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.