What Are Mission, Vision, and Values Statements For?

VIEWS AND REVIEWS

“Once doctors understood that medicine was more opinion than science, so were tolerant, supportive, and respectful of differing perspectives” Des Spence, p 49 PERSONAL VIEW Nadeem Moghal What are mission, vision, and values statements for?

ealthcare organisations, probably Despite these contorted and often duplicated Delegating inspiring leadership to the world over but certainly in the statements, every one of these organisations mission, vision, and values statements UK, have aped corporate behaviour surely has only one primary reason to exist: to is not inspiring leadership. It isn’t any in other sectors in establishing state- prevent illness, cure disease, and relieve suffering, kind of leadership ments of mission, vision, and values delivered by reliable systems of care, and delivered Hthat purport to describe why they exist and set by people who care. What is missing in this state- commissioning group is going to make a deci- aspirational direction. Their statements can be ment are marketing fodder words—“excellent,” sion for the patient? Even if we get into a genuine found on websites in the “about us” section, in “the best,” “cutting edge.” What is in this state- competitive market, are the mission, vision, and glossy annual reports, on posters staring at you as ment is the word “reliable”—that is, a system in values statements the basis of consumer choice? you wait in the emergency department, which the patient sees the right person at The consumer is surely more interested in, we on headed paper, and maybe even on the right time in the right place for the right are repeatedly reminded, how good the organi- corporate mugs. Some if not all of care; an operational definition that can sation is based on outcome data. We all want to these statements will have been be used to measure system reliability, be the best. But how good are we now? And are the result of earnest and meaning- and it comes with a number. we improving? ful executive and non-executive More critically, a reliable sys- If the staff delivering the work on the ground soul searching on away days. tem, by definition, delivers qual- know why they do what they do, and the users of What is the primary ity care. “Reliable” assumes an healthcare services continue to access the near- purpose of a healthcare understanding of its meaning in est and most convenient service rather than most provider? Why does a healthcare so perhaps the state- aspirational, then for whom are these statements healthcare provider exist? ment could read: “To prevent intended? Might they be for those who work in To coin a phrase, “To illness, cure disease, and healthcare organisations not delivering the clini- provide healthcare, relieve suffering, deliv- cal work but managing the organisation at some stupid.” Who provides ered by quality systems distance from where the clinical work is done? Do that healthcare? “The of care, and delivered they, the managers, executives, and board mem- clinicians, stupid.” Do by people who care. A bers, need to define for themselves a purpose for the clinicians need mis- quality system can be their existence? They go on away days to define sion, vision, and values delivered only by a reli- organisational purpose and come back with some statements to remind able operating system.” “groupthink” articulated in a mission statement— them why they do what Is it necessary to be explicit the modern manifestation of the early 20th cen- they do, why they come to about healthcare being deliv- tury factory floor poster, imploring and reminding work, and why they exist? ered by caring people? Surely workers, the people who deliver the purpose of Perhaps. After all, there seem we all come to work to deliver the organisation, to work harder to deliver that to be enough examples of care, and caring is what we do. purpose. Delegating inspiring leadership to mis- troubled services that would be Perhaps. But we know from a sea sion, vision, and values statements is not inspir- served by a mission statement to of data, including complaints, litiga- ing leadership. It isn’t any kind of leadership. remind staff why they are there. tion, seemingly failed and failing trusts, A straw poll of nurses, doctors, and healthcare One region’s mission, vision, and values investigative journalism, and patient feedback assistants confirms that no one can begin to recall statements, filtered through a word cloud appli- tools, that we cannot assume that caring is part even a fraction of these statements, because they cation, which gives visual weight to words in of the DNA of all those who interact with and con- have no obvious meaning or value for them. I proportion to their occurrence, reveals the most tribute to the care of patients. have not been brave enough to test an executive. dominant words to be: “patients,” “quality,” If “To prevent illness, cure disease, and relieve One day the “about us” section of a trust’s website “services,” “care,” “staff,” “health,” and “best” suffering delivered by quality systems of care, and might be less about statements of mission, vision, (above right). If you were to read these state- delivered by people who care” is what defines the and values, and more about the data that show ments either your eyes would glaze over as you why and the how for a healthcare provider, how the clinical and experience outcomes that reveal lost the will to live, or they would roll up as you can any individual provider possibly differenti- the reliability (and therefore the quality) of the wondered if these imploring, aspiring statements ate itself from its neighbouring trust or compet- systems of care that the healthcare provider exists really would inspire and motivate the workers, ing service? Does the mission, vision, and values to deliver, and improve. draw patients away from potential competitors, statement draw a patient into an organisation for Nadeem Moghal is a consultant paediatric nephrologist, and give meaning to the organisation. You would that cure or relief of suffering? Do the statements Newcastle, UK [email protected] recall, I suspect, very little. indicate how a general practitioner or clinical Cite this as: BMJ 2012;344:e4331

BMJ | 30 JUNE 2012 | VOLUME 344 31 VIEWS AND REVIEWS

PERSONAL VIEW Susie Gabbie Lessons from a paediatrician-parent: did I help or hinder in the care of my limping child?

few months ago my bright, active 4 year old started to limp. As a hospital paediatrician, I ignored it and thought he was being melodramatic. After a few weeks, I decided that perhaps Ahe had hurt himself and needed an x ray. So I duly took him to my work, and asked one of our juniors to arrange radiography, which was normal. He limped on for a couple more weeks until one day my medical family noticed that his right ankle was hot and swollen. This was intermittent, and by the time he saw another of my colleagues, it was back to normal. A couple more weeks passed, during which time the ankle was hot and swollen, and he could only hop. We were seen as a favour in orthopaedic outpatients, where the opinion was that this was most likely to be juvenile idiopathic arthritis. Within a week we had

started down the arthritis road, and as a family GREENHILLS/ALAMY had to start adjusting to life with a child with a chronic condition. It’s difficult as a working parent to make time to go to the general practitioner, Magnetic resonance imaging had been when it is easier to just bring your child with you to work arranged, and by the time the slot came round it seemed almost unnecessary because the the general practitioner, when it is easier or process what is happening. I thought diagnosis seemed clear. So it was to our great to just bring your child with you to work. this too, and it contributed to my feelings surprise when I was telephoned to say that our But as a result, when things got confusing, that I had to speed things up, see everyone son had osteomyelitis, not arthritis, and would there was no one person coordinating. And straight away, and not sit at home waiting need surgery straight away. our general practitioner was bombarded for imaging and answers while my child was Since then I have become an unwilling with letters that made no sense, full of in pain. expert at bones, long lines, antibiotics with contradictory diagnoses and plans. What have I learnt? Firstly, everyone bony penetration, and life as a mother of The NHS is often a slow moving beast, needs to give up control eventually. I asked a child who needs frequent hospital visits. with referrals between teams dictated, a colleague to be our paediatrician so she But now that he is finally improving, I sent to India to be typed, approved, posted could advocate for me when things didn’t have time to reflect on my experiences as a internally, and sometimes finding their way make sense or when all the consultants paediatrician and a mother. And I wonder, to the correct person. We were lucky to be involved didn’t agree. Secondly, as a did having a medical parent help or hinder? slotted into clinics quickly, and nothing was working parent with three kids, life is a Most paediatricians fall into two camps too much trouble in terms of arranging for finely tuned balancing act. And it doesn’t with regard to their own children: some us to be seen. But in retrospect, maybe had take much to knock things off balance. The of us are extra neurotic, needing full we waited for the imaging before seeing logistics mean that you have to ask anyone investigation for every last sniffle. But most the rheumatologists, the correct diagnosis and everyone for favours that you might of us fall into the second camp: “It’ll be would have fallen into place without the never be able to repay. better in the morning,” and “he just needs a initial confusion. And finally, I’ve learnt that in the end, bit of paracetamol.” There is no doubt that Diagnostic uncertainty is something the care you get through the NHS is good. I took longer to acknowledge his symptoms that parents have to deal with all the time. It may take persistence and patience, but than an average parent would have. I wish During my spell as a specialist registrar all the staff had our best interests at heart, I had reacted quicker because he must have in paediatric oncology, one of the things and they went out of their way to help get us been in pain, hopping along for months. parents spoke about eloquently was that back on two (non-limping) feet. I didn’t go through my general the most difficult part was the time spent Susie Gabbie is consultant paediatrician, Royal Free practitioner to get referred, so there was no knowing that your child is seriously ill Hospital, London NW3 2QG one holding everything together. It’s difficult but having no idea of the details or a clear [email protected] as a working parent to make time to go to plan of action. You cannot plan, or adapt, Cite this as: BMJ 2012;344:e4392

32 BMJ | 30 JUNE 2012 | VOLUME 344 VIEWS AND REVIEWS

BETWEEN THE LINES Theodore Dalrymple MEDICAL CLASSICS War and development The Seagull A play by Anton Chekhov; first performed, in Russian, in 1896 How many lives have been saved, and Chekhov spent many years as a rural physician (BMJ how many quality adjusted life years 2009;339:b3395), a fact often cited in the examination of his obtained, from the medical advances characters and their country life, and he famously said, “medicine occasioned by war? It would be is my lawful wife, and literature is my mistress.” The Seagull is one obscene, even for a health economist, of a few of Chekhov’s plays to include a doctor. Dr Dorn is a curious to work it out, yet there is little mix of the irascible and the compassionate. Having travelled the doubt that war has occasioned such world and spent many years in practice (and in various amorous advances, especially in traumatology. relationships) he has a somewhat detached air. He is genuine but Plastic surgery in particular, advanced sometimes overly forthright, particularly with his longstanding by the work of Sir Archibald McIndoe friend, Sorin. His assessment of Sorin’s wish to live on long past BETTMANN/CORBIS (1900-60) during the second world Richard Hillary: facial operation 62 is that it is “Foolish. Every life must have an end.” This is brutal, war. One of his patients was Richard and a risky strategy for communication in membership exams, Hillary (1919-43), whose memoir, The become world famous, is portrayed as but most doctors will identify with this conflict between patient Last Enemy, was published in 1942 driven and kind in a bluff way suitable expectation and medical reality. Likewise, his disbelieving response and was instantly recognised as a for servicemen. to Sorin’s request for medical advice (“Treatment! At sixty!”) would minor classic. The book records the author’s probably raise some eyebrows these days. We can perhaps forgive Hillary was a student at Oxford change in attitude to the war, brought him because this patient is also a friend, and the two make for when the war broke out and he joined about in part by his experiences in uncomfortable bedfellows. the air force. He was a fighter pilot hospital. He started out with a brittle, Despite these outbursts, Dorn remains level headed in The with five enemy planes to his credit cynical outlook. He did not join up Seagull’s carefully constructed psychological drama about a closely when he himself was shot down and from any motives of patriotism or to knit group, bound by ties of family, friendship, love, and habit, in a rescued from the sea, badly burned. fight evil. He did so, rather, as a form of provincial Russian village. It is Dorn whom the other characters look He became a patient of McIndoe, who self development. Specifically denying to for support. In the opening act Dorn comforts a passionate and operated extensively on his face. Hillary any other or selfless motive, he told a frustrated playwright. Kostia’s desperation to break free of theatrical was sent to the United States to plead friend: “I am fighting this war because and social convention had met with only the British cause, but in the event his I believe that, in war, one can swiftly puzzlement and dismissal, but Dorn tells him injured appearance was felt more develop all one’s faculties to a degree it that he’s “got talent and must carry on.” likely to arouse antiwar sentiment than would normally take half a lifetime to Sadly Kostia becomes estranged from his to help, and he was allowed only to achieve.” family and friends and distanced from his lover, broadcast over the radio. Despite his The end of the book is almost Nina. Kostia’s mother, a minor celebrity, is too residual injuries, he insisted on a return unbearably moving. On short leave busy with her own vanity and keeping happy to flying, but was soon after killed in an from the hospital, Hillary takes a her younger lover, the famous writer Trigorin, accident. London taxi ride, but because of an air to engage with her son’s decline. In a tortured In the book, he does not present raid, goes for refuge with the driver in a effort at self expression, Kostia kills a seagull himself as the perfectly stoical patient. pub, the George and Dragon. The pub is and presents it to Nina as a gift. Horrified, Nina At one point he curses the whole of bombed, however, as is the house next pulls away and finds herself drawn to Trigorin, the British medical profession for door. As he and the driver emerge from whose whimsical possession, ruin, and rejection of Nina echoes the having made him worse; he insults the the wreckage, a rescue worker says to pointless destruction of the seagull. In the last act, Kostia and Nina Irish nurses who look after him with them, “almost apologetically,” “If you realise they can never be together. devotion. Perhaps he had some reason have nothing very urgent on hand, I In the final scene, everyone is playing cards around the table to be angry with the profession. When wonder if you’d help a bit here. You see when a gunshot rings out. It is, once more, Dorn who rises to calm first rescued, and before he reached it was the house next to you that was hit people. He returns from investigating and reports that a bottle of McIndoe (who was a New Zealander), and there’s someone buried in there.” ether has burst in his medicine chest, then he manoeuvres Trigorin his burns were coated with tannic A little child is pulled out, dead, and to one side and reveals to him that Kostia has shot himself. Dorn’s acid, which formed a hard dark crust then the mother, still alive. Hillary gives importance as a foil is felt throughout the play, but it means that over them and which was thought to her a little brandy from his flask. “Then Dorn is never truly a full protagonist. Like all doctors, Dorn is both allow healing underneath, until it was she started to weep. Quite soundlessly, inside and outside the lives of those around him. His intimacy generally realised that it ­promoted and with no sobbing . . . ‘Thank you, with the other characters is expedited, but also weakened in its infection instead and often ended in sir,’ she said, and took my hand in hers. humanity, by the professional aspect of his perspective. Dorn’s septicaemia. McIndoe, who had not yet And then, looking at me again, she said role reminds us that although we often have ringside seats to our His burns were coated with after a pause, ‘I see they got you too.’” patients’ lives, we ultimately remain spectators. tannic acid, which formed a She dies, and Hillary realises that self Ben O’Leary is a core medical trainee, Whipps Cross University Hospital, development is the least of it. London E11 1NR [email protected] hard dark crust over them and Theodore Dalrymple is a writer and Cite this as: BMJ 2012;344:e4329 which was thought to allow retired doctor bmj.com/archive ̻̻Medical Classics: Ionych by Anton Chekhov (BMJ 2009;339:b3395) healing underneath Cite this as: BMJ 2012;344:e4328

BMJ | 30 JUNE 2012 | VOLUME 344 33 LAST WORDS

FROM THE FRONTLINE Des Spence What happened to the doctor-patient relationship?

An old maxim of general practice despite most contact with patients doctors who share their health beliefs. says that doctors get the patients they being driven by abnormal health Changes in working patterns mean con- deserve, because patients actively seek seeking behaviours, cultural aspects tinuity is broken and doctors are less out like-minded doctors who share their of care, or medically unexplained available and less experienced. Doc- own health beliefs. The health-anxious symptoms—facts lost to the educators. tors’ consultations have been reduced seek health-anxious doctors; both value And the medical model is ever more to some universal unit of medical time, so called thoroughness, and referral, powerful; opinion is usurped by the not a long term relationship of the and refuse to accept any uncertainty. perceived infallibility of so called evi- like-minded. In every consultation, Likewise, some doctors and patients are dence. Despite the glaring weaknesses onscreen pop-ups prompt us to record bound together by a degree of fatalism. and naked commercial interests found blood pressure, weight, screening, and Both are happy to accept risk; happy Once doctors within much research, “you can’t go the rest. Payments provide incentive for not to treat, refer, or investigate. What against the evidence.” The rise of the this intrusion, making refusal difficult. passes as denial to some seems like only understood that superspecialist means absolutism is Everyone is made into a patient; there common sense to others. Once doctors medicine was now the norm not the exception. The is no opt-out clause, no choice. Patients understood that medicine was more more opinion paradox is that medicine is supposedly complain that they are “pushed onto opinion than science, so were tolerant, than science, so more enlightened, but it has never been pills”; captive to constant computer supportive, and respectful of differing were tolerant, more tyrannical, hierarchical, control- generated recall, yet no one listens. Med- perspectives. But this balance is under supportive, led, intolerant, and dogmatic. Working icine shows no respect for any fatalism, threat, with any, even realistic, fatalism and respectful doctors who dissent are cowed because openly scolding patients if they have dif- increasingly deemed unacceptable. of differing failure to comply with the medical ferent health beliefs. This is all set to get Despite modern medicine’s supposed perspectives orthodoxy threatens livelihood and worse, more pervasive, more paternal- so called patient centredness, the medi- registration. Much of modern medicine istic, and less persuasive. Are patients cal model (that all symptoms have a is an intellectual void. really getting the doctors they deserve? pathological cause, to investigate, treat, Twitter The current situation is far worse Des Spence is a general practitioner, Glasgow and cure) is absolutely still the prevail- ̻̻Follow Des Spence on for medically sceptical patients, who [email protected] ing mindset within m­edicine. This is Twitter @des_spence1 are denied the opportunity to consult Cite this as: BMJ 2012;344:e4349

STARTING OUT Kinesh Patel We’re too weak to strike

I don’t like armpits. Unpleasant things. much greater solidarity than doctors, No matter how much we grumble, Especially when they’re not your own. lose? It has got nothing to do with and we do like to grumble, we The result of the recent bus strike in politics or the waning power of the generally like medicine and we like London was human beings foisted trade unions in the 1980s. It was our patients. We do not want them further into each other’s armpits on the for the simple reason that the lights to suffer, even if it means putting tube than normal. This was only the stayed on. Had we been plunged into ourselves at a disadvantage. Weakness beginning. The insurrection of the bus darkness, the dispute would have been is usually presented as a negative drivers is planned to carry on until they settled quickly, and the trades union characteristic, but this sort of weakness get what they want. movement might well look different. is probably something to be proud of, The best phrase I can find to The bottom line is that doctors are and something the bus drivers could describe the doctors’ strike—sorry, day weak. The government knows that we This sort of learn from us. of action—is “damp squib.” Did the do not have it in us to do what it would But that is a fantasy. The government public even notice on 21 June? Strikes really take to make them acquiesce to weakness is is already talking about giving in to the are nasty, aggressive things. If you are our demands: a shutdown of entire probably something bus drivers, with extra money already going to go down this route, there are a general practices and hospitals. When to be proud of made available for them even before few (simple) rules. You have to publicly the other side knows you are weak, the strike took place. Meanwhile, commit to more action should your why would it bother negotiating? resolve against doctors is hardening. grievance not be resolved. Admitting in Unfortunately, we have been made bmj.com/archive Make of that what you will but I would ̻̻Head to Head: Are advance that it is a one off is probably to look silly without any outside help. suggest that you prepare yourself to doctors justified in taking not the best negotiating strategy, nor is The universally negative publicity was industrial action? (BMJ work longer for less. announcing publicly that you are not entirely predictable, and given our 2012;344:e3175, e3242) Kinesh Patel is a junior doctor, London that committed to the cause. intrinsic weakness makes any further ̻̻Helen Jaques’s industrial [email protected] Why did the miners, a group with action inconceivable. action live blog: bit.ly/L7idB5 Cite this as: BMJ 2012;344:e4387

BMJ | 30 JUNE 2012 | VOLUME 344 49