The very big and the very small

By Alex Fox | 24 July 2020

The biggest problem the world has faced in decades is being caused by a virus so small we couldn’t even see it under a microscope. So far government solutions have been huge: temporary hospitals in vast warehouses, and trillion-dollar bailouts. Solutions on a vast scale haven’t proved a good fit for thousands of small social care services, much less for many older and disabled people isolated in their own homes.

Ordinary people however have shown governments and leaders what can be achieved by taking a small-scale, ‘viral’ approach: thousands of grassroots mutual aid groups sprung up with little fuss or infrastructure. The help they have provided will never be measurable and is easy to ignore. But what if, instead, our leaders chose to learn from the mass reach and deep impact of these micro-scale solutions?

Here are three ways we might move from thinking big, to thinking small, as the crisis moves into its ‘new normal’ phase:

Think inequalities not whole population

The first phase of the crisis was a whole-nation challenge. The response, once we had one, was to lock down all of us in order to protect those of us who are most vulnerable to COVID-19. We are learning more and more about the mixed results of that approach. Broadly it worked when it started, and would have saved many more lives if it had started earlier. But some groups and communities have been much harder hit, particular older people living in care homes, who are likely to make half those who have died, and black and minority ethnic (BAME) people who have been disproportionately affected, with at least a significant part of the reason for this being structural inequalities. There is a stark divide between those of us privileged enough to have white collar jobs that we can do from home, and to live in places with space to socially distance and gardens to keep us sane, and those living in overcrowded housing and communities, and who are back in risky workplaces.

So the next phase must focus on those hardest hit and most at risk. That’s not to say that all of us won’t need to continue to change our behaviour: older people in particular are relying on it. But public services need to build much wider and deeper conversations with those suffering most, and focus on tailoring their responses to be led by what those groups and communities need, in the way that they need it. This kind of ‘personalisation’ can only be done in partnership with community organisations and the voluntary sector – at a time when at least one in ten charities face bankruptcy unless more is done to save them at a time when they are most needed.

Put as much energy into making homes safe as we do into hospitals

The NHS has learned much about how to make big hospitals virus-proof. This thinking and the testing and equipment needed to make it happen are belatedly being trundled out into social care services. But what we have all learned is that the safest place to be is at home with one or two supportive people, not in big buildings with large staff teams.

There is renewed talk of merging the NHS and social care in some fashion. What would make more impact would be for both sectors to agree the shared goal of a renewed focus on keeping people safe and well at home. That is not just about delivering services where people are, it’s a mindset shift towards helping people stay well, mentally and physically, rather than waiting to respond to a crisis which may mean a hospital or care home admission.

Help people who need support to have fewer, deeper support relationships

We all understand the new risks of contact with lots of other people. The evidence is longstanding for the risks of lacking meaningful contact with people, particularly for the 1.2m chronically lonely older people. Shared Lives, Homeshare and a handful of other deeply-personalised and relational approaches to long-term support have demonstrated the health-giving potential for a different way to offer support: via a small number of chosen, meaningful support relationships with people who can go the distance as approaching a quarter of us are on decades-long support journeys with often multiple long-term conditions. We are already seeing mental ill health on the rise during lockdown. We cannot afford to see a mental health crisis come hard on the heels of an ongoing physical health emergency. We need to move away from the core assumption at the heart of public services: that we will offer people an unlimited number of brief professional/client transactions, towards support relationships which can work with the grain of our lives, families and the web of social relationships all of us need to live well.

Alex Fox OBE is the Chief Executive of Shared Lives Plus, the UK network for Shared Lives and Homeshare.

comments powered by Disqus
Voluntary sector NHS Communities Adult social care inequality Mental Health Homecare Coronavirus

Coronavirus Update


In light of the ongoing coronavirus crisis, some of you may not be able to receive your copy of TheMJ magazine. If you’d like to change your delivery address, please contact our subscriptions department at
Read The MJ for free

Keep up to date by subscribing to our daily newsletter

theMJ products