Looking at reform differently: From the inside out

If there’s one message we’ve taken from our past year of research, it’s this: the future of the NHS depends on relationships just as much as structural reform.

We talk a lot about productivity, digital tools, new models of care. Yet we heard – repeatedly – something different from leaders we interviewed across health, local government and social-purpose organisations. 

What matters most is how people relate to each other – patients to staff, teams to teams, communities to services.

That’s the big shift sitting quietly inside Labour’s ten‑year plan, Fit for the Future. The headlines focus on moving care closer to home, prevention and driving digital progress. Easier to miss is the clearly stated, bold ambition: a shift in power, trust and agency.

It’s intended to be a move away from a command‑and‑control mindset and toward a system where people closest to the work can shape it.

If we’re serious about that then we need to talk more candidly about designing services around relational working.

The dozen senior leaders we interviewed were clear that relational approaches are key to improving outcomes. We also learned that the current system makes this work much harder than it needs to be.

We need both in order to cope with the scale of the NHS, but right now, the balance is off. The desire to respond to the needs of each and every patient in an integrated and holistic fashion has never gone away, but the service struggles to design ways of doing so at scale, or sustain them long-term. Relational ways of working often survive despite the system rather than because of it.

Relational approaches can be labelled ​“soft” in contrast to the ​“grip” of New Public Management. It isn’t. It’s disciplined, humane, and evidence‑based. Our research suggests that it’s essential if we want lasting change rather than another cycle of short‑lived initiatives.

One image from an interviewee, an NHS professional, stuck with us: they speculated that a quarter of people’s time is spent on ​“pointless tasks” that push people around the system. We’ve built sub‑teams of sub‑teams, while losing the essence of teams that function well.

Transactional models optimise processes. Relational models ask what really matters to a person and then work alongside them. Both have value. If we want better outcomes, we need to redesign structures so teams can use their judgement – not just follow protocols. 

Across our interviews eight themes emerged: one core – the need to rebalance the system away from being overwhelmingly transactional and towards more relational practices – with seven enablers.

Relational care works but it needs time, trust, and flexibility. There are powerful examples of teams doing this well across the public sector – from North East London’s Relational Care Faculty to Changing Futures Northumbria’s ​“Liberated Method”. Each showed similar patterns: deep listening, collaboration with communities, and a focus on what matters to each person.

The question is not whether this works. It’s how we embed it for the right person, at the right time at scale, without burning people out or drowning them in bureaucracy.

One of the strongest feelings in the NHS system is fear. Fear of something going wrong, fear of blame, fear of deviation from the script.

Yet we need staff to be comfortable handling risk-informed decisions in the day to day to meet dynamic needs. There is value in a move away from ​“what might go wrong” to ​“what happens if we don’t act”. 

Furthermore, those interviewed told us that the more you know about someone, the less risky decisions are. When frontline staff have meaningful information and the trust to use their judgement, they can prevent crises before they happen.

A shift from ​“no, unless permitted” to ​“yes, within clear boundaries” is possible.

Compliance has become an end in itself. Instead, relational services benefit from pooled budgets, outcome‑focused contracts, and governance structures where staff, patients and communities have agency. Changing Futures Northumbria’s ​“procurement for learning” model is a great example of this.

If we want a more relational system, we need to recruit, develop and reward different capabilities. Curiosity, emotional intelligence, comfort with ambiguity, humility, adaptive leadership, data storytelling, design thinking. These should be valued.

Some organisations are already building these capabilities; for example, North East London NHS Foundation Trust’s use of Open Dialogue training. But it needs to be the norm, not the exception.

Real co‑production isn’t consultation. It’s sharing power. It’s participatory budgeting, community‑led boards, and teams spending more time in neighbourhood spaces – not offices.

Brent Health Matters and East Ayrshire’s neighbourhood planning are strong examples. But this mindset is still rare in statutory services.

People told us they are exhausted by top‑down change. They want leaders who create space, not pressure. Leaders who can hold uncertainty. Leaders who value relationships over metrics.

Adaptive leadership came up repeatedly: the ability to sit with discomfort, make sense of complexity, and support teams through defensiveness.

Change must be incremental and iterative. Prototypes should be treated as living systems that evolve with learning, with evaluation built into daily work, and protected time for experimentation and peer review. 

Investment in external horizon scanning and internal knowledge management and absorptive capacity allows novel concepts to be pulled in.

Relational systems need continuous learning, not one‑off pilots. They need real‑time insights, qualitative signals, and feedback loops. They need data as a conversation starter and narrative, not a judgement tool.

None of this is easy. Relational work is emotionally demanding, as is change. Leaders feel isolated. Innovators can feel like outsiders in their own organisations. Burnout is real.

But the positive impact is real too. People feel heard. Staff rediscover purpose. Teams become more human and more effective.

If we want relational approaches to be sustainable, we must design systems that support emotional labour as much as operational change.

For us, the takeaway is simple: we don’t have a shortage of ideas and will. We have a shortage of supportive conditions. 

The next phase of our work will be focused on what needs to change technically – structures, processes, governance, skills, sequencing – to make real a health system that is relational at its core, better balancing transactional and relational needs.

If any of this resonates, please read our full report, and if you want to explore the questions outlined in your own context, we’d love to hear from you. Click on our author profiles at the top of this page and send us a message.