Getting tied up in value knots does not help when making practical health policy decisions

Summer is the season of family gatherings and barbecues, and that means it is usually the season we encounter people who have different ideas about what a good society, a good government or a good health system looks like.

Many a vigorous discussion or acrimonious argument is fuelled by differences in ideas about how things ought to be. Values lie at the very heart of politics. But how should values, and particularly different and competing values, be handled in health policy?

Some would have it that policy decisions need to be based on facts and research, and that appeals to values are emotive and have no place in policy. This reflects some pretty outdated, mid-20th century thinking about the separateness of facts and values, thinking that persists today in the ideal of evidence-based policy.

Those who espouse this position are usually unaware of their own implicit value preferences, or they assume that their values are shared by all.

Public health professionals typically value the improvement of health outcomes, and often assume that everyone else does too. In one sense, they are right. Few people would say they don’t value health.

But better health is a value that can frequently conflict with other values, and we all make value trade-offs.

The most effective policy for reducing traffic-related injuries would be to ban the use of cars, trucks, electric bikes and scooters. We don’t do this, because we balance this value with other important things, such as freedom to get around.

The difficulty is that different primary care policy actors have quite different, and often conflicting, ideas of what quality, equity and integration actually entail in practice

A more nuanced answer is that values are important in working out the direction we ought to go but, once that is decided, technical experts can work out how to get there.

We may, for example, collectively decide improving access to primary healthcare should be prioritised in policy, but then give the job of determining how best to do it to health economists. I call this the “quarantined” approach; values have their place, but only at the beginning of policy processes.

But how do people decide collectively which values are most important?

Elections are one possible way – debates about which valued ends are most important are settled through electoral competition between political parties. Parties can be distinguished in terms of ideologies (coherent “packages” of values), so elections determine which package is most preferred.

But elections are too crude a mechanism for determining which valued objectives are most important in very specific policy debates. And there aren’t many policy issues where it is practical to clarify agreed policy directions before searching for solutions.

Another problem with this quarantined approach is that solutions are not value-free. To improve access to primary care, a government could use subsidies to general practices, subsidies to patients, or laws and regulation to cap fees. Each of these options taps into broader debates about whether such policy tools ought to be used. Clearly, regulating fees has implications for the value of professional autonomy.

A third, broad approach takes a different tack, and regards values as at the heart of good policy. We see this suggestion in the Health and Disability System Review – Interim Report, Hauora Manaaki ki Aotearoa ki Whānui – Pūrongo mō Tēnei Wā in its call to develop a “common set of values and principles guiding the behaviours of all parts of the system”.

I doubt this approach will be very practical. Pretty much everyone in primary care agrees there needs to be better integration with other health and social services, quality improvement is important, and significant access barriers need addressing.

Unlike issues such as euthanasia or legalisation of cannabis, there isn’t a lot of debate about values in primary care. Who do you know who argues against integration?

The difficulty is that different primary care policy actors have quite different, and often conflicting, ideas of what quality, equity and integration entail in practice.

American health services scholar Walter Leutz famously said, “Your integration is my fragmentation”. In some recent conversations with primary care representatives, I have encountered diametrically opposed understandings of what continuity in primary care means in practice.

A different way of thinking about values is that they serve as rhetorical resources in policy argument.

If you want to be taken seriously in primary care policy processes, you need to talk the language of quality, equity and integration. This means these values can be useful ways of bringing together stakeholders with quite different ideas and interests. Having a common language of values is the easy part. It is rarely possible to “read off” specific, practical policy implications from values.

In any case, the idea that we need common values to underpin policy is often overrated. Fundamentally, public policy is about working out what to do next. In many contexts, different stakeholders are quite capable of working out what to do even though their values do not coincide.

In the 1990s, Māori health activists and National Party politicians agreed that creating space for Māori health providers was a good idea. Each justified their support using quite different values (tino rangatiratanga on the one hand, and reducing reliance on government organisations on the other). So, while it is a mistake to ignore the importance of values in health policy, it is also a mistake to place excessive weight on them.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland