PPF61 Relational system redesign for people with severe mental illness (SMI) and palliative care needs: insights from ethnography and international case studies

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Background People living with SMI experience functional impairment, high morbidity, and premature mortality (average: 20 years). Two-thirds die from conditions amenable to palliative care, yet receive it half as often as people without SMI. Reliance on unplanned/crisis care results in persistent distress and ineffective resource expenditure. Question Can relationship (shared understanding about meaningful resource use and willingness to change through genuine exchange)1 drive systemic change for people living with SMI and advanced incurable physical illness? Methods 1. Socioculturally-orientated ethnography (London, n=154, hospital and community settings). 2. Eight innovative system case studies examining integrated care, special population provisions, relational design, delivery, and evaluation (Churchill Fellowship, USA, Canada, Australia). 3. Qualitative integration identifying drivers for equitable, inclusive high-quality care. Results Service users and providers expressed frustration at system conflation of uncertainty, risk and harm with misattribution of structural problems to individual failings. Overspecified service criteria undermined care, creating additional low-value work. Patients equated inclusivity with meaningful choices, balancing dignity of risk with duty of care. To achieve this, collective social safety (safety in relationship, regardless of circumstances) was essential. Professional workarounds, including risk-taking, addressed systemic gaps, but they concealed successes due to system mistrust. Case analyses identified seven relational drivers of systemic change: 1. Reframing risk through better decision-making; 2. Enabling ‘doing the right thing’ by strategically embedding relational work, coordination and interdependence; 3. Reimagining structures as porous containers to facilitate preapproved boundary-crossing; 4. Expanding workforce mix and mobility; 5. Co-designing special provisions alongside mainstream integration; 6. Narrative evaluation/reward of relationship producing good outcomes, with learning from new positive deviances. 7. Addressing upstream structural vulnerabilities. Conclusions People living with SMI represent a sentinel case for relationship-based redesign to improve outcomes and experiences, enhance resource stewardship and advance social justice. Collaborators are invited to drive change evidenced by inclusive research and practice-based partnerships. Reference Jay D. Relationality: how moving from transactional to transformational relationships can reshape our lonely world. USA, North Atlantic Books, 2024

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