Our Learnings

These are some of the hard-won perspectives gained through the year-long project. They are a little unstructured at the moment - just a list, really. We hope to translate them into a more coherent paper in the near future.

There are lots of definitions of coproduction; the one we use is not the only accepted definition. We use this, "Coproduction is a process that involves people in the design and, crucially, in the delivery of the services they enjoy. Codesign is a similar process, it involves people in the design of services."

There are lots of reasons to use coproduction, but don't do it simply because you want to save money.

Coproduction means that in a very real sense you are handing over some control of the project to people who may not share your sense of the problem, the solution, its urgency or priority. This has several consequences...

• what you felt was the issue, the health problem, may not be the same problem as perceived by the community; this means you may have to change the permissions you have, your stakeholders and your priorities, if you accept their view; if you don't, you may have to change your mind about coproduction or working with this community,
• with a redefined problem, you may have to accept that their ideal solution no longer lies completely within your domain (ie, within the NHS); this may have implications for your project, if you accept their view; if you don't, you may have to change your mind about coproduction or working with this community,
• the community may not share your sense of urgency - this is not their job, it is a small part of their lives, nor do they necessarily have your access to data and even if they did it might not mean the same to them - so you may have to accept that the timing of the work is no longer under your control; this has implications for deadlines, local agreements, budgeting and project resourcing,
• people's energy and passion is part of the new resource to support new ways of delivering service, so finding it, maintaining it and even building on it is the real work in coproduction; because these projects can take some time, the maintenance of this energy is a crucial challenge,
  energy can be maintained by ‘hard' factors: time, money, child care, etc or by ‘soft' factors: fun, kudos, respect, acknowledgement, socialisation - team work, shared experiences and events, etc.

People get used to the idea of coproduction at different rates, and use different bits of information or experiences to complete that journey. Don't assume that because you said it once clearly people have got it; repeat, rephrase, reinterpret. Allow time for the shared meaning to emerge. Don't assume that usage of the term implies understanding; radical processes are often mutated into old, familiar processes but with the new names.

Coproduction has more in common with the principles and aims of ‘community development work' than with those of traditional NHS roles; it has been far easier for community development workers to do this than health professionals. Professional training emphasises complaints and problems, which the professionals will solve for their patients and clients. Co-production requires complementary approaches such as collaboration, negotiation and the identification of capabilities (not simply deficits).

There is a ‘layer' of people (which includes the CDWs) that are perceived to be half in the community and half in the PCT; as a consequence their relationship with people is broader, deeper and more empathetic. PCTs need to develop this layer as a necessary and important interface to the larger community. Don't forget, from a community perspective GPs are probably in this layer.

Ethnography (anthropology) is becoming a core competence for codesign and coproduction; it delivers a holistic understanding of why people behave the way they do - the rationality behind the seemingly irrational. As a minimum, it requires a degree of ‘emotional intelligence' from staff who work with the community, an openness to accepting people as they are and working with that understanding, rather than assuming they will change.

This rich and holistic understanding of people and cultures can tend to reside in the heads of too few people. To avoid reinventing (and asking people the same things over and over again) you may need to develop knowledge management systems to hold, communicate and utilise all of that information.

There are possibly some methodological issues to get out of the way first: some people believe it is inappropriate or unethical to get so close to a few people or that we shouldn't pay people to help us develop services.

Coproduction implies that the project team has the authority to make offers to people. At one level it means that, before you embark on a project to coproduce a service, you should have the authority and resources to complete that journey in a way that is meaningful to the participants. It also means that someone in the project needs to know the contractual context, to check whether it is constrained by another commissioned contract, for example.

We're all still working out how to do this; none of us are operating as technical specialists to plug a deficit, we need to position our work as a "co-enquiry" - together we'll work out the best way to do this.

A good place to start a coproduction is with ‘outrage'; if you can find people who are prepared to bang the table about something, if there is ‘energy' about a certain topic, then you are much more likely to create a movement, which means you have more people to help, they are already motivated and your solution is more likely to have broad appeal. It may also mean that your sternest critic is now your prime resource, you have to be able to see disagreement as good energy.

If coproduction is your goal then the presence of this energy is as important as statistics and strategy. To get this it may be necessary for senior people to spend time with the community, doing the ethnography we mentioned earlier.

This sometimes requires the creation of a neutral space for conversations, which is what a good commissioning PCT should provide, but legacy relationships may get in the way. We need to think more about how to handle these long-standing relationships and ‘ways of doing things', and also bring in more help to create the necessary conditions for collaboration.

It seems that commissioners do not yet have the systems to do ‘commissioning' comprehensively. They have focussed on the use of public money to support service provision through commissioning, with all the requirement for audit trails, transparency, efficiency and good governance. What World Class Commissioning is identifying is the need for skills in engagement and collaboration with all sorts of communities of interest both public and professional.

Coproduction projects must guard against being cast in a paradigm that requires clarity of objectives, resources, stakeholders and schedule from the outset, as this is unlikely to be appropriate to an innovative, coproduced (and therefore emergent) process.

Hence, in reporting progress of work, you should emphasise the value you have added, the changes you have made, as it maybe that you cannot demonstrate completion of objectives that were modified by experience or that became inappropriate during the work.

In this regard narrative recordings throughout the work are important indicators of the direction and magnitude of change; do lots of this, and allow ways for all team members to record easily their own personal discoveries and learnings at any stage.

Coproduction is relatively new and causes anxiety; organisations may seek to mitigate any risks they foresee by restricting access to certain groups. Our experience suggests that you need to have free rein to connect with whatever groups seem appropriate as the project matures. ‘Hygienic' projects risk creating solutions that will not be robust, do not have all stakeholders on board, and are less likely to create system-wide learnings.

Don't imagine that this is Day 1, at the start of any project. There will be history. Ask about why they are where they are, why the situation is as it is.

Try to do coproduction as much as possible in multi-lateral meetings rather than in a series of bilateral meetings, it establishes openness, trust and fosters a shared understanding of language, aims and process.

With sufficient facilitation and support, it is possible to coproduce at each of these stages of the commissioning cycle: Assessing need, Reviewing service provision, Deciding priorities, Service design, Procurement, and Service delivery. Can we provide examples at each stage?

PCTs have developed expertise in doing stuff, now they need to get better at working with others to do stuff. The change of emphasis is significant; many of the existing systems of compliance and performance management are designed to stop people doing their worst, rather than helping people to do their best. This new posture will rely on goodwill and reciprocity as much as it will on rules, governance and contracts. It will require possibly all levels of the PCT to consider how they can facilitate others (ie, the community) to deliver what was formerly the PCT's sole responsibility.

PCTs need to think about resources in a way that doesn't assume their value is solely financial. Two examples: both PCTs couldn't get their GPs to do anything significant without paying them; there was an assumption that community members' ‘participation incentives' would be cash-based, rather than socialisation, kudos or childcare, for example. Coproduction provides a way to have this debate, to re-value what happens outside the contracted economy. PCTs simply don't have enough money to do everything, and in a credit crunch they will be even more constrained; they have to be a part of a contract economy and a gift economy and other sources of resourcefulness.

It seems clear that PCTs can work at one of three levels: they can offer services, they can offer capacity building, or they can offer gifts (grant aid). The first two permit some measure of control and require performance management, the last does not (though you can affect some control via the selection process). We believe that organisations will have to understand more clearly what constitutes a ‘valuable' gift in their community, as it may not be money that motivates and sustains coproduction.

If the gift economy is based on reciprocity and exchange it will be ‘managed' very differently from the ‘money as resource' system. The necessary processes for probity in the spending of other peoples' money may not be helpful in gifting and supporting the release of resourcefulness in communities.

Inertia, lack of belief and learned helplessness are often used to describe the mindset of some participants in this work. Possibly true, but hardly ever fair. What seems to help is simply to do something together, success breeds success; make the project steps small and highly likely to succeed, let people see and experience the progress and they will begin to believe. In innovation we don't know when small changes will evolve into a breakthrough, so lots of small starts is a good strategy.

Engagement, the process of connecting with a PCT's stakeholders, has to be seen as a means to an end rather than the end itself. There is a tendency to engage, but then not to value, integrate, act upon, or be open about the information that was collected.

What keeps things the same? Why isn't there more dissatisfaction with the status quo? We believe this sort of energy is necessary at all levels for coproduction, or significant change, to be considered.

The NHS always has two core purposes. To produce personal goods for individuals and public goods for populations. We need to develop some ideas around how we scale up from personal, coproduced solutions to services for populations.

Maybe the conditions for the spread of a new idea - coproduction - are upon us: the policy desire for better engagement and involvement, the community's needs for more personalised services, plus their increasing desire for a better experience of care, the epidemic proportions of lifestyle-associated long term conditions, and financial constraints due to the recession.