Beauty of Care: Part nine of Connecting Well

When the director spoke about relating to patients she didn’t quite say “see a patient – run, hide, tell” but the police mantra for dealing with a terrorist attack would not have felt out of place.

I was only listening because I was up next at the conference, speaking about something completely different but I wondered what would happen if I used the word “love” or even “trust”, “respect” or “empathy”. When and how did fear so grip the providers of our public services that our capacity for compassion, the essence of humanity, could be routinely and mindlessly conflated with its brute, polar opposite?

We talk a lot these days about a duty of care but seldom of the beauty.

As a society we have become so afraid of abuse, and so confused by it, that we ask our nurses to look after our elders, our teachers to care for our children, our social workers to support our most troubled parents and then we tie their hands together when the natural reaction, the one that works, is to put an arm around. We should be relentlessly diligent in selecting, checking, training, supporting and managing staff for these positions. Then we should trust them.

Deep Value is a term that Community Links has used for many years to describe the value created when the human relationships between people delivering and people using public services are most effective. In these relationships, it is the practical service or the. transfer of knowledge that creates the conditions for progress, but it is the deeper qualities of the human bond that nourish confidence, inspire self-esteem, unlock potential, erode inequality and so have the power to transform.

The Community Links “Deep Value Literature Review” considered the evidence on the role of effective relationships in employment services, education, health and legal advice. It reached a lot of useful conclusions which I started to edit for this blog. In the end I decided that the full set was too important to be selectively filleted so I am going to cover them all in short form.

Revisiting this work, in which I was heavily engaged six years ago, I am still thunderstruck by the sheer weight of the evidence. We discovered for example, that “the relationship between the advisor and the client in employment services has consistently been found to be a key element (in) helping people into employment”, that “pupils who develop positive relationships with teachers go on to achieve better academic results”, and that “patients who experience a good relationship with their healthcare professional are more likely to engage in positive behaviour change”.

The conclusion was unequivocal “effective relationships are not just a ‘nice to have’ but increase the likelihood of achieving a positive outcome across all of the sectors examined in this review. Effective relationships are not an added extra but are core to the delivery of effective services. Increasing the effectiveness of relationships, therefore, is a lever for improving quality and performance.”

If meaningful relationships became the central operating principle at the heart of our public services the provider would be more effective and more efficient, the client would be better served and both parties would be happier with the outcome.

Here, in summary are the key findings from “Deep Value Literature Review” (Smerdon M. Bell K. Community Links 2011)

People using public services put great importance on the human relationship with the person providing the service.

• The quality of relationships people have with others in all parts of their lives is an important determinant of happiness and well-being. The evidence for this is so compelling as to be referred to in the psychology literature as a “deep truth.”
• An effective relationship with public service providers is a crucial factor in client satisfaction appearing repeatedly in studies of what people want from public services and in client feedback.
• Clients value this because they use services at times when they seek comfort. They may be angry, embarrassed, guilty or confused.
• Alongside the professional competence of the service provider, people make direct links between the effectiveness of the relationship and securing a good outcome.
• This seems to be especially important where people have more complex and chronic needs and have lower levels of skills and confidence.

The elements of what make for effective relationships are strikingly similar across all areas studied in this review. These are:

• Understanding – the service provider seeks to understand the needs and circumstances (economic, personal, emotional, cultural) of the user and treats people with dignity and respect. In return people using services acknowledge the pressures on providers and their need to make judgements about good use of public funds.
• Collaboration – there is trust, founded in part on demonstrable competence of the professional, both sides have confidence in each other, both are honest and achieve a position where decision making is shared.
• Commitment – where both sides demonstrate dynamism and commitment
• Communication – where the service provider listens and opens new lines of questioning to draw out relevant deeper issues.
• Empowerment – where relevant, an aim of public services should be to support people to change thinking and behaviour so as to cope differently with challenges in the future. This may involve challenge and confrontation but if the other elements of effective relationships are in place, the result can be powerful for the individual and cost effective for the public purse.
• Time – having the time is important, but this is not open-ended. With the right skills and systems in place people can quickly put these elements of effective relationships in place.

The effectiveness of relationships is therefore dependent on both parties taking responsibility. Delivering and securing good public services is something of a mutual endeavour and one in where the citizens’ relationship with the state is established. Using public services responsibly and effectively then can be seen as an act of good citizenship.

A critical issue bearing down on the relationship is the ability of a service provider to balance the role of supporter with the role to challenge, to ration public resources and even to issue sanctions. Evidence reveals that even where people do not get the outcome they want from services, if the relationship has been effective they are more likely to accept the result.

Where relationships are effective, they contribute to achieving a range of valuable benefits: the failure to realise these benefits can be damaging.

• The relationship between the advisor and the client in employment services has consistently been found to be a key element of a successful approach to helping people into employment.
• Pupils who develop positive relationships with teachers go on to achieve better academic results.
• People who access advice services funded by civil legal aid are more likely to reveal full information if the advisor builds a trusting and respectful relationship, thus leading to swifter resolution of cases, and clients who are more satisfied with the outcomes.
• Patients who experience a good relationship with their healthcare professional are more likely to engage in positive behaviour change.

These outcomes are secured through a range of processes that work better when relationships are effective:

• Information is gathered accurately ensuring that the problem or issue is correctly identified. Needlessly expensive responses are avoided and correct responses are implemented more swiftly.
• A fuller understanding is achieved of the issue being tackled and wider problems that may be contributing to it.
• The correct action is identified and unnecessary action is avoided.
• Both sides are more committed and motivated to achieving the outcome, taking responsibility and sticking to decisions and action plans.
• The person using the service is more likely to accept the outcome, even if it is not the one they wanted.
• Immediate problems are addressed and prevented from escalating, helping to reduce future demand and save future costs.

The damaging consequences of a failure to attend to building meaningful relationships go further than simply not achieving the benefits above.

• Public services miss opportunities to support people more effectively.
• Poor relationships with people using services are a significant and measurable contributor to staff burnout.

Securing these benefits and avoiding these consequences are particularly urgent for vulnerable people with the most complex problems.

There was a clear consensus in the literature about the types of working conditions and practices which were more conducive to building effective relationships.

The conditions for establishing effective relationships are:

• Front line autonomy – excessive focus on a set process, and on ‘output’ targets (as opposed to outcomes) restrict the ability of advisors to treat the client as an individual.

Advisors who have autonomy over how they carry out their work can build better relationships.

• Continuity and time – building an effective relationship requires time, and ensuring that a client sees the same person over the period in which they are interacting with a service helps to provide this time and establish a relationship.
• Training and skills – clients will trust providers when they know that they are competent in their role.
• Attitudes of the provider – professionals need to have an attitude towards their clients of trust and respect, and to be proactive in pursuing their case.
• Separation between ‘policing’ and ‘supporting’ – professionals may both ‘police’ the system and assist clients to access it. Situations in which there is a clear separation of these roles – or these roles are conducted by different people, may help to build the relationship of trust between the client and the professional in the ‘support’ role. Where this is not possible, the relationship with the provider assumes even more importance.

We conclude that the literature shows that effective relationships are not just a ‘nice to have’ but increase the likelihood of achieving a positive outcome across all of the sectors examined in this review.

This conclusion has some clear implications:

• Effective relationships are not an added extra but are core to the delivery of effective services. Increasing the effectiveness of relationships, therefore, is a lever for improving quality and performance. Effective relationships are much more important and complex than just offering ‘tea and sympathy.’
• The effectiveness of relationships varies – this is not something that can be expected just to happen based on the skill and willingness of front-line public servants. Some types of planning systems and working practices are more conducive to developing effective relationships.
• Acknowledging the important role of the relationship in securing outcomes has important implications for equity. For if good relationships require action from both sides, where people using services may have lower skills or self-confidence it is even more incumbent on service providers to ensure that the relationship is effective.
• Policy makers therefore need to assess proposals to reform public services against their ability to preserve or improve these relationships. Policies that break the link between professionals and clients may undermine the potential for policies to achieve their desired aims.
• Significant focus has been placed on what type of organisation is delivering services – public, private, or voluntary. We think that a better question to ask is what type of services they are delivering – and the type of relationships that they encourage.