If health secretary Frank Dobson takes Greg Dyke's recently tendered advice in The New NHS Charter - A Different Approach, the Patient's Charter will be replaced by a number of locally determined commitments.1 There will also be a national NHS value statement - which
presupposes that the NHS knows what its values are, or should be. But that is not necessarily so. And Messrs Dyke and Dobson might be surprised if they were to enquire into the values that are perceived to operate in the everyday, local NHS.
Early in 1998, we undertook a feasibility project to try to discover something more about the complex ecology of lived and acted values prevailing in the NHS.2 To do this, we consulted health service users and workers at all levels, throughout England and Wales. Service users were interviewed and asked to share their experiences of the NHS.
Between May and July 1998, seven one-day workshops were held in London and Leeds at which chief executives, nurses, doctors, patients, ward clerks, health authority managers, healthcare assistants and a chaplain were invited to tell a story that encapsulated an important aspect of their experience of the NHS over the last two or three years. We wanted people to come and tell us about events that had had a significant impact on them and their work.
We believed that people would remember incidents or events that had given them particular pleasure or pain. Such key events crystallise ways of thinking and behaving in the NHS, revealing how people make sense and meaning out of their experiences and how they understand their work. In turn, the pleasure or pain emerging in stories would show specifically and particularly individuals' loves, allegiances, hates and aversions.
If we had asked people to talk about their values in abstract terms, we would have received generalised responses. By asking them to tell stories about important experiences, we were able to see something of how values reveal themselves in a complex, varied and shifting way in practice.3
Participants were asked to write down their stories and then present them. There was no set time for the accounts, which took from about 30 seconds to 10 minutes.
Participants quickly understood the few ground rules that were laid down about confidentiality, not interrupting others and responding with further stories rather than comment or analysis.
Most people found it easy to tell at least one story that captured something of significance about their work and context. The storytelling mode was interesting and participative and facilitated respectful communication. It revealed people's perceptions of their own, and others' enacted beliefs and behaviours.
It also prevented more senior or more loquacious staff from dominating proceedings and, equally, limited flights into abstraction, generalisation and pontification. After initial anxieties, most people enjoyed and valued being listened to and listening to others.
Our study produced about 120 narratives. These provide an excellent, if unorthodox, picture of life on the ground in the NHS 50 years after its foundation. On preliminary analysis, several main themes emerged.
Emerging themes
Attitudes
A persistent theme in many stories was the negative or, more accurately, de-personalising nature of relationships between professionals and service users in the NHS. People told stories of trying to change the culture of their organisation to make it more responsive to patients only to be chastised for it. Often men bullied or humiliated women. A number of women told very unpleasant stories about male superiors.
One manager described being summoned to her bosses' office, where he told her off, claiming she had not kept him informed, and banged his fists on the table.
Clearly, many participants adhered to the value of personal respect and were shocked and saddened when it was violated. But they saw it violated frequently in everyday practice as professionals and managers treated individuals and groups of service users like 'frozen peas'. One woman described a 20-year wait for a diagnosis of endometriosis and a hysterectomy. The condition had ruined her marriage, ability to have children and career.
Mismatched expectations
Many people told stories that exposed a difficult, and sometimes tragic, mismatch in expectations between service users and health workers. Often, both groups had high expectations - but they were different. Effective communication and negotiation to arrive at mutual, realistic expectations never occurred. Disillusionment and even formal complaints resulted. The values affirmed here, often in their absence, are those of mutual communication, understanding and appreciation between service users and professionals.
Disparity in care
Many of the stories reflected disparities and inequalities of care and provision in different parts of the country and in all aspects of service. The value that was reflected here was that of the need for some kind of justice and equality. People felt this value was often honoured more in the breach than in the observance and it made them uncomfortable.
Working the system
What emerged from many stories both from service users and professionals was the sheer courage and determination that is needed to get what one wants out of the NHS. Often, individuals had to go to heroic lengths to work the system and get what they wanted for themselves, their families, their patients or their staff. But there were also tales of abuse.
One doctor described a surgeon who contracted personally with the local GP fundholders, undercutting his own service in the hospital by a small amount per patient, and doing no more than the minimum he could get away with in his clinics, thus building up his waiting list. He then gathered all these patients into a bus and took them to a private hospital. He has a waiting list and does the work from his own list privately under the waiting list initiative.
Abuse of power
Many of the stories told by staff reflected a culture of blame and fear in the NHS. People working in the service clearly value an environment in which trust is possible, creative risks can be taken and mistakes can be made without retribution. This is seldom found and easily destroyed where it exists. A nurse recounted how a mistimed injection was dealt with so harshly that the whole staff felt they would not report further errors.
There were many tales of bullying throughout the hierarchy. There was a strong feeling of people being rebuked for things they were doing in good faith to make the situation better. There was a culture of blame and risk aversion, rather than risk management. One participant who worked in hospital administration said she was astonished when a doctor said: 'Thank you, you have done a good job.' It surprised and thrilled her.
Being valued
Perhaps the most prominent theme that emerged in the stories was that of people, particularly staff, not being listened to, recognised and appreciated by colleagues - and especially superiors.
The value espoused here is one of respectful care and attention for others. It does not appear to be much in evidence at any level or in any kind of institution in the NHS. Its absence seems to be demoralising. Furthermore, it leads to lack of self-respect and self-worth among healthcare workers of all kinds.
A nurse described how she was asked by the trust chair to do a presentation to the board for which she prepared overhead projector slides. At the board meeting she found that the projector was in the middle of the room and needed to be moved if she was to use her OHPs. No one budged, and when she indicated she needed to move the projector still nobody moved. She could feel everyone getting annoyed with her, so she made her presentation without the OHPs. After her presentation a doctor came in - with his own OHPs - and immediately the chair and chief executive moved so he could use the projector. 'I just remember feeling so mortified,' said the nurse.
There was a sense of everyday life as a process of attrition. One of the workshops was held the day after the NHS's 50th anniversary. But nobody seemed very celebratory. There was a sense of being up against it, and not a lot of laughter.
Service users and workers in the NHS have strongly held value preferences to which they are personally deeply committed. It seems significant that many of the things people most valued were things they could not see or felt unable to enact in practice. Indeed, some were aware of enacting values contrary to their own deeply held convictions in their work.
People seemed capable of holding and enacting contradictory or competing values in their practice. Living with value tensions is, it seems, very much part of working in and using the NHS. This dissonance is undoubtedly uncomfortable.
The themes that came out of the stories were presented in a short drama during the 'Living values in the NHS' conference held in London in October. Those present included workshop participants, service users, professionals and managers. We were both sorry and relieved that participants recognised the stories all too clearly.
A number of points and implications arise from our study. There is much scope for better understanding the value ecology of the NHS at all levels - especially, perhaps, at the level of everyday service delivery.
The use of narrative seems a promising way of exploring the subjective reality of everyday, enacted and espoused values in the NHS. It may be wise to take the prevailing values more fully into account before rather than after producing any national NHS 'value statement'.
It will make no sense to produce a statement that negates the deeply held convictions and behaviours of staff and service users.
It may be sensible to examine the obstacles that prevent workers and service users from realising and acting on the treasured values and aspirations they already have, before promulgating 'official' values that cannot and will not be implemented.
In addition, any national value statement will need to address disparity and inequality in types and quantity of care. This is genuinely distressing for service users and workers alike and cannot be disposed of by devolving responsibility downwards to localities.
REFERENCES
1 Dyke G. The New NHS Charter: a different approach. Department of Health, 1998.
2 Pattison S, Malby B, Manning S. 'What are we here for?' HSJ 1998; 108 (5595): 26-28.
3 Pattison S. 'Questioning values'. Health Care Analysis 1998; 6: 352- 359.
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