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Understanding service improvement in healthcare
Understanding service improvement in healthcare

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2 Understanding ‘service’

A ‘service’ can be thought of in different ways, for example as:

  • Something contracted and exchanged for a reward: Healthcare unions emphasise the contractual nature of a service. Practitioners exchange skills and knowledge in return for rewards in the form of pay, status and related privileges.
  • As a product: Healthcare systems may be conceived of as a product, a whole package of skills, know-how, problem solving, needs meeting, priority-determining activity, one that people feel passionate about (hence recurring debates on any changes to the way in which the service is conceived or delivered). National health services in countries like Belgium, France, Germany, Sweden and the United Kingdom are examples of this.
  • As an activity: This can be further differentiated as people-based or resource-based. Are people working closely with patients’ expectations and experiences or making the best use of finite resources? Is ‘service’ based on needs or on available resources? This poses some interesting challenges for reflecting on improvement, because the question arises: how do you evaluate such a diverse activity?
  • As a necessity: Healthcare is not a service that people can necessarily choose to take or leave, so working towards improvement involves partnership with clients or consumers. If the service comprises essential activities, facilities that cannot realistically be obtained elsewhere, then changes to that service affect the vested interests of a great many people. Okpokoto (2013), for example, describes the necessity for primary healthcare in developing countries.
  • As a promise: In some countries healthcare is seen as a right. For example, Swedish policy states ‘that every county council must provide residents with good-quality health and medical care, and work to promote good health for the entire population’ (Healthcare in Sweden, 2016). The NHS Constitution in the UK portrays the National Health Service as a place of rights and responsibilities. You might consider that such an interpretation enhances the transparency of expectations, creates opportunities for conflict, and highlights the need for teamwork/corporate definition of service.

Activity 2

It is time now to exercise some Socratic reasoning. Reflect on the following two questions and then note down your thoughts.

  1. Is our description of ‘service’ a complete and adequate portrayal of the different ways healthcare as a service might be portrayed in your setting?
  2. What are the possible implications for improvement if one or other definition of service is adopted?


Some definitions of service might work better in some areas of healthcare than others. What is important is realising how different understandings of such a fundamental term can either assist or undermine work towards service improvement.

There are often far-reaching consequences of defining ‘service’ in particular ways. This may be made worse where individuals or agencies don’t specify how they are defining service. If you don’t discuss what you mean by key terms, then they may mean different things to different people, and later undermine collaborative work. This seems particularly true with regard to care service providers and service users. If service is a commodity, responsibilities will be of one sort or another, either vendor or purchaser. But if service is a partnership, one of negotiated activities and contributions, then responsibilities will seem rather different. It becomes easy to work towards shared goals and initiatives only as stakeholders start to unpick what is really meant by a service.