1 The Third Sector and the Near Future of Drug and Alcohol Treatment Ian Wardle, Lifeline CEO October 2013 Reducing harm, promoting recovery, challenging inequalities
2 2 Table of Contents Introduction... 3 The Three Horizons... 5 The Model itself... 5 Moving beyond the Three Horizons approach... 8 Scenario-based Futures Work The Treatment Marketplace The Outsourced Marketplace The Social Innovation Marketplace The Multi-Market Scenario The Scenarios: Benefits and Risks The treatment marketplace Benefits Risks The outsourced market place Benefits Risks The social innovation market place Benefits Risks The multi-market scenario Benefits Risks Markets, People and Values: a three-way interaction People Management Conclusion: Our Values Further Reading Appendix
3 3 Introduction Like many people working in the Social Sector, those of us who work for Third Sector organisations in the drugs and alcohol treatment field have real concerns about the future. We worry about our security, about having meaningful and interesting careers and, when we ve finished worrying about these things, we worry about whether we are making a real difference. Aside from the worries, however, is it possible to think and talk strategically about the future of our field: our future? Who should be involved in this discussion? Where should one reasonably expect to arrive in this discussion? Is there any real point in attempting to look together at these issues? In our field, there are certain things in our past that we want to move away from and certain things we want to move towards. Equally, there are some things from the past that we want to take with us, just as there are some futures that most of us would want to avoid. So really, if a group of us, people at any and every level in our field, are looking at the future, we want a way to do it; a way that enables a rich and, as far as possible, focused discussion. This brief paper looks at some different ways of having worthwhile discussions about the future of our field. It assumes, as always, that one cannot approach our future in isolation from broader social and economic trends. It is also sensitive to the fact that many senior people in our field are careful about what they discuss in public. This reticent approach shouldn t mean, however, that we aren t able to talk about our future at any and every level. There are, after all, a number of very pressing questions. What happens, for instance, when a whole industry, a whole therapeutic approach and the understanding upon which it is built is not guaranteed a future? What about the roles that many of us in the Third Sector are now asked to play; roles that involve an ever-tighter integration with the government policy of the day? Are we in danger of becoming little more than the drive train of government? Or, with the current wave of outsourcing, are we in danger of becoming little more than appendages to the private sector?
4 4 How will our business development choices affect our values and our people management practices? Put another way, will the market choices we make change the nature of the organisatons that we work for and the jobs that we do? If we facilitate these discussions according to models that everyone understands and can participate in, then we can both pick the questions that we want to discuss and, with a surprising degree of precision, define the nature of our questioning. Futures Thinking and the Futures Field have been driven by consultancy. However, most Futures consultants have a relatively high threshold for engaging with a particular industry or organization. They tend to set out ambitious, expensive, and time-consuming programmes of work. This comes with the added disadvantage that often they don t fully understand the industry for which they are pitching their own consultancy services. This is particularly true of Scenario based futures work. This can very easily become overwrought and over planned, even as it produces very satisfying and interesting results. There are good reasons, therefore, to devise manageable, effective and affordable ways of talking about our future. The following brief accounts describe two different ways of holding productive discussions about the future. The first approach is called the Three Horizons approach. It is a flexible, intuitive and user-friendly way of situating discussions in such a way as to enable quite far-reaching and wellinformed examinations and exchanges about the future. The second approach is the Scenario- Based approach to futures thinking. It is easy to be put off by this latter approach if one reads too much of the specialist literature. Nevertheless, if one can dispense with much of the preparatory planning and move reasonably quickly to looking at possible scenarios, the Scenario-Based approach can augment and build upon the Three Horizons approach. These two approaches can, therefore, be combined in such a way as to enable an examination of our future in informed and critical ways. In the substance abuse field, Third Sector organisations are poised at the threshold of a world where their approaches to business development will no longer be confined principally to acquiring as many locally procured treatment contracts as possible. There are new and potentially destabilising choices to be made. These choices go to the heart of how we define ourselves, what we believe and what we want, for our service users and beneficiaries and for those who want to build a career in our field. The paper continues and concludes, therefore, with a brief examination of the need for congruence between our market choices, our people management practices and our values.
5 5 The Three Horizons The Model itself The Three Horizons approach is intuitively simple and inviting. There is a 1st Horizon that is usually construed as the status quo. A status quo, moreover, that has reached the peak of its influence and is beginning to show signs of lessening its grip, both from a material and a symbolic point of view. There is also a 3rd Horizon that is set, according to the timescale of one's choice, in the future. In this future, whether one is thinking across the near term or a more distant future, one can discern a range of signals, some clearly, some less so; some desirable, some less so; some easy to read, some less so. Finally, there is the 2nd Horizon. This horizon is our current position. It has the benefit of detail and proximity; after all, it is the daily reality we inhabit. At the same time, it is a discursive space where one can expect to find disagreement and challenge. This space is, therefore, a contested space. In it, one can have rival interpretations of the past and competing visions of a preferred future. Our Three Horizons model assumes therefore, that our futures discussion takes place within the 2nd Horizon. This approach makes clear that whatever kind of past you are seeking to move away from and whatever kind of future you are trying to create, there will always be a present where conflicting values and strategies fight it out. The Three Horizons approach is a very good way of examining both current realities and future trends. Firstly, it examines the broader environment and determines whether there is a good strategic fit between a particular approach (as a company or industry) and all relevant emerging social, political and economic trends. Secondly, it enables you to set a time scale in order that you can focus on the short, medium or longer term. You can look three years ahead, five years ahead, ten years ahead, and so on: the choice is yours. In fact, it is a particularly good way to enable movement back and forth in time in order to compare key strategic changes within our field against broader, more fundamental social trends. So although, over the past seven or eight years, we have spent a lot of time talking about industry specific issues around methadone and recovery, we have also reached an understanding that
6 6 broader influences are at play and these influences can, will and do shape our world despite and beyond our immediate analyses and concerns. Of course there may be important background developments that we are conscious of, but choose, for a number of reasons, not fully to discuss. In an age of economic uncertainty, people and organisations may not want to speak out on the key political issues of the day. This is unfortunate, particularly from the point of the Third Sector where there is a strong historical commitment to some sort of campaigning zeal. A certain reticence, however, is probably to be expected. There is a clear difference, however, between, on the one hand, knowing certain political and economic trends are working themselves through our society and choosing not to make a fuss about it and, on the other hand, not only not discussing these trends but also ignoring the strategic impacts that they are likely to have on one's industry, one's company, one's clients or beneficiaries and one's staff and volunteers. A properly tailored 'futures discussion' can factor in these broad political and economic impacts. One can, moreover, shape the discussion in a number of ways. One can, for example, choose to look principally at strongly predictable (i.e. overwhelmingly likely) high impact change and the range of possible, associated consequences. For instance, it is overwhelmingly likely that we are moving to a period where there will be much less public money available to fund our industry. Alternatively, one can focus upon those impacts that are less clear and less certain. This latter approach to the Three Horizons enables the detection of what are sometimes called weak signals: weak signals from the future, both from the distant future and also, in some circumstances, from the near future. Some kinds of change can be discerned from quite a long way out and can be seen gradually to move closer and become more real. The gradually growing impact of consumers and service users and the gradually diminishing power of expert professions is one slowly emergent trend that has been described for the last forty years: personalisation, co-production, self-care and experts-byexperience, are all terms that we have become accustomed to and now use every day. Unlike these long-duration trends, however, the recovery movement burst on to the scene much more quickly and much more unexpectedly. The recovery movement did not arrive slowly and steadily from a far point in the future; it arrived quickly and unexpectedly from the near future. The weak signals of such a strong emergence were either not strong enough for most of us to discern or, were misread as something else entirely. Applied to our field, the Three Horizons approach models our recent history and current predicament in a way that is immediately recognisable. It shows three trend lines, set on two axes. The horizontal axis represents the timescale under examination. The vertical axis represents the degree of strategic fit. Each trend line takes the form of a curve. Each trend line represents a horizon. The higher each horizon s trend line curves on the vertical axis, the more closely it fits the external environment. The lower the trend line curve dips, the less its relevance. From left to right one can see the trend lines for the 1st, 2nd and 3rd Horizons. If one were to draw the Three Horizons model for our industry, one simple version would be as follows. (See the Appendix for a diagrammatic representation of the Three Horizons relevant to our field).
7 7 The 1st Horizon trend line enters the diagram on the top left hand side and has, at its point of entry, a high degree of fit with the external environment. At the foot of the diagram, one can see the time frame. In our field, if one takes 1995 as a start point, one can see the clear dominance of the clinically led, harm reduction trend, both as a policy and a practice trend. This trend, with its ever-stronger criminal justice element, remained dominant until at least The 2nd Horizon trend line enters the diagram at quite a low point on the vertical axis and then, from 2005, climbs quite steeply in a very short space of time. By 2008, a new dominant trend was established and by 2010 this trend had been consolidated at the highest level of national strategy. Today, five years later, we are still, clearly, in this 2nd Horizon space. Over the course of the past five years, we have seen the fragmentation of our field, at policy, commissioning and provider levels. We have also seen, in this Horizon 2 space, the clear and wide scale acceptance of mutual aid as a key intervention in treatment and recovery. Despite widespread criticism of the practice of Opiate Substitution Therapy, the clinical hegemony of the medical establishment has been reestablished principally through the influential Medications in Recovery report of Even so, there is a widespread understanding that the substance abuse field as a whole, and the drug treatment industry in particular, are moving in fits and starts away from a clinical model and towards a social model. The recovery movement has, thus far, focused principally on the ageing cohort of people who have been treated for opiate dependence. As they age and as the positive impact of recovery facilitates a greater number of treatment exits for those able to move away from dependence, the number in treatment will decline. A substantial proportion of this remaining group will be so ensconced in long-term dependence that only the life-changing transformation of 'recovery' will be sufficient to secure the possibility of their exiting what otherwise would be life-long treatment. Over time, therefore, this trend line can be expected to dip and intersect with the 3rd Horizon trend line as the emerging trends that it describes begin to assume a better fit with the external environment. The optimistic, person-centred philosophy of recovery and the models of intervention that it embraces are already to some degree convergent with other self-care models that are emerging as part of the Third Horizon. In this way, elements of the recovery movement will move into the future in close alignment with some of the trends that only now are appearing on the Third Horizon. The 3rd Horizon is a trend line that has relevance to both broad strategic, political, social and economic trends and also to our own industry. This is the point at which the discussion about the future begins. Gradually a certain kind of future takes place. The trend line is our best set of guesses and judgments about what current signals from the future will establish the best strategic fit with the future environment we are best able to envisage. In a sense the Three Horizons model enables discussions to take place where one can: a) look at the near past and see what one has left behind and whether there is anything worth keeping; b) look at the present and see what is being contested, what is at stake for both now and the future and c) what kind of future is available to us, what are those trends and forces we can't change and what is worth fighting for in respect of those things we can influence. The Three Horizons approach can get you into a discursive space where you can focus up or down, back and forward: it's pretty much up to you how you set your preferences.
8 8 Moving beyond the Three Horizons approach All models have biases and built in distortions. One can counter this built in bias to a degree, but there comes a point where one is unable fully to counter the distorting effects of the model one is using. Advocates of the Three Horizons approach argue that it enables participants to bring together Visioning and Scenario Planning. Without going into detail, this is a strong and positive claim to make. Visioning is less popular than it was a decade ago when it was often described as Blue-Sky thinking. The environment in which we now live and work makes a more hardheaded approach to the future seem more appropriate. From this point of view, Scenario Planning which enables one to build in harsh realities as possible ingredients in various future scenarios may seem better suited to the times in which we live. Whatever one s view, the particular strength of the Three Horizons approach is that it is very well suited to an initial series of futures discussions. It is also designed in such a way as to make the transition to a more specific examination of scenarios a natural and largely seamless process. There will come a point in one s discussions about Horizon 3, where one wants to break up the tendency to generalize about the future into a series of harder and more specific alternatives: scenarios.
9 9 Scenario-based Futures Work To repeat: the approach here falls far short of the resourcing, rigour and planning necessary to derive full-blown scenarios according to the approved methodology. It is usual for these kinds of fully developed scenario planning exercises to look ahead by as much as 10 or 20 years. It is also common for them to seek to identify high impact events of an uncertain and difficult to predict kind. Failure to predict developments such as the Internet, and particularly its far-reaching impact on business, and failure to predict the global financial crash of 2008 have served to justify this particular feature of futures work. One might separate out such fully resourced, stakeholder scenario based exercises from those that are produced over a shorter time scale with a different methodology and are produced for the consumption of a specialist public. Here, a common methodology is the expert Delphi focus group. Experts produce scenarios and then look at particular ramifications of each scenario. The UK Drug Policy Commission, (UKDPC) used a Delphi focus group to inform their final major publication: A Fresh Approach to Drugs. The sort of futures work currently needed by our industry, and particularly by the Third Sector component of our industry, has a much shorter time scale. Rather than looking ahead to 15 years hence, we need to focus on the near future with a maximum time frame of no more than five years. Momentous change is imminent; in fact, it is upon us. That s why we don t need a methodology that will enable us to discern potentially devastating but difficult to discern change fifteen years down the road. We need to be able to look at the realities that challenge us now. We need to examine our key choices in more detail. We need, furthermore, to identify the kinds of business framework in which these choices are made. More specifically, we need to look at our market choices and ask which markets will be available to us and which will enable us to flourish. And, to use a technical term, what will be the opportunity cost of entering certain markets and departing others. Here are four different market choices that face Third Sector providers at this time.
10 10 1. The Treatment Marketplace At the moment, the drug and alcohol treatment fields are quite heavily populated by a range of Third Sector organizations varying in size and annual turnover from 100 million down. As a sector, our penetration of the drug and alcohol treatment market place is continuing to grow from an already high base. Some organisations within our sector are growing quickly, some are losing ground, others are holding their own, some quite comfortably, others with difficulty. All of us realise, however, that this is, to use another technical term, a mature market place. For years we have been talking about, and worrying about, that point in time when the money would not be there to invest in drug and alcohol treatment. Quite rightly, we do not feel any complacency in terms of our claim to being a key public health priority, at least not from the point of view of drug treatment funding. At the moment, we are told that our contract income, with certain exceptions, can be expected to hold steady until What then? The best one can say is that there are no guarantees. 2. The Outsourced Marketplace At the same time as we are exploiting to the maximum our ability to win treatment contracts, we are witnessing a very large-scale privatization of the public sector. The privatization of the Probation Service is the latest wave of this outsourcing to the private sector. The Work Programme, Transforming Rehabilitation and the procurement of large-scale health contracts are changing the traditional public sector landscape very quickly. Third Sector organisations may well want to participate in this new world, either as consortia or as subcontractees of a Prime Provider. They will, however, be very aware of what happened to some Third Sector providers who suffered closure as a result of involvement in the Work Programme. The new model of Payment by Results is an integral part of this new world and organisations will need to learn quickly how this can impact on their cash flow and underlying financial balances. 3. The Social Innovation Marketplace The social innovation market place is positioned and described very differently from the world of mass privatization and outsourcing. In Growing the social investment market 2013 progress update, 1 the coalition government reports on an aspiration to grow the social investment marketplace in order to secure both improved delivery and innovation. The update states that 1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/205295/social_inve stment_strategy_update_2013.pdf
11 11 growing this market is likely to disproportionately benefit disadvantaged groups and their communities. Many social enterprises are based in poorer areas and actively employ people further from the labour market, such as those with disabilities, the long-term unemployed and exoffenders. Eighty-two percent of social enterprises reinvest their profits locally. This attractive picture of an innovative, caring localism is very different from the multi-million pound, incentivised market place dominated by global outsourcers. The attractions of the language are indisputable and many Third Sector organisations will endorse the ideas that seem to underpin this vision. Certainly, there is a serious attempt on the part of the government to make this look like a viable market choice. 4. The Multi-Market Scenario Many providers will quite naturally want to perform successfully at every level and compete effectively across each of these three marketplaces. The aspiration and the intention will be to continue to thrive in the mature treatment marketplace, at least for as long as it flourishes; to make a successful adjustment to the privatization of public services by successfully entering the outsourced marketplace, and, lastly, to be a successful incubator of social enterprise and a credible community-based provider. This hybrid model may appear to be the sensible way of not over-committing to one of the other three models. It does, however, come with risks of its own.
12 12 The Scenarios: Benefits and Risks The above market place descriptions can, for the purposes of this paper, be treated as four scenarios. We are able on the basis of identifying these scenarios to do a number of things. Firstly, and quite briefly, we can describe these scenarios. Secondly, and even on the basis of these brief descriptions, we can produce an outline of the benefits and risks of each scenario. Subject to time and resources, these descriptions, or narratives if you prefer, can be worked up to any level of detail, as can the sections on benefits and risks. 1. The treatment marketplace A market place dedicated to continuing to respond to substance abuse. One where clinical competences, a scientific evidence base and core therapeutic ideals, despite economic threats, still hold sway. Benefits 1. The substance abuse marketplace has shown strong resilience and ability to resist attacks from without and within. 2. Substance abuse sits at a strategic crossroads in UK social policy with a very strong research, policy and practice community. 3. Many Third Sector providers have a strong brand and reputation in this field. Our workforce are more energised and focused upon our field s broad mission than at any other time. 4. Many companies are gaining penetration of key geographies and, at the same time, expanding into new areas. 5. We are all developing new expertise in 'coming' areas of importance like alcohol and families. 6. Our growth in this sector has helped many organisations to develop critical mass (both capacity and capability) in project mobilisation, service management, business development and innovation.
13 13 Risks 1. There is a possibility of a shrinking market place prior to and post There are dangers of an hourglass shaped workforce with a clinical elite at the top and a semi-skilled, part time, sessional and volunteering workforce at the bottom. 3. Many of us are over-optimised for treatment markets and this deters our ability to develop real investment in new ventures. 4. An over-absorption in what is still a medically dominated field has an inhibiting impact on experimentation. 2. The outsourced market place A market place centred upon employment, reduced-offending and the transition from welfare to work. This is a market where the for-profit sector has effectively gained control over an incentivised market place in which funding is dependent upon results. Benefits 1. A real opportunity to establish Third Sector organisations in a major new marketplace. 2. Procurements like Transforming Rehabilitation provide a natural area of expansion for many Third Sector substance abuse organisations. 3. Outsourcing provides a major chance to build upon our competitive strengths in the new models of delivery. 4. It provides a further opportunity to consolidate, expand and strengthen our various approaches to building our workforces. 5. Transforming Rehabilitation seems to offer the opportunity to link up prison and community interventions and thus provide seamless services along that critical pathway. 6. Early entry into this market place can seal long-term contract security. Risks 1. The rush for money may blind us to unforeseen opportunity costs. 2. There are dangers that flawed PbR models will fail to deliver results and hoped for financial rewards. 3. There could be a loss of credibility if the public rejects the outsourcing model. 4. The sector may fail to sustain its core values in the new environment of 'challenge' and 'coercion'. 5. The sector may experience a loss of mission and integrity with accompanying loss of any fundamental rationale. 6. We may experience a loss of real executive control.
14 14 7. The new ways of working may result in loss of genuine empathy and cultural understanding of service users. 8. We may lose the ability to genuinely harness the best energies and aspirations of key sections of the young workforce. 3. The social innovation market place A marketplace emerging in response to a virtual drying up of large-scale public funding where greater local resilience, diversity and innovation are clearly identifiable features. In this scenario, health behaviour change will be more strongly peer led and will take a more cluster-driven approach to damaging health behaviours. Benefits 1. A wide mix of different kinds of intervention will bring numerous opportunities to experiment and innovate. 2. Freed, to an extent, from the yoke of contract delivery, the Third Sector may develop social impact measures that can attract early research and investment interest. 3. We can work in a more integrated way to tackle clusters of disadvantage and damaging health behaviours. 4. We can focus upon and expand a mix of population-based, life- course approaches on the basis of genuine inclusivity. 5. We can continue to develop strengths in grant-based funding and begin to attract other forms of social investment. 6. We can build organisations with a genuinely congruent approach to values, people management and market performance. Risks 1. Most organisations with significant contract funding will risk falls in overall income. 2. The risk of patchy provision and a loss of investment income as well as other size-related corporate and workforce benefits. 3. Possible shrinkage may well affect Third Sector organisations ability to work nationally and to attract talent. 4. There is a danger of widespread deskilling and a perceived lack of core expertise.
15 15 4. The multi-market scenario The most likely real 'future' will certainly contain, in some measure, elements of all three of the above scenarios. The key questions, therefore, will probe the ability of Third Sector organisations to successfully vary their mix of values, people management and market strategies in response to real emergent trends, irrespective of which scenario, however configured, establishes dominance. Benefits 1. This scenario presents the opportunity to develop a fully flexible series of business models able to respond successfully to all kinds of opportunities, both large and small. 2. It will encourage providers to avoid the dangers of over-optimising their strategies toward a single market place. 3. Our sector will have a range of approaches, each of which can enrich and learn from the others; we will be in a position to align ourselves more successfully with different 'buyer behaviours'. 4. We will be able to develop a strategically agile workforce, alive to and able to respond to all opportunities at every level. 5. We will develop values that can inform our work across sectors and business models and will not be blind to the potential ethical and reputational opportunity costs of growth and expansion. Risks 1. There is a risk of failure to fully meet the challenge of complexity. 2. We may fail to develop meritocratic and fair reward systems. 3. There is a major challenge around the development of effective knowledge management and information systems. 4. There is a challenge of developing adequate systems of complex integrated governance. 5. A dissipation of focus upon one key market may lead to a failure to develop critical 'developmental' mass in any one sphere.