Thinking about relationships in health – more than a game of billiards.

A crisis of trust, the compassion gap, and growing health inequalities – what do they all have in common? They all say something about how we relate to each other, and, I would suggest, an inability to take these relationships into account in the complex health and care settings we find ourselves in as patients, managers or policy makers. Healthcare organisations have multiple partners and a wide range of communication channels. The needs of people for health and care services are also increasingly complex. And yet we appear to gravitate toward what I call the billiard ball approach to understanding and managing the health and care system We are increasingly aware of how the world around us is connected. Scientists use this as the basis of their experimentation and our everyday experience bears it out. But a simple cause and effect theory of everything when it comes to understanding people, groups and organisations is clearly inadequate. We are not billiard balls that ‘bounce’ off each other so that we can use precise measurement to predict the new landscape once all the balls on the table have come to rest. Relationships are more than simple connectedness. Relationships also play a vital part in our wellbeing, i.e. “the condition of an individual or group, for example their social, economic, psychological, spiritual or medical state” (wiki). Whilst more precise definitions may be available we are generally content with recognising the multi-facetted nature of wellbeing. We are also all intent on improving wellbeing. But here lies the rub. Our culture, and the tools we use to evidence progress toward greater wellbeing can leave us blinkered or imbalanced to the contribution that the relational dimension, can and should make. The relational wellbeing of individuals, groups or organisations therefore merits significantly greater attention. We need new ways of thinking about, and accounting for the contribution this makes. The way I am proposing is to use the language of relational value. This is what makes our connections as people more than just the cause and effect of the green baize. But it seems that in health and care services we sometimes behave as if there was only connectedness. We shuffle the deck chairs, prescribe precise targets, legislate, inspect and penalise when things go wrong. When the billiard balls don’t land up in the right place we either intervene with the white gloved hand of the referee or reset the table. Through our work with the University of Leeds School of Healthcare Studies in a Knowledge Transfer Partnership we are now uncovering evidence that relationships count. This is probably simply confirming what we already know instinctively, but it is none-the-less adding to our ability to understand and harness this dimension in new ways. And we now have a list of what we think are probably the most relevant attributes of relational value. They are required in different combinations at the individual, group and organisational level but all have potential merit in building relational value. They are:

  • Integrity – as a result of consistent behaviours over time and in different situations.
  • Respect or appreciation – as a result of the ability to put yourself in someone else’s shoes and factor this into the way in which we behave.
  • Compassion or empathy – considering the other, typically involving ‘going the extra mile’, often with a strong sense of story.
  • Justice or fairness – as a result of openness, candour, benevolence and even the sacrifice of individual or group ‘rights’ in the interest of a greater good.
  • Trust – in some ways being the result of the combined effects of the previous four. It arises from consistent, appreciative, empathetic and fair actions habituated into a person-to-person, group-to-group or organisation-to-organisation relationship.

Each of these attributes contributes to relational value, but they are born out of the behaviours we adopt in given situations. Consider trust. You or I may be a trusting individual (our behaviours exhibit trust), we often call this a virtue. But the interplay between behaviours and individual virtues will result in the development of ‘trust’ as something that, whilst being dependant on our actions, is in some way also distinct. We leave a deposit of trust that can be relied on, and that has benefits because it builds resilience and capability for current and future actions. However, the behaviours we exhibit, and therefore the attributes of relational value that emerge in given situations vary – and such variation is necessary and appropriate. Each relationship has a purpose, for example to care, to manage, to direct and lead etc, and therefore the relational value necessary to achieve that purpose will reflect a different mix of attributes. Generally relational value needs to be recognised and built, hence my opening remarks about our lack of regard to this important dimension. But more of one or other attribute, particularly at the expense of others, is not always necessary or even better – we know that from coveting a lot of intrinsically good things, like chocolate! What is important is that the attributes present in a given situation fit with those needed for the effective delivery of a given purpose. What we need are strategies to develop and/or maintain relational value. We are therefore exploring how we can help people to work out the right balance in behaviours and the appropriate mix of attributes in specific contexts, as well as how you illicit knowledge about what levels of each is present, and how they develop and change over time. So, when thinking about the relational dimension of individual, group and organisational wellbeing, rather than a set of balls on a billiard table let’s consider a set of dials on a dashboard. Each dial provides a read-out of what’s going on in the relational dimension. But we can’t simply tweak the dials. We should be able to set an optimum balance of how the dials should look, but the way that we influence the readings is through changing the behaviours that contribute to the development or loss of these relational attributes. Finally, however, we should not assume that the individual, group and organisational levels are distinct and unrelated. The relational values of inter-organisational wellbeing, and particularly the associated behaviours that contribute to them, influence or even constrain the behaviours at a group or individual level. The responsibility of leaders, makers and shakers in the health and care system, to both recognise, understand and model the development of relational value is foundational to achieving the overall wellbeing we desire.