Remaking the public services that staff the frontline of the addiction epidemic


July 27, 2017

Each February it is my habit to trek through regional New South Wales. In an unconvincing mid-range SUV, I visit places like Tamworth, Armidale, Gunnedah, Narrabri, Coonabarabran, Coonamble and Gulargambone. I sit down with any journalist, councillor, Mayor, businessperson, trade-unionist, teacher, doctor or nurse willing to meet me. We talk.

This year, I had a fascinating conversation with a senior police officer in the Barwon Command. He worked in that region for more than thirty years. What struck him, enough to share with me, were how the callouts his officers were receiving were changing.

At the start of his career, almost all of them were for property crimes. Today, he sees less of them. He sees more of the same crimes afflicting city cops: men beating up women; people on ice-benders. I asked him what can we do about it? He says, very little. I push back: surely we can do something? Well, he replies, we could talk about what’s causing all of them. I ask, what’s that? He says it’s simple: addiction.

The addiction epidemic

Addiction, if spoken about at all, is always spoken about with adjectives. People suffer from ‘drug’ addiction. They are recovering from ‘alcohol’ addiction.’ They’re fighting ‘gambling’ addiction. The adjectives are why a conversation about addiction soon morphs into a fight about morals. We are nudged into judging the virtue of a person by substituting our opinions about the severity of their vice. Inevitably, lines harden. Are you liberal, or are you conservative? Is this a crime problem, or is it a health issue? Do you prefer being tough on crime, or is your preference to be tough on the causes of crime?

If the argument is framed this way, the space for consensus dwindles. So even though reasonable people agree that reversing the grip of homelessness, indigenous inequality, intergenerational poverty, domestic violence, mass incarceration and child removal require redress of addiction’s impact, even routine adjustments, designed to update old settings to suit new conditions, are lost in the fog of politics.

This is why there is reform lag in NSW. Other jurisdictions, like Norway and Sweden, radically rethink their prison system to reduce recidivism, yet introducing similar reforms here is fraught. Here, if an advance is made in one domain, like gambling, cross-pollinating the same idea into other areas, like alcohol, is hard. The same debate repeats, with the same language and, often, the same players.

Obviously, the addicted lose in this climate: the cycle they are trapped in ends with their marginalisation. Yet, more stories about their suffering — which powered the slew of reforms made so far — will not guarantee that the next wave of reform is a political slam-dunk. The next wave of progress requires enough honesty to say: the public is losing too.

Take the dollars spent annually on incarceration in New South Wales. Add the money spent on child protection. Factor in spending on domestic violence. Increase by police spending. Throw in court costs. Add welfare spending. Throw in health spending. Price in lost educational investment. Even if addiction is responsible for only a sliver of this expenditure, the addiction epidemic already costs taxpayers billions each year. This is the direct cost.

Now add the civic costs. If it is acceptable to abandon the addicted to their fate, it is acceptable to abandon others too. This is why the far-right (and too many in the near-right) soon liken welfare recipients and single mothers to addicts. In their telling, intervention risks adding to all of their ‘dependency.’ None of them should be helped ‘for their own good’. If they curdle into a permanent underclass, so be it: it is their fault. Even if the result is two distinct societies — separate and unequal.

Turn to the final cost. These demonisation campaigns have their antecedent in the de-humanisation campaigns waged against Indigenous Australians. Waging against them again is doubly cruel because in 2017, like in 1917 and in 1817, the Indigenous community remains the community most ravaged by addiction. If Australia is to make progress against the high rates of indigenous incarceration and child removal, or the relative low levels of indigenous life expectancy, it has to deal with addiction. ‘Closing the Gap’ — making meaningful reparations — is impossible until we do.

So what should be done? Even though for some on the extremes, another assault on addiction means girding for more culture wars, I prefer a different approach: solutions first. Bob Carr established the heroin injecting room by rising above the simplistic solutions of Liberal and Green party extremists. The next Labor government should follow suit. It should plant its flag in the terrain most fertile for progress.

Its mission should be remaking the public services that staff the frontline of the addiction epidemic, making them fit for purpose. The next Labor government should join them up, scale them up; and then it should unleash waves of experimentation.

Joining together our public services

It is impossible to properly render the disjointedness of our public services. An addict might struggle to have their child attend school every day. They might breach their tenancy agreement with the Department of Housing. They could miss appointments with Centrelink. They might also have repeated contact with the NSW Police, the NSW Court System and the Department of Family and Community Services. Not one of these agencies is likely to co-ordinate their efforts with another. No one asks them to.

Yet there is evidence which shows the incredible impact of different agencies acting collectively. The first is in the sphere of child-protection. On the Central Coast, officers of the Department of Health, the Department of Family and Community Services, and the Department of Education all answered calls made to the local mandatory reporting hotline. By physically sitting next to each other, these agencies sped up their decision making about whether a child was at risk of serious harm. They rapidly decided their next action. They swiftly chose the lead agency responsible. The impact of this simple change was impressive. Response times tumbled. Assessments were better. Help was faster.

In Redfern, a similar experiment; this time relating to domestic violence. Every Monday, the local police, hospital and education office met with the local community legal centre, and the area’s leading women’s shelters. Together, they would review each instance of domestic violence any of them learnt about in the previous week. With the same information visible to all, they soon identified the few perpetuators responsible for the overwhelming number of Redfern’s DV incidents. The agency judged most likely to maximise effectiveness lead their joint response. Later, they’d meet to assess the results.

The Redfern and Central Coast agencies showed the mindset NSW Labor should embrace: a citizen’s needs informs the system’s design; not the inverse. In the addiction sphere, this should be the norm — not the exception. Even though it seems mundane, it results in more people receiving help, at a lower cost, early enough in the addiction cycle to stop the need for more dramatic interventions later. Usually, they are too late.

Scaling services that work

For an addicted person with means, access to first-rate treatment is simple enough. Enter the private market; use your own money; and if treatment ‘fails’, the tab is on you. For an addicted person without means, which is the overwhelming number of addicted people, reality is different. Help depends on other people’s compassion — especially their family’s. If they exhaust their patience — not hard if someone else pays for the expensive treatment you will statistically ‘fail’ multiple times before you succeed — marginalisation is inevitable.

The only actor which can shoulder this risk is the state; but right now the state’s resources are misdirected. If an addict needs high-levels of assistance from the government — 24 hour-shelter; warm clothing; three meals per day; drug-treatment; mental health care; education — some help is available. But first, you need to commit a crime. NSW’s gaols remain the only institution which technically meets these needs.

If even a fleck of the money spent on incarcerating the addicted was instead spent on providing them with the same services pre-incarceration, those services would dramatically scale up. If our minimum-security prisons more closely resembled treatment facilities, and not maximum-security gaols (like in Norway), assistance for lawbreaking addicts would increase too.

The next NSW Labor government will succeed a government which is locking up more citizens than any time in recent memory. Billions have been spent making absolutely no impact on re-offending rates. Some of those dollars should be spent on scaling up programmes which keep addicts out of prison. Some of those dollars should be spent remaking our prisons so they rehabilitate people who will eventually rejoin the community. Public order is better served by this redirection. So is the cause of compassion.

Unleashing experimentation

Scale itself is not a complete solution. Even if every addict could gain access to treatment, we would still have addicts. Addiction is physiologically, psychologically and sociologically complex — no-one has invented treatments which succeed in the majority of cases, let alone all of them. Hence effective anti-addiction strategies allow for experimentation. Which means they fund failure.

Failure is hard for governments. With incredible responsibilities in areas like health, education, defence, welfare and economic development; subjected to extreme pubic and media scrutiny; facing political opponents ready to seize on every mistake, the Silicon Valley ‘fail fast’ philosophy doesn’t cut it. The majority of people (rightfully) think if the government is involved, the government knows what it is doing.

Failure is equally hard for the community services sector; it cares for the most addicts amongst us. Nothing destroys morale, culture or capability more than being told to experiment, only to lose funding if they become ensnared in the same phobia of failure as governments. Even worse is if they lose funding without failing, because sustaining public investment in an area as politically fraught as addiction is hard for any government.

Failure isn’t easy for the private sector, but the private sector has coping mechanisms the public sector can copy — especially when financing risk. Some governments have already, using instruments like social impact bonds (SIBs). They allow the private sector to profit from a public service if they yield a better result than is normally achieved, so long as they’re willing to lose their money if they don’t.

For some progressives, SIBs harken back to a time when it was acceptable to profit from the poverty of others, which is a fair enough complaint. Yet social impact bonds have features useful in a duel with addiction. For one, if an intervention fails, it’s not taxpayers who lose. Two, if an intervention succeeds, then taxpayer funding can be used to scale the programmes proven to work. Three, funding is long-term. It is unheard of for a community organisation to obtain a five-year grant from government; five-year SIBs are common.

If government uses SIBs to either vacate the field, or to simply transfer wealth from the already-put-upon staff working in the community sector to financiers, they are dangerous. Already, the community services sector is blighted by high levels of job insecurity and the systemic under-payment of staff (mostly women). SIBs should not compound these problems. The next Labor government should use them if they can be shown to bring new resources to the fight against addiction.

So then?

Joining together public services, scaling them up, and then unleashing experimentations leaves certain questions unanswered. The next Labor government will need to resolve the meaning of harm minimisation 25 years after the party first embraced it. We will also need to temper efforts to constrain an individual’s personal choices in spheres like alcohol and gambling if they resemble nanny-ism and state paternalism.

Many governments have been caught by these tripwires; the next Labor government is not immune. My point is: public service reform is our best innoculation. Because this is our point of consensus with the right-wing: public services should work. We can use that argument with the public. We can use it to create broad coalitions for reform. Then, we turn to the harder questions from a superior position: armed with sharper public services, treating more patients. Having shown everyone: the addiction epidemic is not insoluble.

Daniel Mookhey is a member of the NSW Legislative Council for the Labor party.

This article has been republished from a forthcoming NSW Fabian Society essay collection looking at the priorities of the next NSW Labor government.

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