Approaches to Co-Production: Overcoming Inequalities and Empowering Citizens

In this blog, our Senior Research Officer Tom reflects on his experiences of working in Co-Production for National Co-Production Week (4th- 9th July).

In my role at Healthwatch Essex, I have sought to promote approaches to Co-Production that reflect models devised by thinkers such as Cahn and Gray (in Pestoff et al, 2013), Leach (2006) and Barbera et al (2016). These academics describe Co-Production as a process grounded by the concept of positive liberty. In doing this, they each suggest that the application of Co-Production in services may be improved by reducing inequalities that disadvantage individuals when participating in decision-making forums. Through this, they implicitly reference the works of scholars such as Crocker (1980, p.121), whose thesis examining the relationship between positive liberty and equality depicts society as preferencing those who ‘naturally swim with the stream’.

These analyses provide an understanding of the basis on which approaches of Co-Production ought to be built. They infer that Co-Production should be contingent on the existence of spaces in which actors are free to interact, share experiences and make decisions, irrespective of their identities (Cole, 2019). This freedom ideally empowers individuals from diverse communities: enabling them to use their lived and local experiences to effect change. Such a notion is evident in Cahn and Gray’s (in Pestoff et al, 2013) study of time banking wherein the authors refer to the value of acknowledging and including all forms of expertise within decision-making. Equally, it is found in the work of Leach (2006), whose framework for collaborative decision-making emphasises the importance of reducing structural inequities.

This type of analysis is also observed in less normatively orientated studies that focus on the products of Co-Production and the types of activities in which Co-Production can occur. Loeffler and Bovaird (2019) and Nabatchi, Sancino and Sicilia (2017), for example, discuss how Co-Production should be predicated on reducing inequalities between participating actors. In doing this, the authors emphasise the necessity to empower individuals before they engage in forms of decision-making and speak to the importance of promoting solidarity between co-producing actors (i.e., service users and providers).

The perceived necessity to prepare individuals to take part in Co-Production, thus, suggests that opportunities for participation alone do not necessarily enable participants to actively engage in decision-making (Alderwick, Dunn, Mckenna, Walsh and Ham, 2016). Milewa (2004) supports this assertion. In his examination of NHS participation under the New Labour government, he argues that service users were regularly given opportunities to participate in forums that influenced the policy direction of NHS trusts. However, Milewa proposes that interactions in these forums were informed by ideological and procedural parameters set by the government, thereby limiting the scope of participant discussion (Ibid, pp.244-245). In this way, service users were not free to shape the meaning of their participation nor manifest outcomes that reflected their lived and local experiences.

This example suggests that the provision of opportunities to participate are not equivalent to the attainment of powers to actively shape and contribute to decision-making. As Pestoff (2012, p.25) writes, citizens are not equivalent to a ‘jack in the box’. They are not always prepared for someone to turn the proverbial crank, thereby allowing them to engage with providers and make decisions about national and local services. Rather, effective Co-Production is a product of empowerment. This is why thinkers like Carr (2007, pp.269-272) argue that participation in Co-Production ought to be supplemented by processes which enable actors to overcome societal conventions (such as those relating to class, ethnicity, race, gender or disability) and promote their individual and collective interests.

It is, thus, important that researchers, organisers and activists alike commit to an empowering vision of Co-Production. At Healthwatch Essex, I have embedded this commitment within my work by actively engaging with and preparing participants before decision-making takes place. In employing approaches to Co-Production centred on enabling individuals to consider their experiences, overcome anxieties and deliberate with others, I have sought to ensure that participants feel confident when collaborating with others and making decisions. This ambition has been achieved through the implementation of preparatory practices that promote participant understanding of the decision-making process and topics being discussed. Equally, it has been realised through activities that enable participants to play an active role in shaping the direction of Co-Production.

For example, as lead researcher on a joint Healthwatch Essex and Mid and South Essex Foundation Trust project entitled Understanding Inequalities: Co-designing accessibility to health services in mid and south Essex, I worked to ensure that participants felt capable of taking part in deliberation. To attend to this aim, I sought to include participants in the project’s early stages by inviting them to participate in two/three one-to-one conversations centred on learning and providing accessible information delineating project aims and methodology. These efforts promoted researcher-participant rapport, thereby ensuring that participants felt confident in my capacity to support them. Equally, they supported the development of participant knowledge as they enabled participating actors to understand how, when and where the project was to occur.

Beyond initial conversations and information provision, I also worked with participants to increase the accessibility of our deliberative forums. In doing this, I sought to empower service user, carer and family member participants to define our approach to empowerment. This interpretive turn was achieved through further interactions with participants wherein I sought to learn from their positive experiences of accessible Group or Collective Co-Production. Moreover, it was supported through surveys designed to assess whether participants felt capable of taking part in processes of Co-Design. Through these efforts, I enabled participants to shape the constitution of the deliberative space: encouraging them to refine how we incorporated forms of assistance and support within the project.

Dr Tom Kerridge