Restoring relationships as part of fixing the healthcare system

Reform in healthcare and the wider public sector is coming, and as Darzi made clear, the current system design is not always ensuring we see the outcomes we aim for. If something is broken, it follows that restoration may need to be part of the fix. In a system made up of people as much as process and technology, that means looking at and restoring relationships. Long term, if we’re serious about the health system radically changing the relationship it has with communities and people, then it has to radically change the relationship it has with itself.

Learning and research in patient safety offers us a useful lens for this challenge. Specifically work in just culture could help guide leaders to ready themselves and their staff for change, and help them mend, re-energise and feel motivated after a difficult few years.

Just culture goes by various names and draws from a number of different great thinkers and researchers, but for me, the simplest frame is from the work of Professor Sidney Dekker: who is hurt, what do they need, whose responsibility is it to meet that need? 

His ideas have already proven to work in the health system, most famously underpinning the work at Mersey Care NHS Foundation Trust on their Restorative Just and Learning Culture, with an economic benefit to the organisation in the £millions since it launched in 2016. Although most usually focused on restoring relationships after patient harm, why can’t this approach lend itself to helping to fix a struggling system?

Why seek to restore relationships now?

The system is experiencing a significant productivity challenge, well documented and discussed at length. There is no single quick fix - the solutions are multifaceted, complex and not about working people harder, as a recent NHS Providers report Achieving Value for Money made clear. It’s far more about making it easier for people to work well.

Amongst Darzi’s themes to underpin the 10 Year Health Plan was clear recognition of a need for better engagement with staff. Darzi also acknowledged the emotions of staff working harder in a system that isn’t functioning, with the wasted time, disempowerment and disconnection this leads to. More broadly this also, anecdotally, includes exhaustion, burnout, lack of access to food, impersonal rota setting, anxiety around staffing and rising complexity, tension between staff groups due to new roles, and lack of recognition and support to mend post-covid. For any change to really take root, there’s also a need for hope and belief that better is possible.

Overall, there is a suggestion that it is all simply too difficult, evidenced by retention data, for example, recent NMC data show the number of nurses leaving the register within five years of joining has increased by 25%. This is not a Covid issue – the signals were there beforehand. For example, only 42.6% of junior doctors opted to move directly into specialist training within the NHS after completing their foundation years in 2017, with the numbers dropping every year since at least 2011.

There is also evidence that relationships are not where they could be. Mary Dixon Wood's exemplary report to the Thirwell Enquiry explains the cultural challenges in the NHS. A snippet is that the 2023 staff survey noted that 54% of respondents believed teams in their organisation work well together, and only 57% that team disagreements are dealt with constructively.

For those sceptical that we should focus limited resources on staff non-clinical needs, there is plenty of evidence that ignoring this is a mistake. Some trusts have mechanics already in place to listen carefully, over time at what their people need. Northumbria Healthcare Foundation Trust have a long-standing commitment to this. In the pandemic, they prioritised understanding staff experience, with an analysis more than 3500 comments in 2020 detailing asks such as ‘Listen to me’, ‘Care about me’, Keep me safe’, Keep me connected’, ‘Lead me’, ‘Keep me going’, ‘Notice me – honour my work’. Royal Berkshire NHS Foundation Trust is another that pays serious attention to staff needs, checking in with what matters to them every two years.

Prof Kevin Fong’s covid inquiry testimony a few weeks back was a stark reminder of what staff went through and still carry. Alongside this, recent research on why people leave the NHS showed that leavers are driven by the inability to meet their intrinsic motivation to practice according to their professional standards as much as terms and conditions. The most recent NHS staff survey results showed that nearly 1/3 of staff often think about leaving and nearly 35% find their work emotionally exhausting. Around 30% feel burnt out because of their work, with over 40% left feeling unwell as a result of work-related stress. With fewer than 60% reporting their organisation takes positive action on health and wellbeing, there is an opportunity here to not only fix the processes of the system but find out more about what will help the people.

Why take a lead from safety and improvement?

Concepts in patient safety have evolved from seeing people as liabilities and risks to control and manage, to assets on whom safe care depends, with a shift from preventing harm to also better understanding and enabling what goes well. If considered a ‘simple rule’ for the system overall, might this mindset change behaviours, assumptions and how time and money is spent, helping to achieve different outcomes?

This matters because the study of complexity tells us that complex adaptive systems – which healthcare is accepted by most to be – are inherently unpredictable with outcomes that are not directly controllable. We see this in the fact that so often actions result in unintended consequences, and when obvious, simple solutions fail. It is the relationships between people and people and their environment, paying attention to what is happening and learning what works, and that ability to adapt safely and recover from shocks, that matter – we need to design risk out of the system where possible and increase the likelihood of getting the outcomes we want. That includes improving conditions and easing people’s experiences of the system, both patient and staff.

A recent revisit of a well-known study into 21st century public servant characteristics reinforces what this means for leaders and how they go about their work. Recognising the need to work with complexity, it outlines skills such as being “a relationship curator”. Others label this ‘Architect leadership’. This is not command and control. Board members at provider trusts have long sought to move towards problem framing over problem solving, and being problem – not comfort – seeking, with evidence-rich improvement capacity and capability an enabler for this. It’s now important that this is well supported through leadership development, and that other aspects of the system reimagine their roles in this same way and move away from the idea that saying the same thing louder helps.

It is also well-evidenced that fatigue, hunger, high cognitive load and many other considerations affect human decision making and performance. Practical and psychological need can cloud judgement. This needs to be taken seriously in a system driven by professional judgement at the frontline. Research also shows that anxiety creates predictable group dynamics, and triggers social defences and interpersonal issues in the workplace. Healthy people and healthy relationships matter - recognising our very human vulnerabilities is part of that.

The evaluation of VMI / NHS programme evaluation evidences this link between healthy relationships and improvement; cultural readiness, social networks and accountability for behaviours were all enablers for a learning and improvement culture to take root and progress. Professor Nicola Burgess’ work over the last decade examined how NHS provider organisations have employed various improvement approaches to address the productivity dilemma – addressing this without compromising quality and safety. She recently reiterated that this work yielded two clear lessons. “First, quality must be the top priority; focusing solely on efficiency will not deliver meaningful improvement or desired productivity gains. Second, pay attention to social contexts; sustained improvement depends on thoroughly assessing and addressing the relationships, mindsets and behaviours of those involved in and affected by change efforts.”

Why this matters now

For all the emphasis on “system working”, “broken system” and “fixing the system”, the reality is that systems only function – they don’t actually exist. We create them to help us organise ourselves and make sense of the messy reality we live in. If the three shifts central to the coming 10 Year Health Plan are to succeed, this will be defined by the perspectives of the human stakeholders.

Any change needs energy, motivation and belief. To align effort and energy towards achieving the three shifts, we will need to focus on meeting the human and emotional needs of those who will do the work to make this happen. Existing policy, if taken to its combined and natural conclusion, also supports this. The People Promise, People Plan, Long Term Workforce Plan, the National Patient Safety Strategy, and Messenger Review all have people’s wellbeing, with its relationship to results, as themes. For example, identifying that the NHS too often focused on tasks over people.

Yet, this hasn’t been enough to make this business as usual and an organising principle of all work. As an example, funding for the network of 40 post covid staff wellbeing hubs launched in 2020-21, as a way for NHS staff to get fast access to support with any wellbeing or mental health issues they were facing, including pandemic-related trauma, was drastically reduced for 23/24 and expected to end.

What else needs to change to systemise the fact that staff are assets to better support and enable? How can we find out ‘who is hurt, what they need, and who should meet that need’ and so maximise the chances of people having the bandwidth and motivation to help achieve what the system will set out as priorities for the next decade? How can existing policy that speaks to this be better joined up alongside other priorities?

Some ideas on what we could do now are below but you tell me in the comments below. Is this not as important as my gut feeling tells me it is? Is this already being addressed systematically and strategically enough? What opportunities does this moment of change give us?

• During the remaining 10 Year Health Plan engagement, ask staff who is hurt (metaphorically or literally), what they need now, in the medium and long term, and who should meet that need.

• Look into what other safety critical industries do to support staff to cope with risk and complexity long term, from human factors led design and procurement of machinery to trauma and high stress management.

• Start to look at how consideration for staff needs and ongoing nurturing of positive relationships can be baked into a reformed system. There are many practical ways this can be improved and scaled from what is happening in some areas locally (self rota'ing for instance) but, for me, this also includes space to pause and sense-make together, longer term horizons for funding and planning, large scale listening to hear meaningfully and use insights strategically, and more sophisticated communications approaches to speak to different groups) and who is responsible for what at each level.