Hunt vs Hawking. Both are wrong, and things are worse than we thought

For the first time in weeks I have no work this weekend, so I wanted to catch up with a couple of topics that I had written about previously, and which were finding their way back into the news.

For those who follow such things my old pal the Jim Reaper has left Whitehall and returned to Northumbria Healthcare to resume his roles as CEO.   When he left Whitehall he let rip at the oversized centralised bureaucracy that has sprung up since the Lansley reforms.  

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The Conservatives made a big noise about reducing the size of the NHS management cost, but have instead created a dysfunctional centralised system, which adds nothing to patient care. 

https://jon-chadwick.com/2017/11/11/nhs-managers-are-great-lets-hire-loads-more-of-them/

It is axiomatic that when an ambitious right wing politician announces a change programme that will reduce bureaucracy there will be more paperwork and more centralised administration afterwards.  The more ambitious and right wing the politician, the bigger the pile of paperwork.   

The Trust that Jim is returning to is part of one of the first Accountable Health Organisation pilots:

https://www.kingsfund.org.uk/projects/supporting-new-nhs-care-models/northumberlands-accountable-care-organisation

I am optimistic about ACO’s because they start and unpick the expensive management structures which sprung up around the internal market, and which have been a feature of the NHS from the Thatcher era onwards.   I don’t for one minute think that this is something that Jeremy Hunt would have chosen ideologically, but the shortage of cash in the NHS is driving change in directions that the Government might not have chosen.   The changes to drugs policy I wrote about last week is another example.   

ACOs aren’t universally popular and Stephen Hawking has joined a legal action to try and stop the ACO pilots.   They are the latest management vehicle to be accused of being part of a secret agenda to privatise the NHS:

https://www.theguardian.com/society/2017/dec/08/stephen-hawking-lawsuit-foiling-jeremy-hunt-nhs-shake-up?CMP=share_btn_tw

I don’t for one minute agree with the basis of this legal challenge, and I think that Prof Hawking is badly misinformed here.   The ACO structure doesn’t encourage or discourage private sector involvement in the NHS, it just reduces the costs to the system of maintaining a commissioner and a provider management team.  It is just as possible to use ACOs to reduce private sector delivery as increase it, and I don’t agree that private sector involvement in healthcare delivery is always a bad thing…. it has been part of how the NHS has operated since 1947.   The problem is that the companies who are getting the contracts are among the worse private sector providers while some of the really good private sector organisations are being locked out.    This is giving private providers a bad name.

Apologies for writing so much on healthcare topics.   I intend to revamp the blog in January, and return to more business and labour market issues. 

The reason for so much health policy recently is because I am afraid that the NHS is entering into a period of profound crisis, which neither main political party really has a grip on, and which Brexit will make a lot worse.

To illustrate the impact this slow motion crisis is having I want to return to something I wrote about in the Summer about the impact of austerity on life expectancy.   For some groups in society improvements in life expectancy had stalled and were starting to be reversed.

https://jon-chadwick.com/2017/07/15/does-austerity-really-kill-if-so-how-many-how-can-it-if-we-are-all-living-longer/

The latest ONS data on life expectancy is much much worse than I expected.

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nationallifetablesunitedkingdom/2014to2016

The ONS are remarkably calm about this, but it looks like pretty much all of the increase in life expectancy since 2017 has been reversed.  The predicted average life expectancy for a man is now below 90 years again.

 

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It is tempting to suggest that maybe there is a limit to how much we can increase life expectancy, and that the rate of increase will slow as we reach that limit.   Japan, and Scandinavia still live much longer lives than us, and the reverses that we are experiencing aren’t happening there.

We do know that life expectancy links close to wealth inequality.  The richer you are, the longer you live.  The gap in life expectancy between the riches and poorest wards in Local Authorities like Westminister or Kensington and Chelsea are as big as the gap in life expectancy between the US and India.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00150-6/fulltext

There is no real need to construct elaborate theories about this.  If you take a poor population and you make it poorer, less well fed, less securely housed, and colder you will increase the rate at which they utilise health resources and reduce their life expectancy.   

For anyone interested in actuarial tables this means that the data which was used to raise the state pension age is now wrong, and the justification George Osborne presented no longer holds water.   I doubt that this will change the decision.  

I will be back next week with a longer blog, and a scary story for Christmas…..

How close are we to legalising drugs? Are the Tories more liberal on drugs than Labour? Will Boris Johnson be remembered as the man who decriminalised cocaine?

 

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I found needles and ampules in my neighbourhood this week.   I live very near a big hospital, which means that it was more likely to be medical rather than heroin, but I rang the Police nonetheless, being a concerned citizen.

For those who don’t know Durham runs the most liberal drugs regime in the UK, not so different to Amsterdam but without the cafes.   The Police and Crime Commissioner has recently visited Switzerland and wants Durham to have the UK’s first legal “shooting gallery”.

Wading through the mass of statistics about drugs is a daunting task.  Police, Home Office, Standing Committee on Drug Misuse, Border Agency, NHS National Treatment Agency, London Mayor and each Police Force all have their own statistics.

What we do know is that overall drug use in the UK is falling.   20 years ago when the Conservatives left power drug use was at an all time high.   In 1997 13% of the population, and over 30% of 16-24 year olds had used illegal drugs in the past year.   Today those numbers are 8% and 18% respectively.  I realise that this is a big shock to people who are used to newspaper stories about drugs and inner cities, but actually drugs policy is showing some signs of success.

Young people aren’t getting high the way they used to. 

The New Labour  administration that came to power in 1997 had a different attitude to drugs to the outgoing Conservatives.  Many New Labour luminaries were from the North East and were associated with a left wing book shop in Newcastle called Days of Hope, known colloquially as Haze of Dope.  While Blair always denied taking drugs, Yvette Cooper was the first serving Cabinet Minister to admit smoking dope, and the then Secretary of State for Health John Reid apologised to the Police after his Protection Officer found small amounts of Cannabis at his constituency home.  After Yvette’s admission a number of other New Labour figures came forward; Charles Clarke, Jacqui Smith, Patricia Hewitt, Alister Darling, Andy Burnham, Harriet Harman and John Denham all admitted historical dopery.

New Labour debated significantly amending the The Misuse of Drugs Act 1971, particularly after the Runciman report in 2000 but bottled it due to their neurotic fear of bad press. 

They did however allow a number of pilots which trialled new approaches to drugs.   The most high profile of these was the effective decriminalisation of cannabis in Lambeth by the then Borough Commander and future “I’m a Celebrity…” star Brian Paddick. 

Less well know, but more significant were the RIOTT trials – Randomised Injectable Opiate Treatment Trials.  Chronic street heroin addicts receiving conventional methadone treatment but who continued to inject street heroin were recruited to 3 NHS centres  (London, Brighton and Darlington).    Patients were randomly assigned one of 3 treatment options: supervised injectable methadone, supervised injectable heroin, or optimised oral methadone. For the first time the UK had offered injectable heroin on the NHS, and the first time the NHS had offered offered opiates since the criminalisation of heroin in 1956 after a campaign by the Daily Mail.   

These trials ran parallel to the introduction of Drug Treatment Orders which were created under the 1998 Crime and Disorder Act, replacing the Rehabilitation schemes under Section 1A(6) of the 1991 Act.   These took several years to get going, and continue to operate despite having a relatively poor record.  Few finish the programme, and even fewer stay away from using afterwards.  The outcomes from RIOTT were by far and away better than the DTO regime. 

In 2004 the Home Affairs Select Committee and and Advisory Council on the Misuse of Drugs published a report into cannabis which led to the then Home Secretary David Blunkett reclassifying cannabis from Class B (which it had been since the 1971 act) to Class C.

I was involved tangentially with some of this work.  I worked closely with Teesside Police on a number of programmes which spanned Police and Health, including the Teesside Drugs Action Team  Many of the communities I worked in were experiencing drugs use for the first time, and I spent a lot of time talking to local anti-drugs campaigns.  Later on I worked for the NHS Trust who ran the Darlington RIOTT clinic.   

There were 2 view points that came through very strongly in discussions with the Police in this era.   

Firstly that the way drugs policy was implemented was discriminatory.  If you were affluent, and lived in a quiet neighbourhood you could take drugs with little or no risk of detection.   If you lived in a  poor, high crime area you were much more likely to be stopped and searched, and be arrested for relatively small amounts of possession for personal use.  This meant that drugs arrests were a feature of poor communities, often with large ethnic minority populations

Lots of people on the left are highly suspicious of the Police, based on very real problems at Orgreave and Hillsborough.  But there were a great many Police Officers with different views, who thought a lot about the way the justice system impacts on communities, and the McPherson report into the death of Stephen Laurence gave them a powerful voice.  I remember vividly walking into the back office in Redcar Police station to find that the Divisional Commander had covered the walls with the MacPherson definition of racism in letters a foot high produced on a dot matrix printer.  A proud moment. 

The other view commonly expressed was the failure of drugs enforcement.  Teesside had a relatively quiet heroin trade at the time, with little of the violence associated with the drugs scene on Tyneside where night club doorman were being shot.  This was a result of a large stable market, plenty of users, and a regular supply through Teesport.   The quietness may have kept the politicians happy, but it was not a good sign.

Barry Shaw, Chief Constable Cleveland Constabulary became the first serving senior Police Officer to come out and publicly say that the war on drugs had been lost, and that the current enforcement regime was causing more harm than good.  He openly called for decriminalisation.

These attempts at moving the debate on drugs forward met with a predictable backlash.    The Daily Mail published lurid allegations against Brian Paddick, which while proven false, damaged his career, and he was moved away from front line Policing.   The Mirror ran a sting against Jack Straw’s son Will, after he sold them a quantity of Cannabis so small it wouldn’t get you through Dark Side of the Moon.

The decision to upgrade cannabis back to class B by Jacqui Smith in 2008 following stories in the tabloid press about Skunk was a huge low point, particularly when it emerged that she had never even met her own chief drugs policy advisor Prof David Nutt.   Wacky backy Jacqui Smith is the only Home Secretary whose name became rhyming slang for a spliff. 

In the same year Ken Livingstone lost the London Mayoral election to Boris Johnson, beating Brian Paddick into 3rd place.   Boris was one of the first Conservatives to admit smoking dope and snorting cocaine, and in his early years as Mayor called for a debate on decriminalisation.    I will say nothing about George Osborne.

Boris Johnson diverted Police resources towards tackling problems with Crack Cocaine across the capital.  This wasn’t a bad idea – crack use was increasing, and it was driving a wave of acquisitive crime and gang violence, including use of knives.   The flip side of this is that resources were moved away from other drugs, including cannabis and powder cocaine.

This took place at a time when there was a shift in powder Cocaine use.  Historically cocaine had been a high price, high purity drug, with limited distribution.  An elite vice.   During the latter part of the first decade of the C20th cheaper, more adulterated forms of the drug had begun circulating, and cocaine had become more widely available demographically.  Effectively a 2 tier market had developed based on price and purity.    

With Police resources targeted towards crack cocaine low level infrequent social drug use attracted little risk of Police intervention.  The problems highlighted by the Police years earlier about the potential discriminatory effects of drugs policing became magnified.

Effectively Boris Johnson decriminalised low level cocaine and cannabis use among affluent Londoners who had little or no risk of being caught.

I tried to source the convictions data to support the shift in resources from powder Cocaine to crack, however this data proved remarkably hard to come by:

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The national Police data set has no data older than the last 4 years, and doesn’t break down to different kinds of cocaine.  The new Mayors priorities don’t even feature Drugs as a headline; stop and search; use of tasers; use of force and hate crime are all higher priorities.

Because so few of us take drugs these days the creeping decriminalisation of powder cocaine and cannabis didn’t really hit the headlines, and I only noticed when I encountered middle aged first time cocaine users chewing their cheeks in a Champagne bar in Durham.

The policy of decriminalisation by deprioritisation spread through Police forces as budgets were cut – some by as much as 30%.   Forces began quietly moving resources away from pursuing low level drugs offenders.  This however simply perpetuated the discrimination built into drugs policy.

Durham Chief Constable Mike Barton called for the complete decriminalisation of drugs in an article for the Observer in 2013.  The quiet decriminalisation of drugs for middle class people started to become a movement to publicly decriminalise drugs across all social groups. 

Durham Constabulary no longer takes action against Cannabis users for low level offences, including growing for personal use.  This attracted a lot of media attention, particularly as the rationale was presented as being as much about lack of resources as progressive policy.   Less well know is that Durham Police offer a similar programme, called Checkpoint, for people arrested for Class A drugs.   Offenders who signed up to a 4 month programme of treatment, drug awareness, restorative justice and community work can have their offences expunged from the record.   Of the 68 arrests made by the Police last year for drugs offences in County Durham only 3 ended with a conviction – all of the others were dealt with through treatment routes.

Avon and Somerset and Devon and Cornwall Police are introducing similar schemes.

One of themes of my blog is the way policies sound great in Westminster and in the press and then are a disaster on the ground.  The criminalisation of heron is a great example of that – usage increased hugely in the following decades.  

The last 2 decades has seen a mixed set of attempts to liberalise drugs policy, which have gathered pace under the Conservatives.  These changes have been driven as much by lack of funding as by instinctive liberalism. It would be mighty convenient for this blog if I could show a neat correlation between drugs policy and drugs use, however drug policy has moved forward in a disjointed manner, and falls in drug use has declined with a similar random walk.   Drugs data is imprecise and scattered across different agencies. Key data is missing, maybe on purpose.  There is however enough of a relationship between declining drug use and liberalisation of policies to make the case for the expansion of the Durham model nationally.   

The Liberaliation of drugs policy might turn out to be one of the biggest social changes introduced by the Cameron/May Government, although this is in the context of a rather thin set of legislative achievements.

And the syringes and ampules?  The Police sent someone rom the Council to clean them up.  No statements taken, no crime number.

https://www.kcl.ac.uk/ioppn/depts/addictions/research/drugs/riott.aspx

http://www.icpr.org.uk/media/5602/Dtto%20findings.pdf

https://www.theguardian.com/commentisfree/2013/sep/28/ending-war-on-drugs-cut-crime-mike-barton

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/411574/acmd_final_report_12_03_2015.pdf