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Copyright © 2012, Emerald Group Publishing Limited
What PbR may do to us?
Article Type: Editorial From: Drugs and Alcohol Today, Volume 12, Issue 1
This year several pilot sites across the country will be introducing their respective versions of funding drug treatment services, a reform that has been bundled into the self-explanatory “payment by results”. There will be some variation in the disbursement of payments, criteria for success and the contractual arrangements with service providers. For managerial convenience, however, all schemes will invariably favour the larger service providers and lead to the concentration of service provision in the hands of fewer agencies. One of the long-term consequences will be the creation of local cartels, where a small number of providers with the cashflow to see out the hazards of a difficult market place, can establish themselves at the expense of all other players. Initially this may well deliver cost savings, as services are forced to restructure and in all likelihood, let people go. But for service users the reduction on local services and the mid term disappearance of small providers is ominous. Though in one sense they have with the outcome of their own treatment journey some leverage in negotiating with their treatment provider, the reality is a stark choice between treatment on certain terms and no treatment at all. The guise of the market prepares for the return of a far more punitive and censorious approach. While in the past the care worker/client relationship, could at least be potentially supportive of clients’ wishes and allow for autonomous decision making, this will in future be precluded by a sharp focus on prescribed outcomes.
The risk of this process backfiring impacts on two important domains. The first is the clinical, as many studies suggest that the sense of autonomy, of being in charge of one’s own recovery is a prerequisite for successful treatment outcome. This is, of course, open to debate, and particularly the advocates of in prison treatment provision have long argued that “quasi-coerced” treatment can deliver successful results. The intent behind this argument has been to deconstruct a long established notion that voluntarism is an essential precondition for recovery, that clients have to “hit rock bottom” before treatment can take effect. The experience of rock bottom, or the pressures from loved ones, the stark poverty and sheer danger that come to characterize the street addict’s life are all “pressures” negating the autonomy principle. Persuasive though this stretch of “coercion” may be, there is the risk of semantic slippage facilitating a shift towards poor practice. Restricting client choice even further may have severe consequences in outcome terms, even though large cohorts of clients may be processed in the short run. We may find the number of self-referred clients drying up and treatment providers becoming entirely dependent on referrals from the criminal justice system, providing a medical alibi for a coercive practice.
There are further questions with regard to the duty of the NHS to provide care to all, not simply those who present with the correct intentions. Will it lead to publicly funded services reserved for a self selecting sample of the drug using populations? And, conversely, will treatment agencies cherry pick their clients according to the likelihood of successful completion?
We also see risk in the financial dimension as large service providers establish themselves as “social businesses”. Once established with large overheads and significant commitments, the need for generating cash flow will displace the concern with client welfare. The strict provisions of the PbR contracts will lend authority and urgency to their demands and weaken the already fragile negotiation position of service users even further. It is difficult to envisage new agencies starting up to challenge existing services. Client complaints will fall on deaf ears as long as contract criteria are being met – indeed, it is hard to see what role service users are to play apart from helping deliver prescribed outcomes more effectively.
What we will then be left with is the expense and cumbersome complexity of a treatment system, with few of the therapeutic benefits. Moreover, the existence of these services and the official policy of “helping addicts” places a double burden on drug users, whether problematic or not. After several decades or incremental recognition that drug use would not be done away with by a combination of the right policies and real commitment, we are now back in an abstemious fantasy land. Much of this may be owing to the cultural baggage of a politician raised in the shadow of rationing and nostalgic for a nation with a unity of purpose and social deference. It is both unfortunate and significant that the failed Tory leader was sent into the proverbial wilderness of “broken Britain” to find out more about the poor and powerless and stumbled upon drugs as one of the primary causes.
As ever, the well meaning patriot with a charitable concern for the less privileged, is supported by opportunists who promise that their way is the right way. Any accommodation with drugs, according the Centre for Social Justice means waving “the white flag of surrender” before drugs. When it comes to drugs, it seems, commentators can safely depend on clichés to drive their argument. The war on drugs was phoney (get the historical reference to the centre’s favourite period in history), police have to be more “robust”, policy makers should take a “tough line”, young people need a “clear message” and drug dealers are ruthless.
That this chatter is now presented as a contribution to debate has been made possible by two policy disasters which have long been criticised in these pages. First, the reduction of the client/service provider encounter into a data gathering exercise, and secondly the roll-out of methadone maintenance treatment (MMT). Methadone, to be clear, is a nasty, synthetic substance that problematic drug users are right to be wary of. Most people with substance issues, or let us be precise, opiate problems, look for help with getting control over their lives. Things are not going well in any department, their health is poor, they frequently run into trouble with the authorities, poverty becomes chronic, relationships are in a mess and at the root is that behavioural problem that drives people to abandon care and caution in pursuit of psychoactive pleasures. What many service users ask for is help with getting control over their own selves to tackle the complexity of a messy life. Often understanding what it is about them and the drug is a good starting point, which is why many seek out services in order to talk things through.
But talk or discovery is not really what they are there for any longer, because the drug treatment industry has defined what addiction is and claims to own the tools to manage it. Presented by its manufacturers as medicine, methadone serves to legitimate a dependence substitution that has the dubious benefit of locking service users into a relationship with the treatment provider. It may be successful in reducing the consumption of street drugs, but only because the service is now the dominant drug supplier. It is well known that many service users resist methadone prescription and even more accept it reluctantly. Primo, a prodigious consumer of alcohol, cocaine and heroin throughout the 1990s, summarises widely held views: “Methadone sucks. I hate it” (Bourgois, 2000).
Many service users who are on a script report negative health consequences and a rapid transfer of dependency. Moreover, the transmogrification of methadone into medicine has stultified the development of alternatives, be this the use of opium tinctures used traditionally in opium cultivating countries or the treatment modalities utilising psychoactives like ibogaine or ayahuasca.
Most inimical to the wider drug policy reform and treatment ideals has been the way Methadone Maintenance or opiate substitution therapy (OST) has become a substitute for harm reduction. Whereas HR provided drug policy with a new overarching principle, a toolkit of methods and an acknowledgement that drugs were part of the cultural fabric, the rise and rise of OST prepared the way for the counter revolution. By pointing to the obvious flaws of MMT, critics have been able to could tear down the network of harm reduction policies and services built up over a couple of decades. For this is where the current “recovery” is heading, back to the 1980s when drugs were part of a simple Manichean world of moral halves. All one needed was more robustness, toughness, messages, grim-faced policy announcements and the dispersal of funds to favoured agencies. These would repay the debt by weaving a screen for the government’s social and economic policy failures.
The emphasis on recovery means resealing the wormy can of drug policy, while presenting to the electoral world a conservatism with a human face. Maintaining tough sanctions has kept social conservatives on board while the money for treatment assuages the liberal democrats. But the shift from reducing harm to targeting drug use bodes ill for service users and the treatment system. One can only hope that funds are simply not available for more “robust” policing of drug consumers. More to the point will be how treatment services will manage the notorious rate of relapse when abstinence only delivers a return.
As ever, there is a positive outcome potential in all this. Critical study of results may raise questions about the medical model and feed into policy debates. The shift away from MMT is a gain in its own right, and may lead to the randomized injecting opiates treatment trial dropping two consonants and being rolled out nationally. Particularly if the withdrawal of service provision from clients with no intention of becoming abstinent should be linked with a sharp rise in offending. The last government’s generous investment in the sector, it should be remembered, was an imaginative way of being tough on the causes of crime. Ironically, the party conventionally associated with law and order, has relegated this objective behind the moral imperative of abstinence. But a surge in property offences during the age of austerity could prompt the extension of opiate treatment.
Rationalisation of services will create new opportunities for self-help groups, local services and new charities with a different ethos. Drugs have a tendency to confound policy makers and cause upset to the best laid plans. we look forward to the eventual evaluation of this strategy.
Bourgois, P. (2000), “Disciplining addictions: the bio-politics of methadone and heroin in the United States”, Culture, Medicine & Psychiatry, Vol. 24, pp. 165–95