How can you help clients of all ages to feel empowered in healthcare and beyond, while ensuring your own listening skills are as good as they can be? Journalist Anna Scott reports.
Effective listening is fundamental to health and social care. It serves to ‘build trusting, caring and therapeutic relationships’ (McKenna et al, 2020). But recent research and individuals’ stories have highlighted that many groups of people do not feel listened to in healthcare, social care, educational settings and beyond.
‘LISTENING TO PATIENTS AND
CARERS NOT ONLY IMPROVES
INDIVIDUAL OUTCOMES. IT CAN
HELP THE HEALTHCARE SYSTEM
WORK BETTER FOR EVERYONE’
Most women (84%) surveyed for the Women’s Health Strategy for England said they felt their healthcare professionals were not listening to them at times (Department of Health and Social Care, 2022). And MPs who launched a hard-hitting all-party report on birth trauma in May stated: ‘Too many of the stories we heard involved women not being listened to’ (All Party Parliamentary Group on Birth Trauma,2024). Sophie Randall, director of charity the Patient Information Forum (PIF), notes: ‘[Health professional] biases on pain tolerance for non-white women have been well documented and reported by women in an ongoing PIF project on maternity care.’
Meanwhile, Healthwatch England’s survey of more than 2000 people published in March found that poorer people were less likely to feel listened to by a health professional than those who were deemed ‘financially comfortable’ (Campbell, 2024).
| Who’s listening? |
| A woman who finally received a diagnosis of endometriosis after 18 years of symptoms and visits to 20 different doctors said she felt validated |
| 84% of women surveyed for the Women’s Health Strategy for England said at times they felt their healthcare professionals were not listening to them |
| Only 10% of teenagers believe they have the power to influence the issues they care about |
Fuller and PA Media, 2024
Many children and young people don’t feel heard either. Only one fifth of those in England surveyed from September 2023 to January 2024 believed their views to be important to the adults who run the country. And just 10% of teenagers believe they have the power to influence the issues they care about (Children’s Commissioner, 2024).
‘Many young people have told us that they don’t feel like people in power are listening to them,’ says Professor Peter Fonagy, psychoanalyst, psychologist and chief executive of Anna Freud, a mental health charity for children and families. ‘This is often because they’re seeing policies that will significantly impact their lives and wellbeing – from climate change and the economy to NHS and social care funding – implemented without their experiences being considered.’
WHY IS LISTENING SO VITAL IN HEALTHCARE?
‘[Feeling listened to] empowers patients, encourages them to talk, giving a clearer understanding of their concerns and needs,’ says Athena Lamnisos, chief executive of charity the Eve Appeal. ‘It enables the patient to be involved in decision-making processes, supports personalised care and information and improves outcomes for both patient and healthcare professional.’
Clients are vital partners in healthcare, says Sophie Randall from PIF. ‘They know what it is like to live with a condition, manage side effects of treatment and recover from surgery. Parents and carers know their child. They know how they respond to pain and how they behave if they feel ill. Listening to patients and carers not only improves individual outcomes. It can help the healthcare system work better for everyone.’
‘PROFESSIONALS MUST
ALSO EMPOWER PEOPLE,
WHICH COULD INCLUDE
HELPING THEM ENGAGE
WITH LOCAL INITIATIVES,
SUPPORT NETWORKS AND
RESOURCES EFFECTIVELY’
It’s vital not to dismiss young people’s feelings as ‘normal teenager problems’, highlights Chris Quinn, Northern Ireland Commissioner for Children and Young People. ‘If they have a bad experience, where their confidence is broken by a mental health professional, then it makes it more difficult, or stops them, from seeking help in the future. A positive interaction with a friendly and kind health professional could transform a young person’s views of healthcare, so it is vitally important that they assume that role.’
| EMPOWERING PARENTS TO SPEAK UP |
| Athena Lamnisos, CEO of the Eve Appeal Remind parents to make a list of symptoms and questions they want to ask in their medical appointments. Say to them, ‘Be prepared for your appointment – think about the most important things you want to cover before you go in.’ Check what should happen next and when, what to do if symptoms worsen or don’t improve, and who to contact. ‘Do not be afraid to ask if you do not understand any words or terminologies.’ |
| Sophie Randall, director of the Patient Information Forum Take someone else with you if you need more support and asked for an interpreter if you need one. ‘Before your consultation, contact a patient support group or charity. They are an excellent source of information and support. Most will have helplines you can contact. They will have up-to- date information on treatment choices,’ [see Resources]. If you think a clinician has not listened to you, politely point that out to them. ‘If you are not happy with the outcome, use Martha’s Rule. If you are really unhappy about the way you have been treated, you should complain. ‘During the consultation, do not be afraid to ask the doctor or nurse to pause if you have a question or just need a moment to reflect. It can help to record the consultation [with consent] so you can listen back afterwards.’ |
From a biomedical point of view, a central component of good medical practice is hearing what the person has to say and how they’ve understood their symptoms and what they might mean for them, says GP Sharon Dixon, who is also a National Institute for Health and Care Research doctoral research fellow at the University of the Oxford-based Nuffield Department of Primary Care Health Sciences. ‘Good listening underpins compassion, effective care and being able to make a shared decision and management plan,’ Dr Dixon adds. ‘This can include knowing when [a clinician] has got it wrong, and they have to be open to hear that.’
In England, Martha’s Rule – which seeks to ‘provide a consistent and understandable way for patients and families to seek an urgent review if their or their loved one’s condition deteriorates, and they are concerned this is not being responded to’ – will be rolled out across 143 hospital sites by March 2025 (NHS England, 2024). The scheme is named after Martha Mills, who died from sepsis aged 13 in 2021. She was not admitted to intensive care even though her family expressed concerns about her deteriorating condition (NHS England, 2024).
FEELING UNHEARD
People don’t feel heard during health appointments for a myriad of complex reasons. Limits on healthcare professionals’ time and systemic workforce pressures – including meeting top-down targets – play a major role. Since 2008, the NHS focus on quality in health services has had three components: clinical effectiveness, safety and experience. However, as NHS England (2015) admits, ‘for much of that time experience has not been regarded in practice as being equal to clinical effectiveness and safety’.
‘If you’re going to understand how well a healthcare system is doing, speaking to the people on the receipt of that healthcare is really important,’ says Dan Wellings, senior policy fellow at The King’s Fund think tank. ‘Some issues around listening are about culture and power sharing, as well as recognising that the health system doesn’t have all the answers.’ Dan highlights the views of one community: ‘We’ve spoken with the Somalian community in Birmingham, and they talk about being in the shadows, not feeling seen or heard.’
When it comes to seeing a doctor, there are too few GPs for the number of patients needing care, points out Professor Kamila Hawthorne, who chairs the Royal College of GPs. ‘Years of underfunding and inadequate workforce planning mean that GPs and our teams are struggling to get enough time with our patients, especially when seeing 50 or more patients in a day, which many GPs report is a common occurrence,’ she points out. ‘We are delivering millions more appointments than we were five years ago, with 880 fewer fully qualified, full-time equivalent GPs.’
While good communication and listening skills form a key part of GP training and assessment, the reality is that intense pressures on family doctors and their teams can result in consultations being shorter than patients and GPs want. As a result, Professor Hawthorne notes, it’s ‘very difficult’ to have ‘the in-depth conversations we often need with patients, particularly those with complex health needs’.
Athena Lamnisos adds: ‘They want to do a good job for their patients, and they know that building trust will lead to better care. [But] because they are under such a range of pressures, spending time “listening” can feel like a “nice-to-do” rather than essential.’
‘CHILDREN WANT TO
BE ASKED HOW THEY FEEL,
AND I THINK WE ALL NEED
TO KEEP THAT AT THE
CORE OF EVERY INTERACTION
WE HAVE WITH THEM’
Professor Fonagy feels there’s a tendency to focus on young people’s problems rather than listening to them to hear what solutions they suggest. ‘In this way, we contribute to depriving them of agency and self-determination. We’re also prone to the crisis narrative that pictures young people as troubled teens with a set of negative perceptions which obscures a focus on providing support for positive development. We pay attention to what is currently happening rather than how to prevent it. Youth mental health needs to be built, not retroactively repaired.’
| GIVING CHILDREN AND YOUNG PEOPLE THE CONFIDENCE TO USE THEIR VOICES |
| Professor Peter Fonagy, chief executive of Anna Freud Remind young people that they are the expert in their lives and that their voice should be heard. ‘It’s okay to ask “why?”.’ Remind them that stress and difficulties are common and normal and may not be an indication of mental ill health. ‘However, for those with mental ill health, having the time and space to talk about your diagnosis can be incredibly empowering too.’ |
HONING SKILLS
School nurses and health visitors are expected to use advanced communication skills to build mutually trusting relationships with children, young people and families, points out Elaine Robinson, the NMC’s nurse education adviser. A registered children’s nurse and HV, Elaine says: ‘This includes actively listening [see Professional guidance], understanding, and advocating for an individual’s needs to positively influence their care and ensure their voices are heard.
‘Professionals must also empower people, which could include helping them engage with local initiatives, support networks and resources effectively. This ensures they can take appropriate interventions to improve the health and wellbeing of everyone in their care.’ Elaine adds. They should also recognise and respect the contribution that people can make to their own wellbeing.
PIF director Sophie points out that good clinical skills for clinicians do not always come with good communication skills. ‘The good news is that good communication skills can be learnt, including active listening,’ she adds. ‘There is a lot of jargon in healthcare and it’s easy to forget the terms used in consultations every day are unfamiliar to most people. This can lead to patients being overwhelmed, not asking the questions that matter to them or simply saying “yes” when asked if they understand.’
| RESOURCES |
| > The Patient Information Forum’s joint project Removing Barriers to Shared Decision-Making and Trusted Information Creators |
| > British Heart Foundation’s 10 tips for active listening |
| > Ask Eve’s nurse-led information service, including trans and non-binary screening tips, plus advice for healthcare professionals: – facts and tips for cervical screening – tips for your appointment – for healthcare professionals |
| > Martha’s rule |
| > Mental health charity Anna Freud has various resources for children and young people to them to make informed choices about their mental health and wellbeing |
Jessica Streeting, a school nurse (SN) by background, is a public health nurse consultant for 0-19 services at Centra London Community Healthcare NHS Trust. She says that while time pressures are very real, they are never a reason for children and young people to feel rushed. ‘You may be the first person they have confided in and it’s important you are non-judgemental and receptive to their needs, giving them space to open up,’ she notes.
Jessica points out that by listening carefully to the young person, we can gain insights into their lived world. Chris Quinn agrees: ‘A young person’s view is often very different from the perspective of the healthcare provider. They need to feel involved; they need to feel comfortable by showing an interest in what you are telling them. Children want to be asked how they feel, and I think we all need to keep that at the core of every interaction we have with them.’
Dan Wellings points out that many healthcare professionals are doing all of this anyway. ‘I think the frustration for many frontline staff is that they know what could work better,’ he says. ‘They are the people bringing the insight, particularly if you’re visiting someone’s home, and getting a huge insight into that person’s life and what they might need.’
Giving healthcare professionals – whether GPs, SNs or HVs – the time and space to be able to properly listen to clients is about so much more than the individual professionals. It’s about organisational culture, national targets and leaders of organisations understanding challenges. In the meantime, you can continue to nurture empathy and strong relationship with your clients.
PROFESSIONAL GUIDANCE
WHAT EXACTLY IS ACTIVE LISTENING? PLUS, ADVICE FOR HEALTH PROFESSIONALS INCLUDING CPs.
Dr Sharon Dixon, GP says that active listening for her is about ‘being with the person, having your mind on nothing else, being respectful, and letting the person speak uninterrupted – they need to tell you the whole story’. She adds: ‘It can be hard, though important, to hold this when you’re also thinking about what you need to ask next, and what tests you need to think about.’
Jessica Streeting, public health nurse consultant: ‘Listening actively involves paying attention to body language, so take your lead from the young person and keep things informal. For example, don’t sit opposite them behind a desk or fold your arms. Try not to be glued to your laptop, but do take down direct quotes from the young person as these can be very powerful when you advocate for them.’
Professor Peter Fonagy, psychoanalyst and psychologist suggests working with children and young people collaboratively to encourage them to find places where they have opportunities to take healthy risks and have positive relationships with peers and adults. ‘[Young people] should be supported in creating a life narrative that’s about health, curiosity, adaptation, resilience and discovery,’ he adds. ‘We have to move away from persistent alerting and move towards offering an accurate and motivating sense of what is possible.’
Sophie Randall, PIF director urges medical professionals to ask open questions and ‘chunking and checking’ – breaking information down and checking the patient understands after each point. ‘It is also important to examine unconscious biases and how these might be affecting interactions with patients.’
EXAMPLES OF LISTENING WORK
- Children’s Commissioner for Wales Rocio Cifuentes explains that her team works with public organisations to help them think about how they can make sure all children and young people feel listened to. ‘For children to engage with health services they need to be able to trust professionals and feel safe and comfortable in the places they get help from.
‘We’ve held specific events for health boards in Wales to come together to share good practice, and to help each other to listen effectively to all children who use their service.
‘Health boards in Wales have done some great work to engage with children and young people, including setting up youth boards that give feedback on services and developing youth charters to help raise awareness of children’s rights in health.’ - Children and Young People’s Commissioner Scotland Nicola Killean says ensuring that children and young people’s views are heard is central to her team’s work. It’s even a keystone of the United Nations Convention on the Rights of the Child – see Nicola’s full interview for more.
- The Patient Information Forum (PIF) worked with the Patients Association and NHS Nottingham and Nottinghamshire Integrated Care Board on a project that made it easier for patients to take part in shared decision-making around pre-surgery lifestyle changes.
The project also highlighted the negative health consequences of failing to treat people with dignity and respect. ‘One participant was told bluntly she was too overweight to have the hip replacement surgery she had waited for,’ says PIF director Sophie. ‘She was so upset by this she became depressed and gained more weight. Later she was referred to another clinician who treated her sensitively and supported her to lose weight. She was then able to have surgery.’
REFERENCES
All-Party Parliamentary Group on Birth Trauma. (2024) Listen to Mums: Ending the Postcode Lottery on Perinatal Care. See: theo-clarke.org.uk/sites/www.theo-clarke.org.uk/files/2024-05/Birth%20Trauma%20Inquiry%20Report%20for%20Publication_May13_2024.pdf (accessed 23 June 2024).
Campbell D. (2024) Worst-off find it harder than well-off to access NHS care, survey finds. See: theguardian.com/society/2024/mar/04/worst-off-find-it-harder-than-well-off-to-access-nhs-care-survey-finds (accessed 23 June 2024).
Children’s Commissioner [for England]. (2024). The Big Ambition. See: childrenscommissioner.gov.uk/the-big-ambition/ (accessed 23 June 2024).
Department of Health and Social Care. (2022) Women’s Health Strategy for England.
See: gov.uk/government/publications/womens-health-strategy-for-england/womens-health-strategy-for-england#ministerial-foreword (accessed 23 June2024).
Fuller C, PA Media. (2024) Women saw 20 doctors before endometriosis diagnosis. See: bbc.co.uk/news/articles/cjkdpmk5pd2o (accessed 23 June 2024).
McKenna L, Brown T, Oliaro L, Williams B et al. (2020) Listening in healthcare. See: onlinelibrary.wiley.com/doi/abs/10.1002/9781119554189.ch25 (accessed 23 June 2024).
NHS England. (2015) Improving Experience of Care through people who use services. See: england.nhs.uk/wp-content/uploads/2013/08/imp-exp-care.pdf (accessed 23 June 2024).
Northern Ireland Commissioner for Children and Young People. (2018) ‘STILL WAITING’: A Rights Based Review of Mental Health Services and Support for Children and Young People in Northern Ireland. See: niccy.org/wp-content/uploads/media/3114/niccy-still-waiting-report-sept-18-web.pdf (accessed 23 June 2024).
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