Transcript Getting clear about drug strategy.

UKDWF Conference 2009
Ian Wardle
October 2009
Joining up 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
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:
1.
Ministry of Justice – To protect the public and reduce re-offending
2.
Department of Health – Improve the health and well-being of
people in England
3.
Home Office – Reduce the harm that drugs cause to society, to
communities, individuals and their families.
Outcomes Paper PDTSRG, September 2009
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
1.
Therapeutic Change paradigms challenge
the dominant philosophies and models of
care.
1.
Systems theorists and practitioners
challenge the ruling paradigms of
management and government.
Therapeutic Paradigms Systems Paradigms
1.
Linear and Reductionist
1.
Contextualist
2.
Single system approach
2.
Multiple sub-systems
3.
Simplicity
3.
Complexity
4.
Suitable for difficult problems
4.
5.
Milieu focus with emphasis on
individual
5.
Suitable for Public Policy
‘Messes”
System-mapping focus with
emphasis on populations
6.
Concern: direction of strategy
6.
Concern: isolation of strategy
7.
Critical of evidence base and
mainstream expert driven
knowledge production
7.
Critical of gaps in knowledge,
historical ‘forgetting’ and lack
of integration and innovation
and efficiency
Therapeutic Change Approaches
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 solutionfocused recovery paradigm"
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.”
1)A
criticism of the dominant roles of professionals, particularly
in medicine and psychology;
2)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;
3)
4)An
understanding that addiction is a phenomenon that is
best tackled at the level of the communities in which it is
found.
1.
2.
3.
Systems Thinking and LSPs
Systems Thinking in Organisations
Systems Thinking in National Policy
1.
Complexity stares you in the face when confronting
wicked issues with multiple stakeholders, which is
what Local Strategic Partnerships do.
2.
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.
3.
Making performance management work in these
circumstances is a current frontier of policy
development.
1.
Places matter because they are open, dynamic and
adaptive systems that do not have a simple causeeffect relationship with national or global drivers of
economic, social or policy
2.
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,
“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
Key questions for the drug treatment field in
2010.
(A) CENTRALISED, EXPERT,
MODEL
The current, silobased, centralised,
target-driven expert
–led, evidencebased therapeutics
sit within a strategic
framework of
population-level risk
management
(B) LOCALLY LED,
RECOVERY MODEL
The new local,
systems-based
‘Recovery’ therapeutics
aim to enable a more
accessible, personcentred, communityembedded and
qualitative social
therapeutics of need
1.
Can we go from a predominantly stabilising and
palliative model of care to a recovery-based
model;
2.
Can we go from a silo-based, command and
control model to a local soft-systems approach
where partners share learning and performance
objectives;
3.
Can we go from a national system of directional
leadership to regional, sub regional and local
systems characterised by partnership,
personalisation and community embeddedness.
Three transitions:
1.
2.
3.
From Centrally Driven to Locally Owned
From Expert-Led to Person-Centred
From Silo-Based to Systems Based
(A) Centrally Driven
Palliative/
Expert-Led
(B) Locally Owned
Silo-Based/
Simple
Recovery/
PersonCentred
SystemsBased/Com
plex
(A)
Existing Professional And Medicalised
Therapeutics Sit within a Paradigm of
Population Level Risk Management
(B)
The New Therapeutics aim To Enable a
Broader Person-Centred, User-Led,
Community-Based Social Therapeutics
of Need
•
Corporatist Organisations fed by
government
•
‘Sovereign’, Independent Institutions
•
Centralist
•
Devolved and Localised
•
Medicalised and individualised
(biopsychosocial) interventions
•
A broader, social understanding of
addiction
•
Commissioned by local agents against
national targets
•
Commissioned against sustainable local
criteria
•
Stakeholder and Expert led
•
Beneficiary and Public led
•
Service users endorse system
•
Service users drive system
•
Detached (professional)
•
Embedded (community)
•
Evidence Based and Best Practice
•
Experiment and Innovation
•
Compartmentalised according to
department, profession and agency.
•
Partnership and joint planning
•
Standards driven up by
competition
•
Standards driven up by shared learning
1.
Our industry has grown strong under precisely Centralised,
Command and Control system that John Seddon criticises;
1.
The LSP, devolution, revolution will not necessarily chose those
national indicators that prioritise, either directly or indirectly, drug
treatment;
2.
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;
3.
National targets, however onerous and, it may be argued, misplaced, have at least come with National Priorities and Central
Investment.
5.
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.
6.
Our own industry debates are susceptible to political appropriation.
7.
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.
8.
Improved health for patients and public, lower rates of drug-related
offending and re-offending and safer communities.
9.
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 politicallymotivated changes of direction.