1 Speculating about knowledge

Before you can fully explore what is meant by the concepts of ‘service’, or ‘improvement’, it is important to examine what knowledge consists of and how it is obtained. A great deal of knowledge is tentative, partially developed, and perhaps conflicts with other knowledge. Arguments about what improvements should be made often draw upon a variety of knowledge, attitudes and values. Indeed, knowledge is rarely ‘objective’.

Understanding what you value, what motivates you, what you understand as ‘truth’ is a critical starting point for improving healthcare practice. Healthcare is ‘lived’ by clients, patients and practitioners. It would be surprising, therefore, if matters such as human values and attitudes did not play a part. Often, in healthcare practice, concepts such as ‘improvement’ and ‘quality’ can become battlegrounds for competing interests, where even the definition of a term might be influenced by the standpoint you adopt (or are given) as a practitioner, manager or service user.

Understanding the plural nature of the values that drive people can reduce the risk that you dismiss or downplay others’ agendas. As soon as issues are discussed relating to what ‘should happen’, or ‘what could be done’, different notions of improvement come to the fore. Even where consensus exists that a service improvement has been achieved, external forces (like research and policy), or unintended consequences of the change, are likely to lead to a new set of problems to be addressed. This recognition that the ‘final answer’ may remain stubbornly elusive is a key insight of reflective practice. Despite that, the effort of reflecting, discussing and debating is worthwhile as it can broaden your appreciation of the issues.