This opinion piece was written by Hilary Cottam, a social entrepreneur and author who has worked with governments across three continents. Her book, Radical Help: How we can remake the relationships between us and revolutionise the welfare state, was published by LittleBrown in June 2018.
What is the role of the modern state in creating the good life? Are we, the public servants of today, simply humanisers of the inevitable (a phrase I borrow from the Brazilian political theorist Roberto Unger), those who must mop up the fall out of rapid techno-economic change. Or can we be the radical architects of a much-needed social revolution?
Everywhere the social systems, tools and frameworks we inherited in the last century are proving unfit for purpose. Take health: our industrial health systems were brilliant at curing 20th century infectious disease but today one in four of us have a chronic condition: ailments which include diabetes, depression and the complications of old age. Our health services can’t cope. In Britain, 70% of hospital expenditure is dedicated to managing these complex conditions which cannot be cured. We need motivation not medicine, and this requires a wholly different way of thinking and working.
Or take employment. In most parts of the world, those out of work face industrialised systems of support: conveyor belt services meant to slot the individual worker into a job. These expensive systems have high failure rates (over 60% in the UK) because they ignore wider seismic economic change, shut out the challenges of low wages and are blind to the problem that progression in work is more difficult than finding a job.
21st century welfare starts where you are
I work with people like Anne. Anne is unwell, in pain and overweight. Keeping appointments with nine specialist doctors is her full-time job. But when I meet the doctors, they tell me something Anne already knows — the drugs don’t work. Anne needs radical help to change the way she lives.
I set up in doctors’ surgeries and ask them to send me “heart-sink” patients like Anne. A small team then starts to unpick the always complex problems that lie behind ill health. Anne decides to take up her embroidery again, her mood lifts and she is ready for the next challenge. The remedies are unorthodox, more often social than clinical, but the data impresses the clinicians and the service is low cost.
And I work with people like Earl. Earl has trouble holding down any job and has a criminal record for petty drug dealing. He wants to be a chef but the employment service thinks that’s laughable and tries to get him to do an entry-level job he finds demeaning. I invited Earl to help me design a new service.
We create simple tools and use public meetings to connect people in and out of work together. The emphasis is on practical steps towards long term goals. Simple digital platforms enabled us to work with many at low cost. Randomised control trials show our approach cost one fifth of current services, fostered skills and enabled 87% of members to make progress in or towards work.
This is 21st century welfare. It starts where you are, and instead of commanding change or trying to fix you it offers support to grow capability. It includes as many people as possible, given that it is our relationships that help us find work, keep healthy and care for one another.
I design with people. I ask families isolated on tough estates, who feel angry and locked out, to draw on new support with transformative results; I work with older people on a community service that brings joy and affordable warm care. In every case, I work in partnership with exceptional public servants to create and grow new work: social workers, politicians, policy makers: engaging with sleeves rolled up at every stage of the process.
The effect is powerful and low cost.
Perhaps on the surface it sounds familiar. Many of us practice design thinking or use focus groups to ask citizens what they think should happen. But the work I am describing is very different — it is about a shift in power and mindset. It starts not by asking questions from our point of reference as public servants: how can I change this or fix that. Rather it asks about your life: what do you do, care about, want — and how can we collaborate to make that happen.
This new public mindset is one of investigator, facilitator, inventor — not that of the previous century; gate-keeper, auditor, commander. And, when we do have the solutions, we don’t try to distribute them once again through an industrial pipeline, but instead seek to embed the solutions locally in new ways, ways I describe fully in my new book Radical Help.
The role of the public servant is no longer that of controlling the mechanical levers, it is that of the head gardener: setting out the design, planting, tending, nurturing and, where necessary, weeding.
It is only the state that can create the new framework we need
Every public servant I know is committed to making change. We have not signed up to be humanisers of the inevitable. And our challenges from climate change to demographic shifts, from health to education are too great and too pressing to tinker any longer with the tools and attitudes of the last century.
As I argue in Radical Help, it is only the state that can create the new framework we need, only our public servants can nurture the vision and model the behaviours. I propose a new and active role: this is Radical Help. — Hilary Cottam
(Picture credit: Flickr/Eden Project Communities)