Values and leadership (2024)

In the face of bureaucratic change and low staff morale, what can medical institutions learn from the commercial sector? Using their experience in working closely with both medical and commercial organisations, the authors consider the role of values and what leaders in the medical world need to do to put values into practice

Values are deeply held views that act as guiding principles for individuals and organisations. When they are declared and followed they are the basis of trust. When they are left unstated they are inferred from observable behaviour. When they are stated and not followed trust is broken. In this paper we explore the place of values in two contexts: values that underpin the work of “good doctors” and values that define what medical organisations stand for. For the past 20 years we have worked closely with medical organisations and commercial organisations; we will draw from both worlds in considering the impact of values on an organisation's performance and on its members.

Values in the commercial world

Values have recently become more prominent in the commercial world. Research in business organisations is notoriously poor, because it often uses little other than correlational evidence, without any controls or attempts to establish causality. Nevertheless, several studies over the past decade have indicated how powerful an organisation's values can be in improving its performance. Three such studies are worth considering here.

Waterman studied nine companies that satisfied three criteria.¹ They had to have a statement of their company values; to have mechanisms in place to ensure that they put the values into practice; and to have been in existence for more than 25 years. The share price of these nine companies had outperformed that of the Dow Jones industrial average by 350%.

Collins and Porras analysed why a number of companies had outperformed their competitors over many years.² They considered several possibilities but showed that the companies that were successful in the long term were strongly oriented to values. They had a strongly ethical culture that supported predetermined and declared values. The authors also pointed out that to have a beneficial effect a company's values had to be discovered rather than created. No “designer” values would do; values had to be real and credible. They had to be embodied in the very fabric of the organisation—in its systems, processes, practices, and rewards, not just in its annual report or on wallet cards carried by the company's officers.

O'Reilly and Pfeffer compared the performance of eight companies that had superior results in their sector with the performance of similar companies, matched on size and industry sector.³ The more successful companies had an approach to leadership that was based on values. As the authors put it, “The most visible characteristics that differentiate the companies we have described from others are their values and the fact that the values come first, even before stock price.” Their values acted as guiding principles that helped them make crucial and difficult decisions.

Cynics may scoff at commercial organisations that purport to focus so strongly on values, but the organisations cited by O'Reilly and Pfeffer align all their internal processes with their values—from recruitment to induction, to reward and recognition, and to the regular tracking of their culture and credibility.³ Indeed, the authors emphasise that you do not get partial benefit from partial alignment. Alignment acts exponentially, not arithmetically, so these organisations devote much time to its pursuit. They do not seek to prioritise their values: they aim to function in such a way that all their values are shown, and they work hard to resolve clashes of values. In this way they build trust, motivation, and commitment.

Values in the healthcare world

The twin themes in medical care are science and caring, as encapsulated by the motto of the Royal College of General Practitioners (“Cum scientia caritas”). The rigorous pursuit of knowledge, skills, and research excellence is valued alongside the essential humanity of the medical practitioner who responds to need with care and compassion.

Medical bodies are perfused with values, yet they tend to emphasise their standards. Standards and values are similar in many ways. Both are most powerful when they are declared. Both act as guiding principles. Values state what is important; standards state what is good or acceptable. Values tend not to vary, whereas standards—both the current standards that have been achieved and what is regarded as acceptable standards—may well vary.

Crucially, values are inextricable from vision. For an organisation to be well led, it needs a big idea to define its purpose. Its values must be clearly articulated—thus it states unambiguously what it stands for and the guiding principles it will use in making decisions and governing its affairs. It may even be that it is more important for an organisation to know what it stands for than where it is going, as the former will not change whereas the latter will change regularly in response to the issues of the day.⁴

Which healthcare organisations and professional bodies have stated their vision and values? The values of many healthcare organisations are like the British constitution: found in many places rather than drawn together. Some statements relate to values of the medical practitioner that need to be promoted, such as the principles set out by the General Medical Council (box ​(boxB2)B2) and the Royal College of General Practitioners (box ​(boxB3B3).^5,6 It is harder to find statements of the values of institutions themselves. In the US Declaration of Independence of 1776 the truths that were held to be self evident were still drawn together and clearly articulated. If we are to release the potential motivating power of the vision and values in action, it may be time to articulate the values of our organisations more explicitly.

Why do we need to be concerned with values now?

There are two major reasons for us to concern ourselves with values now. The first is overwhelmingly positive. When we search our experiences to find examples of medical care at its best, we will discover tales of values in action. We will see care, expertise, insight, communication, and extraordinary effort. Espousing and serving values such as these dignifies both the doctor and the patient. These examples form a contrast to the second reason, which is negative.

Over the past few years we have seen a dramatic decline in morale and motivation among providers of health care. A recent survey of general practitioners by the British Medical Association showed that the current shortage of general practitioners was set to worsen, as 40% of the youngest doctors wanted to reduce their hours of work in the next five years and most doctors in their 20s intended to retire early.⁷ More depressing, however, was that two thirds of the respondents said that morale was low or very low, and a similar proportion said that morale was currently lower than it had been five years ago. Nearly half would not recommend general practice to an undergraduate or junior doctor. More than 80% found that work related stress was excessive, and 20% found it unmanageable.

The situation is not confined to general practice. “Morale is at an all time low” has become almost an annual evaluation of today's NHS. Resource constraints are often cited as the main reason. What is less often recognised is that doctors have been increasingly forced to work in ways that interfere with—even compromise—the values they hold most dear. This alone causes great distress, since our core values are touchstones by which we live and work. They do not change simply because new government directives tell us to do things differently.

Most doctors have entered medicine to care for patients. Their values are concerned with maintaining high standards of care—with doing the best for the patient without the constraints of waiting list targets or balance sheets. They perceive that managers of healthcare organisations may have a different agenda—a difference that is referred to as an “ethos gap” and that is often at the root of conflict between managers and clinicians or indeed within healthcare teams.⁸ When team relationships work well and morale is high, it is often because the team members share similar values; and these, in turn, are invariably modelled right at the top of the organisation—through the leadership.

At times of great change or stress, people and institutions often revisit their core values. This may be why we have seen a resurgence of publications about professional values in the past three years. One of the most powerful was Clever's “call to renew”—a plea to try to “restore the enthusiasm and resilience of early years.”⁹ She identifies several key touchstones: excellence, kindness, integrity, and loving relationships.

Earlier this year Jones wrote of the decline of altruism and the erosion of open and honest dialogue between doctors and patients as medicine “has become more complex, fragmented, episodic, and impersonal.”¹⁰ He suggested that the conditions that encourage clinicians to stay in their posts are not dissimilar to those that are needed for the development of altruistic behaviours. Employers ignore such professional and clinical values at their peril. If doctors and nurses can no longer exercise altruism and other deeply held professional values they will neither join nor stay in their profession. The increasing difficulty in recruiting general practitioners, for example, is testament to this, as doctors are less willing to subjugate their family values to the demands of work. Similar concerns about an increasing “deprofessionalisation” of medicine have been eloquently expressed by Pereira Gray, raising yet again the profile of this area of debate.¹¹

The physician charter

One of the most significant restatements of professionalism is the physician charter (box ​(boxB4),B4), a joint publication between the United States and Europe declaring a set of commitments that underpin professional relationships between doctor, patient and public.¹² The challenge posed by the charter is “to live by these precepts and to resist efforts to impose a corporate mentality on a profession of service to others.” A similar clarion call is issued by Marshall and Roland in response to the new general practitioner contract: “If we can respond to the challenges of the new contract without losing our core values then we will be providing primary care that will truly be the envy of the world.”¹³

The values of medical practitioners clearly have an impact on their work and motivation. They know what the values stand for and how they apply to their professional lives. They may be less clear about what their professional organisations stand for. This poses a major challenge to the leadership in medical care.

The leadership challenge

Leadership begins by defining a purpose: a compelling future that we are all trying to create and the values that will guide our actions along the way. Leadership re-examines the procedures that organisations follow and ensures that these procedures fully reflect the organisation's vision and values—that they prepare it for its future challenges, rather than merely reflect its former glories. On these bases it builds an aligned community of likeminded and committed individuals who encourage one another towards their aims. Leadership inspires and then focuses effort so that motivation is not dissipated wastefully. Leaders help organisations to articulate their values and make the tough choices needed to put the values into practice.

The medical professions and their professional bodies have a proud and outstanding history, reflected in their traditions and standards. They are currently experiencing a crisis of confidence and uncertainty. One response in these circ*mstances would be to seek to recreate the past, re-establishing their former status and approaches. Another would be to redefine their purpose, vision, and values, involving their members in defining their future and the guiding principles that they will use in its pursuit. In our view, the latter is the preferred course of action.

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