Pain

Solving problems that don’t belong to anyone

As I write this, I am in pain. I have endometriosis, which means every so often I have a day like this, when I feel that my whole abdomen is on fire, and intermittently, stabbing pains will take my breath away. Mine is a mild case, in that I only feel like this three or four times a year. And so none of the interventions that might help seem worth it. Millions of women’s lives are affected much more profoundly than mine.

But there are other reasons why I haven’t sought more help than I have. Pain is slippery; when it’s gone, you can’t quite remember it. You start to doubt if it was really that bad. And you know that the doubt is there in others. Medical professionals. Bosses. Colleagues. Even friends. Pain is invisible, and when the thing that causes it is invisible too, it can feel exhausting to assert your own reality. Better to hunker down and wait it out.

Mine is not an interesting story. But pain is an interesting story - one I have been planning to write about for some time, and today became the right day. Pain is an almost canonical example of the kind of problem the modern state should be able to address, and cannot.

The thing you need to know is that, in the academic realm, the UK really excels at pain research: we are searingly good across a staggering range of sub-disciplines from public health to new drugs and treatments. The puzzle is why we can’t marry up that advanced knowledge with real-world change.

The answer is a vignette of the system failures that I’m determined for us to crack: if we find a way to solve for pain, I believe we can solve for most things.

A dragonfly on the slopes of Helvellyn

Pain matters
First: why. Pain is one of the most common, persistent, and socially consequential human experiences. In the UK, around one in four adults lives with chronic pain. Many more experience recurrent or poorly managed pain that quietly reshapes their lives: limiting what work they can do, how they learn, who they depend on, and how they participate in family and civic life.

So you don’t have to care about individual wellbeing to believe this is important. Pain threads through almost every domain our political leaders claim to care about. It fills GP waiting rooms and specialist clinics; it drives repeat appointments, long-term medication use and, too often, avoidable or escalating interventions and all the costs associated with them. It shapes working lives through sickness absence, reduced productivity, early exit from the labour market and the distribution of care responsibilities within families. When pain begins early, it interrupts education and learning, altering life chances long before policy ever notices. It is part of the story of youth unemployment.

And of course, pain bears down unevenly, falling hardest on women, on lower-income families, on disabled people and on people from Black and minority ethnic communities. All these are more likely to be disbelieved when they say they are in pain. They seek less help, and suffer more, to keep themselves safe from the experience of being judged and doubted.

If we know a lot about this, and a lot about how to address is: why aren’t we doing it well? Seven habitual state failures explain why:

1. The problem belongs to everyone, and therefore to no one

Pain cuts across departments, budgets and mandates. The costs of reducing it are typically borne by one part of the system, while the benefits accrue elsewhere: to employers, families, the welfare system, or the tax base years later. Even within healthcare, pain rarely has a natural home. It is a symptom of almost everything, and so becomes everyone’s responsibility and no one’s incentive.

We see this across the state: siloed institutions and misaligned incentives make it rational for individuals in the system to do nothing different.

2. Prevention is structurally disadvantaged

Pain illustrates a dynamic that recurs across public policy: prevention is always celebrated in principle and sacrificed in practice. Resources intended for early intervention and coordination are steadily absorbed by acute demand which is so much more politically poignant. Treatment is easy to measure and see; prevention is often abstract and much harder to quantify. In pain, the consequences are stark: early, manageable pain becomes complex, chronic pain; chronic pain becomes disability. The system pays more, later, for worse outcomes.

3. Policy is shaped by moral narratives rather than evidence

There is broad agreement that more people should be able to work, participate and live with dignity. But political energy has increasingly flowed into coercion rather than support: tougher assessments, harsher conditionality, and suspicion in place of trust. This persists despite weak evidence that punishment improves outcomes, particularly where pain and fluctuating conditions are concerned.

Every part of the enforcement state suffers from this challenge: performative toughness appeals more than empirically grounded policy.

4. Trust is low

Pain has an acute relationship with the crisis of trust in institutions and expertise. So many people living with chronic pain have had awful experiences in the healthcare system. So many people without chronic pain believe there must be malingering and fraud in a welfare state that spends so much on invisible problems.

That is compounded when large sums flow into research ecosystems that feel distant from lived experience, protected by technical language and institutional prestige, but unable to demonstrate real-world change. People in pain can feel more studied than helped. When publicly funded knowledge repeatedly fails to close the loop back to public benefit, faith in institutions weakens.

5. Knowledge exists - but doesn’t travel

The UK is world-class at pain research, spanning discovery science, clinical trials, public health, data and emerging technologies. Yet translation into practice is slow, partial, and uneven. This is part of a chronic problem: universities are rewarded for discovery, not adoption. No institution owns the path from evidence to sustained impact.

Some universities have very successful technology transfer offices, creating spin-outs that commercialise research into real-world change and bring in cash that can fund the next generation of research. But in most universities these functions are small and short of capacity, leaving plenty of research stuck in the lab.

And almost everywhere, the primary focus is on spinning out ‘venture scale’ businesses: new drugs or technologies with investable intellectual property. But this isn’t the majority of the new knowledge UK science generates: treatments that rely on behavioural interventions or talking therapies, for example, can rarely be patented. There’s no investment model for this kind of innovation.

6. Institutions struggle to adopt new ways of working

Even when evidence is strong and shared widely, translation is uneven. Of course, brilliant practice exists in places. But pilots proliferate and rarely scale. Large systems lack the mechanisms, incentives, and accountability structures needed to routinely retire outdated practice and replace it with better ones. I wrote about how hard it is to do that translation work here.

7. Transactional public services can’t manage chronic problems

Pain is longitudinal, relational and context-dependent. It responds to trust, continuity, expectation, work conditions, and social support, not just to discrete clinical interventions. Systems designed around transactions, episodes and hand-offs inevitably fragment it. I wrote about the need to design relational service models here.

Seven problems: one answer

This is where pain becomes so interesting as a design challenge. I think there’s a strong case for making pain a national priority for its own sake - particularly for working age people, given how politically and economically important it is that we support people back to work. But that’s not the case I’m making here.

Let’s imagine we, the nation, set ourselves a serious goal - say, reducing the prevalence and impact of chronic pain by 25 per cent over a decade. To deliver it, we’d need to think radically differently about the mechanisms of the state. It would force us to confront the problems we’re leaving unaddressed.

• We’d need to rebalance funding systems towards prevention.

• We’d need to rebuild trust in public institutions.

• We’d need to unite public services, charities and the private sector behind common goals.

• We’d need to have the political courage to argue for evidence-based policy making.

• We’d need to redesign the incentives and mechanisms for research funding to connect them to real world impact.

• We’d need an investment model for commercialising and translating research that has higher social than commercial value.

• We’d need public bureaucracies that were agile and adaptive, set up to absorb innovation not reject it.

• We’d need public services that know how to build and sustain relationships with citizens and across communities.

• We’d need to break down the silos between government departments, probably by pooling budgets and forcing collaborations at local level.

In other words, if the state could organise itself to reduce pain - coordinating across sectors, investing early, translating knowledge into practice, rebuilding trust - it would have learned how to deal with a whole class of challenges it currently fails at: long-term mental ill health, caring, disability, crime prevention, early childhood adversity, and more.

If it cannot, then no amount of excellence in individual departments or disciplines will compensate.

I understand the desire to hunker down and wait for the pain of state failure to go away. But chronic problems only get worse when you ignore them.

An invitation: A new model for pain research
I’m currently working with some new friends on a project that would be one piece of this puzzle. Provisionally dubbed a new National Pain Institute, it would be a new way of organising research and innovation on many of these issues. We’re trying to design a model that would accelerate the journey from knowledge to impact. We believe this would help reshape the relationship between research and public trust, both by involving citizens and by delivering practical change.

We’re already working with a small group of academics and charities, but are eager to hear from anyone else who wants to be involved or hear updates on our progress.