The Social Determinants of Relationships

Pritpal S Tamber

May 22, 2019

In health care we’re obsessed with health. 

But what if we changed our focus? What if we looked at other sectors trying to respond to the social circumstances that impact their outcomes. What might we learn? 

Last week I published an interview of Paul Taylor, the Innovation Coach of Bromford, a housing association in the UK. Bromford builds lower cost homes for people to rent or buy. However, they’re seeing more and more people struggling to pay their rent due to social challenges, such as economic insecurity, drug or alcohol dependency, and social isolation. 

Bromford realised that they couldn’t “offer solutions to all of life’s challenges”, Paul told me. However, they believed that they could “work in a way that involves giving power to communities so that they can solve their own problems”. 

This new way of working required devolving more and more autonomy to frontline staff. Bromford had a hunch that the company’s “rules and bureaucracy…were getting in the way of building genuine trusting relationships with residents”. And so, they set about liberating their staff, changing their core activity from rent collection to neighbourhood coach. 

Although the change has been successful, Paul says it’s not been easy. Over five years of testing and phased implementation, they’ve had to help some colleagues leave. The coaching model is not for everyone, especially with the lack of certainty that comes with “no set hours of employment” and building a “personalised service based around what works for each customer”. 

Looking from the outside, perhaps on a site visit or something, it’s likely that what one sees at Bromford is the apparent informality of the work – the no set hours, the no rules to follow. But listening to Paul what becomes apparent is that at the core of the change is a belief in people – in one’s staff and in the citizens they’re serving – as well as the power of human relationships. 

Elsewhere last week I heard that same belief, this time in youth justice in Limerick, Ireland. In R Talks, a podcast, Michael Little of Ratio spoke with Sean Redmond, an unusual person in that he works both in policy (at the Department of Children and Youth Affairs) and academia (at the School of Law at the University of Limerick). 

Sean has been looking at the lives of young people repeatedly involved in serious crime. His lens of analysis is an unusual take on ‘governance’. Rather than focus on financial governance, for instance, he examines social policies and interventions on the basis of how they’re experiencedby the citizen. 

Sean believes that if the intention of a youth justice policy is to “get kids to do more good stuff than bad” then what’s key is the relationships between youth worker and youth. And so, the question of governance becomes how does everyone involved in the system contribute to that relationship and the experience of the youth? 

It’s a question that he believes is not sufficiently asked by systems. 

Both of these examples – Paul in housing and Sean in youth justice – make me think of the idea of changing people’s ‘social spaces’ in order to bring about different outcomes. 

Researchers Sarah Nettleton and Judith Green explored this idea in their recent paper on behaviour change. In trying to make sense of our behaviours, they argue that our perceptions are in constant dialogue with our social spaces. If our perceptions align closely with our spaces, we accept the world as it is and we assume our behaviours to be the norm. 

Paul illustrates this beautifully in the interview. He talks about how a tenant with drug or alcohol dependency that’s getting into debt was unlikely to raise this with Bromford, the rent-collecting landlord, for fear of being evicted. In that scenario, the tenant’s perception of Bromford as only caring about the rent aligned with the social space created by Bromford – one of rent collecting. 

Such close alignment of perception and social space leads to what feels like the obvious, normal result: increasing debt, missed rent payments, eviction. 

But by changing the social space – by making the relationship about coaching not just rent collecting – Bromford make it possible for more positive outcomes to occur. As Paul says, through Bromford’s change, residents felt more supported, more in control of their finances, and are even reporting some beneficial effects on their wellbeing.

Although Nettleton and Green’s paper made my head hurt, they also helped me find a thread between Paul’s hunch and Sean’s radically different way of understanding governance. 

So, if you’re in a community health meeting this week (obsessing, as ever, about health), ask yourself what you can apply from Paul and Sean’s work. Is there enough trust in frontline staff such that you can liberate them from rules and bureaucracy? How precious is the relationship between staff and citizens? And how is your system judged on its contribution to establishing and nurturing those relationships? 

I realise these are not easy questions but if we’re going to learn from other sectors that are also dealing with social circumstances, we clearly need to be asking them. 

Dr Pritpal S Tamber MBChB 

PS: If you’re not in a community health meeting this week but really wish you were note that the good folks at Kokua Kalihi Valley Comprehensive Family Services are looking for a full-time family physician. They’ve made my head hurt in the past but they’re very much in the business of developing relationships and changing social spaces. Check out their advert

Further Reading

  • The interview with Sean Redmond is part of the excellent R Talks series exploring what it takes to put relationships at the heart of public policy
  • You can learn more about Sean Redmond, including his ongoing research and recent publications, from his bio
  • Nettleton and Green’s paper is part of the special issue of Sociology of Health & Illnesslooking at behaviour change 
  • The first issue of Community & Health was on the fallacy of behaviour change [link]
  • And if you’re interested in how Kokua Kalihi Valley Comprehensive Family Services made my head hurt, I wrote about my time with them here

Banner photo by Toa Heftiba on Unsplash

Pritpal S Tamber

Independent Writer, Researcher & Consultant | pritpal@pstamber.com

I'm an independent writer, researcher and consultant focussing on community health and medical information. I'm a former physician, medical editor and medical publisher, and also the former Physician Editor of TEDMED. I began my career at The BMJ. For more information, see the About page.

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