This project seeks to align health and social care perspectives by focusing upon person-centred practice. Therefore this project is exploring the application of co-productive approaches (commonly referred to in the social care sector), and improvement methodologies (commonly referred to in the health sector). This section describes how co-production and improvement methodologies have been interpreted for this project.
Definitions of co-production are not in short supply. The concept emerged in the 1970s when Nobel prize winner for economics, Elinor Ostrom, and her team at Indiana University, used the term ‘co-production’ in a series of studies about the Chicago police. In the case studies she highlighted the weaknesses of large, centralised public service delivery, observing how police officers had abandoned close involvement with citizens on the beat for policing at a distance in patrol cars. The word ‘co-production’ was coined to express what she viewed as the lack of close involvement or connection on behalf of the police (Boyle and Harris, 2009). Ostrom’s team defined co-production as the ‘process through which inputs used to produce a good or service are contributed by individuals who are not ‘in’ the same organisation’ (Boyle and Harris, 2009, p13). This implies that no one organisation or institution is responsible for delivering services; services are developed and delivered by professionals and citizens.
Later in 2000, the word ‘co-production’ was used by Edgar Cahn to explain his Time Dollar and Time Banking systems. He claimed that money was the reason human capacities were being devalued. These capacities include: caring for each other; coming to each other’s rescue; rearing infants; protecting the frail and vulnerable; standing up for what is right; opposing what is wrong; coming together to meet agreement; and acting as guardians of what we feel is precious. In his opinion, co-production redefines the connection between the world of market and non-market, and sets the terms on which the two economies need to relate to create a world that rewards altruism and care as much as it rewards competitiveness, aggression and acquisition (Cahn, 2004).
Boyle and Harris (2009) assert that co-production is central to growing the ‘core economy’ and that it encourages equal partnership as opposed to just ‘service user involvement’ or ‘citizen engagement’. The ‘core economy’ was a term introduced by an economist Nevan Goodwin, who used the analogy of a computer operating system on which systems work. The ‘core economy’ or operating system comprises family, neighbourhood, community and civil society (Boyle and Harris, 2009). This marries with the sentiments of Bovaird and Loeffler’s (2013) definition of co-production as ‘…professionals and citizens making better use of each other’s assets, resources and contributions to achieve better outcomes or improved efficiency’ (p23). The professional expertise of the professional is partnered with the lived experience of the person. These partnerships are based on four values (Horne and Shirley, 2009):
- Everyone has something to contribute. Citizens are empowered to contribute their own resources (time, will power, expertise and effort) and give them greater control over public resources to achieve outcomes. This is often referred to as an assets-based approach.
- Reciprocity is essential (two-way relationships where risk and power is shared). In essence, services ‘do with’ and not ‘to’ the people that use them.
- Social relationships matter.
- Social contributions (rather than financial contributions) are encouraged.
In essence, co-productive working places more emphasis on ‘relational’ rather than ‘transactional’ approaches to delivery (Needham and Carr, 2009, p3).
Levels of co-production
Needham and Carr (2009) identify three levels of co-production:
|Descriptive co-production||The people who use services already make contributions to each stage of the service provision process (assessment, planning, commissioning, monitoring, evaluation), with little consideration of the potential for more meaningful involvement of individuals and communities. This type of co-production can result is a clash of priorities between individual outcomes and service outcomes. For example, services are often too focused on targets, hierarchies, funding and risk to consider being more flexible and responsive to those who use services.|
|Intermediate co-production||This is co-production that acknowledges and values the input and views of people that use services and their carers, and creates better feedback channels for them to shape services. This form of co-production is often led by a member of staff rather than being embraced by all members of staff equally. This model may also involve new responsibilities being imposed on the people who use services, leading to concern that co-production can be used as a way to manipulate people who use services or more successfully exploit their labour.|
|Transformative co-production||This type of co-production changes the fundamental nature of relationships between the people who use services and staff and facilitates new forms of peer support. The service user is viewed as an expert and their contribution is a valued component of service provision. Transformative co-production incorporates quality of life issues, rather than just clinical or service issues. The people who use services can be involved in shaping the ethos of care and in empowering frontline staff as well as themselves. It embodies whole system or culture change.|
Types of co-production
The Co-production Star (Governance International, 2014) identifies a range of service activities which can be included under the co-production umbrella. These are: co-commission, co-assess, co-design and co-deliver.
|Co-commissioning||Can involve co-planning of policy eg deliberative participation, planning for real, open space; co-prioritisation of services eg personal budgets, participatory budgeting and stakeholder representation in commissioning decisions; and co-financing services eg fundraising, charges, agreement to tax increases.|
|Co-design||Can involve user forums, service design labs and customer journey mapping.|
|Co-delivery||Embraces co-managing services eg leisure centre trusts, community management of public assets, school governors; and co-performing of services eg peer support groups (such as expert patients), Nurse Family Partnerships, meals-on-wheels and Neighbourhood Watch|
|Co-assessment (including co-monitoring and co-evaluation)||Co-assessment of services eg tenant inspectors, user on-line ratings, participatory village appraisals.|
It’s worth discerning the differences between improvement science and improvement methodology. Improvement science is the study of methods that make improvements effective. According to the Health Foundation (20011, p6) ‘Improvement science focuses on systematically and rigorously exploring ‘what works’ to improve quality in healthcare and the best ways to measure and disseminate this to ensure positive change’. It maximises the learning from improvement and brings research and practice closer together. Improvement methodology on the other hand, is the framework for the delivery of change that is planned, evidence-based and follows established methods (NHS, 2012). There are proven methodologies to support different kinds of change, but improvement methodology incorporates large-scale change across systems, and not just process improvement. Proven methodologies include PDSA (Plan, Do, Study, Act), Lean and Six Sigma.
The Improvement Guide (2009) identifies five fundamental principles of improvement: (i) knowing why you need to improve (ii) having a feedback mechanism to identify if improvement is happening (iii) developing an effective change that will result in improvement (iv) testing a change before implementation (v) and implementation.
The guide goes on to describe The Model of Improvement, which comprises three questions and the PDSA cycle as a framework for applying the five fundamental principles.
- What are we trying to accomplish?
- How will we know that a change is an improvement?
- What changes can we make that will result in an improvement?
When the answers to these questions are established, a PDSA/PDCA cycle – ‘a systematic series of steps for gaining valuable learning and knowledge for the continual improvement of a product or process’ (W. Edwards Deming Institute) – is used to action the changes. This cycle is also known as the Deming Wheel, or Deming Cycle as the concept was first applied by Dr. Edwards Deming in the US. PDSA encourages small-scale changes in a process, as well as a way to analyse changes and spread the process throughout the system.
|Plan||Establish the objectives and processes necessary to deliver results.|
|Do||Implement the plan and action the process. Collect data for analysis in the ‘study’ and ‘act’ steps.|
|Study / Check||Study the results of the ‘do’ and compare against the expected objectives.|
|Act||Take actions on the differences between actual and planned results. Analyse the differences to determine their root causes. Decide what to change that will involve improvement of the process or product.|
We found there has been little evience shared of co-production and improvement methodologies being used together, so we spoke to several people who have applied this approach to learn from their practice, and designed our own approach for this project.
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