The Drug Treatment System and its key transitions. Three Current Approaches and how to Integrate The

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The Drug Treatment System and its key
transitions.Three Current Approaches and how to
Integrate Them

• UKDWF Conference 2009
• Ian Wardle
• October 2009

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Introduction

• Joining up the individual and the social

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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

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Context 3Joining-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

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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

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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.

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• Therapeutic Paradigms

Systems Paradigms

• Contextualist
• Multiple sub-systems
• Complexity
• Suitable for Public Policy 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

• 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

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Critiques of the Status Quo 1

• Therapeutic Change Approaches

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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"

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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.

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Therapeutic Change CritiquesCommon 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.
•  

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Critiques of the Status Quo 2 --Systems Change
and Complexity

• Systems Thinking and LSPs
• Systems Thinking in Organisations
• Systems Thinking in National Policy

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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.

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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,
  

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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

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3. Systems Thinking in National Policy, Scotland
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Centralism or Localism? Or a mixture of both?

• Key questions for the drug treatment field in
  2010.

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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 new local, systems-based Recovery
  therapeutics aim to enable a more accessible,
  person-centred, community-embedded and
  qualitative social therapeutics of need

• The current, silo-based, centralised,
  target-driven expert led, evidence-based
  therapeutics sit within a strategic framework of
  population-level risk management

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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.

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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
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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.

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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.

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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
  werent clearly warned about the consequences of
  disinvestment from treatment or from taking
  ill-informed and politically-motivated changes of
  direction.