What are the many NHS provider mission, vision, and values statements for?
Dr Nadeem Moghal
Doctor - Pastist - Essayist & Pamphleteer - CMIO - Director - Advisor - Coach - Mentor - Consigliere ??
Someone somewhere is celebrating 25 years of consistent NHS logo rules-based branding, detailing the font, letter ratios, and colours allowed.
From the NHSE branding page:
Our research shows that the NHS logo is instantly recognised and evokes positive, rational, and emotional associations of trust, confidence, security, and a sense of dependability. Therefore, its position as one of the most cherished and recognised brands in England needs to be maintained and protected.
The NHS is the only game in town for over ninety percent of the population, so the logo being able to evoke those adjectives and emotions must be true (1).
At the same time, public satisfaction with the NHS has dropped from a high of 70% in 2010 to a record low of 24% in 2023 (2). In 2024, about ten million patients will be in NHS queues waiting, waiting, waiting (3). The reasons why are self evident but the population might be better off believing all that the Ministry of Plenty reports (4).
This essay questions why, despite the one NHS brand, we have hundreds of unique aspirational mission, vision, and value (MVV) statements set out by every NHS provider—statements that must now have less and less currency.
Why do Boards feel the need for the MVV, and to what purpose? What do they mean, especially now that the providers are trying to become collaborative systems?
NHS MVV statements can be found on websites in the “about us” section, in glossy annual reports, on posters staring at you as you wait in the emergency department, on headed paper, email signatures and maybe even on corporate mugs that once existed during the years of plenty. Some, if not all, of these statements will have been the result of earnest and meaningful Board soul searching away days and, of course, earnest engagement with the workers. As any comms department will admit, getting high single digit engagement is a win…
As always, how all this started is lost in time—it will have been a Board trying to define its purpose, and like the patient story that is now a ritual at Boards (5), it spread like a rash.
Research, of sorts
There is no worthwhile research on the value of MVVs in healthcare. In classic corporate research, a retrospective review of success is proof of something - Good to Great, to not so great now...(6). Remember Enron, whose set of values clearly proves that actions matter more than words (7).
There is a paper (8) that describes a tabletop exercise reviewing the MVVs of the top five hospitals in the world - all in North America, of course. To save time, let’s rush to the conclusion:
The top five hospitals in the world have several common valuable cultures in their missions, visions, and values, regardless of the properties of the hospitals or their management models. In addition, each hospital also has some enlightening descriptions that reflect their particularities.
The authors go on and say something about MVVs generating hope and saying, without any evidence or data triangulation, that the MVVs are, in effect, why the top five hospitals in the world are the top five. On that basis alone, every provider in the NHS should be world-beating.
Common purpose
What is the primary purpose of a healthcare provider? To adapt a phrase, “To provide healthcare, stupid.” Who provides that healthcare? “The staff, stupid.” Do the staff need mission, vision, and values statements to remind them why they do what they do, why they come to work, and why they exist? Perhaps. After all, there seem to be enough examples of troubled individuals, teams and organisations that MVVs would serve to remind everyone why they come into the buildings. The Ministry of Truth archive has, somewhere, the Mid Staffs MVV before the scandal broke.
Collecting the MVVs across all the Trusts and filtering them through a word cloud application ten years ago surfaced the dominant words: patients, quality, services, care, staff, health, best. Today the words innovation, partnership, collaboration, and inequalities will likely dominate.
When you read MVVs, either your eyes glaze over as you lose the will to live, or they roll up as you question if these imploring, aspiring statements really inspire and motivate the workers, draw patients away from neighbouring, formerly competitive providers, and give meaning to the organisation. Some are so aspiring, even the United Nations would be proud of the ambition.
Like regimes trying to get the people aligned to a common purpose, perhaps the MVV is an instrument of subconscious indoctrination. If you see the words everywhere, on posters and even as Trust wallpaper in corridors and stairwells, you will eventually believe and succumb to the beliefs that define the building you enter every day.
No harm trying, especially when part of the CQC special measures escape strategy - a Trust refreshing the MVV at a cost just north of ￡3m. Wallpaper isn't cheap but what price to lift the people, and tick a regulator box.
There can not be a Trust, desperately trying to escape the grip of CQC, that hasn’t created easy-to-digest scripts, including MVV cards to slip into the back of the identity badges to help staff answer CQC inspector vivas in corridors - do you know your Trust values? When the quality regulator believes the MVV contributes to the quality of care, then the MVVs are here forever, deepening the indoctrination (9).
What price escaping CQC?
Community and Culture
One not unreasonable explanation for every NHS provider having its own MVV is the need, at least from a leadership perspective, for an artefact that symbolises the idea of a community - the organisation and its people - and hoped-for culture. The MVV is the artefact that connects the thousands of people that come into the buildings, each with their own values, to do the work, to try and meet the needs of the sick and vulnerable.
Despite the idea of one NHS with its one brand across the land, there are hundreds of providers, each with its own history, culture, and connections with the neighbouring landscape and people—employing locally. This variation alone must explain the variation in MVVs across the NHS, even if only a few miles apart.
Take this example from a Trust:
Our mission is to inspire hope and provide unparalleled care for the people and communities of [place name], helping them enjoy life to the fullest.
Sixteen miles away, there is this from a neigbouring Trust:
Our mission is to work in partnership to provide high-quality, affordable integrated services. We provide safe, effective and personal care to our patients.
Then there is this, from a large hospital chain:
Our vision is to be a high-performing group of NHS hospitals, renowned for excellence and innovation, and providing safe and compassionate care to our patients in [place name] and beyond. We are now striving towards becoming an outstanding group of hospitals.
Which is trying to consume another Trust 13 miles away, albeit reluctantly which says this:
To provide the very best care to our patients, we also work closely with our health and social care partners so that together, as one healthcare system, we work as efficiently and effectively as possible for the communities we serve.
The same Trust also says this:
The Trust is committed to working closely with its partners in the community to place patients’ needs at the centre of its services. The Trust’s primary aim is to provide the right care, in the right place and at the right time to the highest standards.
Fine words that are more honestly expressed in the comments section of the Health Service Journal where the failing arranged marriage has revealed the realities of the weakness of the brand, the presumption of trust among consultant colleagues, and the spiky bumps towards collaboration. DM for details…
Then there is the acronym effort. It must be the job of comms departments to make the MVV memorable. Even if the acronym is a stretch (10).
You get the drift, literally.
Needs
Despite the contorted, overlapping blurring MVV statements, every one of these healthcare providers surely has only one primary reason to exist:
To meet patient and population needs delivered by people who care.
What is missing in this statement - marketing fodder — excellent, the best, cutting edge, high quality, innovative, safe - Who doesn’t want to be all those things?
Needs matter. Implicit in meeting needs is the idea of understanding those needs that are not just about the broken hip, the daily grind of dialysis, or living with heart failure, or surviving cancer. Also implicit in the idea of needs is the idea of reliable systems of care that, as an outcome, can tick the quality domains - more on that another day.
Staff needs matter too. Instead of trying to instil values into staff, might the organisation be better placed to invest in understanding and meeting staff needs - needs that directly impact on delivering the staff skills to get the best outcomes for the patients.
Is it necessary to be explicit about healthcare being delivered by caring people? Surely staff all come to work to deliver care, and caring is what all healthcare workers do. Perhaps. But we know from a sea of incidents, serious incidents, never events complaints, litigation, seemingly failed and failing trusts, investigative journalism, hidden cameras, patient feedback tools, and type B monsters (11), that we cannot assume that caring is part of the DNA of all those who enter the healthcare workforce.
If “Meeting patient and population needs, delivered by people who care” is what defines the why and the how for a healthcare provider, how can any individual provider possibly differentiate itself from its neighbouring Trust in an NHS that, despite efforts to use competition to encourage choice and raise quality, is still all about the local service first. Does the mission, vision, and values statement draw a patient into an organisation for that cure or relief of suffering? Do the statements indicate how a general practitioner is going to decide the best service for the patient? Are the mission, vision, and values statement the basis of healthcare consumer choice?
The consumer is surely more interested in how good the organisation is at healthcare. It cannot be the CQC rating akin to the out of 5 restaurant hygiene rating, which tells the consumer nothing about how good the chefs are at the one thing the regulator does not test - meeting needs, delivering clinical outcomes to evidenced standards. We all want to be the best. Best at what?
Leaders’ needs Community needs
When the provider CEO changes, the urge to refresh MVVs can sometimes be overwhelming. Is the new leadership seeking to make a mark, to be different, better? Have the staff shifted in their purpose, and so a re-alignment is needed? There should be an emoji here, but you get the drift again.
Perhaps it really is about the modern day community - which no longer exists as they did pre-industrial age. Today, the factory, the building, and the work become a community, and leaders use the tools of a community of a bygone age to bring together people and employees to work together to deliver a purpose, build a culture, and meet a need.
A straw poll of nurses, doctors, and healthcare assistants confirms that no one can begin to recall even a fraction of these statements because they have no obvious meaning or value for them - they are busy doing the work. Except when someone’s conduct becomes a problem - the conduct gets described against a value statement or even the acronym - That goes against our PRIDE values… ammunition when used in a corridor for all to hear. Perhaps there is at least that value, assuming that encounter leads to behaviour change.
If the leaders are serious about the idea of building a community in the building, then they might want to invest in an anthropologist to build the elements that define a community.
Becoming a system
It gets complicated now. All the providers in a system have to collaborate and behave as one: provider collaboratives, integrated care boards, integrated care systems… They have done the jumpers and sandals love-in bit. The CCG desks and chairs have been rearranged. They have even established their very own vision and values. The hard work of collaboration and agreeing the tough decisions has barely started.
Does that mean each Trust will abandon its very own MVV and fold into the one system MVV? Would anyone notice?
How about this as a common mission that every provider could use:
The NHS belongs to the people.
It is there to improve our health and well-being, supporting us to stay mentally and physically well, get better when we are ill, and, when we cannot fully recover, stay as well as we can to the end of our lives. It works at the limits of science, bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need when care and compassion are what matter most.
The NHS is founded on a common set of principles and values that bind together the communities and people it serves – patients and the public – and the staff who work for it.
The text above - the introduction to the NHS England Constitution (12). It even has a set of values listed:
Working together for patients
Respect and dignity
Commitment to quality of care
Compassion
Improving lives
Everyone counts
Imagine if in line with the one NHS brand thing, every provider used the NHS constitution to fill the MVV space. One brand. Would anyone notice?
The vision (the organising principle) could be - to meet the needs of the patient and population provided by people who care. If we are to take the ideas of integration and system seriously, then the organising principle could include something like - optimising the life chances… (13). Because we know that the growing health inequalities dominating demand are not in the gift the NHS to fix, in any shape or form (14) - that will take meaningful partnerships beyond health provider organisations.
One day, the “about us” section of a Trust or even ICB website might be less about statements of mission, vision, and values and more up front about the data that show whether the clinical outcomes and needs are being met, revealing the reliability and therefore the quality of the systems of care that the healthcare provider and system exists to deliver; consumer choice made real, one day driving providers to meet needs.
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Dr Nadeem Moghal
Your friendly neighbourhood contrarian
April 2024
Note
References
2. Public satisfaction
3. Waiting waiting waiting
4. 1984
5. Patient stories
6. Good to great to gone
7. Enron
8. Top 5 hospitals
9. CQC and values
10. ExCEL
11. Sex, lies and the intentionally difficult doctor
12. NHS Constitution
13. Alder Hey organising principle
14. Inequalities
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I help leaders and organisations transform their relationship with anxiety.
11 个月Nice article Nadeem! I noticed that the mission statements of Trusts you provided are somewhat disconnected from the text taken from the intro of the NHS England constitution...In that the mission of the Trusts' focus on the activity of providing high quality health care, and the constitution of the NHS focuses on the outcome of improving health and wellbeing. These might not be the same thing, high quality activities may not result in improvements in health. And this might be connected to why there's never enough funding for the NHS, as the system is focussing on treating an endless supply of sickness and not enabling people and communities to be healthy? I accept that what the NHS does is provide healthcare and that doesn't mean we will get healthier as a result.
Author of How to Climb a 12 Foot Wall, Motivational Speaker, PhD Student, Company Secretary
11 个月Nadeem, I really think you are onto something here, while the Army has a vast array of different organisations (cap badges) there is only one set of Army values that bind us all together!