Is there a need to spell out the fundamental values underpinning the NHS? Would it help to tell people what these principles are, and explain why not all of them can be given equal priority?
A report to be published today at a conference run by the Institute for Public Policy Research and the King's Fund on the future of healthcare argues that such a move is now essential, and that it is the job of ministers to do it.
There is, it says, 'a growing sense of unease' that the NHS is losing touch with its values as the private sector encroaches on its territory.
The report, drawn up by independent policy analyst Bill New for the IPPR's policy forum on the future of healthcare, delves through official documents of the 1940s and 1980s in a bid to pin down the values that drive the NHS.
It draws out eight 'high-level' values presented to the service over time which, it says, constitute its 'moral basis' (see box).
But it also acknowledges that such values will often conflict with each other. The job of ministers and the NHS Executive, it says, is to explain to the public how it is that those taking decisions in the health service 'juggle' these differing priorities. HSJ asked a range of opinion formers for their views.
Nigel Edwards, policy director, NHS Confederation
'Managers and clinicians already work to a set of more or less explicit values in their everyday decision making. But at the moment, policy documents contain a menu of rather vague third- way value, and some clarity would be useful. In that respect, the King's Fund work is useful.
The NHS Confederation, with the NHS Executive, is in the process of developing values that can be used to inform the development of the leadership programme.
This is a relatively uncontroversial use of values. It is much more problematic to try to use values to make trade-off decisions or for priority-setting - you have to know the relative importance of each of the values and have a way of calculating the nature of the trade-off.
For example, recent disputes about hospital closures show that the public may place a much higher value on access for the many than they do on possibly higher-quality outcomes for the few. There are a number of principles that are absent from the list, particularly effectiveness, responsiveness and accessibility, all of which are key elements of this government's health policy, and values that are implicit - and often explicit - in local policy making.'
Claire Perry, chief executive of Bromley health authority and chair of the New Health Network
'This completely reinforces what we have done locally in Bromley on values. We have been very keen to be clear about our decision-making processes with the public, and we developed a schedule that we could make decisions against.
There are too many values and some conflict with each other. Our practical conclusions have been that it is important to be explicit, and that you are never going to live up to all your values.'
David Green, director of the health and welfare unit, Institute of Economic Affairs
'I don't think we should try to devise an explicit statement of values of this kind. We should seek a different balance between the powers of the state and civil society, with the government maintaining the legal framework and a guarantee of access defined by a market test rather than a political judgement.
The thing I reacted to most badly in this was 'universality'. It seems to be making an assumption that universality entails a public sector monopoly. What the IEA has argued over the years, and most people who favour a free society have argued, is that you can have universal access to some agreed, guaranteed standard without having a public monopoly.
The definition of 'efficiency' is a very collectivist view of what the health service is all about. The principal job of the health service is to serve consumers - and they might decide that maximising their health is not their top priority. People choose to smoke, for example.'
Stuart Marples, director- designate, Institute of Health Services Management
'I definitely think it is worth spelling out the values the NHS is based on, and it is always worth re-examining them to make sure they remain relevant to us as we go into the next century.
Seeing a set of values spelled out like this does make you go back and think about what you are doing. I think generally these values feel about right, though I would have liked to see access given a higher profile.'
Andrew Corbett-Nolan, marketing director, Association for Quality in Healthcare
'By and large it is to be welcomed. The NHS really needs underpinning by some values, so as an exercise this is well worthwhile, and there is nothing wrong with putting in a few controversial ones.
If you look at the performance management framework it reflects a lot of these points. But the essential point about the performance management framework is that it is measuring things that are measurable. Some of these things are not. How does the NHS know if it is being accountable - particularly since some of the organisations, such as community health councils, which are supposed to help hold them to account, have been frozen out?
The interesting value is 'health'. It is quite a judgmental definition, but people have the right to make mistakes about their health. The sort of language about persuading people 'of the error of their ways' is a touch Orwellian.' A Good Enough Service: values, trade-offs and the NHS. Institute for Public Policy Research, 30-32 Southampton Street, London WC2E 7RA.£7.50.