Care quality and risk. As systems of health and social care become more complex, more specialised, more expensive with rising demands, and subject to ever more intense political scrutiny, the risks of weak organisational and inter-professional relationships become more acute. Reviews of major service failures consistently highlight the role of weak relationships. Knowledge is not shared, communication is misunderstood, poor practice or decisions are not challenged and personal and organisational goals are misaligned. Alongside this the relational essence of caring and therapeutic relationships have been compromised by service design, staffing pressures and organisational cultures. Among the results are neglect and abuse of service users, particularly older people and those with disabilities.

Relational determinants of health. While healthcare is still often seen in terms of the treatment of disease through technological innovation, there is now greater awareness of the contribution to public health of, for example, improved sanitation and nutrition, as well as the benefits of strong social support. A recent meta- analysis concluded that the influence of social relationships on the risk of death is greater than that of physical inactivity and obesity and comparable with well-established risk factors for mortality such as smoking and alcohol. Local public health bodies (such as Health and Wellbeing Boards in the UK) should have good data about the state of relationships in their area, should seek to foster high levels of social support, and promote access to relationships support and counselling.

Partnership and collaboration. The knowledge, skills and resources to make a difference are rarely located in one profession or organization. Organizational silos, differing funding streams and accountability processes, as well as different professional cultures and training consistently impair the integration of services around the needs of patients and service users. Professionalism is no longer confined to knowledge and technical skills, but must also be reflected in the development and conduct of relationships with patients and communities, own and other professions, partner organizations, and regulators and policymakers.

Reform and accountability. Where the funding of health services is the subject of intense political debate, there is great pressure to show that spending translates into improvements, often linked to pledges and targets. The pressure to meet targets easily causes long term damage to trust in relationships and distorts outcomes. Reform leads to changes in organizations, in care pathways, and in the ways services are purchased or commissioned. Failure to consider adequately the impact on relationships compromises the effectiveness of such programmes. After a significant re-organization it can take months – and usually years – to regain the same levels of understanding and trust that are necessary to manage a complex system effectively, with an overall loss of effectiveness and efficiency. Changes to both national policy and local services should be informed by better understanding of the state of the relationships that are essential to these programmes, and how those relationships might be affected by the changes.