News and Comment

Dear Doctor, your patient is ready to see you now: Changing relationships between patients, healthcare professionals and the health service

Tuesday 1 July 2014

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The need to ‘hear the voice of patients’ has been recognised within the NHS for a long time, as has the desire to shift healthcare services away from a paternalistic model where clinicians ‘do things to’ people in favour of greater interaction. While no one disputes the principles and aspirations behind these, getting things right in practice, however, is a different matter. The fact that we are still calling for ‘compassionate care’ post-Mid Staffs is an indication that the type of desired systemic change that puts patients at the heart of care has yet to materialise.

The Health Foundation’s Closing the Gap through Changing Relationships programme was launched in 2010 recognising that to improve healthcare quality we need to change the way healthcare systems work, and to challenge the beliefs and behaviours of those who use and provide health services. Over 2011 and 2013, seven projects were funded, which aimed to change one or more of three types of relationships:

  • between the individual using a service and those who work in healthcare provision;
  • between people using services and the wider healthcare system; and
  • between communities and the wider healthcare system.

The capacity for a person to make an active contribution to their care is not a choice they can make alone. To inspire healthcare services to effectively reorganise around the needs of the people using them requires a shift in philosophy, culture and behaviours. This is, of course, easier said than done. There is very little in the evidence base on what happens ‘on the ground’; contributing to the widely noted ‘implementation gap’.

OPM’s recently published report on the evaluation of the Closing the Gap through Changing Relationships programme contributes to the evidence base by shining a light on what ‘successful implementation’ looks like in context.

We found that successful interventions aimed at changing relationships must be built on a solid foundation of good project management, strong leadership and effective engagement. While essential, these per se will not bring about relationship change. Changing relationships require a number of ‘enabling mechanisms’ to be activated, including: (a) changes to patient beliefs, attitudes and behaviours; (b) changes to health professional beliefs, attitudes and behaviours; (c) changes to systems and processes; and (d) changes to organisational culture and environment. These can look very different in different contexts. The important thing to note is that ‘activities’ must not be conflated with ‘mechanisms’ enabling change. An activity may lead to positive change in one context but may have no effect in another. We must always be clear about what it is underpinning any activity that creates desired change.

Changing relationships is not something that can simply be articulated or aspired to and then left to happen on its own. Relationships do not change simply because of good intentions. Instead, it is about systemic change, and requires an explicit and sustained focus by:

  • making changing relationships an explicit objective, stating its centrality, and explaining the rationale behind this;
  • making changing relationships tangible to all key stakeholders in terms of what it looks like in practice; and
  • spelling out the likely implications of relationship change, and put in place effective plans to capture and disseminate the evidence of benefits as well as to minimise any anticipated or perceived adverse effects.

Having said this, the wider system within which interventions aimed at changing relationships have been implemented can be perceived as prioritising some things (e.g. cost-saving) over others (e.g. genuine patient involvement which can be resource-intensive). As long as the quality of relationships is talked about and measured as if it is separate from the quality of care and of health outcomes, it will remain challenging to maintain the link between improvement and compassion. Yet we have known for some time that person-centred care can help to improve outcomes and reduce the burden on health services. It is high time that the quality of relationships receives the attention it rightly deserves.