behavioural sciences can do anything for them.

Register today for a webinar to be held at 11am-noon on 27th April. This webinar will provide busy Public Health Specialists a route map to understand the breadth of behavioural sciences and how they can be applied in public health, to help increase impact of your plans and strategies. You’ll also hear about the forthcoming national framework for behavioural sciences in Public Health.

Information on joining instructions will be circulated to registered attendees in due course.

Click here to join

Behavioural and social sciences in Public Health: getting consensus

UPDATE

The Webinar is now  open for registration .  Co-led by PHE, ADPH and HPPHN. 27th April. Register here

In 2014 the Chief Medical Officer Dame Sally Davies and others published a paper in The Lancet which argued we need a new wave in public health improvement – if the first was the improvements in life expectancy brought about by sanitary and water engineering, the fifth is cultural. Much debate has followed.  I am convinced that the nature of our society is such that social, behavioural, environmental and cultural factors are very much part of the challenge we face in improving and protecting the health of the population.  Which is why I believe behavioural and social sciences have an important contribution to make in Public Health.

Some promising starts but need more traction – a quick overview of 16 years’ work

This isn’t a new focus. There have been several attempts to do this before. The American Psychological Association produced a book on this 16 years ago, which is still a good read. A 2005 article also outlined some contributions from psychologists to Public Health. The US CDC produced an outline on its work as early as 2006. There were even special issues of the British Journal of Health Psychology in 1998 and the Journal of Health Psychology on the links between Public Health and Psychology.

More recently Professor Sir Michael Marmot asked the British Academy to produce a series of papers on the contribution of social sciences to Public Health. I was on the editorial group and co-wrote the introduction. I think it was a mixed start: some issues were addressed, many not. Much more remains to be done.

I could produce a bibliography and links list as long as my arm on how epidemiology and spatial criminology, public health and crime reduction, sociology and anthropology and lately operational research professionals have been publishing notable books and papers much more widely on their work around public health issues. I am planning a “rough guide” seminar on this. A webinar for public health people wanting a quick overview of how to navigate this whole world is coming in April 2017. (See the bottom of this blog for more details)

Incidentally, operational research methods – called the Science of better have both an affinity with and much value for Public Health at organizational level, so watch this space for another venture for public health in the next year. I’m also currently working on embedding some of these skills in my own organization through a programme where people who have graduated from our corporate leadership programme undertake a hybrid training programme combining public health skills like problem analysis, evidence-based practice and prioritization and operational research skills like problem structuring, problem analysis and modeling, to have a go at solving some of the challenges we face in the next few years.

Finally, several very useful and straightforward resources I would like to draw your attention to are those aimed at public health professionals by the BPS Division of Health Psychology.

The growing system role and appetite in government

Public Health England has been taking more of a system role in this with some great work shown at their conferences. Amanda Bunten (as of yesterday Dr Amanda Bunten!) one of the PHE team was profiled in The Psychologist with a piece which is great reading for anyone who wonders what a psychologist can do in public health. The work of my own colleague, Michelle Constable, was showcased with that or other local authorities in a recent Local Government Association (LGA) publication on behavioural insights for health used in local government.

But despite this and many other examples I could mention, those of us who have been advocating the stronger integration between the behavioural and social sciences and public health seem to be struggling to get much traction beyond some great work on behavior change, with places like FUSE, and the Cambridge and UCL centres being but a few I single out among many.

The Academy of  Medical Sciences report on the health of the population in 2040 applies, in my view, just as much to the need for social and behavioural sciences to work on this area as biomedical sciences.  Social Sciences will shortly launch its own report on the Health of the People. I for one see this as adding further impetus to the need to develop this work.

Public Health England have good reason to tell us that government is now very open to the inclusion of social and behavioural science in public health and a range of other issues. And this can only be to the good. That means the rest of us – practitioners, researchers, academics and commissioners – have an opportunity to come together and identify a way of how we all go about doing this together.

Perspectives

The barriers to greater integration and use  of social and behavioural sciences in public health remain. From the rich discussions people have given their time and energy to recently,  some of those are cultural, some of those are about training those of us did or didn’t get about different professions (in some EU nations they are much better about breadth of foundation training than we are in the UK), but there are two big challenges for me.

The first is mindset – if you see Public Health as a science in its own right, it doesn’t necessarily follow that you are as open as you could be to the insights other sciences have to bring.  But if you see public health as an integrating mindset which takes insights from a range of fields- epidemiology, sociology, psychology, law, biology, medicine, toxicology and so forth – and integrates them to improve and protect the health of the population – then openness to new insights becomes a critical priority not just an add on.  That brings me to the second set. Even if you have that mindset, how do you learn?  To an outsider, the social and behavioural sciences can look fiendishly complex and confusing, and if you have limited time, how do you navigate to insights, tools and perspectives that can help you in your task. The issue of language itself – what do we mean by social science, what do we mean by behavioural science? can put people off. I still remember from my postgraduate psychology training debates on the difference between social social psychology and psychological social psychology that left me thinking the finer debates of philosophical hermeneutics looked simple and non-contentious by comparison.

These are major practice , policy and training issues which we need to find solutions for. I think our efforts to integrate will continue to falter until we address these coherently.

The need to help policy, practice and research meet

This set of challenges were among the reasons I helped found along with colleagues the Health Psychology in Public Health Network. I kept having people saying to me there was a need where practitioners, researchers, academics and commissioners with an interest in this could get support and help. I was determined to make a contribution to addressing this.  In three years we have provided a place where over 1,000 people from students and trainees to academics and policymakers have come together on LinkedIn and in full membership. We try to model the Public Health – Psychology integration. I have just finished an amazing three years as first chair.  Dr Angel Chater, a health psychologist, has now taken over as Chair.  We have even issued our first awards for research students integrating social/behavioural and public health perspectives in their research. I’m hoping a book will come.

Moving as a system: promising work 

I think we are on the verge of a major step forward. Yesterday, 17th March 2017, around 50 people representing a wide variety of agencies and stakeholders convened for an initial conversation on what we could do; brought together by the Association of Directors of Public Health (ADPH) , Health Psychology in Public Health Network  (HPPHN) and Public Health England.  The aim was to articulate the need for a framework for this work, to make the most of how social and behavioural sciences and public health could work together.

A small group with Public Health England, HPPHN, ADPH, LGA, British Psychological Society and Faculty of Public Health had previously convened to discuss and agree the need for work, produce a short document arguing for this, and then convene the stakeholder conversation yesterday.

It has been exciting working alongside Dr Tim Chadborne and colleagues at Public Health England, with the HPPHN and ADPH folks on this.  And yesterday we had people as diverse as local authorities, ESRC, British Psychological Society, LSE FUSE, NIHR, many universities Society of Social Medicine, NICE and many more in the room.

We shared a co-written prospectus for developing a national framework for the use of behavioural and social sciences in Public Health and we asked people for their views on whether this was a good idea. We asked them to identify priorities and challenges, and what we should do next. We packed all this into two hours of work.  And the day went well, even if the technology kept failing us. We have some rich material to write up, prioritise and turn into a plan.

Suffice it to say that the most important things for me were the atmosphere of consensus and good will in the room, and the fact we got enthusiastic support that we needed to do this. A writing group is being convened with a small number of volunteers and we will start to build more partners into the conversation going forward.

The work is only starting, but I think everyone yesterday shared a willingness and a determination to work together.  We’ll keep you posted.

April webinar Behavioural Sciences for Public Health: the rough guide for busy PH specialists | Registration now open | 27th April

 

 

 

 

 

PrEP for HIV…now what?

PrEP for HIV rolled out nationally would, on the figures I have seen, cost less than the NHS spends on dandruff and paracetamol. Much, much less. But does that make it a good investment?  The only way we will find out is through a proper, transparent and robust prioritization process.

The Court of Appeal ruling today means that will now need to happen. The Court has dismissed NHS England’s appeal. It upheld much of an earlier judgment which NHS appealed against. The full judgment needs studying but the effect of the ruling will be that NHS England needs to put PrEP through a fair, transparent and proper prioritization process.

NHS England immediate response

This has been met by a disappointingly grudging and obfuscating release from NHS England https://www.england.nhs.uk/2016/11/update-on-prep/

I’ve blogged elsewhere including in Local Government Chronicle that of course we understand NHS England has to prioritise, the point is it needs to do it fairly and transparently. The tactics over PrEP were distasteful, condemned by charities representing patient groups they tried to play off against one another and, unfortunately, has now cost an awful lot of taxpayers money to confirm what most of us first contended.

NHS England’s news release among other things said three things about the judgment, some of which miss the point:

“First, it establishes that NHS England has the ability but not the obligation to fund PReP.”  Actually that’s been the contention of most of us all along. This is a redundant point.

“Second, it means that should we decide to do so, we would not be subject to legal challenge on these grounds from rival ‘candidates’ for specialised commissioning funding.” Indeed. but the contention of many of us is that NHS England needs to face this fair and square through a proper, transparent and methodologically robust prioritization process. Waving round threats about legal action from others isn’t going to let NHS England off the hook from doing this properly. And NHS England seems to be slow to learn that this is just what happened – NAT and LGA took legal action and NHS England lost. So the point of all this, surely, is prioritise properly and fairly.  Otherwise we’ll end up back in court.

“Third, it overturns the High Court in helpfully clarifying that Parliament did not intend that the NHS was expected to fund local authorities’ public health responsibilities just because they have not done so.”  This is entirely beside the point and is a tenuous reading of the judgment. The point is NHS England CAN , contrary to their argued position, commission prevention initiatives. They contended all along they couldn’t. Let’s not start re-writing the history of the case and its particulars now NHS England have lost.

Things to remember during the coming months

Throughout this and what comes next, we need to remember the following key points:

  • NHS England are up against it financially. But so are local authorities. Working together, not resorting to legal action, is the way forward.
  •  As I said above, PrEP will cost much, much less than the NHS currently spends on Paracetamol, and dandrfuff!  And it will, in cost-return terms, save more. It makes, on the face of it, economic sense.
  • The bigger prize, and a prize the health economic literature is starting to address, is the effect of investing in PrEP to stop the epidemic and end new transmission in England effectively.
  • Fair and equitable prioritization needs to be a key process in the future of health and social care. Time to start now.

The wider issues

Importantly, it is established that NHS England has preventive powers, including powers to prevent HIV and commission drugs like PrEP. This is a victory for good sense and a joined up health and care system, which should put prevention at its heart. This decision makes good sense

  • for the taxpayer, because it enables an intervention that will save more than it costs to be commissioned
  • for people, because we have another powerful tool in the armoury of HIV prevention
  • for a strategy to end HIV transmission in England, which is now within our reach, but only if we work better together, and use PrEP as one of the many tools to achieve that

What’s next?

It’s time to draw a line under this and work together to deliver a joined up HIV and sexual health system, which is what the taxpayer has a right to expect. NHS England has said today:

“In the light of the Court ruling we will therefore now quickly take three actions. First, we will formally consider whether to fund PreP. Second, we will discuss with local authorities how NHS-funded PreP medication could be administered by the sexual health teams they commission. Third, we will immediately ask the drug manufacturer to reconsider its currently proposed excessively high pricing, and will also explore options for using generics. We expect to be able to update on these developments shortly”

That’s immensely welcome, on all fronts.

I think most of us realize times are tight. And NHS England is right that we need to prioritise. My point all along is that their chosen tactics were a poor way to do it. It’s time now for everyone to come to the table, work together, and set about fair prioritization.

Work still to be done?

The work of doing a proper, fair and thorough prioritization process now must begin. This will need to evaluate, fairly and transparently, all the data in favour of PrEP and all the data against, as well as date in favour of other contender interventions.  And it will need to compare them, fairly, on a like for like basis.

Having been involved in health care prioritization for many years, up to and including judicial review, the real work starts now. What has happened hitherto has been a tactical game.

It may be the decision is still to prioritise something else, but a few of us are coming together to make sure we subject the NHS process to as much scrutiny as we can possibly give it. The health economics appraisal, the statistical appraisal, the comparative cost-benefit appraisal and the process of decision making will all now be subjected to intense scrutiny. NHS England played the game of “we’ve had legal advice we cant commission this” then played the game of “other candidates might sue us”.

The only safe way forward is a methodologically robust, transparent, equitable and fair prioritization process.

I, and many others, will be watching this with intense interest.

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