Fiona Birkbeck – The Cry for Professional Intimacy: Healing and learning in the 21st century. Changing client/expert relationships in our post-industrial public services.

Fiona Pic So, what are you researching? ‘ is the perennial question.
‘Public Services,’ is my answer.  ‘Client expert relationships in the NHS and in Education.’
In the past, the eyes of my questioner would begin to glaze over.  Maybe, I would reflect sadly, it’s the combination of ‘public’, with its connotations of toilets, and ‘services’ conjuring up a tired Costa Coffee and a limpid bun …

But lately things have changed. We seem to be reaching a crisis point in the delivery of ‘care’ and ‘learning’.  Suddenly, my questioners want to carry on the conversation, if they are practitioners they want to be involved. ‘Healing’ and ‘learning’ have retaken the political centre stage. The clients, the practitioners and the policy makers, however different their entry point into the discussion,  have a shared understanding that a revolution in ‘care’ and in ‘learning’ is in the air.  There is a homogenous desire for a more ‘personalized’ delivery. There is a cry for ‘professional intimacy.’

My background in health was as Head of Rehabilitation Education for Long Term Patients for a Mental Health Trust.  Sounds impressive. In reality, I was head of a demoralized and paranoid team of teachers, who suspected (rightly, as it turned out) that they would be made redundant by ‘Care in the Community’. We met our clients in classrooms which were in the basement of a vast, decaying Victorian mental health hospital. I started work there when my son was eight weeks old. They were desperate for me to get into post, even for the few hours I could offer at that time, but it was an overly ambitious undertaking and on my first day I was, of course, late. On rushing up the steps, not knowing where ‘my’ basement was, I breathlessly grabbed the first chap in a white coat that I saw.
‘Where is the basement. I have to get to the basement,’ I gasped, clutching his arm.
The man in the white coat smiled. ‘My name is Doctor Bob.  I don’t think I’ve met you before, dearie.’ He took a firm hold of my elbow. ‘What is your name? Now, why would you be after the basement?’

Finally we found someone who knew who I was and why I was there.  Bob relaxed. Then the penny clicked.
‘You thought I was a patient!’ I cried.
Doctor Bob smiled again. ‘In fairness to me,’ he said, ‘you do look a bit strange. And you were definitely agitated.’
He indicated my appearance. I looked in the mirror beside the stairs. There was a strange white patch of baby sick on my shoulder and my hair was sticking up. Who combs their hair when the baby’s hungry? I explained.
‘Well’, said Doctor Bob, ‘any woman with an eight week old baby is a bit, well,  mental.’
Bob was a Glaswegian, and in one fell swoop of colloquialism, he had wiped out DSM 3, 4 and probably 5.
A bit ‘mental’. Fair enough.

I thought of Bob a few years ago when I began to carry out workshops developing resilience for practitioners working in Health and Education. They often told me that they felt under increasing pressure at work.  They felt a bit, well, ‘mental’. My research question is to find out why.

The relationship between the ‘client’ i.e. the patient, the pupil and the ‘expert practitioner’ i.e. the GP, the senior nurse, the hospital consultant, the teacher is changing in our post industrial public services. The outdated ‘one size fits all’, industrial model NHS and Education services fail to provide the individualized,  relationship-led ‘healing’ and ‘learning that we all want.  Social policy and government directives ask for each pupil, each patient to be treated as unique. Each pupil, each patient wants to feel that they are known and understood by their teachers and carers.

The senior practitioners who have contributed to my research all want to design and provide an excellent service to society. They all recognize that to do it three  things are needed: an increase of ‘emotional labour’ amongst practitioners (Hochschild 1983); training  and support in what is called ‘deep care’ (Persaud 2004) and, above all, the time to offer this ’deep care’.

They go on to say that we may want this kind of relationship with our practitioners, but we are not providing the structure to allow it.  How can practitioners deliver 21st century professional intimacy in a 20th century structure? We have 30:1 teacher pupil ratio in our schools; an  8:1 patient/nurse ratio in our hospitals; GPs have 10 minutes for a consultation and, on nights, 1 junior doctor may be covering three hospital wards.  My participants, all senior practitioners in our public services, indicated that they recognized this mismatch between the expectations and the reality of delivery as the cause of an alarming increase in stress related illness amongst teachers, doctors and hospital nurses.

This longitudinal study of over 300 doctors by McManus et al  describes a possible causal model for the increase in stress related illness in our ‘healers’ and ‘teachers’.

Fiona Graphic

Please click to enlarge

McManus (2002) discusses the concept of ‘depersonalisation’. He is indicating the uncaring practitioner, too tired to be interested in their clients as individuals.  He suggests that the practitioners who are under stress but who then are driven by a sense of professional responsibility to become more efficacious may simply increase their stress, and eventually they may burnout. The practitioner who does not increase their involvement with the patient, or the pupil, survives. Thus, ‘depersonalization’, which we might describe as cynicism or callousness, is adaptive whilst increasing professional efficacy is maladaptive.

And we, the clients, get the very practitioners we don’t want. We get the ‘uncaring’ nurse, the ‘uninterested’ doctor and the ‘weak’, ‘uninspiring’ teacher. These undesirable practitioners do exist.  They are not a figment of the media’s imagination.  But we must examine the possibility described by McManus (2002) that shocking incidents of ‘unprofessional’ behavior are the product of a system which is, in some situations, unworkable and not always caused by an alarming increase in the employment of unsuitable staff.

The policy makers certainly point to the unsuitable individual as the root cause of the problem in the delivery of our services.  We have the introduction of psychometric testing for teachers in 2012 as a way of sifting out those who lack the emotional intelligence to be teachers (Smithers 2011); we have the introduction of ‘role play’ in the induction of medical students (Report. GMC 2012), in order to find those with the ‘empathy’ needed. Our trainee nurses are to spend a year working as HCAs to ensure that they have the necessary caring attitude (Denis Campbell, The Guardian. March 2013). Of course, we all want teachers with ‘emotional intelligence’, doctors who are ‘empathetic’ and nurse who ‘care’. In the 21st century, we are increasingly needful of being offered ‘professional intimacy’ from our practitioners.

Head teachers, GPs, hospital consultants  and senior nurses have told me that prospective staff come to work in Health and Education precisely because they have those qualities, as they always have done.  But they have also told me that if the system is not redesigned to allow those qualities to be nurtured then we will continue to lose good practitioners from our services and the cry for ‘professional intimacy’ will become a wail.

Fiona Birkbeck BA MA
PhD researcher, University of Nottingham


Denis Campbell. Nurses must spend a year on basic care. The Guardian. March 26th 2013
DfE 2010  Initial Teacher Education (ITE) Inspection Handbook. 2012
Guidance on Safe Nursing Levels; Staffing in the UK. Report. RCN Policy Unit 2010
MAGUIRE P., Piceathly C. Key Communication Skills and How to Acquire Them. BMJ 2002;325;697
MCMANUS. I.C., Winder B.C., Gordon D. The causal links between stress and burnout in a longitudinal study of UK doctors. Lancet 2002; 359: 2089-90
Hochschild,  A. R. 1983. The Managed Heart: Commercialization of Human Feeling. Los Angeles, California, United States of America: University of California Press.
PATTANI S, Constantinovici N.,Williams S., Who retires early from the NHS because of  ill health and what does it cost? A national cross-sectional study. BMJ. 2001; 322: 208–9.
PERSAUD, R.  2004. Faking it: The Emotional Labour of Medicine. Viewed May 4th 2013. Available from:
RCGP Curriculum 2010, Statement 2.01 The GP Consultation in Practice. Revised 30 May, 2012
Recommendations of The Francis Report BMJ. 2013; 346; f854
Smithers, A., and Robinson, P., The Good Teacher Training Guide.  Report. University of Buckingham. 2011
The Black Review; Working for a Healthier Tomorrow. The Cross-government Health, Work and Well-being Programme. Report. 2008
The Education and Skills Committee Secondary Education. Teacher Retention and Recruitment. Report. Fifth Report of Session 2003-04
The State of Medical Education and Practice in the UK. Report. G M C  2012


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