It isn’t a trick question. Surely any major public service should have high-level objectives? Especially one that has been around for half a century and spends £100 billion a year.

But does it?

If you go to the NHS website you will find “core principles”, not objectives as such. When the NHS was founded in 1948 they were:

• That it meet the needs of everyone
• That it be free at the point of delivery
• That it be based on clinical need, not ability to pay

In 2000 these were extended by the Labour Government of the day to:

• The NHS will provide a comprehensive range of services
• The NHS will shape its services around the needs and preferences of individual patients, their families and their carers
• The NHS will respond to the different needs of different populations
• The NHS will improve the quality of services and minimise errors
• The NHS will support and value its staff
• Public funds for healthcare will be devoted solely to NHS patients
• The NHS will work with others to ensure a seamless service for patients
• The NHS will help to keep people healthy and reduce health inequalities
• The NHS will respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

We can tell that these are principles, rather than objectives, by asking ourselves a simple question: could we tell if the NHS failed to achieve them? The answer is: not easily.

In 2010 the same Government published the NHS Constitution, which contains “Seven key principles”, “underpinned by core NHS values”. Although there are overlaps, they are different from the core principles listed above. The Constitution principles were:

1. The NHS provides a comprehensive service, available to all
2. Access to NHS services is based on clinical need, not an individual’s ability to pay
3. The NHS aspires to the highest standards of excellence and professionalism
4. NHS services must reflect the needs and preferences of patients, their families and their carers
5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population
6. The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources
7. The NHS is accountable to the public, communities and patients that it serves

… and the core NHS values were:

• Respect and dignity
• Commitment to quality of care
• Compassion
• Improving lives
• Working together for patients
• Everyone counts

Hmm. We aren’t any closer to something crunchy. What about the more operational guidance produced by the NHS? Does the annual operating framework contain any objectives?

Indeed it does. The current operating framework contains 18 “existing commitments”, for example:

A maximum wait of one month from diagnosis to treatment for all cancers”

and 63 national “vital signs” in three tiers of priority, for example:

NHS Breast Cancer Screening Programme will be extended to all women aged 47–73 by 2012

Much crunchier, but suddenly we’re deep into the detail. These are really sub-objectives created on the basis that, if you achieve them, then they will contribute to your overall objectives. The operating framework does direct us to the 5-year plan for the NHS which “set out a five year vision for the NHS and should be read in conjunction with this NHS Operating Framework which operationalises the first year of that vision”… and so we are straight back to the “vision” again without finding any high-level objectives in between.

Is there anywhere else we could look? How about the legislation that governs the NHS, now consolidated into the NHS Act 2006. Its opening clauses say:

The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—
(a) in the physical and mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of illness.

…which has several qualifications in it, but could become an objective by changing the first line to: “The objective of the NHS is to secure improvement—”. Add an objective to spend within budget, and to secure local political agreement before making changes to services, and we are starting to build something like high-level objectives for the NHS.

Other areas of life have objectives. For a business it might be “maximising owner value over the long term by selling goods or services” (Sternberg); carefully worded, requiring plenty of sub-objectives to make it happen, but a high-level objective nonetheless.

It seems the NHS has chosen not to define its high-level objectives, preferring to leave a wide gap between vision and detail. Which leads us to the next question. Why?