Co-production – I wish it well

One of our aims in this blog is to generate interest and responses, and so we are encouraging a wide range of views. In this way we hope to contribute to both extending the parameters of coproduction and to moving to make it happen in reality. Huda, this week’s guest blogger, makes a valuable contribution to that process.

An initial response to ‘co-production’….

I have to confess reading an explanation of ‘co-production’ with a sinking heart: “Oh no, here we go again, I’ve heard all this before – new label, old content”, I thought with a groan and a sigh.

So, am I a disillusioned cynic, a perceptive realist or simply a knackered participant (I hesitate to call myself an activist though I have been described as such) burnt out with the time-consuming (and sometimes almost soul destroying) process of engagement and involvement that has proved largely futile in delivering real and sustainable organisational change? Who knows – perhaps I’m all these things – but this is my dilemma: unless you’re a dictatorial fascist steeped in indifferent ignorance or an unaware paternalistic and benevolent altruist bent on doing good regardless of how that all too often ‘bent goodness’ is received who can possibly disagree with ‘co-production’?

Not I for one, but isn’t it the latest name within health and social care ‘industries’ that resembles countless previous initiatives down the decades advocating similar values?

Amongst other descriptions, I am a black disabled woman and a qualified (person-centred trained) psychotherapist who has served as a non-executive director within the NHS. There are many things I am passionate about – not least culturally appropriate and relevant values of dignified inclusion, choice, control, independence, justice and equity (I’m not that fond of the word ‘equality’ because it’s become a lazy shorthand for meaning that we are all the same and should be treated as such – and, clearly, whilst we should all be of ‘equal’ value, we are uniquely different so to be treated ‘equally’ is oppressive). In psychotherapeutic terms my focus is on reaching our human potential – holistically and practically – or, at the very least, approaching that potential as best we can.

For this to even begin to happen barriers that prevent or disadvantage human potential have to be removed rather than ignored, denied or excused – both by those who experience them and by those who impose them whether advertently or inadvertently.

Sadly I have come to the conclusion that the closest I’ve got to experiencing effective ‘co-production’ that makes a difference to human potential is within the one-to-one therapeutic relationship whether that be client-with-therapist or supervisee-with-supervisor.

Does this mean sustainable ‘co-production’ is doomed to failure at an institutional level? Or, put differently, why is it that ‘co-production’ is nothing new but has merely donned various names from past initiatives and will, no doubt, don new names in decades to come? Indeed, I would suggest that if previous initiatives had been fully implemented and imbedded ‘co-production’ would not now exist – there would be no need for it. Looked at from another angle, examples of good practice would be the norm rather than the exception (if, indeed, sustainable examples can be found).

I believe this unending cycle of ‘same old same old’ will continue unless some of the following systemic, structural and cultural based barriers are addressed (though I should add that no human being can be forced to reach their unique potential even if barriers become non-existent):

Power imbalance: there’s an inbuilt hierarchy between not only ‘professionals’ and employees within organisations but also between service ‘providers’ and service ‘users’ and here it must be noted that the very language used is in itself a barrier perpetuating a fundamental power imbalance between active subjects (the ‘givers’) and passive objects (the ‘receivers’). I would even suggest that ‘the powers that be’ neither want to deal with active ‘receivers’ of services nor know how to due to their varying degrees of assertiveness, confidence, expertise, perceived ‘militancy’ and difficult ‘challenges’ they often present for ‘professionals’ who, in fairness to them, can also feel disempowered by organisational restraints. Furthermore, initiatives all too often are either imposed from the ‘top’ or sneak in underground from the ‘bottom’: rarely, if ever, are they inspired from both ends in any integrated and effective way. The question for me, therefore, is whether it’s ever possible to get rid of the thinking and language underpinning organisational hierarchies of position and status and implement a working ethical practice of differing roles and responsibilities (from CEO to cleaner and service ‘provider’ to service ‘user’) in a way that reflects diversity and avoids marginalisation? After all, all are essential to the life of the organisation and the fact that some are paid more depending on these differing roles and responsibilities doesn’t need to reflect the dubious value of position and status.

Short- and long-term imbalance: it seems to me that organisational focus within health and social care intrinsically favours the short-term over the long. Driven by crisis after crisis these institutions are constantly fire-fighting and are thus forced to react to people’s lack of health and wellbeing rather than proactively promoting these: cure and ‘fixing the problem’ takes precedence over prevention as does ‘sickness’ over ‘impairment’ and ‘acute’ over ‘chronic’ conditions. A medical model approach invariably gets overall attention even if a social model approach gets a look-in every now and then. Removing social barriers doesn’t seem to be as ‘sexy’ as removing medical ones: the former is essentially a long-term commitment dependant on building meaningful relationships to make any impact whilst the latter wins clever experts funding and the publicity of accolades especially where lives are saved. If this is the case then the question is whether health and social care will ever be able to invest and build for the future in a way that is effective and sustainable whilst still having the capacity for responding to immediate crisis: can such an approach be embedded systemically in organisational structures, procedures and policies to endure the inevitable turnover of staff, changing technology and constant strain on budgets and resources that seem to prioritise performance targets over quality of life? And if the answer is ‘no’ then concepts such as ‘co-production’, like its many predecessors, will result in little more than tinkering round the edges of disempowerment and marginalisation wherever it’s experienced.

Piecemeal and holistic imbalance: too much of health and social care interventions and initiatives lack cohesion and integration because, essentially, they fail to see human beings holistically. On the contrary, the physical, psychological, social and spiritual aspects of our total wellbeing are outsourced to different ‘specialists’ often located in scattered ivory towers. And this even when, in theory, it is recognised that human wellbeing is multifaceted. This imbalance is exasperated by the competition between public service and privatised business where valued indicators are driven by profit and a divide-and-rule approach to winning lucrative contracts. Even the voluntary and independent sectors have been forced to bend the knee to market forces and mission creep has replaced their original reason and purpose for existing in an attempt barely to survive: evidence-based outcomes, whilst serving a useful purpose, has become an obsessive mantra that fails to recognise that many things of worth and value cannot be proved.

So, am I against ‘co-production’? On the contrary, I wish it well!

Huda B Bishara

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