Putting people in the ‘prudent healthcare’ picture

Ruth Dineen says partnerships are key to prudent healthcare working.

Co-production – one of the key principles of prudent healthcare – is an approach to public services, which enables the public and professionals to share power and work together in equal partnership, creating opportunities for people to access support when they need it and to contribute to social change.

Co-production is an approach based on relationships of trust and reciprocity; on acknowledging that everyone is an expert in their own life with something to contribute. These relationships create a culture within which professionals become willing to share power and people, in turn, become willing to share responsibility. And that, not surprisingly, improves outcomes for everyone.

Traditionally, service providers ask tick-box questions: what do you need; what are you eligible for? But with co-production the questions become a conversation: what does a good life look like for you; what strengths can we build on and how can we work with you to achieve your goals? It’s about thinking less about fitting people into pre-determined services, and more about empowering people to contribute to achieving the outcomes that matter to them.

In other words it’s led by people, not by systems.

If co-production became the way we do things, what would it look like? And what would we be doing differently?

Here’s one view from community worker Dave Horton: “We move across the boundaries that exist between us and others and listen to, and value, those with different experiences. Together we identify common needs and work in solidarity with others to meet these needs. We develop relationships in which everyone receives what they need and in which everyone is able to make a contribution that is valued. Through these relationships and our co-operative efforts, we transform our society into one that is more just and equal.”

This is what’s happening in a suburb of Cardiff where Dave runs ACE – Action in Caerau and Ely – supported by Communities First and Spice. A network of more than 80 community groups and organisations co-produce projects and activities. Most are active participants in ACE’s Timeplace time bank providing more than 31,000 hours of volunteering, by the community for the community. There’s a community-designed health strategy, mentoring and befriending schemes and volunteer community ambassadors helping others to have a voice and to make a contribution, particularly in relation to services which improve physical and mental health.

The impact has been extraordinary. A recent evaluation by Spice revealed significantly improved health, happiness and wellbeing – 71% of participants reported a better quality of life; 50% said they felt healthier; 22% required less social care support and 20% needed to visit the doctor less frequently.

There has also been a positive impact on the community and third sector organisations which work in Ely and Caerau; in this new context, 50% of them have been able to provide improved services with the same or fewer resources. And the increased confidence and engagement of community members is having an impact beyond the community itself. They recently helped to design the new NHS Direct/111 service, providing a unique expertise that led to new insights and potential improvements.

This is what co-production can achieve, as Nick Andrews states, through a restoration of “warm humanity as the driving force for public services, rather than compliance with increasingly centralised and de-personalised processes and systems.”

Co-production needs to become the heart and soul of prudent healthcare. It’s the element which will make the difference between success and failure.  If we rise to this challenge, co-production will increase the impact of all the principles of prudent healthcare. If not, we risk business as usual; at worst we risk the collapse of the NHS. Without co-production, we will continue to do harm, albeit unintentionally.

Here’s an example. Carol is 83, funny, kind, clever and interested in the world. For 10 years she lived independently in a Cheshire home in Abergavenny. Free to come and go with the aid of a mobility scooter, she had friends, a social life and the opportunities to make her own decisions and her own choices – she had an ordinary life. Then she had several falls and ended up in hospital. While recovering she was seen by a consultant who hadn’t seen her before but who looked at her case notes. Without further discussion he insisted that she move to a residential care home.

Frightened that if she chose a residential home she would have to move again if her condition deteriorated, and pressurised to make a swift decision, Carol now lives in a nursing home. The other residents have dementia. It’s on a steep hill so she can’t use her scooter to get out and about. She has no one to talk to, no one to share experiences with. “I feel like a prisoner.”

From a strictly clinical point of view, the consultant probably made the right decision. But those decisions exist in an individual, human context. From that vantage point, the decision was disastrous.

Without co-production, we limit our capacity to only do what is needed, and do no harm since we don’t fully appreciate the needs, hopes and assets of those we are treating, or the community assets, which might be available to support them – and us.

And unless we make the most effective use of our skills and resources in our co-production approach, we will continue to make decisions about who does what, and how, with only a superficial understanding of the on-the-ground reality. Critically, we will continue to ignore or undervalue the vital skills of communication, building trust, empathy etc, and all the capabilities and potential our staff possess that we haven’t thought to ask about or acknowledge.

In short, if prudent healthcare principles are simply passed down from on high as yet another set of requirements on overworked staff there will be no ownership, no engagement and no buy in. The result will be tokenistic compliance.

So what’s stopping us from embracing co-production?

A major barrier is a risk-averse, task-based approach to health and social care which allows and even encourages us to ignore our common humanity and to stop caring for those we are expected to care for. The Mid Staffordshire scandal wasn’t primarily about medical failure – it was about a failure of compassion, compounded by a “system which put corporate self-interest ahead of patient safety”.

There’s another problem – not a lack of compassion but a lack of equity and reciprocity, often for the best possible reasons. Professionals are trained to be the experts and expected to be the authority, offering advice and providing solutions. Service users are viewed, by themselves and others, as passive recipients of this expertise, as problems waiting to be solved.

The result is passivity and dependence, undermining people’s sense of agency, their confidence and their self-belief, with negative impacts on both health and wellbeing. These perceptions can become self-fulfilling, leading to assumptions about people’s incapacity and inadequacy by both health professionals and people themselves.

The people who can make co-production a reality in the NHS are the people involved – staff, third-sector and community partners, and the public. We need to find ways of including everyone in the conversation – from the start.

Above all, we need to take this journey as equal partners, sharing power and sharing responsibility. If we do so, we just might realise Aneurin Bevan’s vision of “empowerment [through] collective action to transform society and lift us all together”.

Ruth is Director of Co-Production Training UK. This is an edited version of Ruth Dineen's article Co-producing prudent healthcare: putting people in the picture, which is published on the Making Prudent Healthcare Happen online resource www.prudenthealthcare.wales

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