A historical review of the concept of severe and multiple disadvantage and responses to it

The effect of combination and accumulation

If a disadvantage is severe it is generally multiple. If it is multiple it is generally severe. However, there are complicated ways in which severity and multiplicity combine. For example, when less serious problems accumulate they may well constitute a severe disadvantage. Indeed, research by Rutter and colleagues (Rutter, 1979) on the mental health of young people has shown that each additional disadvantage compounds the severity of the overall problem and that it does so exponentially. Similarly, Gordon and colleagues’ (Gordon, Parker and Loughran, 2000) survey of disabled children in Britain illustrates how one serious condition is usually combined with other disabilities and that the more severe it is, the greater the number of additional problems and vice versa.

Hence, the question of how different disadvantages accumulate is crucially important, both for understanding how situations worsen and how they get better. Does the process of accumulation differ depending upon individual situations, upon ‘precipitating’ factors or upon how long this or that disadvantage has been borne? It has been commonly assumed that certain disadvantages or conditions inevitably lead to others: drunkenness, idleness, delinquency, chronic ill-health, family break-up, homelessness, persistent unemployment, drugs, vagrancy, and so on. For example, Rowntree and Sherwell, writing in 1899, gave pride of place to the heavy and rising consumption of alcohol. In the 1960s the ravages of homelessness received much publicity, not least as a result of the film Cathy Come Home, which portrayed how being without adequate material facilities – shelter, privacy, belongings and often food and money – leads to a dearth of psychological relationships, a state of anomie, rootlessness and not belonging anywhere.

Considerable attention, both professional and administrative, has been devoted to the determination of severity, not least in the debates about who should be reckoned to be poor (in the 19th century more often who was actually destitute). Likewise, the assessment of degrees of physical and mental disability has played a central part in ascertaining eligibility for certain benefits (and at what level) as well as being linked with decisions about treatment. The history of war pensions provides a telling example, their level being fixed in 20% bands depending upon the assessed degree of disability that wounds and trauma have created (Ministry of Pensions, 1949).

Although the assessment of degrees of severity has been a prominent feature of the welfare and medical systems, its multiple character has tended to be overlooked. Yet, if anything, it is a more complicated concept (and reality) than severity. If that were better appreciated, the amelioration of disadvantage might be able to be more effectively organised. How, for example, are the different elements in multiple disadvantage related? Some are causally linked, as when deafness produces social isolation. Others may follow in sequence or interact in ways that bring certain conditions into prominence, as in degenerative illness or when those suffering disadvantage are thrown together by force of circumstances.

Indeed, disadvantage (whether severe or not) can have a ‘ripple’ effect, one person’s disadvantage being liable to create disadvantage for the people with whom they are closely associated. Studies of informal kinship care show that those who do the caring (principally women) can be disadvantaged in the process, especially when they are already poor, disabled, sick or grappling with the problem of caring for (and about) more than one person (Selwyn, et al., 2013). In the contexts of the family or community, such clustering of disadvantages has been more readily recognised in regard to the family and community than it has in the case of the single individual.

Although concern about the ‘spread’ of disadvantage has been prominent in the history of public health (Smith, 1979), it has also been significant in other welfare systems; for example, in the way in which the poor law endeavoured to prevent one generation of paupers producing the next (Crowther, 1981; Webb and Webb, 1910; 1927) and, more recently, in attempts to combat what was termed the ‘cycle of deprivation’ (Rutter and Madge, 1976), which in its various manifestations has a long and chequered history – witness the eugenics movement, which attracted prominent supporters well into the late 1930s (HMSO, 1933; Searle, 1976; 1990). Indeed, a good deal of disadvantage has been attributed to inter-generational continuities, much of it (such as congenital syphilis) being seen as the shortcomings of parents being transferred to their offspring (HMSO, 1916).

The dynamics of disadvantage

Disadvantage is rarely static. In most cases there are several stages in its development: for instance, onset, progression, response to interventions and treatment and (one hopes) escape. Some disadvantages are permanent, others episodic or transitory and each has the possibility of getting worse or better. These are all important distinctions. The situation of young people who have begun life with a grave disadvantage, such as deafness or brain damage, is different from that of those whose disadvantages have occurred later in life, such as progressive hearing loss or the harms inflicted by severe addictions. In these latter cases there will have been a history of living without those particular burdens, a matter that might be important in the kinds of help provided.

Various disadvantages can be reduced or eliminated by technical changes, such as digital hearing aids, power chairs, new drugs or the provision of prosthetic limbs. However, some severe disadvantages are associated with a lack of confidence or poor self-image and these aspects of multiplicity may be able to be addressed without great cost or resort to high technology; for instance, by orthodontic treatment, speech therapy, skills training or literacy programmes. Even though many of the severest disadvantages facing young people will not be quickly lessened by such measures, progress may depend upon the engineering of numerous small improvements rather than the pursuit of grand solutions. After all, much severe and multiple disadvantage has been created by the downward succession of just such increments, so perhaps an upwards progression (rather in the way that much advantage is created) can be achieved by equally modest steps.

Perceptions of multiple and severe disadvantage

Although there are recognisable patterns of multiple and severe disadvantage, there are also wide variations. Likewise, there are considerable variations in public attitudes towards those who suffer disadvantage, attitudes that are shaped by many factors. Three in particular are noteworthy: age, gender and the nature of the dominant disadvantage.

Historically and culturally the designations child, young person and adult have had no fixed ages attached to them and for legal and administrative purposes almost all ages up to and including 21 (and in some instances beyond) have been, or are, employed in the UK to differentiate status, rights and responsibilities (Parker, 2004). Hence, the choice of a particular age group can raise certain problems, particularly from an historical perspective. Take, for example, the category 16–21 years old. It spans many administrative boundaries between child and adult services, boundaries that have long created difficulties in ensuring the continuity and co-ordination of services; for example, upon being discharged from care at 18, being transferred from child to adult mental health services, having different housing rights, leaving school, and so on. Thus, not being quite the right age to receive this or that service or financial benefit might itself become an added disadvantage. Conversely, certain ‘welfare advantages’ may come with getting older.

Indeed, much of the ‘welfare system’ is, and has been, constructed around an array of age categories that have reflected a mixture of political and economic considerations as well as public attitudes to the rights and responsibilities of people of different ages. Those who continue to be regarded as children (whether children or not) usually evoke sympathy. Generally, however, as age increases, less is likely to be excused and more expected, although these gradations have not always been the same, for example, the age of criminal responsibility, the age of majority (and minority, of course) and the age at which this or that employment has been prohibited. In our culture the ‘transition zones’ between childhood and adulthood have been (and remain) imprecisely defined.

Not only have public attitudes towards those who suffer severe and multiple disadvantages been influenced by their age but also by their gender. Men and women tend to be exposed to different combinations of disadvantage. For women these have often been associated with sexual exploitation and with unmarried motherhood, both of which have been variously attributed to moral laxity, to wanton behaviour and low intelligence (HMSO, 1974). Such opprobrium has constituted an additional disadvantage, not least when it has existed in conjunction with the services offered. Furthermore, in the past many of these services were provided by religious bodies that emphasised the need for moral reform (Young and Ashton, 1956).

Attitudes to disadvantaged men have had more to do with their participation in the labour market. Being unemployed without apparent good cause was considered to show that they were workshy, layabouts, idle, wastrels or scroungers. Indeed, a major part of the poor law system was constructed in order to deter the ‘able-bodied’ (principally men) from seeking (and obtaining) financial relief. Hence, the workhouse test and its associated principle of ‘less eligibility’, which required that the circumstances of the pauper should never be made better than his employed counterpart. Women without paid employment were not exposed to such severe judgements, reflecting the expectation that it was men who should be the principal breadwinners and that women ought to be occupied with housekeeping, the care of children or only secondary outside work (Hewitt, 1958; Millar and Ridge, 2009). ¹

The consequences of severe disadvantage may also be explained differently for men and women. Currently, for example, difficult behaviour among young men is likely to be classed as a conduct disorder whereas, in the case of young women, it tends to be described as an emotional disturbance, both of which interpretations have implications for professional and public responses to what may in fact be the result of a similar combination of disadvantages (Office for National Statistics, 2003).

Age and gender are not the only factors that have influenced how those who bear these burdens are regarded and treated. For example, although most severe disadvantages are multiple, some are more apparent than others and some attract more attention. Attitudes towards disadvantaged people tend to reflect assumptions about the causes of their most prominent disadvantage. Whatever the reality, some disadvantages are assumed to be self-inflicted, and therefore blameworthy, while others are understood to be outside a person’s control and so deserving sympathy rather than condemnation, as in the contrast between the smokers disabled through strokes and those damaged by the consequences of medical errors (such as the use of thalidomide). This is reflected in the public’s favourite charitable donations: medical research, hospitals and hospices, and children and young people (Charities Aid Foundation, 2014). The problem arises in those many cases that lie in the uncertain areas in between, especially where blameless conditions nevertheless result in difficult, challenging, unpredictable or threatening behaviour. Certainly, better understanding has helped, but even then the persistence of such conditions, and indeed their worsening, can exhaust the energy and commitment of those who endeavour to help.

For most helpers (whatever their status) there has to be some kind of reward for such commitment, as there has to be for those to whom help is being offered. We understand rather little about the nature of ‘reward systems’, especially how they survive or crumble over time. A sense of duty, of responsibility, of compassion, of religious mission or simple habit may all play their part. There is a natural tendency to shy away from acknowledging the arithmetic of giving and receiving, although it constitutes an important element in helping relationships, the survival of which depends on the existence of a measure of reciprocity (Blau, 1964). Not being able to reciprocate, or not feeling capable of doing so, can become yet one more (potentially serious) disadvantage.

1. The dominance of the institution

Institutions have figured prominently in the history of disadvantage. In the first place they were a favoured way of dealing with those who were judged to be destitute, mad or bad for whom there was the workhouse, the lunatic asylum or the prison. Walls provided the means of exercising control over troublesome behaviour, a control that was necessary if such behaviour were to be altered and improved. This might be achieved by systems of coercion but quite as readily by training and treatment. It was assumed that none of this could be ensured by occasional contact in unregulated situations (Skull, 1979).

However, admission to an institution carried the likelihood that it would add yet one more disadvantage. Because admission was often a matter of last resort and a mark of social failure, it was a stigmatising process. Such initial stigma was accentuated in at least two other ways. One was by association and the other through compulsion (Goffman, 1963).

Despite the desire of many administrators to separate the ‘deserving’ from the ‘undeserving’ and the ‘reputable’ from the ‘disreputable’, the reality of institutional life has been one of enforced and uncertain association. The choice of associates is limited and escape from the disruptive, distressing or frightening behaviour of other people well-nigh impossible. When people living in institutions are regarded in an unfavourable light, those who are obliged to join them are likely to be seen in the same way, irrespective of the reasons for their admission.

The negative image of institutions has been reinforced by the legal compulsion that has preceded much admission. Until 1930, for example, the doors of public institutions for the treatment of the mentally disordered were closed to all but people certified by a judicial authority as ‘a lunatic, an idiot or a person of unsound mind’ and ordered to be detained. Not only was admission dependent upon certification but the order for commitment carried with it the prospect of its irrevocability. Furthermore, the same system of certification was applied to the mentally ‘handicapped’ as it was to the mentally ill. Indeed, the lack of understanding about the differences between these two conditions was superimposed upon the popular assumption that mental afflictions were hereditary. This meant that the act of certification was often experienced as a matter of family shame. Even though after 1930 it was possible for patients to enter a mental hospital on a voluntary basis, this relaxation did not apply to the ‘mentally defective’ until the reforms introduced by the Mental Health Act of 1959.

Institutional regimes did not affect only those who were admitted. In many cases they were also intended to convey a deterrent message to the far greater number who were assumed to threaten to overwhelm the available resources or to disturb a precarious social order. The discipline of the institution had wider implications.

The history of hospitals is interesting on this point. Before the latter part of the 19th century, most illness was endured at home and sick people only entered hospitals if they were destitute, homeless or lacked anyone to look after them. However, once started, the late Victorian expansion of hospitals proceeded apace with the number of beds in voluntary institutions rising from 15,000 to 57,000 between 1861 and 1921 and separate services emerging within the poor law, the infirmaries and the local authorities, which began to build ‘fever’ hospitals for infectious diseases. The character and public image of hospitals were changing, improved by advances in medicine, the ambitions of the medical profession and the professionalisation of nursing, showing again that both the classification of people’s conditions and the designation of the services to which they are referred have been important in determining the acceptability of that service, as well as the support that it is likely to enjoy.

2. The fragmentation of services

As the ‘severely and multiply disadvantaged’ are such a heterogeneous group, it is not surprising that the services that have been available to them have been fragmentary. There are, however, other factors that have accounted for such fragmentation. Three in particular are notable: decentralisation, voluntary and charitable involvement, and professional developments.

Although the poor law system existed throughout the UK from the 17th century up to the Second World War, boards of guardians exercised considerable discretion as to how that system was administered (Digby, 1978). Each board set its own poor rate (the local tax), decided matters of eligibility for assistance and appointed its own staff. Indeed, the amount of local variation was further increased because those staff (such as relieving officers) could be given, or assume, a further degree of discretion. Hence, despite the efforts of central government inspectors to secure more uniformity in its administration, there was considerable variation in what help the severely and multiply disadvantaged might receive from the poor law in different parts of the country, not least as between England and Scotland and urban and rural areas (Murphy, 1992). Furthermore, it has to be remembered that boards of guardians were elected (albeit initially on a limited suffrage) and that decisions were taken by majority voting. In this, the convictions, prejudices, sympathies and local experience of the members played their part, although from the latter part of the 19th century the patterns of influence began to shift as a result of the election of more women and of others, including women, with socialist affiliations (Hollis, 1987; Prochaska, 1980).

Nevertheless, few of the services that were available from the poor law (and from its successor, the local public assistance committees) were what, today, we would regard as personal services. These were more often provided by voluntary organisations: training for the blind or deaf, aid for the crippled, employment for disabled ex-servicemen, support for unmarried mothers, sponsored emigration, and so the list could be added to. Although varied, such initiatives had four characteristics in common: many relied upon institutional care, little co-ordination existed (in fact, there was a good deal of competition for public support and therefore for funds), their financial states were often precarious and most concentrated their efforts on single, clearly identifiable conditions. Many initiatives were local and often short-lived. Furthermore, there was no notion of a generalised ‘disadvantage’ that influenced the way in which such services were organised. All this added further to the picture of fragmentation and uncertainty – uncertainty about what might be available to whom, when, where and on what terms.

The third reason for the fragmentary nature of the personal services available to the disadvantaged has been the increasing specialisation within the professions involved. This has been especially marked in medicine but also in the development of social work that grew to include welfare officers, psychiatric social workers, probation officers, medical social workers (formerly almoners), court welfare officers, family welfare staff, moral welfare workers and several other branches (Seed, 1973).

3. The emergence of ‘community care’

Although the emergence of community care as a national policy dates from the early 1960s, the idea that help should be directed to areas of marked disadvantage has had a longer, albeit modest history. From the 1880s onwards these were the places of greatest poverty, disease and overcrowding. Improved housing was the obvious remedy, but little was done until the major slum clearance drive that began in the mid-1950s (Donnison, 1967). What was achieved was mostly the result of action taken by some of the largest urban local authorities and by some philanthropic organisations such as the Peabody Trust and settlement movement (Briggs and Macartney, 1984; Tarn, 1973). The identification of certain areas as a means of tackling disadvantage continued off and on into the 20th century but mostly as government inspired initiatives. For example, there have been community development areas (Department of Economic Affairs and HM Treasury, 1967a), educational priority areas (Department of Education and the Social Science Research Council, 1972) and housing action areas (most of which disappointed expectations).

By the mid-1950s another version of community care was afoot, namely, care in the community. This built on the embryonic system, introduced in 1948, whereby local authorities were given responsibility for providing ‘community welfare services’ but these were unevenly developed and focused mainly on the elderly and a number of other people with specific disabilities. If they were to be assisted, the ‘disadvantaged’ needed to fall into an identifiable category.

The new initiative was driven forward by two main considerations. The first was the quest to reduce reliance on institutional care, especially in the fields of mental ‘deficiency’ and mental illness. The buildings (still popularly known as asylums) were old and no longer met certain minimum standards, many having been neglected during the war years and the ensuing decade. Maintenance costs were high. Staff salaries were rising as better qualifications were sought and unionisation became more common, producing an economic imperative to find an alternative.

A second factor that encouraged the development of care in the community was a growing recognition of the psychological damage caused by long periods spent in institutions, especially for young children, a damage that came to be attributed to ‘institutional neurosis’ (Barton, 1959; Parker, 1988). This, and other shortcomings of the ‘institutional solution’, led to the government requiring local health and welfare authorities to prepare and submit plans for the ‘development of community care’ over the ten years from 1962 (HMSO, 1963a). Some of these plans were ambitious, but most erred on the side of caution, not wishing to provide any hostages to fortune by discharging vulnerable or dangerous people to the outside world

Up until the promotion of community care policy in the 1960s, various comparable services were provided by voluntary bodies, many of them locally based. In 1965 Margot Jefferys (1965) published her study of social welfare services in one large county. Among the voluntary social welfare activities, she listed moral welfare work, the National Society for the Prevention of Cruelty to Children (NSPCC), the missioner for the deaf, an old people’s welfare service, the Citizens Advice Bureau (CAB), a worker from the National Spastics Society and at least half a dozen other agencies. However, all were concerned with particular classes of need. It is also important to emphasise that at this time, most care and assistance were provided by families with little recourse to organised services, whether public, voluntary or commercial.

Although progress was made, it fell short of the aspirations that had been expressed. There were several reasons, some of which still apply. First, the scale of what was needed was underestimated. Once more services became available, increased demand followed. The new social services departments became exposed to pressing demands connected with concern about child abuse on one hand and a growing elderly population on the other, with young adults tending to miss out. A second reason lay in the latitude accorded to local authorities to decide upon the balance of their expenditures. There was no ring-fencing of monies for specific community services, although there were some exceptions later.

The third reason lies in the state of the economy and the pressures on local authorities to reduce expenditures. There was an increase of central government funds to support the development of the personal social services in the first years of the 1970s, but this soon ended with the oil crisis later that decade. Prime candidates for cuts were grants to voluntary bodies and ‘fringe’ services that assisted minority but substantially disadvantaged individuals and families.

4. Universal services

It is tempting to think about the services required to combat severe disadvantage in terms of specific individuals or groups. However, looked at historically, it has been the development of universal services that has reduced the extent of severe disadvantage; in particular, public health measures from the latter part of the 19th century onwards, improved nutritional standards from the early decades of the 20th century, compulsory education and, not least, the emergence of the ‘welfare state’ during and after the Second World War. It is worth recalling the five ‘giant evils’ that were depicted in the Beveridge Report (HMSO, 1942). These were: squalor, ignorance, want, idleness and disease. All were tackled to a greater or lesser degree in the cascade of social legislation that followed. The poor law was dismantled, a national health service established, a social security system put in place and an educational programme launched; efforts were made to deal with the poor housing stock and commitments made to a policy of ‘full employment’ embraced. Although progress was and has been uneven, the coming of the war and the welfare state led to a major onslaught on disadvantage, and particularly on multiple disadvantage, and a more equal society. This contribution should not be underestimated. Indeed, the success of specific schemes to aid particular groups has depended, in part, upon such ‘services for all’ and ‘of right’. As is evident from the impact of today’s government austerity measures, the erosion of such services has had and will have a knock-on effect upon the scale of disadvantage and ability of individualised personal services to achieve what is needed.

5. The social market

One of the most dramatic developments in social policy in the last two decades or so has been the delegation of previously publicly provided social services to the so-called ‘independent sector’. However, this term has (conveniently) conflated outsourcing to private-for-profit enterprises and outsourcing to non-profit voluntary agencies. The distinction is important because these are different systems with different philosophies. Here we concentrate on the former, not least because, unlike in earlier periods, they are in the ascendancy.

The extent and speed of this change is manifest in children’s services where there has been a three-fold increase in the proportion of foster placements provided by independent agencies since the turn of the century when the figure was only 12%. This pattern is repeated for residential care where the increase has been five-fold, with private children’s homes now providing 72% of available places. Similar developments have occurred in education, the penal services, re-employment schemes and, not least, in the health services, and there appears to be little evidence of this transformation abating.

These are profound changes. Some have been beneficial in terms of introducing competition, stimulating new ideas and running better services, especially in places where standards were traditionally low. But disquieting issues of durability, care standards, financial stability, accountability, investment in training and monitoring remain. What is more, the effects on securing the co-ordination of disparate services to promote the welfare of children, the development of national policies, the role of the voluntary sector and the expected cost savings are as yet unknown. Of course, not all these issues are unique to the private sector but they now appear in starker relief.

Avoid creating additional disadvantage

Services run the risk of stigmatising their recipients. Whether intended or not, the terms upon which they are provided, as well as the manner in which they are described, can have that effect. One of the reasons for this has sprung from the assumption that a person’s declaration of need confirmed their unworthiness. A second reason derived from the fear that without a measure of deterrence the scale of demand was liable to get out of hand. One further cause of stigmatisation has lain not so much in the deliberate design of a service but in the way in which it has been administered by those dealing with the needful face to face. This has been a particular problem with ill-trained and poorly paid staff but who nevertheless exercised great freedom in the manner in which they interacted with the disadvantaged. There is also, of course, the harm done by untested theories and their associated therapies, some of which have been enthusiastically embraced.

Multiplicity

There has been a long history of the multiplicity of a person’s disadvantages being overlooked or played down. One of the reasons is the difficulty that a ‘system’ experiences in addressing several, often diverse problems in an integrated fashion. Indeed, much organisational reform has sought to diversify functions and responsibilities, often in line with the advance of specialisation in the helping professions. Even when a diagnosis (for want of a better term) has explored and identified the various problems that a person confronts, what is then done has had a tendency to concentrate on single issues, reflecting what help can actually be mobilised. Thus, it is important for second, third or fourth order problems not to be ignored; otherwise they may worsen and accumulate in ways that increase the severity of existing disadvantages.

Chains of events

Much severe disadvantage is the consequence of one disadvantage leading to another. Furthermore, some of these downward increments constitute comparatively small events. Nevertheless, they can have damaging repercussions. We need to know more about such chains of events, how they relate, which (if any) are the prime movers and how far the sequences vary from one person to the next. What are the most important predictors of upward or downward mobility in advantage/disadvantage? Unless we have some reasonably sound understanding of such matters it will be difficult to know how best to mitigate disadvantages, either on an individual or a collective basis.

The balance of advantage and disadvantage

There is a danger that some of the severely disadvantaged people will be seen only in that light. There is a long history of their being disparaged, discounted or blamed. It was often assumed that they could make little or no contribution to their own well-being or to the community more generally. Yet we all experience a mixture of advantages and disadvantages and a mixture that can change over time. Couched in a somewhat different way, the equation might be expressed as a balance of capacities. This shifts the question of what the disadvantaged require to what they are able to contribute.

The importance of visible signs and symbols

Finally, the obvious issue of visibility cannot be ignored. Some features of disadvantage, such as physical disability, are highly visible while others, such as deafness or mental illness, are not. This can lead to misinterpretation when members of the public try to fit what they see into familiar categories. This, in turn, is likely to affect their expressions and displays of sympathy in a way that should not be confused with ill will.

1. Who gets overlooked and why?

Before answering the first question, it is important to note that when viewed historically it is not the case that high-risk groups are consistently overlooked, nor is it only public services that bypass them. There is also an underlying assumption that ‘high risk’ and ‘severe disadvantage’ are describing much the same thing, although this may not necessarily be so. With these provisos in mind we suggest that there are a number of interlocking reasons why the needs of the severely disadvantaged fail to be met.

2. Changing policies, changing systems

A second question that history raises is when, why and how ‘systems’, in this case welfare systems, change. There is a vast literature on this looking at different contexts – social, political and economic – and at various types of change, modifying existing activity, reforming the means but retaining the broad aims and innovation that introduce something radically different (Hall, et al., 1975).

However, these categories are not necessarily associated with particular processes of achieving change. For instance, new legislation can lead to all three types or its intentions being subverted by those who are charged with introducing the new arrangements. Likewise, ministers may drag their feet in issuing a commencement order for legislation already on the Statute Book or the legislation may allow certain things to be done rather than making them mandatory. We should not assume that the outward appearances of change are an accurate reflection of what is actually happening. Indeed, as much can be learnt about the politics of change from what fails to change as from what does. Furthermore, it should not be assumed that all change is progressive; some will be disadvantageous to the cause of ‘welfare’ in general or to particular groups.

Bearing these thoughts in mind, three factors seem to be propitious for effective change: legitimacy, feasibility and support. Legitimacy refers to the extent to which governments and other organisations feel that it is appropriate for them to be concerned with a particular issue and to acknowledge some responsibility for its solution. Feasibility means that a change is judged to be capable of being achieved given the current technology, manpower, knowledge or likely opposition. Support describes the backing necessary in order to see through a change successfully, whether by forming broad alliances, by winning votes, securing financial guarantees or enlisting the help of those with personal or organisational power. Ensuring that these conditions are in place requires diplomatic skills and these, in their turn, rely upon a keen understanding of the relevant political environment. That comes from experience as well as from careful reconnaissance and preparation.

But within a propitious context, other factors are likely to bring an issue into sufficient prominence for it to generate change. We suggest six that are commonly in play.

3. Why has the state become the primary provider of welfare services?

This question raises several issues that need disaggregating. First, what is the responsibility of the state and how does the extent of this affect the nature of its involvement? Second, how is this responsibility divided between direct state control and delegation to voluntary and private-for-profit agencies? Thus, a plethora of arrangements is possible, meaning there is no straightforward answer to this question. So much depends upon what period we have in mind, which services and the prevailing ideological assumptions. However, several factors have influenced both the timing and the extent of state involvement in the provision of social services.