DrugScope Conference 2009 Ian Wardle October 2009

1. The Drug Treatment System and its key transitions.Three Current Approaches and how to Integrate Them DrugScope Conference 2009 Ian Wardle October 2009

2. Introduction Joining up the individual and the social

3. The Individual AND the Social “Medical training can be faulted by social science for its centering on the care of individuals, for individualizing the issues which are properly social and should be taken at the population level. Along both those tracks, Robin Room was a friend who would check me if I ever lapsed too much into a narrowly patient-centred view. The richest insights come and the best policies evolve when one sees and honours the realities of the individual, but at the same time grasps the realities of the population” Griffith Edwards, Interview in Addiction, 1990

4. Context 3—‘Joining-up’ National Policy Outline of Government Targets One of the difficulties of establishing national outcomes measures arises from the fact that each government department has its own aims and objectives, for example: Ministry of Justice – To protect the public and reduce re-offending Department of Health – Improve the health and well-being of people in England Home Office – Reduce the harm that drugs cause to society, to communities, individuals and their families.Outcomes Paper PDTSRG, September 2009

5. Three Key Approaches The Language of Care • Therapeutic Change Paradigms The Language of Integration and Complexity • Systems Paradigms The Language of the Mainstream • Adaptation, Incorporation and Improvement and Retrenchment

6. Two different kinds of challenge • Therapeutic Change paradigms challenge the dominant philosophies and models of care. • Systems theorists and practitioners challenge the ruling paradigms of management and government.

7. Therapeutic Paradigms Systems Paradigms • Linear and Reductionist • Single system approach • Simplicity • Suitable for difficult problems • Milieu focus with emphasis on individual • Concern: direction of strategy • Critical of evidence base and mainstream expert driven knowledge production • Contextualist • Multiple sub-systems • Complexity • Suitable for ‘Messes” • System-mapping focus with emphasis on populations • Concern: isolation of strategy • Critical of gaps in knowledge, historical ‘forgetting’ and lack of integration and innovation and efficiency

8. Critiques of the Status Quo 1 Therapeutic Change Approaches

9. Therapeutic Change Paradigms 1 William White is a thinker stressing therapeutic paradigm change. In his paper, Addiction recovery: Its definition and conceptual boundaries (2007), he describes us as being "on the brink of shifting from long-standing pathology and intervention paradigms to a solution-focused recovery paradigm"

10. Therapeutic Change Paradigms 2 In Fragmented Intimacy, Peter Adams describes how the medical profession, and more latterly, the profession of psychology have, over the course of the past century, defined and dominated orthodox drug treatment. … For Adams, we need to move beyond what he calls the particle paradigm, with its biopsychosocial underpinnings, towards a social paradigm"which shifts the focus of attention away from people as discrete individuals and towards people in terms of their relationships.”

11. Therapeutic Change Critiques:Common Features that interweave this growing body of work • A criticism of the dominant roles of professionals, particularly in medicine and psychology; • An understanding that those who suffer from addiction must play a greater role in their own recovery; • A growing awareness that addiction can best be understood as a social concept and not as something solely about the pathologies of individuals and, finally; • An understanding that addiction is a phenomenon that is best tackled at the level of the communities in which it is found.

12. Critiques of the Status Quo 2 --Systems Change and Complexity Systems Thinking and LSPs Systems Thinking in Organisations Systems Thinking in National Policy

13. 1(a). Systems Thinking and LSPs Complexity stares you in the face when confronting wicked issues with multiple stakeholders, which is what Local Strategic Partnerships do. The growing complexity involved in this governed interdependence is challenging the performance management systems that have become such an established feature of public policy in the UK and worldwide. Making performance management work in these circumstances is a current frontier of policy development.

14. 1(b) Systems Thinking and LSPs Places matter because they are open, dynamic and adaptive systems that do not have a simple cause-effect relationship with national or global drivers of economic, social or policy They are a setting for intervention, but with outcomes more likely to arise from complex causal combinations than linear cause and effect. Tim Blackman--Placing Health: Neighbourhood renewal, health improvement and complexity, 2006,

15. 2. Systems Thinking in Organisations “The fact is that public-service workers have been 'cheating' their systems to meet their targets, a practice which has become known in the NHS as 'gaming' -- a new word for the management lexicon, a word of our time. It is a consequence of the quasi-market. The regime administering this madness is called 'payment by results'. It is a misnomer; it should be called 'payment for activity'. What was supposed to be a system for liberating public-sector organisations has turned into a burgeoning and dysfunctional stranglehold of bureaucratic control.” John Seddon, Systems Thinking in the Public Sector, 2008

16. 3. Systems Thinking in National Policy, Scotland

17. Centralism or Localism? Or a mixture of both? Key questions for the drug treatment field in 2010.

18. Question: Should we aim to go from (A) to (B) or seek to integrate the best of both (A) CENTRALISED, EXPERT, MODEL (B) LOCALLY LED, RECOVERY MODEL The current, silo-based, centralised, target-driven expert –led, evidence-based therapeutics sit within a strategic framework of population-level risk management The new local, systems-based ‘Recovery’ therapeutics aim to enable a more accessible, person-centred, community-embedded and qualitative social therapeutics of need

19. Three sets of Questions • Can we go from a predominantly stabilising and palliative model of care to a recovery-based model; • Can we go from a silo-based, command and control model to a local soft-systems approach where partners share learning and performance objectives; • Can we go from a national system of directional leadership to regional, sub regional and local systems characterised by partnership, personalisation and community embeddedness.

20. We are being asked to make three sets of transitions as part of a single transitional process Three transitions: • From Centrally Driven to Locally Owned • From Expert-Led to Person-Centred • From Silo-Based to Systems Based • (A) Centrally Driven • (B) Locally Owned Systems-Based/Complex Recovery/Person- Centred Palliative/ Expert-Led Silo-Based/ Simple

22. Key points arising from devolution to local, regional and sub-regional structures. • Our industry has grown strong under precisely Centralised, Command and Control system that John Seddon criticises; • The LSP, devolution, revolution will not necessarily chose those national indicators that prioritise, either directly or indirectly, drug treatment; • Post pooled treatment budget, local priorities will shift, the more so since local elections and other forms of local democracy may well result in less being spent on drug treatment; • National targets, however onerous and, it may be argued, mis-placed, have at least come with National Priorities and Central Investment.

23. Key points arising from devolution to local, regional and sub-regional structures. • Drug treatment: its scale, its philosophical underpinnings, its models of care and its ranking as a funding priority are not immune from the party political cycle. • Our own industry debates are susceptible to political appropriation. • At all times we must be capable, as a field, of speaking powerfully, positively and clearly to the public about the full range of social benefits associated with accessible and effective drug treatment. • Improved health for patients and public, lower rates of drug-related offending and re-offending and safer communities.

24. Key points arising from devolution to local, regional and sub-regional structures. • Any politicians that insist upon taking a step back and reversing the progress we have made as a field, must not then be able to claim that they weren’t clearly warned about the consequences of disinvestment from treatment or from taking ill-informed and politically-motivated changes of direction.