Chapter one reviews the focal literatures informing this study and articulates the relevance of the key concepts of ‘value-in-use’ and ‘value co-creation’ to enhancing understandings of patient engagement in health care (direct engagement in own
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health, care and treatment) within individual, micro-level service encounters. In doing so, this chapter draws together perspectives from multiple literatures concerning value, service-dominant logic, patient engagement in health care and public service-dominant logic to outline and justify the key research questions addressed within this study.
Chapter two outlines the systematic research methodology used to conduct this study and the rationale for adopting an interpretive approach to the investigation of the focal phenomena. Features of case study and qualitative research are discussed before detailing the triangulated data collection used in this study. The processes of negotiating access to the study site; study participants and conducting the interviews and observations are additionally relayed and a brief summary provided of the nature of the data collected. Ethical considerations are paid attention to throughout this section. Methods of data analysis are then outlined before reflecting on the research process and how issues such as credibility, transferability and reactivity were managed within this study.
Chapter three introduces the main findings arising from this study. These are arranged into two main sections. The first section investigates service user and service provider conceptualisations of ‘value’ within the context of a UK specialist cancer service setting. The second section presents an analysis of the nature and extent of value co-destruction within the context of a cancer service setting. This section also considers how ‘value’ (positive and negative) accrues or diminishes across individual and multiple service encounters and the potential for value to be recovered within and across organisational sites. This concludes with a summary of the key findings.
Chapter four outlines the main contributions of this study, limitations of the research study and highlights areas for future research.
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CHAPTER ONE: THE DYNAMICS OF VALUE IN HEALTH CARE
“One of the most enduring and controversial topics in medicine is the concept of what constitutes value in health care” (Ramsey and Schickedanz 2010, p.1).
Introduction
In light of increasingly limited health care resources and rising health expenditure, it is not surprising that health care ‘value’ is typically conceived of in economic terms, with emphasis placed on the costs and outcomes of service interventions (Porter and Teisberg 2006; Porter 2010; Ramsey and Schickedanz 2010; Right Care 2011; National Voice 2015). Recently, however, it has been argued that economic articulations of 'value' reflect a ‘payer’ centred perspective that may not appropriately capture the perceptions of health service users regarding what is of most value to them (Tilburt et al 2011; National Voice 2015). These are important considerations in relation to conceptions and metrics of ‘value’, as the perspectives of those using, providing and funding health care may not necessarily be shared.
Given these concerns, framing value from a perspective in the services marketing literature known as service-dominant logic (S-D logic) may afford additional insights into how value is perceived by users of health care services (Akaka and Vargo 2015;
Lusch and Vargo 2014). The S-D logic framework proposes that ‘value’ is a subjective, experiential and phenomenologically determined concept. According to S-D logic, value (benefit or increase in well-being) is only realised in use, ‘value-in-use,’ and is always unique to a particular context (Chandler and Vargo 2011; Vargo and Lusch 2012; Rihova et al 2013; Lusch and Vargo 2014, p.57). Whilst value is co-created through the interactions and activities of various ‘actors’ (e.g. customer or service provider), during which resources are exchanged and subsequently utilised and integrated, value is ultimately determined by the beneficiary of service on the basis of their service experience (Vargo and Lusch 2012; Rihova et al 2013).
The S-D logic framework emerges from efforts to extend and integrate previous research regarding ‘service’ as the basis of exchange (Akaka and Vargo 2015). An
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important aspect of S-D logic is that the term ‘service’ (the application of knowledge and skills for the benefit of another) is distinguished from the plural term ‘services’
(units of output), with the latter associated with goods-dominant logic5 (Kryvinska et al 2013; Lusch and Vargo 2014, p.12). As discussed in the introductory chapter, the basic tenet of S-D logic is that “service is exchanged for service” for the benefit of another actor or oneself (Lusch and Vargo 2014, p.15). Actors are not, however, able to deliver value to another actor. Instead, they can offer potential value through value propositions i.e. a promise of service to be delivered (Lusch and Vargo 2014, p.72). The primary focus in S-D logic, is on operant resources, with the beneficial application and integration of such resources resulting in ‘value’ (Vargo and Lusch 2004a, p.7; Brodie et al 2011). In adopting this alternative logic of exchange, it is proposed that attention be directed towards the “experiential” and
“phenomenological” aspects of value (Akaka and Vargo 2015, p.460).
This interpretation of value, and value co-creation, sits in stark contrast to perspectives which have regarded value as “a ratio between service quality and cost”
(Sandström et al 2008, p.112). In framing value from an S-D logic perspective as
‘value-in-use’, it is proposed that users of the service have a dual role as both judges, and co-creators, of the value of a service (Sandström et al 2008). There is, however, limited empirical research which explores how ‘customers’ themselves perceive value-in-use (Medberg 2016). The relationship between perceptions of ‘value’ and
‘value co-creation’ is also understudied. One outcome is that limited attention has been given to the relationship between customer service experiences and their co-creation practices (Gummerus 2013; Helkkula and Kelleher 2010; Helkkula et al 2012).
Focus of the chapter
The purpose of this chapter is to explore the relevance of the concepts of ‘value-in-use’ and ‘value co-creation’ to enhancing understandings of patient engagement in
5This logic frames exchange in terms of units of output (goods), with the production and exchange of goods forming the central components of business and economics (Lusch and Vargo 2014, p.4).
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health care (direct engagement in own health, care and treatment) within individual, micro-level service encounters6. In doing so, this chapter moves to the foreground, two developing areas of research (‘value’ and ‘value co-creation’), and explicates the relevance and potential application of these concepts to the sphere of health care.
The analytical themes introduced in this chapter draw on emerging literatures in the fields of services marketing (i.e. service-dominant logic) and public management (i.e.
public service-dominant logic) to draw attention to the importance of examining
‘value-in-use’ and ‘value co-creation’ within a health care context (Vargo and Lusch 2004a, 2004b, 2006 2008, 2011, 2012, 2016a; Osborne 2010; Osborne et al 2013;
Osborne et al 2015; Osborne et al 2016).
In undertaking this work, this chapter brings together multiple streams of literature and research to frame this case for the first empirical investigation of these concepts and the S-D logic framework within a UK specialist cancer service setting. Exploration of these literatures also assists with the formulation of the specific objectives of this study. These objectives concern the exploration of conceptualisations and trajectories of ‘value’ within a cancer service context, and the identification of potential barriers, facilitators and supports to value co-creation. Further elaboration of the research questions addressed in this study are provided later in this chapter.
The emphasis in this study, as outlined in the introductory section, is on patients’
engagement in direct care (micro-level service encounters) rather than involvement in organisational design and governance or policy making. The focus on ‘micro-level’
encounters is in response to concerns that this level of analysis has been neglected in UK NHS policy and practice (Coulter 2012). This level of analysis is also under-researched in studies exploring value co-creation (Neghina et al 2015).
Additionally, it should be noted that although value co-creation (as outlined from a S-D logic perspective) may lead to the creation of value for more than one party (i.e.
for patients and health care providers), the main focus in this study is on ‘patients’,
6 Service encounter is a period of time during which a customer directly interacts with a service (Shostack 1985; Bitner 1990).
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as the main beneficiaries of service in health care (Vargo and Lusch 2016a).
Chapter structure
In moving towards an understanding of the contribution of the concepts of ‘value-in-use’ and ’value co-creation’, it is necessary to locate these concepts within the wider literatures discussed within this chapter. This is represented diagrammatically in Figure 1. This work is undertaken in five main sections (illustrated in Figure 1) before concluding the chapter with a summary of these various literatures and discussions.
Figure 1: The location of value-in-use and value co-creation in relevant literatures
Section one of this chapter considers the various definitions of value in the marketing, public management and health care literature. This section incorporates discussions concerning the shift in mainstream marketing literature from viewing
‘value’ as a property intrinsic to goods/objects and thus a commodity that can be exchanged (value-in-exchange), to one which views ‘value’ as an experiential concept and related to ‘use value’ (Ng and Smith 2012; Vargo and Lusch 2004a, 2006).
Attention is also drawn here to conceptualisations of ‘value co-creation’ within the marketing literature and differing ways of framing ‘value’, i.e. ‘value-in exchange’
versus ‘value-in-use.’ A range of perspectives on the process of value co-creation are additionally explored (Vargo and Lusch 2011; McColl-Kennedy et al 2012; Grönroos
Value-in-use and value co-creation
Value (Section 1)
Service-dominant
logic (Section 2) Applying S-D
logic (Section 5)
Patient engagement
(Section 3) Public
service-dominant logic (Section 4)
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2006, 2008, 2011). The potential for value co-destruction, as an outcome of service use is also raised. The inter-relatedness of the concepts of quality and value is then briefly introduced before moving to summarise alternative perspectives on ‘value’ in the public management literature concerning ‘public value’ and co-production (i.e.
Moore 1995, 2012, 2013, 2014; Bryson 2004; Bryson et al 2017; Bovaird et al 2015;
Loeffler and Bovaird 2016). This section concludes with a discussion regarding ways of framing value in the context of health care.
Section two discusses the development of S-D logic and central aspects of this framework. Critiques of S-D logic are explored before discussing research in the services marketing literature which has explored the application of S-D logic to a health care context.
Section three draws on literature in public management concerning patient engagement and involvement in health care. Although the focus of this study is on patient engagement in direct care, it is necessary to locate initiatives at this level in the context of the wider patient and public participation literature. This section discusses how exploring ‘value-in-use’ and ‘value co-creation’ in a health care context could enhance engagement initiatives.
Section four addresses the application of services marketing literature to public management focusing on a body of work undertaken by Osborne and colleagues. This stream of scholarship advocates that public management should be underpinned by service management approaches (i.e. service-dominant logic) rather than business management theories. This section discusses the emphasis within this stream of work on service user perspectives and recent propositions regarding enhanced typologies of co-production. Attention is also drawn briefly here to differing interpretations of ‘co-production’ within public management and services marketing literatures. Differences between the work of Osborne and colleagues and the approach adopted in this study are outlined.
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Section five discusses the potential implications of applying the S-D logic approach to a UK specialist health care context and outlines areas which require further consideration.
Finally this chapter summarises the contributions of these literatures and identifies research gaps where the empirical work undertaken in this study could contribute to extant knowledge. The main research questions identified in this study are then outlined in relation to the empirical application of the S-D logic framework to a UK specialist cancer service context.