Co-production: an inconvenient truth?

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As chief executive officer of West London Collaborative (WLC), a community-led and owned community interest company, I was lucky enough to have a place in the first cohort of The King’s Fund programme Leading collaboratively with patients and communities, together with the chief pharmacist at West London Mental Health NHS trust, Michele Sie.

This gave us the opportunity to reflect on our working relationships and our personal styles of handling conflict and disagreement. We learnt about ‘appreciative enquiry’ – a model seeking to encourage self-determined change – and some useful theories around organisational politics. This has been really helpful, as WLC works in partnership with the NHS to co-produce with patients around complex and difficult issues. As such I regularly have to challenge very senior people and we often get stuck at some point during the process. This usually revolves around denial of one consistent and very inconvenient truth: patient involvement is not co-production.

Co-production is a way of thinking about how our public services are designed, delivered and evaluated. It involves working in equal partnership with communities in spaces where power is shared, making services more effective and efficient, and in the long-term more sustainable. Nesta has described it as ‘the most important revolution in public services since the Beveridge Report in 1942’.

WLC has chosen to use Nesta’s six principles of co-production as a framework to define our approach, and we set this out in advance of any project. Yet no matter how many times I refer to these principles at the outset, I never hear them spoken of again. There appears to be a collective, silent refusal to acknowledge the core values of co-production; it’s most odd. In some meetings I attend with senior professionals in the health and social care sector, there is a vociferous and congratulatory consensus that projects have been co-produced, and yet there is no formal reference to what this actually means, no agreement of what ‘good’ looks like, nor any of the excellent due diligence I see around other board issues such as finance, staffing and modelling. I can think of only one project that has commissioned an independent examination of its co-production, and while the results certainly weren’t all good news, the desire for learning was absolutely there.

Some days, constant negotiating between senior executives, frontline clinical staff, financial stakeholders and short-term consultants feels like Groundhog Day. I have to be ever-mindful of my survival mantra, ‘Rock the boat without getting rocked out of it’. And these are choppy waters. If I don’t rock the boat, staff and patients will miss out on the countless benefits of doing co-production properly, so I hold firm in my pursuit of authenticity. Accordingly, when we first meet our new collaborators I usually receive an email from a member of staff saying they are disappointed, confused or affronted by my ‘arbitrary’ decision to want to work only as their equal partner. We then spend weeks in meetings, debating, emailing back and forth, huffing and puffing and sharing our different perspectives, until finally we establish a team with a genuine collaborative feel. Suddenly we talk, listen and laugh; and working as equals we unpack the assumptions we were all hiding and begin to solve really complex problems together.

And then the collaborative starts a new project with a new team, and another terse email pops into my inbox.

But navigating these tricky relationships is the stuff of genuine co-production. The initial difficulties are part of what happens when you walk the co-production walk – rather than talk the talk. It’s how we work through it, how we stay within this liminal space, that plants the seeds of real change. There are many theorists, economists, academics, activists and visionaries who espouse co-production at conferences. They keep me motivated. But when the conference lights go down and ‘the parable of the blobs and squares’ has been duly discussed, it is us boat-rockers and those aforementioned professionals (the hopeful, disappointed, affronted, confused and finally elated ones) who are really pioneering and giving it a go.

In 2014, West London Mental Health NHS Trust commissioned and funded our independent community interest company to deliver authentic co-production. We were tasked with challenging the trust, holding it to account and mutually solving complex problems. It was a very brave move by the trust. We have been rolling up our sleeves and getting to grips with power sharing and asset mapping. We are now getting substantial experience of how an NHS organisation and a community interest company can work through barriers, triggers and project grenades, tackle power plays, hierarchy and risk, as well as elephants in the room. We are also getting stuck and frustrated and irritated with each other. Sometimes communications break down, we take the occasional wrong turn, we stumble and hurt each other’s feelings – but still we all get back up and try again, because we all care about getting things right.

Working in partnership we have learnt that we need to be able to disagree well, to disagree constructively and without risk of offence, censure or closing down. We need safe, reflective spaces such as the one provided for collaborative working at The King’s Fund. Time and experience of doing co-production rather than just talking about it has taught us one thing: that in practice, co-production needs more than a wonderful six-principled theory – it needs hands-on tools to help us all unpack our inconvenient truths.

  • Tomorrow’s conference at The King’s Fund, How to involve and co-produce with patients and communities, will explore how the six principles of good person-centred, community-focused care can be implemented in a practical way. Videos and presentations will be available on our website after the event.

Comments

Jessie Cunnett

Position
Director,
Organisation
Patient and Public Involvement Solutions
Comment date
31 October 2016
Good to see how this important work is finding its way. Jane I think its helpful be open about the struggles that are faced by all who want to work as equal partners and being courageous and humble enough to dust yourself and start all over again is where success lies. I long for a day when co-production and equal partnership is the language of every day, everywhere.

Bridget Hamilton

Position
Senior Lecturer, Nursing,
Organisation
University of Melbourne
Comment date
31 October 2016
Great work you are doing Jane.
I am hoping to co-develop with Cath Roper a symposium for the European Violence in Psychiatry Conference in Dublin next october 2017. Can we talk?
Bridget

Jane McGrath

Position
CEO,
Organisation
WLC
Comment date
02 November 2016
Definitely Bridget, we have loads to learn from you guys and this sounds right up our street!

jane mcgrath

Position
CEO,
Organisation
WLC
Comment date
02 November 2016
Thanks Jessie - look forward to meeting again and finding out about what your amazing group in Brighton is up to now! Thanks for being there at the moment of birth of WLC - eternally grateful for your professional steer.

Jo Blundel

Position
Dep Director Government Outcomes lab,
Organisation
Blavatnik School of Government
Comment date
03 November 2016
Very insightful piece on what real co-production means. We agree about the need to think about the boundaries of what defines services and how people are part of making things work, not just the customer. Be great to chat.

john kapp

Position
Director,
Organisation
SECTCo
Comment date
03 November 2016
Well done, Jane, for this inspiring blog, and the presentation you gave on tues. I publicly asked about crisis houses and cafes, and privately mentioned my community care centre in Brighton and Hove, see www.sectco.org.uk. I have joined C4CC yesterday, and would like to visit you in WLondon, and meet up with Jesse in Brighton. Please put us in touch. Contact me on johnkapp@btinternet.com, 01273 417997.

Meherzin Das

Position
Trust Lead for Psychology,
Organisation
Dorset HealthCare University NHS Foundation Trust
Comment date
04 November 2016
HI Jane,
As a person who's championed co-production and peer involvement for years, I particularly valued hearing about your work - thank you for your honesty in sharing the challenges you've faced along the way, which are often glossed over... it would be great to touch base with you and compare notes, if possible?
All good wishes - keep rocking the boat!

John Viner

Position
Hounslow Service User and Carer Involvement Lead,
Organisation
West London Mental Health Trust
Comment date
15 November 2016
You've written a truly excellent piece on the challenges and frustrations in Co-Production, usually with highly-paid entrenched staff. For example, the current 'Transformation' work around Local Acute services appears to have no service user or carer involvement from its very outset. Barely two weeks ago, the University of Manchester's report on the suicide rate of those under the Care of Home Treatment Teams and In-Patient Acute wards showed that the suicide rate was more than three times higher in the HT client group. The U of M have been monitoring these figures for 20 years, apparently.

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