Relationships Alliance response to NICE consultation on quality standards
Question 4 Do you agree with the initial list of future quality standards proposed in the consultationdocument (pages 10 -11)?
Question 5 Which ones do you disagree with?
Attachment and permanence
Question 6 Why do you disagree with the topic/s?
Rather than develop the proposed quality standard – Attachment and permanence (Promoting permanence for adopted children and all children with attachment disorder issues across health and social care) – the Relationships Alliance feels it would be more sensible to devote a quality standard to the attachment issues experienced by adopted children and develop a separate one entitled ‘Secure attachment in children’ (with a long title of ‘Promoting the development of secure attachment in children in health and social care settings’). Not all children who are adopted have attachment issues, while the consequences of poor quality of attachment between children and their parents/caregivers are sufficiently significant in terms of children’s outcomes that a quality standard should be developed specifically on this topic in our view.
Question 7 Are there any topics/titles that should be amended and in what way?
Which ones/what amendments:
Yes, Attachment and permanence. As above - rather than develop the proposed quality standard - Promoting permanence for adopted children and all children with attachment disorder issues across health and social care – the Relationships Alliance feels it would be more sensible to devote a quality standard to the attachment issues experienced by adopted children and develop a separate one entitled ‘Secure attachment in children’ (with a long title of ‘Promoting the development of secure attachment in children in health and social care settings’). Not all children who are adopted have attachment issues, while the consequences of poor quality of attachment between children and their parents/caregivers are sufficiently significant in terms of children’s outcomes that a quality standard should be developed specifically on this topic in our view.
Question 9 Are there any other topics you would like to see considered that aren't in the list?
Yes, Relationship health (long title: supporting and developing people’s ability to manage relationship difficulties across health and social care)
Question 10 What are the reasons for your suggestion/s?
Reasons for suggestions:
The consultation document states that ‘NICE guidance is for the NHS, local authorities, charities, and anyone with a responsibility for commissioning or providing healthcare, public health or social care services’ and that NICE quality standards are intended to ‘provide commissioners and providers with evidence-based descriptions of what good care and support should look like’.
The capacity to sustain strong and stable relationships (and, in particular, strong and stable couple relationships) is profoundly important for our mental and physical health and well-being. For example, relationship distress is associated with increased levels of depression and anxiety (it is estimated that 60% of those with depression attribute relationship problems as the main cause for their illness (O‘Leary, Riso & Beach, 1990; Rounsaville et al., 1979)), and with alcohol and substance misuse (Wilsnack, 1984 and Romelsjo, Lazarus, Kaplan, & Cohen, 1991) and poorer cardiovascular health (Kiecolt-Glaser, 2001). Our capacity to work and to be fulfilled in work is also significantly influenced by the quality of our closest relationship. Furthermore, conflict between parents can lead to increased anxiety, depression, aggression, hostility, anti-social behaviour and criminality as well as deficits in academic attainment (Harold, Aitken & Shelton, 2007 cited in St. George’s House and Relate, 2012)) . The Relationships Alliance believes that developing an evidence-based description of the range of activities and approaches which commissioners and providers and healthcare, public health or social care services can undertake to support and encourage people’s ability to better manage relationship difficulties would pay significant dividends in terms of improved health and well-being of adults and children.
Relationship health is seldom focused upon specifically by health and social care providers however, despite a substantial evidence-base showing a range of interventions and approaches which both foster people’s capacity to deal with relationship difficulties in a constructive way and increase people’s resilience in the face of the adversities and difficulties which can put relationships under strain.
Two ways in which this can be achieved are through the promotion of healthy relationships and relationship skills and through strengthening couple relationships at challenging points in the family life cycle. There is significant evidence building for the efficacy of such measures (e.g. Walker et al (2010)). At present, any focus on relationship health is – at best – something of an add-on, often delivered by a professional who feels anxious about their competence to help adults with their relationship or at the other extreme by a specialist couple counsellor or therapist who tends to meet with a couple when problems are more severe. People’s physical and mental health could be improved however if relationship support were made a more central element of universal provision, whether it is for new parents when visiting their health visitor, social workers when assessing the needs of families or the GP when listening to their patient who has depression.
Moreover, if professionals were better trained, and more encouraged, to think about the family system as a whole, they would be better equipped to provide help to those couples whose problems may be spilling over and manifesting themselves as emotional and behavioural problems in their children and to refer patients to appropriate therapy or relationship support.
The Relationships Alliance believes that the cross-cutting nature of relationship health means that the development of a quality standard in this area would be of particular value. While individual clinical guidelines (such as the NICE guidance on depression in adults which recommends the provision of couple therapy for depression as a treatment option) play a key part in improving health, the importance of statements which describe what can be done to enhance relationship health across the board across health and social care and which encourage commissioners and providers to develop a holistic approach to relationship health for the populations they serve cannot be over-estimated. After all, such a focus has the potential to strengthen a family’s own resources, fostering autonomy and reducing dependence on professionals over time.
The Relationships Alliance therefore urges NICE to develop a quality standard on relationship health, and would like to offer NICE its expertise and assistance in developing any such standard.