It’s all about relationships
One of the best insights I took away from the recent NHS Confederation conference was the point made by Rob Webster in his keynote speech that it was time that we saw the NHS, less in terms of buildings and kit, and more in terms of it being a collection of people: clinicians, volunteers, patients and carers. I’d like in this blog to take that point a stage further and to focus on the issue of relationships and why investing in good relationships may be one of the best things we can do to help transform the NHS.
That is not to belittle the logistical aspects of healthcare delivery. In a system as complicated as the NHS, it is crucial that we become better at understanding the optimal approaches to deploying what are often expensive resources to deliver the best outcomes for patients within the finance which is available at any given time. But if we focus exclusively on those issues, as we often seem to do, then we are missing a big deal because effective relationships between the different players is, in my view, key to high quality and sustainable healthcare.
Let’s start with the most fundamental relationship of all – that between those providing and receiving care. Despite all the wonderful developments in science and medicine, human relationships are still a crucial therapeutic ingredient. It is perhaps easier for us to appreciate this in the world of mental health with its tradition of talking therapies but I would argue that it is of great importance in other areas of care too. Medicine is not always an independent agent and patients, especially those with long term conditions, have a major role in their own recovery or, at least, in the management of their own condition. Clinicians who work on relationships, who listen and treat patients with respect, who involve patients in decisions about their care, who coach them effectively in the skills of self-care will, in my view, be more effective.
This is not just about being nice or having good communication skills, important than though those things are, it is the recognition that therapeutic relationships are fundamental to good clinical practice. Many clinicians do this instinctively but it seems to have little place in clinical training and the way in which we organise care on an increasingly fragmented basis serves to discourage the development of such relationships.
The second area is the relationships between practitioners. Much healthcare is delivered in teams. Good teams are greater than the sum of their parts. They share their knowledge and they often share the practical and psychological responsibility for patients. I was very moved in a recent meeting with one of our clinical teams to hear the intensity of a collective sense of pride and relief of how they had successfully supported a young person in a period of acute crisis.
Bad teams are dysfunctional. It would be an interesting piece of analysis to identify in many occasions poor relationships and a lack of effective joint working had been a root cause in a patient safety incident. Poor relationships also help engender a poor culture in organisations. It was very powerful hearing Helene Donnelly, a whistleblower at Mid Staffordshire, and now an Ambassador for Cultural Change at Staffordshire and Stoke NHS Trust, describing how poor relationships undermined the relationships between professionals which should have supported a collective interest in good standards of patient care.
Sadly as a particular factor in healthcare, relationships can be undermined by examples of tribalism between different groups of professionals or what Freud described as the “narcissism of small differences”. The diversity of professional perspectives can be a very positive force for good in healthcare but when energy is narrowly focused on defending a profession’s own ideology or resources it is less so.
The last crucial strand of relationships are those operating across organisational boundaries. The integration agenda and the challenges of meeting the needs of patients with the most complex requirements has highlighted the need for us to find effective means of developing effective models of care which can operate across organisational boundaries. So often the NHS reaches for structural solutions to issues which, like integration, are fundamentally about relationships, between senior leaders and between practitioners on the ground. It is striking, in my book, that some of the best progress on integration is being made in places where continuity in leadership has allowed relationships to develop over a period of time.
So what does all of this mean. Again three things.
It means the NHS should recognise the importance of relationships both in the heart of the therapeutic process itself but also in how it mobilises itself with its partners to deliver complex goals.
Second it highlights the needs for skills around relationship management and systemic thinking to have a much bigger role in the training of clinician professionals and NHS managers.
Third it points to the case for investment in building, maintaining and repairing human relationships as just as an important an element of service transformation as buildings and technology.
Good relationships are indeed at the heart of better care.