While many citizens interact with government services on a face-to-face basis, often these relationships are pressured by targets and administration. Kate Bell and Matthew Smerdon look at new research from Community Links, and make the case for ‘Deep Value’ in public services, where frontline relationships are put at the forefront of public services.
While some parts of government are embracing ideas around the value of one-to-one in public service delivery, there are also powerful trends taking service delivery ever further from the human relationships that should be at its heart. At the policy level, these trends reflect a legitimate interest in creating efficiency and value for money through economies of scale. It can appear that the benefit of investing in one-to-one relationships is difficult to measure and that working in this way is a luxury that we cannot currently afford.
Services are not designed to give primacy to the interactions when two people work together to generate the most transformative outcome. Instead pressure is placed on to the relationship through targets and burdensome administration, lack of time and tight budgets. This puts the relationship under such strain that the outcomes are often frustration, resentment, bad service and poor outcomes.
Community Links have coined the term ‘Deep Value’ to capture the benefits created when public services are delivered through effective one-to-one relationships. In these relationships, it is the practical transfer of knowledge that creates the conditions for progress, but also 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.
At the level of front-line practice, whilst many staff and users of services establish effective one-to-one relationships that address the problems that people face, there are also values, attitudes, behaviours and skills that fall short of ideal. The launch of our latest work on Deep Value coincided with the publication of a damning report by the Health Service Ombudsman into the treatment of elderly people by the NHS, which concluded that the NHS too often failed to treat people with “care, compassion and respect”.
Despite various codes of conduct and clinical guidelines, the Ombudsman describes the actions of staff an “ignominious failure to…respond to the social and emotional needs of the individual and their family”. She added that it is “incomprehensible” that the NHS should need to be held to account for the most fundamental aspects of care. Yet, as the accounts in this report show, even the most basic of human needs are too often neglected.
The report puts a focus on the attitudes of some staff, but it runs deeper – to the wider systems for planning, administering, funding and reviewing services that contribute to poor working practices at the frontline. This isn’t just bad for the people who need support: it is also bad for the public purse in that problems are not addressed early meaning they worsen and therefore are more expensive to handle or correct.
We need to turn the design of services absolutely on their head so that they focus on the quality of the one-to-one relationship at the point where public resources are used by people who need them. As such, we do not believe that focusing on the human relationship in the delivery of public services is a luxury. It is a major element of delivering effective services and securing real value for money. However we recognise the factors that prevent this conclusion from being acted upon more widely.
To address these, Community Links is undertaking a programme of work to develop a deeper understanding of Deep Value. In February 2011 we published a review of over 100 academic articles and policy papers looking at the role of human relationships in public services. This drew on evidence from literature on public service reform, employment services, health services, legal advice and education.
We found that:
- People using public services put great importance on the human relationship with the person providing the service. 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.
Research in 2010 for the Department for Work and Pensions examined “drivers of satisfaction” with employment services. The role of the relationship with advisors emerged strongly. As one interviewee put it “If there was no relationship then you would have nothing to build on and there would be no point… If the advisors didn’t build a relationship or a rapport with the customers then the whole thing would be a failure… it would become ineffective. “
- The elements of what make for effective relationships are strikingly similar across all the areas studied in the review. Indeed, the different literatures on health, education, employment services and legal advice arrive at the same conclusions without any reference to each other.
An on-going six-year study on the impact of debt advice on low income families being carried out by the Institute for Employment Research at the University of Warwick found that ‘someone to talk to’ was one of the three key elements of effective advice. “(This) theme was raised in each year of the research and remained just as strong in Year three as in Year one… At its simplest this really did just mean someone listening… but there were other elements that were critical; advisors being understanding, non-judgemental and sympathetic”.
- Where relationships are effective, they can achieve benefits and where they are not they can cause damage.
Good relationships between patients and clinicians play a strong role in contributing to positive behaviour change in patients. One study in the US argues that an approach that is patient-centred, health oriented and emphasises the therapeutic relationship between clinicians and patients is a “strategy to address the epidemic of chronic diseases bankrupting the (US) economy.” The cost of chronic care is greater than £$1.5trillion a year, or 75% of all medical expenses. The study argues that an increased commitment to being patient-centred is a necessary step to healthcare focusing more on prevention and health promotion.
- There was a clear consensus in the literature about the types of working conditions and practices which are more conducive to building effective relationships.
These were front-line autonomy, continuity and time, training and skills, staff attitudes of trust and respect towards their clients and separation between the ‘policing’ and ‘supporting’ functions of staff.
- We concluded that the literature shows that effective relationships are not just ‘nice to have’ but that they increase the likelihood of achieving a positive outcome.
A 2006 study of a multiple sclerosis patient and her healthcare professionals concluded that “expectations of patients and healthcare professionals are better met when care is redefined as a mutual endeavour in which the caring abilities of the healthcare professionals and the vulnerability of chronically ill patients are taken into account.”
These findings have some clear implications:
- Increasing the effectiveness of relationships is a lever for improving quality and performance.
- The effectiveness of relationships is not something that can be expected to occur independently. Firstly, staff need to be willing to engage with clients, then they need the skills to do this well. Finally, planning systems and working practices can make the environment more conducive to developing effective relationships.
- Acknowledging the important role of the relationship in securing outcomes has important implications for equity. 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. Without this, the likelihood of someone achieving a good service is reduced.
- Policy makers and service planners therefore need to assess proposals to reform public services against their ability to preserve or improve frontline relationships. Policies that break the link between professionals and clients may undermine the potential for policies to achieve their desired aims.
Although much of this is common sense, it is not common practice. We hope financial pressures will not drive out the transformative possibilities of human relationships at the heart of public service delivery.
Read Community Links’ blog here: http://www.community-links.org/linksuk/
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