Co-production has become something of a buzzword often used as a rebadging of patient/service user involvement. The reason for this is that the system tends to co-opt and dilute more radical concepts in order perhaps to be able to slot them into existing structures without the risky and scary business of actual transformation.
The aim of this piece then is to go back to the radical roots of Co-production. Looking behind the buzzword early on created in me a pilot light that ignites when genuine Co-production is present and a warning bell that rings when it is being talked about but is there in name only.
It is about seeing people not just as bundles of needs but as possessors of assets irrespective of how “throwaway” Edgar Cahn society may consider them. Many people are working co–productively without being aware of it. It is not a model; it is a way of being, acting and thinking and as such is hard to define.
In The Challenge of Co-production, the New Economics Foundation defines it as follows:
“Co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbors. Where activities are co-produced in this way, both services and neighborhoods become far more effective agents of change” (NEF 2009)
The key words are “equal” “reciprocal” and “agents of change”. It is not a synonym for public engagement, service user involvement or consultation. It is not just allowing people a say in decisions about themselves individually or collectively. Above all, it is not something that retains power in the hands of professionals with the patient or service user brought in at a later stage.
Elinor Ostrom first used the term at Indiana University on receipt of the Nobel Prize, which came as a surprise to many.
The key point she was making was that public services were shown to work best when designed and run by a combination of professional expertise and community insight. Ostrom’s work divides participation into individual and collective levels, very relevant to health care. We can participate as individuals, in terms of how we take responsibility for our health and in sharing decisions with professionals. We can also link up with others either with similar issues or set of values to participate on a wider level in order to create the social movement of which Simon Stephens talks in the Five Year Forward Review. Ostrom developed in a healthcare context.
Co-production was taken further by Professor Edgar Cahn, a US civil rights lawyer and speechwriter for Robert Kennedy, who suffered a massive coronary at 45. Time spent pondering in his hospital bed upon the resulting apparent loss of self and achievements before he was ill. He used this time well as he went on to found the Time Banking movement – the practical means whereby those declared useless by society for whatever reason are now valued for their assets, skills and life experience.
I read his seminal work “No More Throwaway People” and it immediately resonated, particularly regarding the feeling that his heart attack seemed to rob him of more than just his health.
“I didn’t like feeling useless. My idea of who I was – the “me” that I valued – was someone who could be special for others, who could do something they needed. And here I was, a passive recipient of everyone else’s help” (Cahn, 2000)
Here is a useful summary of the first part of the book from Time Banking New Zealand. The female author earned Time Bank credits for her efforts:
Even more succinct: an animation that distils the central tenets of the book into three minutes – the Parable of the Blobs and Squares.
Perhaps time to reflect – are we blobs or squares? Does our job title or other labels require us to change our basic shape in order to fit?
Time banking is a useful tool to enable organisations to make the traditional patient and public involvement more co-productive by addressing the key core principle of reciprocity. My experience giving my time for nothing as an active service user, at times, felt undervalued. Often the only unpaid person present facing an over-riding assumption that the only skills and experience I had were those related to my illness. I was not motivated by material gain but wondered what these assumptions said about my worth.
There was something about Cahn’s examination of what worth and value means that really spoke to me. I decided to try to see theory in practice by working at the Holy Cross Centre Trust in Camden where Cahn acted as an adviser. I got paid for every hour of my time in one Time Bank credit that I “spent” on accredited training. Being tangibly rewarded for my time restored a sense of worth that the years of illness, unemployment, passivity and largely tokenistic service user involvement had removed. It changed how I viewed myself.
David Boyle explores this concept further in the following article from the Guardian Healthcare Network:
Time banking is one of many ways in which patients/service users can be given a tangible indication of the level at which our contribution is valued. Many of us are unable to accept money or choose not to. My contributions were recognised in the form of genuine opportunities for training and development, such as my Quality Improvement Fellowship with CLAHRC North West London and being given a place on one of the NHS Leadership Academy programmes. These were life-changing opportunities that enabled me to reconnect with the skills and assets that had become frozen over the long period of my illness and gain new ones. It was a major step towards where I am now, working for myself and no longer totally dependent on Benefits.
I wrote more about my personal experience of this in this blog for the NHS Leadership Academy
Our health and social care services cannot afford to allow the insight and other life skills that people using health and social care services possess to continue to go to waste. The only way forward is genuine collaboration – that powerful bringing together on an equal basis of lived experience and professional expertise. This can be challenging for all concerned. It involves redefining our jobs that may have become part of our very identities, coming out of comfort zones and being prepared to admit that we may at best only have part of the answer.
Bovaird et al described Co-production as a radical experiment in policy innovation. Read the full article here.
In Co-production: Manifesto for Growing the Core Economy Cahn warns in the foreword of the consequence of failing to heed this message:
“We will be unable to create the core economy of the future so long as we live in a bifurcated world where all social problems are relegated either to paid professionals or to volunteers whose role is typically restricted to functioning as free labour within the silos of the non-profit world. It will take massive labour of all kinds by all to build the core economy of the future – an economy based on relationships and mutuality, on trust and engagement, on speaking and listening and caring – and above all on authentic respect. We will not get there simply by expanding an entitlement system that apportions public benefits based on negatives and deficiencies: what one lacks, what disability one has, what misfortune one has suffered….Finally, because time banking and co-production grow out of my life and work in the civil rights movement, I have to add that hell-raising is a critical part of coproduction and of the labour that it entails and must value. Those with wealth, power, authority and credentials hold those assets as stewards for those who came before and in trust for those yet unborn.” (NEF, 2008)
I echo Cahn’s rallying cry. This is very far from the rather safe world of the traditional patient and public involvement so often talked about as Co-production. It can feel messy and risky. If we can take the risk of emerging from our boxes of “patient” or “professional” and venture into the territory where boundaries are blurred, and both “sides” are prepared to walk in the shoes of the other, then we have the potential to create something of radically new. This is not about professionals having to relinquish power in an already chaotic and uncertain climate, but about strengthening the power base so there is more of it to go around.
Edgar Cahn called me a hell raiser when we met. It takes one to know one.
Examples of NESTA Co-production Practitioners’ Network and Governance International’s show this work in practice.