An emerging co-production toolkit
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In the old days there was a fairly straightforward link between the health needs of a group or community and the service they received. There was a linear logic between the two - the professional spotted a need (a health problem or deficit) and created a service to deal with it. Different structures were put in place to deal with demand or provide more rationale about cost and benefit, but that was the way it worked.
In the new world we have something between the two called a specification, but the linear logic is still in place, you spot the gap and design a service to fill it, or you identify the problems with a service and work to improve it. This is fine and in many cases it is appropriate and will work well enough.
However, its linearity can be a weakness. By reacting, by simply fixing what's broken, it improves what exists but it risks maintaining something that could and perhaps should be transformed. Also by satisfying what is obvious, clinically indicated, or defined by statistics or the health needs assessment, it may miss the real point. What people need is not always what they want.
These days its focus on deficits is also seen as a weakness. Though it needn't, it does seem to characterise people as uniform and ‘needy', diabetics with the same clinical issues, someone to be done unto, and not as we recognise each other as individuals with skills, resourcefulness and energy.
Our focus on coproduction - getting people involved in the design and delivery of their services - has put this old world focus into stark relief. We know that our research into health need must focus as much on capability as it does on problems. And we now know that if we want to get people involved we have to deal with what they want, not just what they need.
This is a tricky one. In a world of finite (maybe even dwindling) resources, where we can't even afford to satisfy their needs, how can we possible countenance their wants? When the best evidence suggests they need this... can we justify not doing that? Well, in some cases, probably not. But we have also to acknowledge that we do also have evidence of unused medication, therapies ignored and good services under-utilised. In some cases, particularly in "lifestyle" conditions, and where we are consciously aiming at people's engagement in the service, we have to be prepared to do what they want. Where their motivation is every bit as important as our medicine, we must frame our work within the dimensions of their lives.
We need people to be willing participants in their health and in the services the NHS offers; that is probably the only way will deliver a solution on the same scale as the problems.
This project has explored techniques to move beyond the linear logic of need-spec-service. We have rediscovered the value of listening, sharing and empathising and in so doing empowered people working at the interface: health visitors and community development workers. We have created relationships with people that have been sustained over months and which have resulted in them doing things that, as a PCT, would not have had the scale, stickiness or legitimacy they achieved.
