Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: When organisations’ behaviours betray their value statements

BMJ 2021; 374 doi: (Published 08 September 2021) Cite this as: BMJ 2021;374:n2164
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

Value statements are intended to list the core principles guiding an organisation and its culture, creating a moral compass for it and its employees.1 Health and social care organisations in the UK all have such statements. The NHS constitution sets out values for the entire NHS workforce and range of services.2

I’m not sure, however, that we always live up to those values or even try to. Too often they’re reduced to lip service and generic platitudes that no one could disagree with as principles.3 If researchers reported a thematic analysis or word cloud they’d identify some recurrent themes in the stated values: “person centred,” “patient centred,” “based on individual needs,” “supporting patients and their families,” “respecting choice, dignity, and priorities,” “inclusive,” “coordinated,” “collaborative,” and “compassionate” might all feature.

We also find—not least in the NHS constitution—expectations and obligations of staff towards the public and patients and our duty of care; but, crucially, reciprocal rights and responsibilities are a two way street, applying to service users and their families. And we see stated values on employers’ responsibilities and behaviour towards staff.

I haven’t conducted any scientific study comparing the rhetoric with the lived reality, but I think we fall well short and often make a mockery of our values. Clearly, support for staff is often lacking. The annual NHS staff survey shows worsening concern about bullying, unsupportive management, and low morale.45 And staff increasingly vote with their feet or scale back commitments over workload, hours, terms, and conditions. Numerous investigations of healthcare organisations have revealed a culture of bullying or poor leadership.

Meanwhile, instances of patients and the public abusing or harassing staff are increasing, whether in real life, in the news, or on social media.6 Formal complaints about care and communication are rising.7 Yet it’s generally frontline staff who find themselves in the complaint resolution or bereavement meeting, the inquest, the media storm, or the courts for problems often outside their gift to solve, rather than the senior managers and system leaders who create the working conditions and workforce gaps.

Most importantly, we’re urged to provide person centred, coordinated care8 that respects patients’ priorities and preferences and puts them before organisational or professional interests, but do we actually do it? Far too often, we base our offer on how organisations like to structure their work and what’s convenient for them. The interests or financial constraints of funders and providers are also factors of influence.

Look no further than the endless arguments about funding for community health and social care for patients who are stranded in hospital, while each organisation tries to avoid cost or responsibility.9 Look at our refusal to respect patients’ or carers’ choices if they decide on an option we don’t want them to choose: staying in hospital while they regain confidence, going to a care home rather than back to their own home, using emergency departments instead of other providers, or preferring to see a doctor face to face, not remotely.1011

Some of those issues require something you’ll also often see in value statements: candour, honesty, and transparency.12 Capacity and resources in services are so constrained that we simply can’t offer the options, access, or timeliness that people would like. So, let’s level with people, even if it’s unpopular.

I’d challenge all readers—myself included—to go back to the organisations or health economies they work in, look at their value statements, look at the NHS constitution, and ask themselves, “Do we even believe in what we’ve signed up to? How much of this do we really live up to in practice? And how could we get a bit closer to delivering on it?”



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