Values in the NHS.

Abstract

The NHS is going through one of its splitting phases, with an increasingly large number of small organizations containing many people new to the health service, or indeed health services, in charge. In addition, the prospect of local authority Overview and Scrutiny Committees auditing the work of the health groups and the combining of health and social work services under the umbrellas of children’s and elderly people’s trusts will make it increasingly difficult to know where the NHS begins and local authorities end. This is therefore an important time to check on what are the agreed core values of our services. The government obviously believes 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. 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’. 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 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 suggested four core values for the development of management in the NHS: