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Gavin: Hello, welcome to the Lancer voice. It's December 2021, I'm Gavin Cleaver, and today we're going to be talking with Hilary Cossom, author of Radical Help. I'm joined as ever by my co host, Jessamy Bagunel. Jessamy, when we first discussed talking to Hilary, I guess it didn't seem obvious her connection to health, but you're a big fan, you read the book Radical Help, and you suggested this interview.

Why did you think that Hilary was such an interesting person to talk to when we're thinking Kind of health, population health, people's prospects, that sort of thing. A lot 

Jessamy: of the conversations that we've had this year have been about this potential window of opportunity where COVID 19 has put health at the center of so many things, and that there's some political will of a problem being clear and, potentially having the right policy types of interventions.

So that. When we look historically, sometimes out of these crises come a new way of doing things like the Beverage Report, the NHS, these types of things have been talked about a lot. And there feels like that sort of movement is here potentially now. And Hillary has got such a great view on the interface between the social care system, And then the humanity or lack of humanity in that care system and how the lack of humanity and the lack of actual real understanding and trying to have policies and interventions, which are built for people, keeping the sort of human in view, perpetuates these cycles.

of poverty, and we know that feeds into ill health, and a lot of the ways that we also deal with patients in the NHS and other health systems is also this very broad brush approach, which doesn't keep the human in view, and I just think she has an extremely interesting perspective. She brings that sort of social, anthropological, and also real lived experience of trying to create new types of interventions that can make a difference in people's lives.

So she was a great person to speak to, I think. And 

Gavin: while we're talking mainly about the kind of UK care system here, these lessons are more widely applicable, aren't they? Now the UK care system is such a Political football, it's a, it's something that government after government pledges to fix because we all know it's broken, but I think Hillary has some really interesting lessons and teachings for, for the kind of nature of caring worldwide and how this system feeds back into society.

Jessamy: Yeah, and I can't remember if it's in the recording or not, but, she was talking about the Danes coming over to visit her and see some of the work that she's been doing and how shocked they were at homelessness in Manchester. These things are pretty broad across the board. They're happening globally.

This issue of the fact that we have aging populations, the fact that we've got rising inequality. So The experience in the UK is not just UK centric, and I think that the lessons and the experience, the thoughts, the sort of overarching thoughts and architecture which we might need to be thinking about, they're borderless.

Gavin: Okay, so here is Hilary Cotton, author of Radical Health.

Jessamy: We talk a lot about the social determinants of health at The Lancet, but not so much about the welfare state. How do they differ and what's the sort of conceptual framework that illustrates how these concepts of the social determinants of health and the welfare state interact and are connected, in your view?

Hilary: I think this is such a brilliant question because there's alignment and difference and I suppose it goes to the kind of heart of the matter and the conversation that we can have. Because if we think about the social determinants of health, I'm not in your fields, the wider things that are not medical outcomes, but influence medical outcomes, I think that then we can say that Beveridge, when he designed our welfare state was really interested in the social determinants of human flourishing in a very broad way.

He thought about housing, education, health, various kinds of economic allowances. And I think that actually this framing is really important and has been left out of welfare debates because now we think about, what happens in, in education, for instance, can we move outcomes from A to B?

But of course, Beveridge and his contemporaries, when they designed the welfare state, they, they were sort of classicists. They had this kind of great Aristotelian vision of what it means to flourish and what you need and how this is a much broader social question in every kind of sense.

of that meaning. And of course, a lot of the work that I do in my writing in Radical Health is trying to get back to that really and say what would happen if we thought again in this bigger way and in this new moment about what's needed now rather than this sort of very narrow way.

But I also think, again, I understand as a non medical person that the social determinants of health are social, so they're collective. And there I think that the kind of beverage design and definitely the welfare state now is vulnerable because again one of the arguments I make is that we haven't really had any welfare reform what we've had is privatization of post war models and of course what that actually means is a sort of individualization of everything that beverage designed and I mean what I would say is actually the kind of roots of that potential were always there in the welfare state unfortunately but I think what it then means is that the biggest challenges of our time, whether, we're talking on the first day of COP26, whether it's environmental challenges, whether it's demographic challenges of kind of population movements or ageing, whatever, that these challenges are deeply collective, and social, and that we can only really begin to grapple with them if we think very collectively about it from, how we design our public places to how we think about care in a very different way.

And I suppose that what's lost in the welfare debates is this kind of deeper thinking of social now. We just think about how can we help individual, X move from A to B, and we're not going to get there with that. And although the health service, of course, still definitely works like that, I think people thinking in the realms of health around social determinants of health have got a very different vision.

That's something very important that's often missing from the welfare debate. 

Jessamy: Yeah, I think that's true. It's funny, isn't it, how They're so aligned, and yet the conversations are not often brought together in a meaningful way. Anyway, and your book, Radical Health, I absolutely loved. It was a, it was brilliant to read it and to just reflect on that, especially from a clinician point of view and that feeling that.

we have so little impact on the rest of people's lives. You've got this deep understanding of what works and what doesn't work. Obviously, this is just a short podcast, but could you briefly take us through some of these sort of main lessons that you've experienced and that you've highlighted?

Hilary: The first thing I'd say is that I'm still in the foothill. So you're very nice, but I feel like I'm still learning and what works, what doesn't work. I've got ideas. And Radical Help is a story of sort of a couple of decades of practical work, which I tell through these five experiments, but I suppose boiling it down in the book, I say we need these six fundamental shifts.

And if we just did these sort of six really quite small things, which lots of people are already doing, they're not difficult things, we could really make things work in a very different way. And I think actually, just before I talk about what they are, I think that's also very interesting about the design of the health service and the design of our welfare state in general is that It wasn't completely new.

When the when the National Health Service was created, of course, things already existed. And what happened was that there was a new framework put around them. And basically the government said, if you work like this, we'll give you money. And if you don't, we won't. And as we know, doctors didn't want to come into the NHS.

Many of them came in kicking and screaming, but so it isn't that we've got to completely overthrow, but we have got to put things in a really different framework. And for me, that's. starts, the first thing is it starts with a new story. So I think we've got to have a very different story about what all of this is about.

And Beveridge told this big story about how we'd flourish, it was very baggy, people could tell their own story, they could reinterpret it. And now we don't really have that. What we have are management documents and targets. And so we manage, it's very managerial, it's in this very sort of tight framing, it isn't a story about that starts in people's lives and says, health is such a great example.

It's how can we improve waiting times in the NHS? It's never about what actually creates health in this century? What should we do to start there? How can we tell a story that then clinicians and populations can join in? Because one of the reasons people don't join into this work is because our experience as citizens is that any change actually just means something's going to be taken away from us.

But if we tell a story about what we can create, I think that's the first step. And then the second thing, which I think goes to the heart of the book is about this shift that I advocate from meeting people's needs to creating capabilities. And I think this is a kind of really big shift in power from thinking about asking people what do you need and how can I give you that thing to solve that need right now, which of course is important, to asking what do we need to flourish now in this century, what do we really need?

The capability approach was developed by the economist Amartya Sen with the philosopher Martha Nussbaum. And they asked this really simple question, which is, what can I really be or do? And that question is structural. It's systemic. It says, where do I live? Are there places to play?

Can I cycle? What can I eat? Can I really get a good job? Or don't I have the right clothes and the right teeth? There might be great employment, but can I get it? And then it asks really deep internal questions like, how do I feel? What do I understand this for me? What have I been taught? That's for me.

And so it's this much more holistic way of thinking, and it's very developmental. It doesn't try to just, in this transactional way, cure people. In a way, health is dominant. Health is the thing that we love. And the health way of looking at things, this curing idea, is also the Achilles heel of the welfare state in general.

We need to grow and develop, not see everything as a disease that we can then fix. And I think that's what the capability model is about and it frees up resources in different ways. And then of course one of the core, I mean I, in the work I focus on four capabilities, which are health, learning in a kind of broad sense, community but also relationships.

Because I think the kind of strongest and most important thing is To make change, we need to be allied to others. That's, obviously I talk about it in more depth in the book, but at the most simple level, and again, health is a good example. If we want to make a change in our lives to take more exercise or just stop smoking, these very simple examples, they're very hard to do alone and they're very hard.

do without support of people that kind of see our whole person. So I think about this idea of a relational capability and what it really means to system change. And then I talk about how we can think about resources differently. We do have resource actually, even now in straitened times, but the problem is that our resources there's time on the one hand, there's public money, there's private money, we can't blend it all together.

So things feel very closed. We have this risk mindset, which is also, of course, part of the kind of marketization of our services, which is always to focus on what might go wrong and to try and focus on that. So again, I make this, a lot of my work is about really turning things on its head and just saying, instead of thinking about.

risk. Let's think about possibility. Let's think about what people can do. Let's think about what assets are there. And it's amazing. I don't, one can't be polyamorous because I'm working in communities where things are really tough. But it is amazing how flipping that question leads to different possibilities.

And then I suppose the other kind of thing that I think makes things work is to think about how we reinterpret opening things up to everybody again. Obviously the welfare state was universal, and I think we really need to reinterpret what that actually means and how we bring people back in together.

Because unless people feel that this is something for everybody and that we can all benefit, it becomes very divisive in the way that we've seen about lots of things. So I think what works is to think, very holistically about how we bring people in. 

Gavin: Hilary, do you think there's a welfare state in another country that better embodies what you've been talking about?

Hilary: It's really interesting because, of course, in the UK, we always look to the we look to the Scandinavian countries, don't we? And we think that they're, they have the best welfare services. So when originally the Danes were the first to come and say, can we translate radical health?

need this here. I was actually totally surprised. I thought, oh my goodness, why are you asking to look at this? Because this is something that we already we look to you for. And it's really interesting because I think what we see in the Scandinavian model, which we look to is that we, Most of us, working in public systems do think that it's the best that we can look to because it's very well funded.

But what many people there would say is that we have a system that takes immensely good care of you. If you need children's services, if you need health services, our services are very good. But actually it's like a sort of, it's like a net that traps people. And that the same people and the same families are using welfare decade after decade.

It's not a trampoline that supports people to change. So it's been very interesting for me working in Denmark and Norway since the translation of Radical Help to think about how, Conditions for professionals, for example, are completely different, but how we can work with that resource in that context to really change, because I think the big difference is that what's needed now in this century is different.

So even if I could say to you that, yes, the Scandinavian model is brilliant, I think it probably doesn't work for this century. The other thing that I would say that I think has to be very nuanced, but The first half of my working life was working in the developing world in Latin America and in Southern Africa.

And I spent a lot of time living in barriers in particular in Latin America and seeing what I would call barefoot practices, how people organize in completely different ways to deliver health or education. And on the one hand, I don't want to say that we in Britain with this.

enormous economy should go back to that way of thinking, but I think there is something very different about that way of working in which power is shared, in which the sort of narrative of what needs to happen is very rooted in everyday lives. That is something that I would definitely want to emulate in a future welfare state.

Jessamy: I suppose all of these, for me, coincide with, you wrote your book before COVID 19 and since COVID 19, the very stark inequalities in our society have made, and the fact that these sorts of crises often mean that the state and the citizens have a different type of relationship or the relationship is questioned, and there was I felt some real movement to begin with about questioning the way that we organize our societies.

These enormous challenges that we face in this century. The fact that much of everything that we do from the multilateral system to the welfare state has been based on a sort of post Second World War model that's not fit for this century. on top of all of these other challenges that we have. And it's still, it still goes on in the rhetoric of Build Back Fairer.

But the sort of actual action is pretty poor. Do you feel hopeful that there's the political will to really try and reimagine how we do organize our societies? Because it does seem necessary if we're going to survive the next hundred years really with climate change and things like that. 

Hilary: Absolutely.

It's so difficult, isn't it? Because if we'd been having this conversation in the first lockdown, I would have been so optimistic. I felt, mainly because I felt that people finally were beginning to realise the inequalities. They were seeing them, which was really important, valuing different work, some work, in different ways.

And also that experience that neighbours were joining in to help each other. Because I think once you've met somebody and you've actually joined in and done something, you're in a completely different place. And also, actually, because I work a lot with local authorities were calling me and they were saying, we've been trying to create, create ways that we can work together for years and we can't get it done.

But now everybody's taken off their lanyards, they're working together, they've ditched the script, they're just looking at who's in front of them and what they need and how can you help us think about that in a system way. So that was a very optimistic moment. Now things have settled, it feels in a sort of old fashioned way in a quite difficult place.

And I think this goes to, um, what you were saying in the question really, which is, and it's at the heart of the work that I do, which is that I've got a historical framing and I'm very interested in technology revolutions. And when we have technology revolutions, we see that everything has to change, institutions have to change and that we do have these very industrial forms of politics.

It's not just party political. We have a kind of very industrial state, we have a very industrial health system, that's for sure. And I think It's very hard to see how the changes we need can be led through those industrial systems. And at the same time, I think if we do look to history, we know that the state in particular has to draw the framework.

It has to be the chief architect and say, these are the changes we need to make. This is the direction of travel. This is the regulation that we're going to have, go invest, invent, do everything within this framework. And we're very far from that at the moment. So I think it's a sort of plastic moment.

I think, day to day, I feel very differently because obviously my work is in communities, since we've been able to travel again, I've been working again in that way. I can be somewhere like Grimsby where I was a couple of weeks ago. seeing, working in some of the places that are really tough.

There's a place in Grimsby where children are removed, deep poverty and children are removed from their families at 17 times the national rate because families can't cope. But at the same time, sort of huge invention, huge energy, really different things starting to happen around how work is organised and how people think about the place and how they, can own things and do things.

There's so much flourishing. The thing is that at the moment, it's like fireworks. And until we have a kind of bigger story, it's back to the vision thing, until we can tell a story that can enable that to grow, and that we can get money behind those new things, which are really struggling against regulation, and no capital, and in sort of old systems, I think it's quite hard to see what can happen.

Nature regenerates through cataclysm, doesn't it? It's like we've had a forest fire. So I can only believe that change is going to come. But I suppose for those of us who want to see it, that's why I'm honoured, really, that you've asked to talk to me. It's by sharing these stories.

It's about keeping those stories alive and keeping on generating them, that kind of the light keeps shining really and those of us who are trying to make the change find each other because that is what's got to happen. 

Jessamy: Yeah, I hope so. Just to push you on that a bit more for this time of change, what are the types of securities that this state should be offering people now for the next couple of decades?

What do you see as the big technological work, whatever changes that really need to be focused on? 

Hilary: Yes. So actually my current work is about work and good working lives. And that's partly because as I was writing Radical Help, I was thinking about how I've worked for decades on social issues.

And when I started out, I'm quite old, People had good work. It was really almost until the end of the 20th century. And it's by the 1990s, not but it was like beverage designed, that basically people had good work, good lives. And when things went wrong, the welfare state was there to help you.

And now that isn't the case, I'm working in places where good work can't be found. And really the only economy is the welfare state. That, that doesn't work and I think, what, so I've been going into communities and asking people to design good working lives and then design institutions that they think could help that happen and it's been really interesting because in very different places with people from very different walks of life, some very common themes have been coming through and I suppose that the first thing that I think a future welfare system needs to do is it needs to support a just transition because if we think about work, most people in Britain who are doing.

Paid work, and particularly if you left school at 16 or 18 and you've got well paid work, you're doing work that really can't continue if we're going to have any kind of, COP26, if we're going to have any climate. What if we're going to have a future, really? So the question is, how do we think about that?

And how do we, how do we open up a very narrow conversation? Education's very narrow. The idea of skills are very narrow. We really need to think about how people can transition into different work, how that's funded. I'm not a huge fan of UBI, would have a transition income.

So I think that's one whole strand that we need to think about. And actually, that's about in my workshops, people really want to disrupt linear lives. So that's really about thinking how that continues through your life as things change. And, I refer to some of the problems in the Nordic systems, but one of the great things about the Nordic systems is that we know people are much more innovative and they do make change because they feel that this kind of safety net for change is there for them, which is really important.

But the other thing that I think is really going to be important is to rethink care. So in my analogy, the great gain of the 20th century was the weekend, when people, crowded into cities, in the beginning of the Industrial Revolution, if you'd said to them, you're going to have a paid weekend, they'd have said, you're smoking crack, there's never going to be this thing.

Now, obviously, these things can go backwards, we know lots of people don't have that now, but there's this sort of trope that this is the fair and just way to be. And I think the thing that's absolutely got to change now is the alignment between work and care. And how we understand that and how we make because everybody talks about the juggle, our lives are organized as if they're two autonomous things, which they're not for most people.

And we have to think about how we make those boundaries very porous indeed, how we completely reevaluate care work because I think the work of this century will be work of. repair and maintenance of ourselves, but of our kind of, the sort of wider kind of webs that we depend on in order to survive.

And I think carers, they probably won't be called that, but whatever the work of care is, it's like the engineering of the last revolution. And then it matters, how you're paid, how you're honoured. what kind of work you do, that you have to embrace it because you really want to do it.

And I, so I think that rethinking that, which of course was the thing that was completely left out of the beverage welfare state, he swept, he would have had a much more narrow idea of care than I'm thinking about, but he just swept it under the door and said that's women's work.

You can get on with your children, your parents, your neighbors, whatever. But that for me is going to be absolutely totemic in this revolution. 

Jessamy: It's just fascinating. I think the changes that we're going through in this term, pink collar workers, the kind of, that actually they are the only employment sector that is increasing is everything to do with.

care. And then at the same time, you've got women who are also fulfilling most of the unpaid care outside of the paid economy. How are these two things going to align? Because they're such huge challenges and we're basically putting it on one sex and saying, will you go ahead? And do both of these 

Hilary: things.

One sex and primarily one or two races, there's also a kind of massive sort of structural racism problem in this, but it also goes back to your previous question, because also what we are, whatever debate there is about this, which is so limited is still about, can we fund pathways into old systems?

How can we better access something that is, we don't. We just, that's just not the place to start. So it also goes back to the question you asked me before, is that how can we begin to have different conversations? How can we reconceptualize? I do think, one of those things is about having an imagination.

At the moment, people just can't see and touch the idea that we could have something else. And I definitely, because my work's practical, when the experiments in the book, they're all things. that I've built, alternative services and forms of support I've built with communities, that people really join in when they can touch them.

But because we've got this sort of history of cuts, and I don't just mean austerity, I mean from way back before then, there's a sort of nervousness, first of all, about change because people are holding on. It's why we see politicians go to the barricades to defend hospitals, even though behind the scenes they're trying to do something else, because there's a sort of nervousness, because we just think, oh, it's going to be less.

And we've got to talk about how it could be more because history tells us it will be more. We'll get something much better, but only if we begin to organize around it. 

Jessamy: Yes, that concept of the legacy of the past 60 years and how that influences how we can change because there are these very set structures that we work within that, and that defines everybody's thought processes and narrows everyone's imagination in that sense.

Hilary: Yes, but also I don't want to Cut across Gavin, our white man, with us, but it is also, I think of this a lot when I'm doing my current work, that's, there's a lot of writing about work at the moment, it's the kind of subject, and it's very nostalgic, it's let's get back to the 20th century, but I don't think any woman is saying, let's get back to the 20th century and for a huge part, because of, as you were just saying, why should care be women's work, whether it's paid or unpaid, it's we know that, That's one story.

And we don't want that story anymore. We want to rethink how everybody can care and how that's a completely different sort of structure, really. 

Gavin: So much of the political thrust at the moment, isn't it, is about returning to this better time, in inverted commas, that never actually really existed.

Hilary: I know. It's very interesting how nostalgic it is, really and I don't know why. Why that is, why we haven't got more forward look. I do think they're beginning to emerge. For instance, Cassie Robinson at the new lottery, at the lottery, she funded some work about emergent ideas recently.

And it was very interesting who came together to tell new stories. But I think, but, that's not where momentum is at the moment. And it is where it needs to be. 

Gavin: It feels a lot of the time at the moment, as you two have been saying, as a bandage upon a bandage.

Hilary: It's obvious to me that our, our education system is completely broken. It's training us for a world that's no longer here. It's squeezing children to the point that they all rock up in a, in a long queue for a CAM service. We It would be where you have to immediately rethink, you can't get back into those tram lines if when you're 25, you realize you made the wrong decisions about what you trained in.

That's just somewhere that we, we really need to go and think again. But also I think one of the things about the work I do is it's about making, that. I really believe that if we're going to create new things, we need to work in different ways. And I think that one of the reasons that I've been able to create new models, and obviously not me personally, but me in teams working with lots of people, is because it's very practical work.

And once people start to make something, like different ideas come in, a different muscle is exercised, it becomes something quite different. And then it's quite interesting what happens.

Jessamy: Yeah, I think it's a nice interview and as you say, it does bring together, it's all along the same types of conversation of how we're going to use this to make things fairer and better. Michael Marmot actually released a global look at social determinants of health with the WHO yesterday. His view is all, it's all about reaching across these different sectors and having a kind of broad approach, but also that the economic architecture has to change.

And people are saying that loudly. Now they're saying that, fearlessly without kind of fear of reprisal from. market orientated wiggers and libertarians and that, that feels positive. I think, 

Gavin: I think this joined up approaches and it's been missing for a long time, isn't it?

I think maybe we're starting to get the idea that we're going to do something. It's worth doing it broadly and in concert with other areas. 

Jessamy: I think also this stepping back that we've been able to have and to actually look at the last 40 years and say, okay we've made great health gains in certain aspects because of innovation, because of greater scientific understanding, but actually from a societal point of view and a political point of view, we've entrenched mechanisms.

that are holding us back from a health point of view and we need to look at those overarching architectures and we need to change them because without that we're not going to be able to move on to the next stage of better health for our populations. 

Gavin: It has been a theme throughout the year hasn't it and it really strikes me how much of Healthcare ends up treating the symptoms rather than the problem itself and I think when we spoke to Michael Marmot and when you and Jocelyn Clark spoke with Sarah Kaplan earlier in the year, these are all really striking issues of how we can deal with some fairly fundamental societal problems, but make gigantic health gains at the far end just by dealing with them.

Jessamy: Yeah, it's all about these upstream determinants of health and not trying to go too downstream to rescue people, but to try and be more preventative. And you can say that in a kind of siloed public health. Way. And that's not something that's new or particularly special, but I think when you broaden it out to the overarching architecture of the way that we're running our societies on an economic basis, on a political basis.

And to look at all of those different political determinants of health, how they link in with commercial determinants of health and social determinants of health, that's when you're able to really say, these are the types of changes that we need. And they're urgent. 

Gavin: Perhaps some of the optimism that we could change society that was found COVID pandemic is perhaps slipping away a little bit.

Jessamy: Yeah, you and I have been on our own journey over this. I love that tweet that you sent me about saying how funny it was that the co hosts were becoming radicalized over the COVID 19 pandemic. But I don't think it is radical, particularly. It's just very commonsensical when you actually look at it.

But the force is, That are, trying to keep current power structures in place because it benefits them. Of course, those are very strong and those are the ones that are in politics at the moment. And so I think there's so much rhetoric about building back better and it's meaningless because no one wants.

No one in power wants to build back better right now because it would prevent them from being in power. There has to be, there's, that that's the honesty about the situation. But I do think that from an academic point of view, and I think from a health point of view, that is where the health community and the scientific community have a huge role to play right now, that we can't let that message.

Go by the wayside. We can't let that movement this opportunity go. We have to keep platforming those voices and we have to keep advocating for that change and keeping politicians to account in this rhetoric that they like to call build back better, which I think we now settled on build back fairer.

But whatever you want to say that's where the health and scientific community come in from my point of view. 

Gavin: There's been quite an obvious major example in the last couple of weeks, hasn't there, of not dealing with upstream problems. And having serious downstream issues that cost a lot more, which is failing to properly vaccinate people around the world, which has now resulted in, as we've said in a few podcasts over the last year, another variant turning up that does appear to be more infectious from the early data.

Jessamy: Yeah. And I think what's interesting about that as when we spoke to Slim is that the sort of counterintuitive almost approach. that then gets baked in is what we need to hoard more vaccines and we need to vaccinate more of our own population three or four or five times rather than saying this is the over, this is the overall problem.

The fact is that we have had such a lack of vaccine equity that we've got, huge amounts of infection elsewhere in the world and variants are going to keep on coming unless we're able to really approach that and to solve that problem. And. Again, that's a symptom of the whole pandemic over is it that I don't think, nobody saying that's been easy to lead countries or to work in the multilateral system.

But I don't get that sense that leaders have been able to step back and look at what the big picture is and try and galvanize some sort of coalition collaboration, any type of global cooperation to deal with those big challenges. 

Gavin: Now we've gone to wringing our hands about COVID 19. It's probably time to call it a day there.

So thank you to Hilary and thanks as ever to Jessamy. And thanks to you for listening to this episode of The Lancet Voice. We'll be back next week when Richard Horton is going to talk with me and Jessamy about his 2021 and looking forward to 2022. And we'll see you 

then.