Responding to 'wicked problems': policy and governance on drug-related deaths in English and Welsh prisons, 2015-2021.

BACKGROUND: Prison settings have been neglected in the growing literature on drug-related deaths. This paper explores policy and practice issues regarding the governance of drug-related deaths in prisons in England and Wales from 2015-2021. METHODS: Thematic documentary analysis was conducted on national level policy documents published between 2015-2021 (e.g. drug strategies, prison policy documents, Her Majesty's Inspectorate of Prisons and Prison and Probation Ombudsman (PPO) annual reports and guidance for staff). At the local (prison) level, all of the PPO fatal investigation reports and their associated action plans relating to 171 drug-related deaths from 2015-2021 were analysed thematically. Various modes of governance were identified using Head's 'wicked problems' conceptual framework including avoidance and denial, coercive controls, compartmentalised micro-management, incremental and pragmatic adjustment and technocratic problem-solving. RESULTS: There was strong evidence of the dominance of denial of the problem of drug-related deaths, coercive controls, micro-management and reliance on technological solutions in the early years (2015-2018). In some prisons, there developed a move towards the adoption of more pragmatic and incremental policies and push towards comprehensive policies over time. In others, remnants of denial and coercion remained. In our analysis, the focus on new psychoactive substances came to dominate attention, to the relative neglect of other substances and of the contribution of mental and physical illness to these deaths. Staff are not equipped, supported or resourced adequately to deal with the two 'wicked problems' of increasing rates of drug use and mental illness which collide in the prison setting. CONCLUSION: The PPO investigations repeatedly recommend reducing supply and improving monitoring and surveillance and the emergency response. There is less focus on prevention and reducing demand or improving the wider environmental context and culture in which the deaths occur. Policy needs to pay more attention to the fundamental issues driving the current deterioration in conditions in prisons.

The risk matrix: Drug-related deaths in prisons in England and Wales, 2015-2020.

This article explores the factors contributing to drug-related deaths in English and Welsh prisons between 2015 and 2020. Based on content analysis of all Prison and Probation Ombudsman 'other non-natural' fatal incident investigation reports, descriptive statistics were generated. Qualitative analysis explored the circumstances surrounding deaths and key risk factors. Most deaths were of men, whose mean age was 39 years. Drug toxicity was the main factor in causing death, exacerbated by underlying physical health conditions and risk-taking behaviours. A variety of substances were involved. New psychoactive substances became more important over time. A high proportion had recorded histories of substance use and mental illness. During this period, the prison system was under considerable stress creating dangerous environments for drug-related harm. This study highlights the process of complex interaction between substances used, individual characteristics, situational features and the wider environment in explaining drug-related deaths in prisons. Implications for policy and practice are discussed.

The Pub and the People. A Worktown Study by Mass Observation.

Mass Observation was an independent social research organization which, between 1937 and 1949, documented the attitudes, opinions and everyday lives of the British people, using a combination of anthropological fieldwork, opinion surveys and written testimony. The Pub and the People is a classic text for its distinctly sociological approach, seeing patterns of drinking and socializing in context, rather than focusing primarily on pathological consequences. The main conclusions were that the pub is a living social organism and that the traditional approach of British sociology which, Mass Observation argued, focused on 'the drink problem' and the links between alcohol, crime and delinquency, failed to take account of the full social context. Mass Observation's focus on the pub as a place anticipates themes taken up in work on alcohol in cultural geography. Later alcohol researchers and epidemiologists have continued this orientation, recognizing the importance of physical and social environments in relation to alcohol consumption. Other studies have built on the MO initiative by looking at how drug and alcohol consumption links to identity, friendship and sociality or at the connections between intoxication and pleasure. The value of this classic text is that it reminds us that paying attention to the social context is not just a useful supplement, but absolutely central to understanding the use of alcohol or drugs.

The alcohol improvement programme: evaluation of an initiative to address alcohol-related health harm in England.

AIMS: The evaluation aimed to assess the impact of The Alcohol Improvement Programme (AIP). This was a UK Department of Health initiative (April 2008-March 2011) aiming to contribute to the reduction of alcohol-related harm as measured by a reduction in the rate of increase in alcohol-related hospital admissions (ARHAs). METHODS: The evaluation (March 2010-September 2011) used a mix of qualitative and quantitative methods to assess the impact of the AIP on ARHAs, to describe and assess the process of implementation, and to identify elements of the programme which might serve as a 'legacy' for the future. RESULTS: There was no evidence that the AIP had an impact on reducing the rise in the rate of ARHAs. The AIP was successfully delivered, increased the priority given to alcohol-related harm on local policy agendas and strengthened the infrastructure for the delivery of interventions. CONCLUSION: Although there was no measurable short-term impact on the rise in the rate of ARHAs, the AIP helped to set up a strategic response and a delivery infrastructure as a first, necessary step in working towards that goal. There are a number of valuable elements in the AIP which should be retained and repackaged to fit into new policy contexts.

Partnerships and communities in English drug policy: the challenge of deprivation.

BACKGROUND: From the mid-1990s, UK governments developed partnerships to tackle drugs nationally and locally. Over time, increased resources focused on communities and localities in greatest need. This reflected growing awareness of the concentration of problems in deprived areas, with social and spatial segregation being a feature of post-industrial urban areas. METHODS: A review of English drug policy since the 1990s, drawing on:- analysis of documents; a review of sociological studies; an illustrative case-study of one northern town; interviews with local policy players; statistical analysis of key indicators with some of these data presented using Geographical Information System (GIS) mapping. RESULTS: In-depth sociological studies demonstrate interconnections between historical patterns, socio-economic change, cultural complexity, deprivation, limited opportunities and illicit drugs. At local level, there are links between concentrated multiple deprivation, poor health, acquisitive crime and problematic drug use. Partnership policies, encouraged by the provision of ring-fenced funds, have been effective in containing problems. Underlying issues of inequality are however neglected in political debates. The article argues that post-industrial towns and cities are characterised by an increase in problems related to poverty and drugs. Both the real shape and perceptions of what is the problem change over time. In England, the profile of the problem drug user was described in a number of sociological studies conducted from the 1980s onwards. Key features were the concentration of problems in certain social groups (such as the poorly educated or unemployed) and in certain areas (inner cities or outer estates). Responding to rising public concern, national drug strategies developed and the New Labour Government after 1997 prioritised the issue of drugs, directing increased resources to drug treatment with tight control over the use of these new monies through target setting and measurement of performance. The emphasis was on the most dangerous drugs and most disadvantaged areas. CONCLUSION: There is local variation in the pattern of problems and in implementation of national policies. In UK after 1997, New Labour policy aimed to promote a fair and cost-effective distribution of resources and improved availability and quality of treatment services and local policing. Tensions appeared between the drive to meet national targets and local perceptions of need. Ideas of localism, promoting market solutions and flexibility in provision, are now gaining ground in English social policy with the arrival of a Coalition (Conservative/Liberal Democrat) Government. These, together with an emphasis on abstinence and recovery, raise questions about the future adequacy of (a) attention to marginalised problems and stigmatised groups and (b) the distribution of resources in a context of severe fiscal restraint.