As with any other set of tools the values toolkit is used in different ways and in different combinations for different purposes. An early example of the toolkit approach was the Oxford Practice Skills Program linking ethics, law and communication skills. A contemporary application of the toolkit is Ann-Marie Slowther’s developing VLE (Values, Law and Ethics) curriculum at Warwick Medical School.
The missing link
Values-based practice with its focus on diversity of individual values and reliance on process (such as skills) helps to link other tools in the toolkit with individual people. This is why the subtitle of Essential Values-based Practice is ‘Clinical Stories Linking Science with People’. The particular link signaled here is with evidence-based medicine – values-based practice links the generalized scientific findings of evidence-based medicine with the unique values of individual people. But the linking role of values-based practice is generic.
As with any other tool there are limitations as well as strengths in the individual-centered approach of values-based practice (See Venkatapuram’s important critique in Debates in Values-based Practice). But within its limitations the link with individual values is important if only because in working with values in healthcare, individual values are often the missing link.
Individual values may be the missing link in
- Front-line clinical practice
- Commissioning of services
- Ethics and law
- Evidence-based practice
We summarize each of these here with pointers to further details elsewhere in the website.
Missing Links in front-line clinical practice
One way in which values-based practice links to individual values is by way of clinical decision-making. Chapter 2 of Essential Values-based Practice illustrates how values-based practice links the general guidance provided by other tools in the values toolkit (ethics, decision analysis and evidence-based medicine in this case) with the particular values of the particular individuals involved in a particular clinical decision.
The decision in question in this story is about the management of low back pain. A General Practitioner, Dr Gulati, finds herself at odds with her patient, Roy Walker, over whether or not his off-work certificate should be renewed. The resources of ethics, decision analysis and evidence-based medicine each provide helpful insights into different aspects of the issue. But they leave Dr Gulati still with the decision about what to do. Values-based practice supports her in finding a short-term holding move, and, in the longer term and through its use within the practice as a whole (described in the concluding chapter 14), resolution.
Fulford, K.W.M., Peile, E., and Carroll, H (2012) ‘It’s my back, Doctor’ Chs 1, 2 and 14, in Fulford, K.W.M., Peile, E., and Carroll, H Essential Values-based Practice: clinical stories linking science with people. Cambridge: Cambridge University Press
A second way in which values-based practice links to individuals is by adding content. Communication skills for example are an essential component (Element 4) of the process of values-based practice. But communication skills have traditionally tended to neglect positive aspects of a patients’ presentation (such as strengths) in favor of negatives (such as concerns and difficulties). Values-based communication skills add positives to the traditional negatives (captured in the acronym ICE- StAR)
Fulford, K.W.M., Peile, E., and Carroll, H (2012) ‘Diabetic control and controllers: nothing without communication.’ Ch 7, pps 83 – 96 in Fulford, K.W.M., Peile, E., and Carroll, H Essential Values-based Practice: clinical stories linking science with people. Cambridge: Cambridge University Press
Yet a third link to individuals in values-based practice is in as it were the opposite direction, ie not to individual patients but to individual clinicians. The focus in much of ethics and law has been on patients’ values. This is important. But in values-based practice ‘clinicians’ values matter too’. This is in part a matter of balanced decision-making (balancing for example individual patient preferences with clinical priorities). It is also because in values-based practice diversity of values among team members contributes to understanding of the diversity of values of individual service users. This is why in values-based practice the extended multidisciplinary team is a key link to person-values-centered care.
Missing Links in Commissioning
The two-way relationship between communication skills and values-based practice – each supporting the other – is a model for its relationship with other tools in the tool kit.
Commissioning of services in health and social care is a case in point. Commissioning is a well-developed field in its own right with a number of models used in different contexts for balancing resource constraints against the complex and often conflicting demands of service provision. A shared aim of most commissioning models however is to link services as directly as possible with the values of those who use them. Values-based commissioning offers one model of how to achieve this.
Building on the work of Christopher Heginbotham, Neil Deuchar, NSUN and others, values-based commissioning has been adopted nationally in the UK for mental health and other areas of primary care in the work of the Joint Commissioning Panel: for details see Policy and Service Development, Practice Guidance and Commissioning
Joint Commissioning Panel Guidance for Improving Values-based Commissioning in Mental Health
Joint Commissioning Panel – Values-based Commissioning in Mental Health: Ten Key Messages for Commissioners http://www.jcpmh.info/ten-key-messages-commissioners/
Missing Links in Ethics and Law
The training materials produced by the Department of Health to support implementation of the UK’s Mental Health Act 2007 provide one model for how values-based practice may help to link ethics and law with individual decision-making. The model has proved to have strengths but also limitations.
As described in Policy and Service Development, Practice Guidance and Commissioning the Mental Health Act covers the highly contentious area of compulsory psychiatric treatment and the pre-legislative consultation was correspondingly both protracted and at times acrimonious. There were nonetheless many issues on which all sides agreed: that people should be treated with respect, participation maximized, resources used equitably and so forth. It was these areas of agreement that, codified as a set of Guiding Principles for the Act, provided the basis for a values-based approach to implementation.
The model adopted was that the law (the Mental Health Act) tells us what we can do; the supporting Code of Practice tells us how to do it; and the Guiding Principles, understood in values-based terms, provided a framework of shared values within which balanced decisions can be made according to the particular circumstances presented by individual situations. The Training Materials set all this out and provided a series of case examples and exercises drawing on narrative resources produced by service user researchers with personal experience of involuntary treatment.
Care Services Improvement Partnership (CSIP) and National Institute for Mental Health in England (NIMHE) (2008) Living Through the Act. DVD produced by the service user organization A word in Edgeways
The Training Materials were well received in a series of launch workshops around the country. Experience a few years on however shows that far from a balanced approach, risk and resource issues are the main drivers of how the Act is being used with rates of compulsion rising in most parts of the country. A recently revised Code of Practice and change in regulatory arrangements provide an opportunity for a fresh approach.
The revised Code of practice (published 2015) is available at
Note: the 2007 legislation amended rather than replaced the 1983 Act and hence is technically still the Mental Health Act 1983.
Further details and references are given in the section on Training Materials for the Mental Health Act 2007 in Policy and Service Development, Practice Guidance and Commissioning. For new values-based work in this area see Research and On-going Development.
Missing Links in Evidence-based Practice
As twin frameworks supporting clinical decision-making the links between values-based and evidence-based practice are covered elsewhere in this Reading Guide: see for example the three principles linking values and evidence in the section on Science and Values-based Practice in the Glossary of Key Terms; also Evidence-based Medicine in Some of the Other Tools in the Values Toolkit
The relationship however is two-way. Values-based practice both draws on evidence-based practice (as a contribution to its knowledge base) and contributes to it (by linking the generalized knowledge provided by evidence-based practice with the particular values of the individuals concerned in a given situation).
The need for a two-way relationship between evidence and values is evident also in evidence-based practice. It is anticipated in the definition of evidence-based medicine given by one of its early exemplars, David Sackett, in his foundational Evidence-Based Medicine (2000, p1). Evidence-based medicine, Sackett says, combines best research evidence with clinical experience and patients’ values. By patients’ values, he continues, consistently with the emphasis on individual values in values-based practice, we mean ‘the unique preferences, concerns and expectations each patient brings to a clinical encounter …’.
Sackett, D.L. Straus, S.E., Scott Richardson, W., Rosenberg, W., and Haynes, R.B. (2000) Evidence-Based Medicine: How to Practice and Teach EBM (2nd Edition). Edinburgh and London: Churchill Livingstone.
NICE (the UK’s National Institute for Health and Clinical Excellence), the body responsible for issuing evidence-based guidelines for treatment in the National Health Service, makes similar links. The current guideline for Early and Locally Advanced Breast Cancer for example says (p. 6) that:
‘Treatment and care should take into account patients’ individual needs and preferences.’
The Full Guideline (p xxv) writes similarly:
‘The decision to adopt any of the recommendations cited here must be made by the practitioner in light of individual patient circumstances, the wishes of the patient and clinical expertise.’