Relationships in public services shouldn’t be an afterthought

Catherine Needham

I’ve been catching up on a Health Foundation report from last year, The Puzzle of Changing Relationships: Does changing relationships between healthcare users and providers improve the quality of care?

There’s lots of good stuff here, including a rapid evidence appraisal of various health interventions to improve quality, such as addressing complaints and using peer support workers. There is also some useful theorisation of different dimensions of the patient-clinician relationship (looking at intensity, formality, power and valence).

What I found particularly interesting were the authors’ reflections of how relationships had rarely been a direct focus of attention in any of the studies they included in the review. As they put it,

At the outset it is important to note that studies rarely described how a given intervention was expected to change a given outcome directly or indirectly, for example through changes in existing healthcare relationships. So, perhaps not surprisingly, the majority of cases studies reviewed here did not explain how the intervention was related to changes in relationships and how this can be linked to changes in quality. Indeed, we had to infer such associations from studies reviewed.

Making relationships the key focus, as the report does, helps to understand what it is about relationships that are changing, and why that might contribute to improved service quality. What is it about peer support, for example, that has led to it being evaluated as an effective intervention for people using mental health services? Here the authors highlight the importance of hope: ‘where those with lived experience of a given condition provide a form of role model to the service user, to help them cope with their condition.’

There is a challenge here for all those involved in public service research:

… in existing research attention is paid to process rather than to relationships: the interactions between interventions, relationships and quality have been poorly conceptualised, rarely described and most probably not even considered in terms of either their direct or indirect impact.

Let’s make relationships a core focus of public service evaluation rather than an afterthought.

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