Reimagining the welfare state: health and community with Hilary Cottam OBE

Key:
I:  Anna Charles
HC: Hilary Cottam

I:         What do we really need from our environment communities and public services to keep us well and allow us to flourish?  And are the systems and approaches we currently rely on in the Health and Care system equipped to tackle the challenges of today?  Hello, and welcome to the King’s Fund Podcast where we explore the big issues and ideas in Health and Care.  I’m Anna Charles, Senior Adviser to the Chief Executive of the King’s Fund and today I am delighted to be joined by internationally acclaimed entrepreneur, author and commentator, Hilary Cottam OBE.  Hilary’s work encourages people to radically rethink the role of public services, including health and care.  She works with communities and organisations in the UK and across the world to develop approaches that emphasise the power of human relationships and the strength of individuals and communities, arguing that these should be the starting point for a reimagined welfare state.  Hilary has previously been recognised as a World Economic Forum Young Global Leader and in 2019 she was awarded an OBE for her services to the welfare state.  So she is the perfect person to be speaking to today to try and answer some of those earlier questions.  Hilary, welcome to the King’s Fund Podcast.

HC:      Thank you, Anna, it’s really an honour to be here.

I:         To start us off, can you tell our listeners a bit about who you are and what you do?

HC:      That’s quite complicated.  When I wrote my book Radical Help, my mother said that finally she understood what I do.  Really what I do is I try to connect energy and community to social systems.  I have spent half my life working in the developing world and most recently, the last few decades, I’ve been working here predominantly in the UK, although still global reach.  And what I’m really interested in is how a set of extremely successful social systems designed after the Second World War are no longer working for us.  They’re no longer really able to address the kind of deep social problems we have today and how we might think about reorganising those systems with the energy of our populations.  We’ve got so many ideas and so much energy.

I:         And you mentioned there briefly your book Radical Help, which I think you published in 2018, can you tell us briefly what that’s about and what the book aimed to do?

HC:      Yes, so the book is a story of five experiments that took place starting in about 2004, I think, in Britain.  What I set out to do really was to explore with governments and communities how we might redesign the welfare state for our times.  So just like Beveridge, I went cradle to grave starting looking at early family life, young people, health, work and then older life.  And set about designing new systems that can support people.  And we were able to grow them to some scale, so for example 10,000 people used the older people’s, I don’t want to call it a service, it’s a sort of community support system, and that enabled us to show that the approach that we had (s.l needs to be rooted 0:03:16), well, rooted in the sense of how we could grow people’s own capabilities had much better outcomes, was a lot cheaper, and also that those communities and professionals really loved it.  So what I set out really to do with the book was to share that experience more widely and to see if we could have a bigger conversation and invite more people to experiment along these lines.

I:         And you said that it was based on lots of real examples, so can you say a bit more about what that kind of approach really looks like in practice, either for someone using or someone working in health and care services, say?

HC:      Yes, so if we take the health example, the health chapter, what we know is that the big challenges of this century are chronic conditions, how to prevent them and how to live with them, and care.  And neither of those were part of the Beveridge Welfare System.  Chronic conditions because that wasn’t the challenges to stay and care because actually they had a lot of discussion about what to do about care and they couldn’t come to a resolution, so they decided to basically sweep it under the front door, give it back to women in the home and ask local authorities to patch something together.  And we know that a combination of those two things are now, I want to say breathing the whole edifice, but I think the edifice is beyond – I mean the edifice is crumbling now with our inability to think in a different way about those two challenges.  And so what we did with the health work was very simple.  We set up in GP surgeries and we said to GPs, “Could you just give us every patient you’ve got that really you can’t deal with in the 10 minute slot that you have?  So whether they’re tired, or they’re stressed or they’re not making progress.”  And we set up in a room next door and we asked people just to talk to us and to tell us about their lives and to tell us what they were thinking and what they’d like to do about it.

The point is to listen and then try things out in a very simple way and then work that up bit by bit by bit into something that’s a bigger response.  And what we had in health eventually was something we called Wellogram where we first of all worked with people and supported them individually to make changes in their lives.  Very often those weren’t health changes, they were about building confidence, one of the stories I tell in the doctor’s is about Kate, who said that she’d like to take up embroidery again, so that’s a starting point.  But then kind of building stage to stage and then integrating people into groups so that that kind of work can carry on.  Because we know that making change in our lives is one thing, but sticking at it is much, much harder.  One of the things is very evident in all my work is everybody knows the health advice, but whether they can do it or not, as we all know in our lives, whether we want to run more or drink less or whatever, that’s much more complicated.  And what we were able to show with the first cohort of 2000 people with a randomised control chart was that we had long-term impact on chronic conditions by working in this very socially rooted relational way, rather than addressing head-on health challenges.  So we didn’t differentiate people by their health, whether they had heart problems or weight problems or whatever.  We just worked with everybody in this way, step by step, with some quite profound health outcomes.

It costs about £20 per person, so if you think about how many – as I say the advantage to being in the GP surgery was that we could track their outcomes over time and we could see the impact that we were making.

I:         And when you published the book, it prompted a lot of discussion and debate among leaders for health and care and I think in the wider public sector.  So we’re five years on now, what impact do you think the book has had?

HC:      Yes, that’s a really good question.  I have to say that I wrote the book for the general public, I didn’t actually write it for people who work in health systems or social workers, because one of the things I feel really strongly is that these issues, which are really about how can we flourish in this century have become very polarised and politicised.  And that makes it very, very difficult for health leaders or political leaders to actually facilitate the kind of conversations that we need.  So we see that for instance in health where everybody goes to rush to defend their local hospital, even though everybody knows that that’s not the answer to our problems.  In an era of cuts, that’s a very logical thing to do, but how can we get past that and I thought we had our welfare state and we had the National Health Service because we had this big post-war conversation and this big consensus about what we wanted, and how could we begin to talk again?  So all that just to say that the fact that the book has been taken up by so many professionals, whether it’s health professionals or social workers, I didn’t expect and I’m really thrilled by, and I think it’s because basically I’m saying what everybody already knows, that we need to move in these ways and we need to make this change.  I think that people have seized it and we’ve had experimentation, which is also fantastic.  When I give talks now, I can talk about lots of things that other people are doing that aren’t by work, but are on the same lines, and I think that’s really amazing.

At a system level in the Nordic countries, the book’s been translated, so globally at a system level, we can see in the Nordic countries where they’ve taken the principles in the book and they’ve really shifted housing systems, social systems, family systems, health systems, in a really profound way.  That bit here in Britain is missing.  I think there’s conversations, but I haven’t seen any action.  It’s not necessarily that I expected that to happen, but I think just the conversation hasn’t moved to the systemic action that we need.  Partly I think that’s about the fact that people at the very top of our systems are quite divorced from their everyday life now.  So although this book makes complete sense to health professionals and to social workers who see what I’m talking about every single day, when we hear our political leaders talk about fining people still for not turning up to GP appointments which they can’t actually get, we see that there’s a dislocation that makes it quite hard to make change now.

I:         And a few years ago the King’s Fund published some research looking at the experience and learning from the transformation of public services in Wigan, under the Wigan deal, which I think you were involved in.  The report for that’s available on our website if listeners want to find out more, but I think Wigan’s probably a good example of a local area that has managed to put some of your ideas into practice.  Is there any kind of learning you’d highlight from there or indeed other places around the country that have done similar that you would highlight?

HC:      Yes, so I think what’s really important about that work is that not only did it transform systems, well, that’s the most important thing, but it started with a story that was called “The Deal”, so it started with a kind of vision, not a management document but something that really spoke to people about how we’re going to make these changes, how we’re going to give power back to communities and how we’re going to do that to transform the system.  So I think what was really important about that was this very, very big vision that people could be a part of.  I know that one thing that Lord Peter Smith would say about that experience, so he was the leader of the Council at the time when I started to work with the Council, is that they were very lucky because they made those transformations at a time – when I say they were lucky, actually he’s being modest, they were all very brave.  But they made the transformations at a time when they had some budget that they could put into the system to get some slack to begin to move things around.

And I think actually we do have resource at the moment, but we’ve got quite trapped in similar thinking, so the resource isn’t necessarily within the local state anymore, which is a problem, and where it is it’s being given out as £50,000 grants which makes it quite hard to do the scale of the work.  But I think we do see perhaps not that championing of vision at the high level, but we do see some quite effective – I mean in Barrow, for example, I’ve been involved in some very exciting processes to do some very effective storytelling, which involved a very wide section of a community.  And I mean that not just demographically but also ideologically with the state, with local business, all sorts of people to tell a different story and then think about how services could be reimagined in that context.  And I think that that story is very important.  One of the things we could say about that is in the context of the Health and Care Act and the ICS, Integrated Care Services, Integrated Care Boards, is it would be very exciting if they could think about how they’re going to tell a different story that actually begins to build a relationship with communities in a very different way.  And have these, I would call them coalitions of the willing, that can come together and start to shift systems together.

I:         And from what you’ve seen in the communities that you’ve worked with, what are the things that people struggle with most in terms of putting the ideas that you’re talking about into practice?

HC:      That’s a good and difficult question.  I think one thing I would say is seeing is believing, so I think that the work that I was able to do had success.  It also had failures.  I think one of the things in Radical Help is I talk about what didn’t work, which I think is also just as important.  But I think it had success because people could feel it and touch it.  And I think if we’re thinking about health services at the moment, we need to make some really radical changes in the systems we have.  And because from what we’ve experienced are decades of cuts and withdrawal of funding, it’s natural that we feel a bit suspicious, like if something’s put online, is it really just to worsen it and make it cheaper, if something’s closed, is something better actually going to open?  So I think one of the most important things was that we didn’t talk, we got together and we built stuff and first of all it was like theatre with props and then it became more and more real as we carried on working.  So I think that that gets you over suspicions, really, working in a very inclusive way.

And I think the other thing that’s really important about the work that I do is that I don’t start asking how we could improve health systems, I don’t start with an institutional mindset.  I start by asking people how they can improve their lives and if we’re working in health, what does health mean to you and what would you like to do?  And I think that immediately gets you started in a very different conversation.  But I think that’s quite hard to do because of where funding comes from, so I’m often approached by quite inspirational health leaders, but they say to me, “Can you help me find out how to fix this part of the system?”  And I know that if we go into communities or into other parts of services asking that question, it just doesn’t resonate, people don’t come around about that.  We have to start in a very different phase and ask, “How can we flourish, what does health mean in this place?”

So I think that that is really important.  I think one of the issues that I see now compared to perhaps, say, when I started the work in 2000, is just the pressures on the system are absolutely immense.  That’s partly about hollowing out funding and of course it’s about COVID and everybody is barely coping.  And it’s very, very hard.  We’re talking about work of the imagination and that is very hard if you’re really suffering and barely coping.  One impact of that suffering, I think, at leadership level is that people are rotating through health positions in particular very fast.  Where I’ve been able to do really good work or be part of really good work, like the Wigan work we were talking about, this was the work of a decade.  This doesn’t happen with £50,000 and a six month innovation project.  I think it’s not impossible, it’s definitely happening, but I think it’s only fair to say that that’s – it’s both more needed now and a bit harder to do now.

I:         And I have heard criticisms that these sorts of ideas and approaches could be used as an excuse for cutting public services or passing responsibilities for things to communities or the voluntary sector that should actually be the responsibility of the state, so what is your response to those sorts of criticisms?

HC:      Yes, I think that’s really important.  I see myself as a public servant and I would be concerned about that.  I think it relates to what I’ve just said, which is that one of our biggest national experiences was with the Cameron Government and this idea that citizens should step in, we should put our own livelihoods back on the shelves and that would mean that nobody had to pay for a librarian.  And obviously we’re not talking about that.  I think also what’s important to say is that I’m quite nervous of a fashion that says, “Oh, it’s all about the community.”  The state cylinder goes down and the pressure in the community cylinder goes up and I think what we really need is very new horizontal bonds between state, between community, between professionals, to get out of this verticality in any way and organise horizontally.  And so I think in the work that I do, I’m looking for new alliances between state and community.  I’m definitely very wary of anything that pushes things back on to communities, particularly because if we think about health, the communities that are suffering most from health are those who have got the least time and resource to give time to these kinds of things.  But at the same time I think if the question is health, where is health made?  Health is not made in health systems, it’s made in homes, in communities, in workplaces.  So unless we can build horizontal bonds between communities and the kind of expertise and resource in health systems, we can’t really make change.  But it’s definitely not the big society.

I:         And it goes without saying I think that a lot has changed since you wrote Radical Help, you’ve already referred to it but not least the experience of a global pandemic.  I’ve read that when you’ve been talking about the COVID-19 pandemic, you’ve previously said that it was a cataclysm brutally exposing the crisis in the funding culture and operation of our care systems and that we can honour this recent experience and the deeper legacies of injustice by creating something new.  So can you say a bit more about what you meant there and what you think needs to happen now?

HC:      Everything has changed and everything is the same, if I can say it like that.  What the COVID pandemic did, it was like a hurricane and it blew and it’s like when the trees blow down, what you see in the earth are both the shoots of something new, but also the devastation.  And I think that that’s what happens and we know that when storms come, it’s terrible, we lose these old trees, but these kind of massive shoots of new growth come through if you allow them.  And I suppose that that’s what I’m thinking about.  I think when I wrote that, perhaps I was, I don’t want to say more optimistic, but I think one of the things that I am concerned about now is that there’s this idea that everybody should be coping.  There’s a lot of pressure put on coping and particularly for frontline health staff.  I literally don’t know how they cope and I admire them so, so much.  But I think the dangers of that coping mechanism is that the kind of underlying tensions just keep building and building and building until we have another eruption, and some form of eruptions in strikes but in all sorts of different ways.

So I think it’s really important that we don’t lose sight of what happened and that we do start to build anew.  And on the positive side, of course what we saw in the pandemic was people taking care of each other in really important ways, horizontal ways, from street WhatsApp groups to signing up for things and taking care of each other.  And we can see that we can reimagine care in this way, that people want to care, we want to support one another.  And so what I’m focused on now is really how do we think about what I would call a care economy that includes that energy that people have to support each other with a kind of rethinking of what the care systems look like.  For me, this is definitely not a recreation of a post-War health system as a post-War care system, because it’s got to include professionals and civic action in a different way.  And one of the things that’s really clear is it’s got to include business in a different way, because most people want to care and they can’t because their jobs don’t allow it.  One in four people, one in four women change their jobs frequently because they’re looking for a space where they can care; whether that’s pick up a child or actually care for a relative in a more long-term capacity.  So we’ve got to rethink all these boundaries, really.

I:         And we now have another generational crisis hot on the heels of the pandemic in the form of the cost of living crisis, so what’s your view on what that means for the support that individuals and communities require and how we should be responding to that?

HC:      There are two answers to that question; one is that obviously in the communities I work in I see the [inaudible 0:20:31] impact of that cost of living crisis, where you are making those choices between heating and eating, but more than that, there’s sort of attrition all the time making sums in your head every day about how things are going to add up.  The wear and pressure of that just is extreme, but for me what’s important is the sort of much longer longue durée, if you like, which is that our country has been growing increasingly unequal for some time now.  And so the cost of living crisis is important that it’s on top of a sort of a deeper issue which, for me, my current work is all about work and that is because work doesn’t pay.  Too many people do work where even before the cost of living crisis, it wasn’t possible to have a decent standard of living.  And so I think what we can see is that we need to really think in a very structural way about how we think about our economy and how we seek help as (s.l routers 0:21:30) in that economy.

One thing that’s really struck me recently is we know that people are not working, we know that over 50s have left the labour [inaudible 0:21:40], we know that the biggest attritions between 16 and 24 year olds who aren’t working, and this is part of the mental health impact of the pandemic, and I think it’s also about the work.  I think it would be completely wrong for us to see this as a health problem, I see it as an economic problem that people simply can’t carry on working for extremely long hours under the pressure and with the impossibility of the pay that you receive enabling you to lead a decent life.  So we have to have a fundamental economic transition really in this country.

I:         The role of communities in improving health is clearer than ever.  Integrated care systems offer the opportunity to nurture greater involvement of communities, particularly by supporting efforts at the level of local neighbourhoods where the link to communities is often strongest.  So what does this look like in practice and how can it be done? If you’re interested in those questions and finding out more, then sign up to our two-day virtual conference, “Community Lead Approaches to Health and Wellbeing”, where we will be discussing the impact of community lead and person-centred approaches to health and wellbeing and exploring what further action can be taken.  Early bird tickets are available until 9 April and you can book your place today by heading to our website, the link is in the show notes for the episode.

Welcome back.  You mentioned already there’s a whole set of challenges at the moment facing health and care organisations specifically and people relying on them, whether that includes big backlogs for people waiting longer for care, widespread work fall shortages, given the scale of those problems and you mentioned already the pressures therefore on staff working in health and care, how would you say that people working under those circumstances can find the headspace to engage with the radically different ways of working that you talk about when they’re already feeling overwhelmed by the day to day?

HC:      I want to see that at three levels.  One thing that’s very, very striking in the work that I do now is that if you ask people what a good working life looks like in this century in Britain, what they tell you above everything else is it’s about having time to care.  So what people want is the way to integrate care and work back in their lives.  They’re not talking about care services, they’re talking about how we restructure production and reproduction, if you like.  So I think we really need to have a very big conversation about that, so one thing is how do we stop rushing to think that the care challenge, obviously we’re not going to go back to the 1950s and expect every woman, or man, for that matter to be caring in their home, but I think we need to understand care in a much more human way and that people want to care, so that’s the first thing.

The second thing is working alongside care workers is how innovative they are.  From the smallest ways to the biggest ways, people in their everyday, brilliant care workers find ways to get around systems which they know are inhuman and aren’t helping them care, often at great cost to themselves, whether it’s just through extra time but also through collaborating in different ways, micro ways of ensuring despite these very punitive businesses that many people are working in, that they can offer good care.  But then the other big question is what about leadership?  I think perhaps the thing that’s changed in me since I wrote Radical Help is that I think the nature of the crisis we’re in really requires a different leadership.  It requires a possibility despite everything, which we can’t exaggerate that has happened, to be able to tell a story, to hold a vision and to hold space for everybody underneath you basically, because these are still vertical systems, to do the work that they’re trying to do.  And I think that if at the moment you’re leading a system at some point in health wherever you are, and you actually are not a leader that can do that, if you are a command and control leader that has been brought up in a different way, it probably is time to step aside because there are lots of people that can do this and are hungry to do it, and we need to give those people space I think.

I:         And so for any emerging health and care leaders that are listening to this podcast, what advice would you give them about how they can develop those sorts of ways of leading that you’re talking about, where can they start?

HC:      Yes, so first of all I think it’s all about relationships really.  So the first thing is make sure that you have support because this is not work that one person can do alone and I think what we need is for all the fantastic people we have in our system to stay in the systems.  So this is about how you can pace yourself, how you can find support for yourself, mentoring, colleagues and so on.  And then the other thing is, I think, how you can find a place to work where you can make those horizontal bonds, whether they’re with your colleagues or with people perhaps in a different service in the same place, or whatever it is.  I write in Radical Help that the penguin on the land is very clumsy, but the penguin in the water with the other penguins is swimming in this beautiful way.  This isn’t heroic individual leader work, it’s about finding a space and a place to collaborate with others.

And also I think really to focus on the practice, because one of the things I feel, I said a moment or so ago that what enables me to work is because I’m doing practical things which people can touch and feel, but then people want to join in, so you’re not publishing a pamphlet or talking like we are now about what people should do, you’re actually doing the work is really important.

I:         I’d like to move on to a few questions about your leadership and your journey and learning over the years, so firstly looking back over the different projects you’ve worked on, there must have been times when you faced resistance from individuals or from organisations, so when that happens, what keeps you going and enables you to remain hopeful?

HC:      I’ve just been so blessed with the people that I work alongside.  The work that I do is teamwork, one of the things I think is really important about the complex challenges and the systems that we face is that these are not challenges that can be solved by one discipline, so I’m always part of teams that maybe have designers, anthropologists, economists that can work out when the money’s moving, and then clinicians, let’s say if it’s a health project, so people with kind of domain expertise.  So that’s very, very important, like I said partly because I feel supported by being in a team but partly because I am lucky to work with incredible people.  Radical Help tells a story of work done by the organisation I set up to do the work with (s.l participants 0:28:35), there was 65 people in that organisation who were just exceptional people in different ways and that sort of collegiate nature I think is very important.

I also think that I do get energy from working in communities, I do get energy from the everyday interactions.  I find that everywhere I go that people’s ideas and their commitment and that solidaristic nature that we have that was shown in the pandemic, it is everywhere.  On one level it doesn’t surprise me and then every time it surprises me again.  I’ve said that I’m doing work on the future of work and I have been running these imagination exercises in five different places in Britain.  I can’t tell you how rich those imaginations are and how far beyond the discussion that we read in the press about the future of work, it’s been really incredible.  I mean quite rooted people’s sense of what power is and how they might make change, so of course that gives me ideas, it gives me energy and it makes me feel that I am part of a movement.

The tide is turning, we can either try to hold it back and preserve what we’ve got or we can go with this energy and create the systems that we need to create.

I:         And it’s clear you’ve had a hugely interesting and varied career.

HC:      I know, I’m so lucky.

I:         It’s fascinating.

HC:      I’m very blessed.

I:         What is next for you?

HC:      I am working on work, basically.  The fundamental thing about our welfare services; health, education, social work, is that the idea was that people had good work and they had decent lives, but trouble happens to all of us.  And when that trouble happens, there will be a system to help and support you and to help you get back on your path.  But actually if we live in a society where most people do not have good work and can’t survive on what they have, then it doesn’t matter how great your health system is, you’re not going to have decent health in the societies.  And so because I’m not an economist, I’m a social scientist, I assumed that everybody was kind of doing work on this, but I found that I was asking questions and people were saying, “Oh, I don’t know”, so I thought, “Well, the only way to know is to go and ask communities themselves”, and so that’s what I’ve been doing.  I’m now writing a second book which is thinking about how we can redesign work based on the ideas of this community work I’ve been doing.  And then the next stage will be to explore how we might create that new work in practice.  And I’m really hoping to start that in care.  I think it’s really clear that we can’t think of care unless we have a very different care economy and we have very different care work, which goes back to one of the questions that you were asking earlier.  If we don’t pay care workers well, then we’re not going to have care.  And we do have money in care systems, it’s just extremely extractive and they’re kind of making global returns on equity markets, they’re not paying care workers who are doing the everyday care.

And we’ve got lots of good examples, I’m not talking about something that I’m dreaming about.  We work [inaudible 0:31:42] and we’ve got lots of good examples where there’s been a change in ownership, a kind of mutualisation if you like of those care services which enables people to have control of budgets, be paid well, and then a kind of different care is possible.  And I think that that’s really one of the things we’ve absolutely got to explore.  Just one other thing I should say is that there’s three lenses to my current work; one is about technology, the technology revolution and how that’s changing work, and all aspects of our lives.  The other is we’ve already referred to structural injustice that we have to address and this has been very big in our health systems for example, this agenda at place.  But also the ecological crisis we’re facing, which means that we’re not going to be able to carry on doing the work that we do and working in the ways that we do and some forms of work are going to be extremely important and the work of care, both of humans and repair of environment, I see as core to what’s going to be a generative economy for the rest of this century.  And so that’s where I’m rooted at the moment.

I:         That all sounds like really important work and we’ll look forward to seeing what you produce next.

HC:      Give me some time, I can come back.

I:         We’d love to have you back.  You’ve left me with so much to think about and I’m sure our listeners too, so thank you so much for joining us today.

HC:      Thank you so much for having me, Anna, it’s really a pleasure to be here.

I:         Well, that’s all we’ve got time for today.  You can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast.  The episode was edited by The Spoken Media.  Don’t forget to subscribe, share, rate and review the episode wherever you get your podcasts and you can also get in touch with us via Twitter, our account is @theKingsFund.  And of course, thank you for listening, we hope you can join us next time.