Foundations of Healthcare and Services Marketing

Introduction and Context

Healthcare marketing is the disciplined process through which health organizations understand needs, design and communicate value, facilitate access, build relationships, and evaluate outcomes for patients, communities, professionals, payers, and other stakeholders. It is not merely advertising hospitals or persuading patients to purchase procedures. In healthcare, marketing is closely connected with public trust, professional ethics, health literacy, access, quality, safety, equity, and responsible resource allocation.

Services marketing provides the wider conceptual foundation. Unlike physical goods, services are usually experienced rather than possessed. A consultation, diagnostic examination, nursing intervention, rehabilitation programme, or telehealth encounter is produced through an interaction among people, processes, technologies, and physical evidence. Consequently, healthcare managers must manage both the clinical service and the total experience surrounding it.

Healthcare marketing is particularly complex because the person receiving care may not be the person making the decision or paying for it. A patient, family member, referring physician, employer, insurer, government agency, and community may all influence the exchange. Furthermore, healthcare decisions often involve uncertainty, vulnerability, information asymmetry, and consequences that cannot be evaluated fully even after consumption.

Learning Objectives

By the end of this chapter, the reader should be able to:

1. Define marketing and distinguish important marketing terminology.
2. Explain market orientation and its relevance to healthcare organizations.
3. Analyse how healthcare organizations create, communicate, deliver, and capture value.
4. Describe the evolution of healthcare marketing.
5. Explain the distinctive characteristics of services: intangibility, inseparability, variability, perishability, and lack of ownership.
6. Apply services-marketing concepts to healthcare situations while considering ethics, regulation, and equity.

1. The Meaning and Scope of Marketing

The American Marketing Association defines marketing broadly as activities, institutions, and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society. This definition emphasizes four linked activities:

• Creating value: developing an offering that addresses a meaningful need.
• Communicating value: explaining benefits, risks, conditions, and alternatives accurately.
• Delivering value: making the offering accessible through suitable people, processes, facilities, and channels.
• Exchanging value: enabling an exchange in which parties give and receive resources, such as money, time, information, trust, adherence, or health outcomes.

Marketing is therefore broader than promotion. Promotion is only one part of the marketing system. A hospital that advertises short waiting times but has poor scheduling processes is not marketing effectively; it is creating a gap between its promise and its performance.

Important terminology

Need: A felt state of deprivation, such as the need for relief from pain or reassurance about a symptom.

Want: The form a need takes when shaped by culture, experience, income, and personal preference. A person may want a particular hospital, specialist, or digital service.

Demand: A want supported by willingness and ability to act. In healthcare, demand may be constrained by affordability, insurance coverage, referral rules, or geographic access.

Offering: A product, service, information, experience, programme, or combination presented to satisfy a need.

Customer: A person or organization that obtains or uses an offering. In healthcare, the customer may be a patient, payer, employer, referring clinician, or public agency.

Consumer or patient: The person who receives or experiences healthcare. The consumer may not be the purchaser or final decision-maker.

Exchange: The process by which parties obtain something they value by offering something in return.

Market: A group of actual and potential users, purchasers, influencers, or beneficiaries with a relevant need and some ability to participate in an exchange.

Segmentation: Dividing a broad market into relatively homogeneous groups with different needs, characteristics, or behaviours.

Targeting: Selecting one or more segments for focused attention and resource allocation.

Positioning: Designing the desired place of an organization or offering in the minds of selected stakeholders relative to alternatives.

Value proposition: A clear statement of the benefits an organization promises to deliver to a defined stakeholder, together with the basis on which it will deliver them.

Brand: A name, identity, set of associations, and pattern of experiences that distinguish an organization or offering.

Relationship marketing: The development of continuing, mutually valuable relationships rather than isolated transactions.

Customer experience: The stakeholder’s cumulative cognitive, emotional, behavioural, and sensory response across all interactions with an organization.

Marketing mix: The controllable set of decisions used to create and deliver value. In services, the traditional 4Ps—product, price, place, and promotion—are commonly expanded to 7Ps by adding people, process, and physical evidence.

2. From a Product Orientation to a Market Orientation

A production orientation assumes that users primarily value availability and affordability. In healthcare, this may appear in efforts to increase capacity, standardize delivery, or expand basic access.

A product orientation assumes that stakeholders will prefer the offering with the best technical features or quality. A hospital may emphasize advanced equipment, specialist credentials, or clinical innovation. Technical quality is important, but a technologically sophisticated service can still fail if it is inaccessible, confusing, or poorly coordinated.

A selling orientation focuses on persuading people to use an existing service. It is visible in aggressive promotion, sales targets, and short-term volume objectives. This approach is risky in healthcare when it encourages unnecessary utilization or exaggerates benefits.

A marketing orientation begins with stakeholder needs and coordinates organizational resources to satisfy those needs better than alternatives. It does not mean giving every stakeholder everything requested. Rather, it means balancing needs with clinical appropriateness, organizational capability, cost, professional standards, and social responsibility.

A societal marketing orientation adds the long-term welfare of individuals and society. For example, a health system may promote vaccination, preventive screening, rational medicine use, or responsible antibiotic practices even when immediate commercial returns are limited.

Market orientation as an organizational capability

Market orientation is often understood through three behavioural components:

1. Intelligence generation: systematically collecting information about patients, communities, competitors, clinicians, payers, regulations, and emerging technologies.
2. Intelligence dissemination: sharing relevant information across departments rather than keeping it within marketing.
3. Responsiveness: modifying services, processes, communication, or policy in response to valid insights.

A fourth element is frequently implied: interfunctional coordination. Marketing information must connect with clinical governance, operations, finance, information technology, human resources, and quality improvement.

For example, patient feedback about confusing discharge instructions is not solely a communications issue. It may require redesign of clinical workflows, translation services, electronic records, pharmacy coordination, and follow-up responsibility.

Market orientation must not be confused with allowing consumer preference to override clinical judgement. A patient may request an inappropriate test; a market-oriented organization listens respectfully, explains the evidence, and supports shared decision-making rather than supplying unnecessary care.

3. Value Creation in Healthcare

Value is not a single concept. Different stakeholders may define it differently:

• Patients may value improved health, relief, dignity, convenience, emotional support, and understandable information.
• Clinicians may value professional autonomy, reliable information, effective teamwork, and the ability to deliver appropriate care.
• Payers may value outcomes, affordability, predictability, and reduced avoidable utilization.
• Communities may value equity, population health, emergency preparedness, and local access.
• Organizations may need financial sustainability, reputation, employee commitment, and regulatory legitimacy.

A useful conceptual representation is:

Benefits can include clinical outcomes, functional performance, emotional reassurance, convenience, and social meaning. Sacrifices include price, travel, waiting time, effort, uncertainty, privacy concerns, discomfort, and opportunity cost. This is a conceptual relationship rather than a universally measurable accounting equation. Its usefulness lies in reminding managers that value is multidimensional and perceived by stakeholders.

Healthcare value should also be distinguished from volume. More consultations, tests, or procedures do not automatically mean more value. A value-based perspective asks whether care improves outcomes that matter to patients relative to the resources used, while recognizing that measurement of outcomes and attribution can be difficult.

The value-creation process

Healthcare value is co-created through a system involving:

1. Needs assessment: identifying unmet clinical, emotional, informational, and access needs.
2. Service design: developing pathways, care models, facilities, digital interfaces, and supporting processes.
3. Value communication: providing honest, comprehensible information about benefits, risks, costs, and uncertainty.
4. Value delivery: coordinating people, equipment, appointments, records, medicines, and follow-up.
5. Value realization: assessing clinical outcomes, experience, access, equity, safety, and financial performance.
6. Learning and improvement: using evidence and feedback to improve the system.

Value is often co-created because patients contribute information, decisions, time, adherence, self-management, and feedback. This does not transfer responsibility for system failures to patients. It means that effective service design must make appropriate participation possible through education, accessibility, language support, and manageable instructions.

4. The Evolution of Healthcare Marketing

Healthcare marketing has developed in several overlapping phases.

Early institutional and professional phase

Historically, healthcare organizations often relied on professional reputation, location, referrals, community standing, and institutional affiliation. Promotion was limited by professional norms and, in many settings, by regulation. Patients commonly had little information and few alternatives.

Competitive and promotional phase

As healthcare markets became more competitive, hospitals and clinics began using advertising, public relations, brochures, websites, physician outreach, and service-line branding. The emphasis frequently shifted toward differentiation and patient acquisition. This phase made communication more visible but also created concerns about exaggerated claims and commercial pressure.

Consumer-information phase

The growth of health websites, online reviews, price comparison, patient portals, and direct access to information increased patient participation. Patients became more active evaluators of convenience, experience, transparency, and responsiveness, although online information varies greatly in quality.

Relationship and experience phase

Organizations increasingly recognized that retention, continuity, trust, and the complete journey matter more than a single promotional contact. Appointment booking, registration, waiting, consultation, billing, discharge, and follow-up became components of the marketed service.

Data-enabled and value-oriented phase

Digital platforms, electronic health records, remote monitoring, analytics, and artificial intelligence have expanded personalization and service reach. At the same time, purchasers and regulators increasingly emphasize outcomes, safety, affordability, equity, and population health. Modern healthcare marketing therefore combines communication with service design, relationship management, experience improvement, and responsible use of data.

The phases are not strictly sequential. A health system may use advanced analytics while retaining a product-oriented culture or weak patient communication.

5. Distinctive Characteristics of Healthcare Services

Services differ from physical goods in ways that influence marketing decisions. The traditional characteristics are intangibility, inseparability, variability, and perishability. Healthcare also requires explicit attention to lack of ownership, because patients generally purchase access, performance, or outcomes rather than a permanent physical object.

5.1 Intangibility

A service cannot usually be touched, inspected, or stored before purchase in the same way as a physical product. Before a consultation, a patient cannot directly examine the quality of the clinician’s reasoning. Before surgery, the patient cannot fully inspect the future outcome.

Intangibility creates perceived risk. Healthcare organizations reduce uncertainty through:

• professional qualifications and accreditation;
• clear explanations of procedures and expected outcomes;
• transparent policies and pricing where possible;
• testimonials used ethically and representatively;
• facility design, cleanliness, and accessible information;
• evidence of quality and safety;
• opportunities for questions and informed consent.

Physical evidence is especially important. A reception area, patient portal, staff identification, signage, equipment maintenance, and written instructions communicate messages about reliability. Physical evidence does not prove clinical quality, but poor physical evidence can undermine confidence.

Healthcare communication must avoid converting uncertainty into false certainty. Outcomes depend on diagnosis, patient characteristics, adherence, clinical complexity, and chance. Claims should be evidence-based, balanced, and understandable.

5.2 Inseparability

Inseparability means that service production and consumption are often closely connected in time and place, with the provider and user participating in the service process. A consultation exists through interaction among patient, clinician, information, and setting. The patient’s account, questions, preferences, and responses influence the encounter.

Inseparability has several implications:

• frontline employees are central to the marketing function;
• communication and clinical performance are intertwined;
• scheduling and access affect perceived quality;
• patients may influence one another in shared environments;
• service recovery must occur close to the point of failure.

Healthcare organizations therefore need employee training, appropriate staffing, teamwork, escalation systems, and psychologically safe cultures. Marketing cannot repair a service process that prevents clinicians from spending adequate time with patients.

5.3 Variability or heterogeneity

Services may vary because people, contexts, cases, workloads, and technologies vary. Two patients with the same diagnosis may require different explanations and treatment pathways. The same clinician may perform differently under different workload conditions.

Variability is not always a defect. Personalized care requires adaptation. The managerial challenge is to control harmful, avoidable variation while preserving clinically appropriate individualization.

Methods for managing variability include:

• evidence-based protocols and clinical pathways;
• competency-based training;
• checklists and standard operating procedures;
• electronic decision support;
• appointment and workload management;
• audit, peer review, and outcome monitoring;
• service scripts for administrative interactions;
• feedback and continuous improvement.

Standardization should concern reliable processes and safety-critical steps, not mechanical treatment of every patient. Excessive standardization can reduce dignity, responsiveness, and professional judgement.

5.4 Perishability

Unused service capacity cannot generally be inventoried for later sale. An empty appointment slot, unused operating-room time, or an unoccupied inpatient bed at a particular time represents capacity that may be lost, although capacity planning must always preserve emergency readiness.

Demand and capacity can be balanced through:

• appointment systems and reminder messages;
• triage and appropriate referral;
• flexible staffing;
• extended or staggered hours;
• telehealth where clinically suitable;
• wait-list management;
• cancellation policies that are fair and transparent;
• demand forecasting and seasonal planning.

Perishability creates an ethical tension. Financial pressure may encourage maximizing utilization, but healthcare organizations must not create unnecessary demand or reduce safe reserve capacity. Efficient capacity management must remain subordinate to clinical appropriateness and equitable access.

5.5 Lack of ownership

In many service exchanges, the buyer does not acquire ownership of a durable object. A patient purchases access to professional expertise, facilities, diagnostic capability, time, coordination, and a hoped-for health outcome. Insurance may purchase financial protection rather than a clinical object. A public health programme may create collective benefits that cannot be privately owned.

Lack of ownership affects marketing in several ways:

• organizations must communicate the nature and limits of access;
• relationship and trust become more important than possession;
• continuity, records, and portability influence perceived value;
• patients may value control, participation, and outcomes instead of ownership;
• switching costs may arise from fragmented records, referral relationships, or familiarity.

Digital health adds complexity. A patient may access an app or portal without owning the underlying algorithm, data infrastructure, or clinical service. Consent, privacy, data portability, and the right to withdraw must therefore be addressed.

Summary table: service characteristics and managerial responses

6. The Expanded Services Marketing Mix

The 7Ps help managers translate strategy into operational decisions.

Product: The core benefit and the associated service bundle. For a diabetes programme, this may include clinical consultations, education, monitoring, nutrition support, and follow-up.

Price: Charges, co-payments, premiums, time, travel, inconvenience, and psychological costs. Ethical pricing requires transparency and sensitivity to financial hardship.

Place: The location and channels through which care is accessed, including hospitals, community sites, pharmacies, mobile units, and digital platforms.

Promotion: Advertising, public relations, professional communication, health education, social media, and direct communication. Promotion must be truthful and appropriate to health literacy.

People: Clinicians, administrators, technicians, managers, and partners. Their competence, empathy, and reliability are part of the service.

Process: The sequence of activities through which care is requested, delivered, documented, paid for, and followed up.

Physical evidence: Buildings, equipment, signage, forms, websites, uniforms, cleanliness, and other tangible cues.

The 7Ps should be coordinated. Promoting a premium patient experience while underinvesting in staffing creates a credibility gap.

7. Ethics, Governance, and Regulation

Healthcare marketing is constrained by ethical and legal duties that may be less prominent in ordinary consumer markets. Core principles include respect for autonomy, beneficence, non-maleficence, justice, confidentiality, and truthfulness.

Common governance risks include:

• misleading claims about cure rates, superiority, or specialist expertise;
• selective presentation of outcomes without relevant limitations;
• exploiting fear, vulnerability, or desperation;
• covert use of patient stories or images without valid consent;
• discriminatory targeting or exclusionary service design;
• misuse of health data for profiling or promotion;
• conflicts of interest involving referrals, incentives, or sponsored content;
• dark patterns that make cancellation, privacy choices, or price information difficult.

Managers should establish claim-review procedures, approval authority, privacy controls, consent standards, complaint pathways, and monitoring of marketing outcomes. Artificial intelligence can support segmentation, forecasting, chat, and personalization, but it can also reproduce bias, expose sensitive data, generate inaccurate content, or obscure accountability. Human oversight, data minimization, explainability where appropriate, security, and continuous auditing are essential.

8. Illustrative Case: Riverside Integrated Care Centre

Background

Riverside Integrated Care Centre is a fictional, medium-sized outpatient organization serving an ageing and culturally diverse urban population. It offers primary care, diagnostics, physiotherapy, and chronic disease management. Although clinical outcomes are acceptable, patient surveys show dissatisfaction with telephone access, unclear instructions, long waits, and unexpected administrative charges.

Problem

The centre’s initial response is to purchase digital advertising promoting “fast, convenient, patient-first care.” Marketing staff report increased website traffic, but complaints rise because actual access and billing processes do not match the promise. Management must decide whether to increase promotion or redesign the service.

Analysis

A market-orientation review generates intelligence from patient interviews, call-centre data, staff workshops, complaint records, and journey mapping. The centre identifies several failure points:

• patients cannot easily distinguish urgent from routine requests;
• appointment reminders are available only in one language;
• registration requires repeated information;
• delays are not explained;
• estimates of charges are difficult to obtain;
• clinicians receive incomplete information because records are fragmented.

The analysis shows that the problem is not primarily a lack of awareness. It is a mismatch among the value proposition, process, people, and physical or digital evidence.

Approach and solution

The centre replaces the broad promise of “fast care” with a more precise value proposition: “coordinated, understandable care for ongoing health needs, with clear next steps and accessible support.” It then:

1. establishes a multilingual navigation service;
2. introduces online and telephone triage with clinical safeguards;
3. redesigns appointment reminders and pre-visit instructions;
4. provides written cost estimates and a financial counselling route;
5. creates a single medication and referral reconciliation process;
6. trains staff in service recovery and respectful communication;
7. monitors waiting time, missed appointments, complaints, patient understanding, and selected clinical outcomes.

Outcome

In this illustrative scenario, the centre experiences improved appointment completion, fewer avoidable complaints, and higher reported understanding of next steps. The changes do not eliminate waiting or clinical uncertainty. Instead, they make the service more transparent, coordinated, and responsive. The case demonstrates that effective healthcare marketing begins with service truth: the organization must improve what it promises before expanding promotion.

Learning points

• Marketing intelligence includes operational and clinical experience data.
• Patient experience is produced across departments, not by marketing alone.
• A value proposition must be specific, credible, and supported by processes.
• Accessibility and equity are components of value, not optional additions.
• Communication should explain uncertainty rather than conceal it.

9. Contemporary Developments and Best Practices

Healthcare marketing is increasingly shaped by omnichannel access, patient portals, virtual care, online reputation, community partnerships, personalization, and value-based purchasing. These developments create opportunities but also require careful evaluation. A digital channel is not automatically more convenient for people with limited connectivity, disability, low digital literacy, or language barriers.

Effective practice generally includes:

• beginning with a clearly defined patient or population need;
• combining qualitative insight with reliable quantitative evidence;
• involving clinicians, patients, carers, and community representatives in design;
• aligning marketing promises with measurable operational capability;
• designing for accessibility and inclusion;
• separating education from commercial persuasion;
• using consent-based, secure data practices;
• evaluating outcomes, experience, equity, and unintended effects;
• treating complaints as intelligence for improvement;
• maintaining clinical independence and professional integrity.

A mature healthcare marketing function is therefore strategic, analytical, ethical, and cross-functional. It helps the organization become easier to understand, access, trust, and use appropriately.

Chapter Summary

Marketing in healthcare is the coordinated creation, communication, delivery, and exchange of value for patients, professionals, payers, communities, and society. It extends beyond promotion to include service design, access, processes, relationships, experience, and outcomes. Important terminology includes needs, wants, demand, offerings, exchange, segmentation, targeting, positioning, value proposition, brand, and relationship marketing.

Market orientation requires generation, dissemination, and use of stakeholder intelligence, supported by coordination across clinical and administrative functions. Healthcare value is multidimensional and includes outcomes, dignity, convenience, information, affordability, trust, and equity. Perceived value can be understood conceptually as benefits minus sacrifices, although it is not a universal financial equation.

Healthcare marketing has evolved from institutional reputation and referral dependence toward competition, consumer information, relationship management, digital engagement, and value-oriented systems. Healthcare services are distinctive because they are intangible, inseparable, variable, perishable, and generally not owned by the user. These characteristics make evidence, employee performance, process design, capacity management, continuity, and ethical communication central managerial concerns.

The services marketing mix expands the traditional 4Ps to include people, process, and physical evidence. Ethical healthcare marketing must protect autonomy, privacy, equity, safety, and truthfulness. Technology and AI can improve access and personalization, but they require governance, human oversight, and attention to bias and data protection.

Key Terms

Need: A felt state of deprivation or requirement.

Want: A culturally and personally shaped form of a need.

Demand: A want supported by willingness and ability to act.

Exchange: Obtaining value by giving value in return.

Market: Actual and potential users, purchasers, influencers, or beneficiaries.

Market orientation: Organization-wide generation, sharing, and use of market intelligence.

Value: Benefits perceived in relation to sacrifices made.

Value proposition: Promise of relevant and credible benefits to a defined stakeholder.

Segmentation: Division of a broad market into relatively similar groups.

Targeting: Selection of segments for focused attention.

Positioning: Desired place of an offering in stakeholder perceptions.

Relationship marketing: Development of continuing mutually valuable relationships.

Intangibility: Inability to fully inspect a service before experiencing it.

Inseparability: Close connection between service production and consumption.

Variability: Differences in service performance or experience across people and situations.

Perishability: Inability to store unused service capacity for later use.

Lack of ownership: Receipt of access, performance, or outcomes rather than a durable object.

Physical evidence: Tangible cues that help users evaluate an intangible service.

Service experience: Stakeholder response across interactions with an organization.

Societal marketing: Marketing that considers long-term individual and social welfare.

Review Questions

Short Answer Questions

1. Distinguish a need, a want, and demand in a healthcare context.
2. Why is marketing broader than promotion?
3. Define market orientation and identify its main behavioural components.
4. Explain intangibility and one method for reducing perceived risk.
5. What is meant by perishability in healthcare services?

Long Answer Questions

1. Explain the evolution of healthcare marketing from institutional reputation to digital and value-oriented marketing.
2. Discuss how healthcare organizations create, communicate, deliver, and evaluate value.
3. Explain the five distinctive characteristics of healthcare services and their managerial implications.
4. Analyse the role of the 7Ps in designing a healthcare service.
5. Discuss the ethical and governance challenges associated with healthcare marketing and AI-enabled personalization.

Analytical / Application Questions

1. A hospital receives many website enquiries but has low appointment completion. Use market-orientation and services-marketing concepts to diagnose the problem and propose an intervention.
2. Design a value proposition for a community chronic-care programme. Identify its target segment, benefits, sacrifices, access channels, and evidence needed to support its claims.
3. A clinic advertises “zero waiting,” although delays frequently occur because of emergencies. Critically evaluate the claim and recommend an ethically defensible communication and operations strategy.

Multiple Choice Questions with Answers

Question 1

Which activity is broader than promotion and includes creating, communicating, delivering, and exchanging value?

A. Marketing

B. Advertising

C. Selling

D. Publicity

Correct Answer: A. Marketing

Question 2

Which sequence best represents market orientation?

A. Promotion, discounting, selling

B. Intelligence generation, dissemination, and responsiveness

C. Production, inventory, and distribution

D. Branding, pricing, and sponsorship

Correct Answer: B. Intelligence generation, dissemination, and responsiveness

Question 3

A patient values shorter travel time but must pay more and wait longer. In the conceptual value relationship, these factors are primarily examples of what?

A. Benefits only

B. Market segments

C. Sacrifices

D. Physical evidence

Correct Answer: C. Sacrifices

Question 4

Which service characteristic explains why an unused appointment slot generally cannot be stored and sold next month?

A. Intangibility

B. Inseparability

C. Variability

D. Perishability

Correct Answer: D. Perishability

Question 5

A hospital uses accreditation, outcome information, and clear explanations to reduce uncertainty before treatment. Which characteristic is it primarily addressing?

A. Intangibility

B. Perishability

C. Lack of ownership

D. Segmentation

Correct Answer: A. Intangibility

Question 6

Which example best illustrates inseparability?

A. A hospital stores masks for later use

B. A patient and clinician jointly shape a consultation

C. A clinic divides patients into age groups

D. A website displays a logo

Correct Answer: B. A patient and clinician jointly shape a consultation

Question 7

Which response manages variability while preserving clinically appropriate personalization?

A. Treat every patient identically

B. Eliminate professional judgement

C. Standardize safety-critical processes and adapt care to patient needs

D. Avoid measuring service outcomes

Correct Answer: C. Standardize safety-critical processes and adapt care to patient needs

Question 8

In the expanded services marketing mix, which element includes staff competence and empathy?

A. Place

B. Price

C. Physical evidence

D. People

Correct Answer: D. People

Question 9

Which statement best reflects societal marketing in healthcare?

A. Maximize procedures regardless of appropriateness

B. Promote services while considering long-term public welfare

C. Target only people able to pay

D. Hide uncertainty to increase demand

Correct Answer: B. Promote services while considering long-term public welfare

Question 10

Why does lack of ownership matter in healthcare services?

A. Patients usually acquire a permanent physical object

B. Users generally receive access, performance, or outcomes rather than owning the service

C. Services can always be stored

D. Clinical services require no relationships

Correct Answer: B. Users generally receive access, performance, or outcomes rather than owning the service