How and when does co-production happen?

In health and social care, co-production happens in different forms, such as individual, group or collective strategies.

Individual co-production activities are now part of the more commonly recognised term ‘shared decision-making’. For example, a nurse practitioner may identify a patient who is struggling to adhere to a medication regimen and will devise a co-produced plan of how the patient can be supported.

Group co-production is a process where professionals organise group sessions with patients, relatives or service users. For example, a support group for people diagnosed with viral hepatitis led by professionals and dedicated service users offering regular meetings to share real-life experiences and provide information. In clinical research, group co-production activities have many functions. The Health Research Authority has regional committees of experts and lay members that review and provide ethical opinions for NHS research (Health Research Authority 2021). Similarly, models of group co-production are encouraged in research by the National Institute for Health Research (NIHR) (2019). Patient and public involvement groups meet regularly to evaluate potential and ongoing research projects.

Collective co-production is a term used when stakeholders from more than one organisation connect to create outcomes, such as policy guidance and standards. In the creation and writing of National Institute for Health and Care Excellence (NICE) guidance, for example, members of the public are actively involved by either being on a committee or reviewing guidelines before publication. This is a method to ensure that specialists and the public co-produce the guidance that will be used widely by health and social care practitioners and commissioners. Stakeholders are also encouraged to contact NICE if they believe the guidance needs updating, to ensure ongoing quality improvements are driven by the public (NICE 2014).

These are some of the many examples of how co-production is now an accepted approach to reconfiguring service delivery and policy improvement.

Core values of co-production

Co-production must have certain core values, which are equality, inclusivity, developing and maintaining engagement, and reciprocity. Equality is important and must be navigated carefully, such as ensuring that service users who agree to be co-producers feel enabled to speak. Differences of opinion can happen and can be challenging for group members, but they must not be a reason to discontinue the activities (Oliver et al 2019). It is thought that managing challenges should be part of the design stages. For example, facilitators should make plans to equalise any power relationship among members (Herrera et al 2010). Historically in co-production, marginalised groups have been unintentionally excluded. People less likely to take part in co-production are those from ethnic minority backgrounds, LGBTQ communities or individuals, people who communicate differently, people with limited capacity and/or people with dementia (Herrera et al 2010).

Methods to ensure inclusivity and accessibility are in their infancy. Suggestions include embracing diversity, such as asking key community members to be part of and recruit to co-production groups. Meetings should be accessible to a diversity of people and documentation for meetings should be carefully considered, such as whether it is a readable text size and available in appropriate formats and languages. For example, one research group developing a mental capacity assessment tool found the use of artifacts such as pictures and images to be a useful method to co-create a series of patient-facing resources. Service users commented on how they felt enabled due to their contributions being highly visible (Cooke et al 2017).

Maintaining engagement and reciprocity may be challenging to fully achieve. Issues may occur if members or professionals are unwilling to take on board other members’ views (Mockford et al 2012). The advice is that members should be encouraged to reflect on any preconceptions or biases that they may bring to the process (NIHR 2018). Recommendations to encourage and maintain engagement include chairs of the group being led by a member of the community rather than a professional in the field. Similarly, there should be opportunities for personal growth and an emphasis on supporting individuals to contribute to the co-production activities.

Members of the co-production group need to be willing to accept and trust each other to ensure reciprocity. Likewise, the contributions of each of the members should be acknowledged and members should feel they personally benefit from being in the group, such as increasing confidence or gaining experience that may help access courses or work experience (NIHR 2018). Understanding the intricacies of managing a co-production activity requires training and consultation with people who have experience as co-producers. Organisations such as NICE offer a range of training and masterclasses to voluntary organisations and the community sector in understanding how co-production activities can be effectively project managed (NICE 2022).

The evidence behind co-production

A systematic review analysing the effect of patient and public involvement in healthcare found that many forms of co-production activities take place in the UK (Mockford et al 2012). In the review, many of the studies reported co-production to be an innovative and successful means of improving a service. For example, service users have co-produced training packages for staff as part of their continuing professional development. Co-production has been reported as a helpful way to navigate challenging issues in healthcare. For example, research looking at diagnostic errors showed co-production to be an effective tool in educating patients about why errors occur. This activity was found to increase trust between patients and professionals (Jo and Nabatchi 2018).

Potential barriers to recruitment and maintaining engagement have been reported in empirical evidence. For example, in the recruitment of co-production members, research showed that staff limited recruitment strategies and tended to ask a narrow selection of patients (El Enany et al 2013). In this instance, research showed a divide was created between patients. Those who were not involved would dislike members who were included in the co-production activities. Although this may only happen in a close community network, this research shows the importance of paying close attention to the recruitment processes. Some have criticised current co-production models as being high in elitism and tokenism. They suggest co-production design should use models that work hard to address potential recruitment and membership issues (Ocloo and Matthews 2016).

Others suggest professional and public roles should be blurred to ensure authentic collaboration in healthcare research design (Cooke et al 2017). An example is when co-producers actively involve community leaders in the design and ongoing running of the project. A systematic review found active involvement of key community members created a greater sense of ownership that contributed to the project’s success. This can be particularly helpful for inclusivity and ensuring populations less likely to be involved are included (Bonevski et al 2014). By including members of the community in the design, co-production activities are open to creativity that will enhance the overall running of the project.

A pilot study suggested that a major step in co-production is to learn from previous experience. In this way, co-production partners from previous projects are invited to the group to share the good and the not so good aspects of their co-production experiences (Lam et al 2017). This activity can act to encourage the group to plan and discuss any potential pitfalls and create a commonly agreed map of what the co-production team hopes to achieve. Therefore, with the help and sharing of other co-production experiences, the process can improve future projects and continually evolve.

Measuring the success of co-production

It is challenging to fully measure the overall benefits of co-production. In a project that evaluated the co-production and implementation of the new Scottish social security system, it was suggested that the ‘ecosystem perspective’ was a way to understand the nature and complexity of measuring effectiveness (Strokosch and Osborne 2020). The ecosystem perspective theorises that services are ‘living systems’ supported or constrained by many entities, such as service users, policymakers, managers and activists, as well as resources and technologies within the service. It is accepted that services are complex due to the interconnectivity between many layers of human interactions that occur on a daily, monthly or yearly basis. Therefore, fully capturing the effectiveness of a co-production activity can be challenging and ‘snapshot’ evaluations may not give a true reflection of the project success. This is due to the ever-changing nature of external influencers, such as political and contextual issues (Strokosch and Osborne 2020). For this reason, leaders of co-production activities may choose a variety of outcomes and time points to measure the effectiveness of a project.

Co-production in higher education

Co-production in higher education is a policy and practice imperative. The Office for Students has co-produced a charter for mental health (Office for Students 2019). Other examples are the development of a new curriculum where students were active members in the writing of learning materials (Evans et al 2015), and in a healthcare nursing curriculum a group of service users with learning disabilities and their relatives were actively involved in the creation and delivery of educational sessions. Informal feedback suggests this has created important and meaningful outcomes for students and service users, such as increasing service users’ confidence and enhancing students’ communication skills.

Vignette 1 below outlines a co-production activity that has successfully involved students as co-researchers. This activity enabled students to gain practical experience in the research process, such as to recruit and interview research participants. This process has been positive in developing relationships and the research skills of the students and staff members. Other activities in higher education and healthcare organisations include addressing prominent issues for diverse groups. For example, academics have developed co-production approaches to address gaps in student and staff experiences, such as for people from ethnic minority backgrounds or LGBTQ groups.

One innovation in nursing, midwifery and allied health education is the development of a monthly online meeting. In this activity, groups of students and staff meet online to discuss student and staff placement experiences, decolonising the curriculum and evaluating assessment criteria to ensure they are inclusive. In this co-production activity, students and academics take on board the core co-production values of ensuring accessibility and reciprocity by creating a platform to hear voices and empower people. The group has achieved many outcomes, such as developing training resources for staff, presenting at a range of conferences and making links with students from other universities to co-create a conference (Vignette 2). Such activities are a grassroots movement aiming to equalise power relationships, address inclusivity and extend to healthcare environments so that co-production activities are familiar to students and future healthcare professionals. Research has evaluated student perceptions of co-production and found the main outcomes are an increased understanding of other people’s roles and understanding their challenges (Garcia et al 2018). It is argued that the aims of co-production should be less about changing and more about enabling individuals and groups of people by increasing knowledge and empowering those involved (Palumbo and Manna 2018).

Conclusion

Co-production is advancing in health and social care services, research and higher education. It aims to gather knowledge and implement changes through shared decision-making in services or educational courses. It must include core values to be successful, such as equality and accessibility. Careful consideration must be given to inclusivity and methods to fully engage partners. The evidence supports the view that co-production can have positive outcomes and often results in improved understanding between professionals, service users and students. Without careful and inclusive recruitment and retention strategies, only a narrow range of views will be heard. Engagement of key community members is important to ensure recruitment and retention throughout the project.

Creativity to improve retention and outcome quality is an important aspect to consider. Discussions with experienced co-producers can help to navigate and steer projects. In higher education institutions, many co-production activities are ongoing, and examples are available that are effective methods to engage healthcare students in gaining research experience in an academic team and developing a platform for people from ethnic minority backgrounds or LGBTQ groups to have a voice. This activity is helping to empower and equip individuals who are the future workforce and leaders in healthcare. Overall, co-production can be positive and with careful design it can become an essential part of leading and managing groups of people and organisations.