Richard Smith: Time for a radical pivot in the welfare state, including the NHS

Every so often we encounter a book, or even an article, that says something important and changes our thinking. Often they are books that express clearly something that we have vaguely thought or partially glimpsed. For me (and others I know) Radical Help: How we can remake the relationships between us and revolutionise the welfare state by Hilary Cottam is such a book. 

She argues that the welfare state, something we all value, no longer responds adequately to 21st century problems:  global warming, mass migration, demographic changes, chronic disease epidemics, concerns about security. and escalating inequality. The welfare state needs not just to change but to “pivot…a special kind of change that involves a new vision, a different solution and a new business model.” The current proposals for restructuring the NHS (yet again) are not a pivot.

A pivot, explains Cottam, is not just another word for change. “The pivot is a special kind of change that involves a new vision, a different solution and a new business model. The pivot offers transformation, the potential for something much better and more successful.” It requires great courage to pivot, and many enterprises and businesses have failed because they lacked the courage.

To pivot the welfare state—and particularly the NHS—may be especially hard because of the national love for the institution. “We are in danger,” says a friend who has worked in the NHS for 40 years, “of loving the NHS to death.” Cottam argues that “Our most difficult relationship—the one that most threatens our health—is our relationship with the medical establishment….Medicine has captured our hearts and our minds. We are in thrall to the NHS and emotionally attached to our doctors.” We look to doctors, other health professionals, and the NHS to solve problems that cannot be solved by drugs, operations, and even simple advice. To avoid dependency we need to look elsewhere for help—to ourselves, our family and friends, our communities, and civil society.

Cottam is not anti-doctor. She is about achieving a better balance between what the NHS does and what others do. The NHS, for example, is well designed for vaccinating the population against covid-19 and other infections, but it is not best placed to deal with the loneliness, despair, inactivity, and unwise behaviour that may result from lockdown. The Lancet Commission on the Value of Death, of which I’m a part, has reached the same conclusion. Death, dying, and grief have moved too far from families, community, society, and culture into healthcare. Health professionals are the best people to administer morphine for pain and treat breathlessness, but not to respond accompany people through the long and lonely hours of dying.

“The current welfare state,” writes Cottam, “has become an elaborate attempt to manage our needs. In contrast, twenty-first-century forms of help will support us to grow our capabilities….Traditional welfare approaches see you as dependent according to their biases and then in response they try to give you something or do something to you, to manage your need in the best way they know how. The capability approach shifts the way support is offered.”

Interestingly, William Beveridge, the architect of the welfare state, recognised that he had made a mistake in leaving out of his plans a greater role for families, communities, volunteers, and civil society. He didn’t like that the state was doing everything. “It did frankly send a chill to my heart,” Beveridge complained. In a report on voluntary action in 1946 “he worried that some core groups were not benefiting from his reforms; and he was increasingly aware that communities, rather than distant, cold and hierarchical institutions, are often much better at identifying needs and designing solutions.” Those “core groups” might be what are now called “the left behind” or the “hard to reach,” people who may generate huge costs to the welfare state, but without getting much benefit. These are groups in whom Cottam is particularly interested.

“Beveridge,” writes Cottam, “had designed people and their relationships out of the welfare state.” She recognises the centrality of relationships to our lives and health. “Relationships—the simple human bonds between us—are the foundation of good lives. They bring us joy, happiness, and a sense of possibility….Building on relationships enables the growth of further capability: supporting us to learn, contributing to good health and vibrant communities. Without strong bonds with others, or with unhealthy relationships, very few of us can feel fulfilled—or even function.”

Many people, including the authors of the NHS ten-year plan, have recognised the changing health needs of the population. When the NHS began the big health problems were infectious disease and trauma, problems that responded well to an industrial, transactional approach. Now the problems are long-term conditions, multimorbidity, poor mental health, loneliness, and the frailties of old age. One in three people over the age of 60 (2.4 million people) in Britain talks to another person only once a week, and one in 10 (850,000) only once a month. These are problems that don’t respond well to an industrial, transactional approach.

Much of Radical Help describes experiments where Cottam and others have designed ways of responding to “problem families,” the unemployed, people with long term health conditions, and the elderly. Building relationships is at the heart of all the experiments, but you don’t build relationships by importing a paid professional. Indeed, you can’t build relationships for people, they have to build them themselves: this is what is meant by “Building capabilities.”

Cottam approaches a problem like a designer, and unexpectedly and controversially was the UK Designer of the Year in 2005. She is a pioneer of what is called “social design,” and what was controversial 16 years ago is now mainstream.

The first step is to identify a problem—perhaps what are called “problem families,” unemployment, loneliness, aging, or health—and a location and partners with whom to work. Those for whom the services are designed must be part of the team: they are the ones most likely to have good ideas for redesigning the system. Many of the people who work with her come from statutory services, but are frustrated, recognise the need for change, and are willing to try something different. Funding is needed, but usually is of an order less than that spent on the failing statutory services.

The second step is to define the opportunity, and this requires a great deal of listening. Who does the listening, who is asked, and how people listen all matter. Cottam tells the story of working in the Dominican Republic to find out why the poorest children didn’t go to school. The Ministry of Education said it was because the poorest children couldn’t afford school uniforms, but reducing the cost of uniforms didn’t increase attendance. Cottam went into the poorest (and dangerous) districts and found that the real problem was that the poorest children didn’t have identity cards, but they didn’t want to tell this to the authorities. Listening works best with people who are not in authority, but who are prepared to listen to those at the edges for a long time. The second step also involves some desk research.

The third step is not to devise a solution, but rather a prototype response that may be continually modified. Resources must be unlocked, and there must be a business case made. Once the concept is validated the programme begins, evolving as it goes.

Cottam describes five experiments in the book, and one was concerned with trying to help people age well. The work began on housing estates in South London, and by listening to the elderly, many of them living alone and lonely, the team identified three requirements for good ageing: somebody to help with small jobs in the home; good company with people with shared interests and with whom you feel at ease; and a sense of purpose.

The team devised Circle, which was “part social club, part concierge service, and part co-operative self-help group.” People paid £30 to belong and were provided via a telephone line with practical support and a rich calendar of social events. The elderly asked for life coaches to help them to find purpose through changes like taking up part time jobs, but it soon became apparent that new friends were more use than life coaches. People needed encouragement to join, and “Those who lead Circles have the mindset of the perfect party host, making sure no one is left in a corner alone, or stuck with someone they don’t really like.” The character and style of leaders seems to be crucial. Much of the value of Circle comes from the build-up of relationships allowed to grow organically.

An independent evaluation of Circle found that four-fifths of members grew their capabilities; a quarter volunteered within Circle, helping to host thousands of hours of activities; 120 000 new relationships were fostered; and unnecessary reliance on formal services was reduced by a quarter. Circle has spread around the country, but Cottam recognises that it didn’t deal with those with severe dementia or those at the end of life. It seems to me, however, that it could be evolved to help with both.

The emphasis in Radical Help is on building capabilities. Cottam identifies four that she thinks matter the most: “learning: the ability to grow through enquiry and meaningful work—the chance to develop our imaginations; health: our inner and physical vitality are central to a flourishing life, and good health implies a delicate balance between the acceptance of our minds and bodies and a commitment to good habits; community: being part of and contributing at the local and planetary level to a sustainable way of life, working alongside others in an effort to bring about change or to make something together; and relationships: a supportive and close network with others, some of whom are similar to us and some of whom are different.*mainstream.”

Cottam is by no means alone in recognising the need for a radical change, a pivot, in the welfare state. Minouche Shafik, the director of the London School of Economics and Political Science, has just published a book, What We Owe Each Other, arguing for a fundamental change in the social contract. She points out that surveys show that “four out of every five people believe ‘the system’ is not working for them in the United States, Europe, China, India and various developing countries.” Shafik points out that Beveridge designed the welfare state for a very different world where most women didn’t have employment, but married and looked after children and elderly relatives, men worked much of their lives at the same work that was well paid and died soon after retiring, children could expect to earn more their parents, the internet was not invented, single-person homes were rare, health problems were mostly infectious disease and trauma, the capabilities of medicine were modest, and death usually came swiftly. Shafik predicts that “The political turmoil we observe in many countries is only a foretaste of what awaits us if we do not rethink what we owe each other.”

The Economist too has observed how the modern welfare state is no longer fit for purpose and how the pandemic has accentuated its deficiencies. The state has had to support many more people and may have to continue to do so, but how best might that support be provided?

Shafik and the Economist are thinking mostly of high-level policies, but Cottam is concentrating on the changes that communities and individuals can take. Hers is a very practical as well as visionary book that local leaders can read and follow. I urge you to try.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: none declared.