How do we meet the healthcare needs of superdiverse populations?

Welfare systems are out of date and under increasing pressure from growing, more diverse populations.

In the UK, barely a week goes by without a headline proclaiming some sort of ‘impending crisis’ facing the welfare state. Further afield, though countries differ in the systems that underpin their provision of welfare to citizens, they are feeling the strain that comes with a growing, more diverse population.

The UK’s welfare state has been over a century in the making. It is the work of every political party that has held office in that period, both on the right and the left – but much of it built on the foundations of Clement Atlee’s response to the Beveridge report in 1942. Most notably, the formation of the National Health Service, celebrating 70 years this year.

The ambitious vision of providing services that were comprehensive, universal and free at the point of delivery has been a point of pride for the UK – but it has since mutated into an incredibly complex behemoth at the heart of the wider welfare system. Population growth, sprawling internal systems and funding shortages have put the NHS, and the broader welfare state, under great strain.

Now, the people depending on it are changing too. A superdiverse community that is more fluid, more heterogenous, and a far stretch from that outlined in the Beveridge report. That was a report reflecting a society where, generally, men worked and married women did not, where lone parents were largely only widows. Where you could expect to work for one company, in one place, full-time for many decades. It is a flat view of society that no longer applies today. 

Though the names and institutions differ, the challenge of how states handle the how a diverse population gain access to healthcare, social care and other welfare provisions is a shared one. A new approach is needed. And perhaps first, a fresh approach to research on welfare provision.

Taking on the challenge

“It’s undoubtedly one of the most challenging things I’ve ever done,” says Professor Jenny Phillimore. A world leading scholar in refugee integration, superdiversity and access to social welfare – she is used to tackling complex issues. This project, UPWEB (Understanding the practice and developing the concept of welfare bricolage) might have been the toughest of all.

“I have to give credit to the Welfare Futures Project for funding it. It’s really quite a risky thing to support, I don’t even think we fully realised how difficult it would be.”

The project investigated case study communities from four European countries with differing welfare regimes; Germany, Sweden, UK and Portugal. Despite their differences, each country has traditional welfare states that were designed for a homogenous and fixed population.

The aim of UPWEB was to develop a better approach to understanding welfare provision, one that reflected the true nature of superdiverse communities and the reality of their changing demands.“Welfare needs have shifted markedly in light of the emergence of superdiversity, and we simply don’t know enough about it,” explains Professor Phillimore. “When people have a health concern they don’t just use one service, they use a whole range, whatever they can to get by – be that primary care, alternative therapies, or something else entirely. Most of the research around superdiversity looks at these services in silos, separating health and social care for example, and so it seemed logical that someone needed to look at the totality.”

“This is where the term ‘welfare bricolage’ came to us – to define that multi-layered, complex system through which people interact with welfare services. Bricolage as a term has been used quite a bit actually, but more commonly found in research around entrepreneurialism or civil society activity, and particularly in the creative sector. But it’s not been used much in relation to welfare, health or migration and I think it lends itself quite well.”

The UPWEB project brought together a multidisciplinary team of researchers; epidemiologists, anthropologists, political scientists, medical sociologists, geographers and social policy analysts to assess this welfare bricolage. To get to the heart of the welfare needs of a superdiverse community, they set about exploring a new question: how do people actually respond to a health concern? Not what the system suggests they do, but what they actually do, with whom, why, and in what order. What are their motivations for doing so? 

By working alongside the community groups and healthcare providers the team started to develop a more accurate picture of the realities of welfare provision – but this was coupled with a growing awareness of the challenge ahead.

A common language

Rather than create extra layers of complexity for themselves to tackle, the team opted to use a parallel sequential methodology. The four in-country teams undertook the same tasks, at the same time, with the same deadline - a significant shift from the more traditional ‘work package’ approach used in international projects.

The researchers first wanted to get under the skin of the superdiverse neighbourhoods by speaking to people in the area and exploring the streets for themselves, before developing a superdiverse group of respondents - over 160 across the project. These respondents would be supplemented with interviews of those working in welfare provision.

“Multidisciplinary work comes with challenges you don’t necessarily think about,” continues Professor Phillimore, “you have to establish a common language. We all have a different way of talking about things and you have to clarify each step along the way. You’ve got epidemiologists whose interest is ‘does it work’ and anthropologists who are more interested in ‘what people do’ and those two viewpoints have to be aligned somehow. Not only that, but we had to find a way of analysing that data collectively using a shared codebook. Which, across different languages and from different disciplinary viewpoints, can lead to some heated discussions!

”However heated those early stage discussions were, they bore fruit and the findings surpassed expectations. With such rich data, the team have already published a number of papers in leading journals and seen their work welcomed enthusiastically by NGOs and healthcare providers.

The headline messages emerged from the data have put to rest a rather common misconception about superdiverse communities and who has an unmet need for welfare provision.

Understanding the unmet need

“I suppose the most striking finding for many will be that access to welfare is not about ethnicity,” states Professor Phillimore. “There is so much focus on that. What superdiversity as a lens offers us is to move completely away from conventional approaches to public health research which focus on ethno-national groups. UPWEB has shown us that it is not a matter of ethnicity and instead we need to look at finding out ‘the differences that actually make a difference’.

”Moving away from an ethno-national approach suggested a number of other factors that are significantly more influential in people with an unmet need for welfare.The findings highlighted the role of structural factors such as income, level of education and, tellingly, ‘newness’. Regardless of ethnicity, being new to a neighbourhood makes it much more likely that people have an unmet need.

Understanding the true indices of inequality in access to welfare is crucial as superdiverse communities becoming increasingly diverse but due to us being a more heterogenous population on the whole. People are more mobile than ever before, making communities more fluid, and have a increasing range of different lifestyles, diets, and needs. 

Professor Phillimore explains how one respondent, a vegan, represented this shift in welfare needs, “This respondent went to the doctor for a problem and was unable to find a resolution. They felt as though they weren’t being understood as the issue had been dismissed out of hand as being a product of their veganism. So they went to someone else with similar results, and then ended up paying for someone specific that understood the importance of veganism.” 

From the decade between 2006 and 2016, it was estimated the number of vegans in the UK jumped from 150,000 to 542,000. It is just one example of a changing population, and one yet to be fully incorporated into understanding superdiversity of welfare needs.

Speaking to Professor Phillimore about the holistic approach taken by the UPWEB team, it becomes apparent that the bricolage approach is designed to be inclusive of any number of new demographic shifts. Perhaps, therefore, it could become the basis of helping key stakeholders to make sense of complexities and how they can realistically go about adapting to it.

A research method that will ‘travel’

Somehow, the team then had to use these findings and develop a research questionnaire that could ‘travel’. One that would be applicable to any country and still make sense within the different welfare systems in place.

Professor Phillimore explains how this was achieved, “We spent a whole week ensconced in a study room in Hamburg, kindly provided by our German partners, and developed a survey. It needed to bring together some certified instruments that are tried and tested in diverse groups, so it can be compared to other datasets, and also some new questions that emerged from our findings about welfare bricolage.” 

“In particular, we wanted to discuss the reasons behind people’s choices. We know a lot of their decisions depend on trust, self-competence, their social networks and other things that are overlooked by traditional methods – this is where our research really moves the field on. Then we went away and piloted this questionnaire for three months with everyone we could!

”The end result is a survey, ready to be deployed in different settings and provide insight into the welfare needs of superdiverse communities. It represents a leap forward for welfare research but the benefits of UPWEB might stretch further if it sparks more interdisciplinary projects. Research on this size and scale, across so many fields, is a rarity in welfare research and considered to be risky and time consuming. 

But if the aim is to help welfare providers move away from a past dependency on ‘how it has always been done’, it needs research groups to break convention too.

Hope on the horizon?

Though the success of the UPWEB project is unquestionable, Professor Phillimore is slightly more guarded about her optimism for welfare provision for superdiverse communities on the whole. She points to the difficulty of bringing together the complexity of the population with the equally complex and expansive system in a meaningful way. 

“It’s a huge task! Take the UK, for example. We need to think about how we restructure our welfare services but that almost requires us to go back to 1948 and somehow reinvent the wheel. There seems to be a resistance here too, we have a tendency to change processes and focus on efficiency rather than looking at the very model of welfare provision as a whole and asking if it needs a drastic rethink.”

“Turning around a decades-old model like a welfare system requires brave, bold thinking. All we can do as an academic community is provide evidence, expertise, understanding and look to influence as much as possible.

”And that research community represents hope. That brave, bold thinking from the UPWEB team has already seen a positive response form NGOs, policymakers and even journal reviewers, who believe it might be the spark for new era of thinking about health in superdiverse communities. 

Banner image - Benjamin John / Alamy Stock Photo

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