In reviewing patient safety investigations and analysing the words that they are using, it has led me to consider how rules based decision making has resulted with inflexibility within our systems and created anxiety for practitioners when individuals do not fit algorithms that have been designed for specific diagnosis.

In shifting to principles based decision making, we can consider values, connection, emotions and rights as part of this perspective and it creates a new mechanism of moving forward, often reducing conflict.

Human values provide a powerful framework for decision-making. When we align with our values, life seems to flow. When there is misalignment, things can start to feel difficult. Principles, associated with values, connections and rights therefore can highlight a new way of considering a problem which enables individuals to feel confident and act autonomously when the world feels complex.

These words should then be present in our narrative and our practice and be represented in our patient safety reports, investigations and embedded in our policies and practices.

Currently, health and care organisations run their services through a rule based decision making process and the language is dominated by technicality with transactional labels.

Human rights are based on principles of fairness, respect, equality, dignity and autonomy, and these principles weave their way through our national strategy and policies. Principles should have created a positive decision making toolkit especially where there is risk and uncertainty.

The ratio of ‘checking things’ in the NHS through assessment, audit, scrutiny, supervisory oversight, justification and inspection to ‘doing things’ such as supporting, nurturing, connecting and even intervening feels disproportionate.

If we embrace the Human Rights Act, there are the basic things we all need to stay alive – like food, water, air, shelter, and sleep, and to feel safe and secure. [Article 2: The right to life. Article 3: Prohibition of torture, inhuman and degrading treatment. Article 5: Right to liberty and security.]

Currently, these rights although part of policy, have not translated into actions.

The need for belonging and connection, family and friendships, love and intimacy, dignity and respect and freedom also form the basis of our Human Rights Act but again often do not translate into practice. [Article 3: Prohibition of torture, inhuman and degrading treatment. Article 5: Right to liberty and security. Article 8: The right to respect for private and family life, home and correspondence. Article 9: The right to freedom of thought, conscience and religion. Article 10: The right to freedom of expression. Article 12: The right to marry and found a family.]

Using these legal rights should have created a lens for thinking about the situations we encounter however they became a rule book which trapped us in a never-ending cycle of screening, triage, signposting, assessing, planning, justifying, referring, delivering interventions, reviewing and following processes. We spend our time defending our decisions and being seen to observe policy and processes rather than understanding each situation. We worry about staying within budget, practicing defensively and I would suggest that we are fighting with, not for, those we serve.

The endless words that reflect technical language and transactions which I have taken from our analysis of investigation reports included complaints, providers, inspections, processes, services, transfers, policy, systems, departments, investigation, risk, guidance, governance, measures, referrals and management to name but a few and these words are distancing, dehumanising and created technical recommendations which have not led to improvement.

There was a shocking absence of words that reflected values, connection, emotions or rights, and therefore there is a lack of humanity within the solutions which presumably reflects the nature of oversight. The absence of words like rights, ethics, advocacy, relationships, connection, creativity, and hope were missing despite these being championed in national strategy such as https://www.nhsconfed.org/publications/messenger-review-nhs-leadership#:~:text=The%20report%20rightly%20points%20out%20the%20gaps%20in,pathway%20from%20recruitment%20through%20to%20mid-career%20and%20beyond or https://www.gov.uk/government/publications/the-hewitt-review-an-independent-review-of-integrated-care-systems

Decision Making Strategy: Rules-based versus principles-based regulation – is there a clear front-runner?

A recently published paper, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10016636/ reviewed an analysis of incidents and utilises a qualitative alongside a quantitative analysis of harm in prisons which included the views of those who had been detained in prison and key stakeholders alongside the quantitative measures and eludes to principles being key with a language that reflected values, connection, emotions and rights including: equivalence, context, ethics, experience, dignity, distress, identity, reality and perception.

I noted the move of the RCN to principles as part of their professional development. https://www.rcn.org.uk/Professional-Development/Principles-of-nursing-practice

Our current regulatory approach is rules based. Recent criticism of Ofsted, alongside CQC and HMIP all demonstrate the impact and un-intended consequence of inspections. Analysis of words contained with a CQC inspection report had zero words that were considered to align to values, connection, emotions or rights.

In healthcare, both rules and principles play important roles, although they function differently and serve different purposes.

Rules are specific, concrete instructions or guidelines that are designed to ensure consistent and standardised care, reduce errors, and maintain compliance with legal and clinical standards. For example, hand hygiene rules or dosage rules for a specific medication.

Principles are broader and more flexible that reflect the fundamental values and goals providing a framework for making decisions and taking actions when specific rules cannot meet the different contexts which exist.

Regulators will require a different approach to analyse whether principles have been applied appropriately. This will require a relationship of shared understanding which requires time to build and a landscape where the regulator is also not punished for deviating from rules base practice.

The choice between rules and principles is not absolute and can partly accommodate nuance.

How can we all embrace values based decision making

Overall, transitioning from rules based decision making to one that that prioritises principles will require creativity, coaching, and open-mindedness to enable cultural, managerial, and operational change and by analysing the language we use could provide a road map to demonstrate success in this journey.

Because every situation is different, values-based decision-making can provide the flexibility needed to adapt to a variety of circumstances. However, it can also be challenging because it requires interpreting and applying values to different situations, can lead to different interpretations among different people.

In real-life situations, many organisations and individuals will use a combination of both approaches. The key is finding the right balance. Too much reliance on rules can lead to rigidity and a lack of creativity, while too much emphasis on values can lead to inconsistency and uncertainty. I would propose that through analysis of the words we use can provide insight into this transition.