Values and the NHS
Friday, August 22, 2008 at 04:10PM 
Recently there’s been a lot of talk in the NHS about values, especially the need for more compassion and respect for patients. This has reminded me of a period when, working for a US not for profit healthcare system, I helped lead a values strengthening initiative.
The most interesting thing about the work was that, after a lot of discussion, senior executives were persuaded that it was no point espousing a set of organisational values that didn’t resonate with the core personal values held by the 12,000 staff. In the end we asked staff what their personal values were and ended up adopting these, wholesale, without any adjustment. After all the organisation is who it employs! The core values staff articulated turned out to be Compassion, Dignity, Integrity and Service. Quite a set and much more powerful than the usual ragbag of 'values' often concocted by management teams acting alone.
The second most interesting thing, to me at least, was the relationship senior executives began to see between Values, Vision and Mission. Typically most organisations still see the relationship in this order (first Mission then Vision then Values). In this model values don’t influence the strategic decisions (these are taken for ‘business’ reasons alone). Instead they influence how an organization behaves once key strategic decisions have been taken. An alternative view that started to become dominant in the US not for profit I worked saw Mission first, then Values then Vision. Here strategic choices are not seen as solely or even largely determined by the operating environment. Instead decisions about what organisational direction to pursue are heavily influenced by an explicit consideration of core values and the need to be as congruent as possible with them.In other words core values influence the what as well as the how.
So what? The NHS has always been values led I hear you say. Perhaps it has, at an unconscious level, but looking around at local PCTs and Trusts, I don’t see a lot of explicit discussion about values and the influence they might have on strategic decision making, but then again, maybe that’s not necessary when managers and clinicians are intrinsically values led?
What do you think?
Reader Comments (4)
I would be interested to know if there were any difference in core values between staff groups.
I am a consultant Neurologist and head up a team within my Trust trying to drive transformational change - we are preparing for our next phase - I would be interested to know if you managed to get a random slection of responses and whether the docs were different?
Steve
Thanks for the questions.
The core values were identified via a series of focus groups, rather than a representative sample survey. It was a long time ago now but I think we had about 30 focus groups with 10 people in each one. Docs were involved but, as you probably know, in the States docs are not generally employees of hospitals. In the system I worked for docs all worked for their own groups and had accreditation rights to practice in the facilities owned by the not for profit employer. For that reason most attention was focused on the nurses and AHPs and support staff. These are the people in that system who spend most time with the patients and 'represent' the delivery system.
We didn't notice any real difference in espoused core values between different staff groups but this was perhaps due to the more consensual nature of how the focus groups were run. Later, about 20 high and low 'anchor' behaviours were agreed for each core value and we did do some statistical analysis of these, in terms of which behaviours were thought to be most important, but I don't remember whether this data was 'cut' by staff group.
When using the values I do distinctly remember that managers were more attracted to integrity and service (often trying to reinterpret the service value in terms of striving to continuously improve quality rather than it's original meaning which was more in terms of being a servant to others), whilst clinicians were more attracted to compassion and dignity.
Consequently a lot of the values 'strengthening' work was directed to helping managers think about what compassion and dignity might mean in a managerial context - to try and close the gap between the managerial and clinical domains in the organisation.
Happy to chat. My phone number is in the About Me section.
Steve
Thank you for this very interesting post.
Your experience at the U.S. not for profit system coincides with mine as director of the ethics program at Harvard Pilgrim Health Care, a not for profit health insurance company in Massachusetts, New Hampshire and Maine. Eight years ago our ethics committee debated whether to adopt an explicit code of ethics. We looked at several examples from the outside. The committee, which includes physicians from the insurance network, consumers, employers who purchase insurance for their employees, and public policy types, as well as Harvard Pilgrim staff, concluded that its own "ground up" process was preferable.
Even though there were no major substantive disagreements with the content of the codes, the perspectives that emerged from the committee's case-based discussions, which drew on the values of the participants and Harvard Pilgrim's brief mission and vision statements, felt much more relevant and alive.
Your question about the relationship between values and strategy at PCTs and Trusts is fascinating. I'm not at all up to date about local activities in the NHS, but at Harvard Pilgrim our answer to your question is that while we count on the organization's leaders to be consider core values and give them weight, consultation about complex values questions can be very useful, just as consultation about finance and law can be useful.
Our ethics committee has no bureaucratic power or "must approve" role. It only considers issues brought to it by the responsible manager in the organization. But in the 12 years of its existence the organization has used it as the founders of the program hoped - to explore complex issues of values in an open, transparent manner.
Best
Jim
I note with interest your discussion about the interplay between Mission, Vision and Values. In the consulting work that I do with organisations, I've found it helpful to look at the notion of being purposeful, embracing all three of these aspects and also Strategy, Roles Actions & Goals. I suggest that the most helpful way of considering the interplay is that there is a logical link between the Misision to the Vision, to the Strategy to the Roles, Actions and Goals of individuals which establishes what needs to be done on a daily basis and for the Values to influence all of these. In this way what needs to be done on a daily basis can always be considered against the acceptable behaviours that will be derived from the core Values. I'm at present using this framework in guiding the restructuring of a large Adult Services Departmnent that works closely with a large Trust and the Trust's staff are seeing increasing clarity and values driven efficiency from their local authority colleagues
Hope that helps