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Values in the NHS
In 2003 Alan Milburn, a Labour
health secretary wrote a whole lot of 'motherhood is good' guff. You
may feel I am being hard, but this sort of stuff is rolled out as a
sort of mantra whenever the government wants to show that it is in
charge, by disorganising the NHS again. This phase was a splitting
one; the importance of local flexibility was emphasised, central
control denigrated. This was followed a few years later by a lumping
exercise, where organisations were merged, for better control and to
reduce inequalities. The Tories are presently re-splitting into even
more small local groups than Alan Milburn was proposing.
Interestingly young Miliband
is talking about the latest NHS changes as 'disorganising the NHS',
but the phrase was equally used during
his attempt to change the structure.
But I digress. This is about
values:
Alan Milburn said:
‘What we envisage is a fundamentally different sort of NHS.
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Not a
state run structure but a values based system:
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Where greater diversity and devolution are underpinned by common
standards and a common public service ethos;
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Where treatment is free and provided according to need wherever it
occurs;(1)
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Where patients can make informed choices about their services and
about their care;
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Where we liberate the talents of NHS staff to improve care for NHS
patients.
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Where government no longer runs a nationalised industry but instead
oversees a system of care;
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Where there is greater
diversity of provision and more freedoms for local services to
improve care for patients.
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Where there is a new common purpose shared across health sectors and
a relentless focus on better health outcomes and less inequality;
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Where there is a single national health service – an NHS
of all the talents. One that puts its patients first.’ (2)
‘The values that underpin our social services – the recognition that
we do achieve more together than we ever can alone – are more
relevant today than they have ever been. The problems society faces
today call for modern active social services. It is the means of
delivery – not the values of social services – that need to
change.’ (3)
That, and the present, government
obviously believe that an increased input from local authorities to
the NHS is likely to make the NHS more responsive to the local
population. Curiously, Nye Bevan resisted giving the NHS
reins to local authorities on the grounds of reducing inequalities
between different areas. (4)
Back to values. First we have to decide whose values should shape these services. It
depends on who has the main role in the NHS – the government, the
physicians, nurses, other professionals, the managers who direct it
or the people who use the system and pay for it through taxes or
their elected representatives. All of these
players have ownership of a sort of the NHS.
The government and
boards have financial responsibilities, the service providers and
managers have clinical governance responsibilities and they
earn their living from the work they do. Each of these has some
expertise about how the system works and could work. One may feel
that trying to reach a consensus on the core values between all of
these groups would be an impossible task. It is, however, important
to try.
The Oxford Shorter English Dictionary defines a value as ‘worthy of
esteem for its own sake; that which has intrinsic worth’. A Canadian
task-force, looking at the reorganization of their health service
(it is a very popular game world-wide) have defined values in
relation to health services as ‘relatively stable
cultural propositions about what is deemed to be good or bad by a
society’. (5) They make the point that they are derived from human
experience, and therefore they do change over time.
In the NHS we are constantly dealing with issues that are
value-laden. Programmes relating to effectiveness of treatment,
quality improvement, equal opportunities, patient’s rights and
rationing health care rely on sets of values. Despite Mr Milburn’s
comments in 1992 there is no real statement of the primary values
underlying the structure, policy and work for the NHS or, for that
matter, for parts of it and no feeling of a need to update our
agreed values on a regular basis if we are agreed that they change
over time. Most of Mr Millburn’s statements are not really things
that have ‘intrinsic worth’; indeed, although most of them are
aspirational many of them raise questions about what is meant
exactly.
Then again, are there ‘evidence-based values’ or are values set at a
level above the need for evidence, as in ‘We hold these truths to be
self-evident ...’? Curiously, quite a lot of work on the values
needed to run the
NHS was carried out when Mrs Thatcher was Prime Minister. Thus
Andrew Wall (6) suggested four core values for the development of
management in the NHS:
● justice;
● value for the community;
● value for the individual;
● sense of duty.
David Seedhouse in a book on ethics (7) has suggested a similar four:
● respect persons equally;
● create autonomy;
● respect autonomy;
● serve needs before wants.
Given these core values one is left with the problem of how best to
deliver them and here evidence does play a part. For example, one
strand, which seems run through these and most other approaches to
values, is equality. This is one of the few areas related to values
where there is evidence for how to employ the
particular value. A systematic review (8) showed the characteristics of
successful interventions aimed at reducing inequity. These included
systematic and intensive approaches to delivering effective health
care; improvement in access and prompts to encourage the use of
services; strategies employing a combination
of interventions and those involving a multi-disciplinary approach;
ensuring interventions address the expressed or identified needs of
the target population; and the involvement of peers in the delivery
of interventions. However, these characteristics alone are not
sufficient for success, nor are they universally
necessary.
One reason for the need for values is when priorities have to be
determined for scarce resources. Social values, the values of the
local community, are often ignored. There are different ways to
measure this. Some evaluations include measures of social value when
judging the benefits of treatments. However, there
are many health decisions that can be made only by choices that need
public debate. It is likely that, if the public is really given more
choice in the services it can use, it will tend to prefer those that
are locally provided to those provided further away, as long as they
are equally effective. Social pressures will therefore be biased
towards local care.
If improving health must include the social values and the
priorities the local population puts upon different groups, the
challenge is to involve the public in debating and setting
priorities. One way is to have elected representatives running the
health authority, and I have mentioned that this prospect is
increasingly likely. At the moment, the primary care organizations
have a small proportion of elected members and some lay
people. This is a newly discovered approach to running the NHS in
the United Kingdom and will be interesting to watch.
The most famous experiment asking the community at large to take
part in setting the values for a health service was, of course, in
Oregon. The Oregon State government (9) had a particular problem, for
many of its citizens were uninsured for health care costs. It
decided that it would like to provide a basic package of care for
all of the uninsured population, but could not afford all available
services for everyone. It decided to set priorities for different
types of medical care, based on a set of values.
The following shows the list of ethical values drawn up:
● prevention;
● quality of life;
● cost effectiveness;
● ability to function;
● equity;
● effectiveness of treatment;
● benefits large numbers;
● mental health and chemical dependence;
● personal choice;
● community compassion;
● impact on society (e.g. infectious diseases);
● length of life;
● personal responsibility (lifestyle).
The public supplied these values at community meetings and in
individual phoned interviews. They were grouped into three:
essential to basic health care, of value to society and of value to
the individual.
Prevention and quality of life
appeared in all three groups. Benefits to many, an impact on society
and cost
effectiveness were the three others described as being essential.
Many of these are not strictly values but characteristics of a well
functioning service. There will be trade-offs between one type of
service and another. Values help one to decide which of these should
have priority when the trade-offs occur.
Most readers will be aware of
the enormous political pressure exerted to undermine this process at
the time, although the basic ideas won out in the end. Perhaps the
most salutary lesson from Oregon was that going to the community for
its views is an intensely political act, seen as extremely
threatening by politicians.
Values are different beasts
from effectiveness and efficiency. A shoe factory may decide whether
to make the best shoes or the cheapest ones, or a better compromise
between these two options than other people. The company would
choose to value high quality or cheapness, both laudable aims, but
choosing the one will, to some extent, rule out the other. The
difficulty for the health service is that governments constantly
give the impression that we can make the best possible shoes for
very little and sometimes we are not sure if we are making shoes or,
possibly, socks.
It might be expected that the primary care organizations consulting
the populations they serve and the professionals they use need to
develop a set of values as one of their first priorities.
References
1 This is a curious statement as the NHS has never been free. The
1948 Act stated that those who wilfully broke their glasses or false
teeth would have to pay for replacements – must have been some
party.
2 Speech by Rt. Hon Alan Milburn MP, Secretary of State for Health
to the New Health Network, 14 January 2002. Available at
http://www.doh.gov.uk/speeches/jan2002milburn.htm (24 October 2002,
date accessed).
3 Milburn A. Speech to Directors of Social Services, Cardiff.
Society, Guardian 2. Available at
http://society.guardian.co.uk/conferences/story/0,9744,814824,00.htm
l (24 October 2002, date accessed).
4 Bevan A. In place of fear. London: Quartet Books, 1978.5 Canada
Health Action: building the legacy. Ottawa: National Forum on
Health, 2001.
6 Wall A. Values and the NHS: a briefing paper. London: Institute of
Health Service Managers, 1993.
7 Seedhouse D. Ethics: the heart of health care. London: John Wiley,
1988.
8 Arblaster L, Lambert M, Entwistle V, et al. A systematic review of
the effectiveness of health service interventions aimed at reducing
inequalities in health. J Hlth Serv Res Policy 1996; 1(2): 93–103.
9 Klein R. On the Oregon trail: rationing health care. Br Med J
1991; 302(6767): 1–2.
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26, 2011
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