10 Statements of co-production

This month I co-facilitated the last of a series of 9 events. I have been working with the Coalition for Collaborative Care, spending a day with each of the of the Integrated Personal Commissioning sites. We were supporting them to develop their strategic plan around care and support planning, and ofcourse, co-production is key to this.

As part of these sessions, a member of the co-production group shared the graphic of ‘what good looks like’ and a handout to help people evaluate how they are doing. This was developed as part of the Think Local Act Personal (TLAP) guide to care and support planning and I wanted to share how these 10 statements of co-production were developed and ways people can use it.

What does good look like.png

I developed the TLAP guide with colleagues at NDTi, working with local authorities to explore what the Care Act (2014) would mean for councils.  I wanted to go further than the brief to explore compliance and costs and also look at whether care and support planning is happening in the way that people want. We need to both be compliant, and be moving towards what people want and expect from care and support planning – what good looks like from the perspective of the person. In the guide are 10 powerful statements that set the standard for what people want.

We brought together members of the TLAP National Co-production Advisory Group and the emerging equivalent at the Coalition for Collaborative Care to develoUnknown-22p a set of statements that reflect how care and support planning has to keep the person at the centre of decision-making, and be done in a way that maximises people’s choice and control over their lives and services. We did this though sharing stories with each other of people’s best experiences of planning, and distilling the key elements of that into the set of ten statements. I think they are appropriately ambitious and challenging, and set an agenda for what coproduction at the individual level looks like.

“Really? I can have this? This is possible?” was tUnknown-23he response from one carer when she read them.

From the statements I developed a checklist for both practitioners and people receiving support. This is simply a rating of 1-5 against each statement. Here are some of the ways that the 10 statements  could be used:

  • To share with people what they should be able to expect from services – so that everyone has the same, shared understanding of what good looks like in relation to co-production
  • Within induction and training, led by people who use services
  • To inform satisfaction surveys and evaluation – is this what people are experiencing?
  • To share what is possible by gathering stories of good practice to share across organisations, for example, ask teams to choose their top three stories that reflect the statements
  • For individual self-reflection for pratitioners. Where are you doing well? Where could you improve? How can you do this?
  • With managers, to agree goals within supervision. One example is that managers could ask for specific examples of how colleagues worked towards these statements in developing care and support plans or in person-centred reviews.
  • Within teams to agree team goals to improve co-production. Here are some examples: ask everyone to share an example of how they are working towards a particular statement; ask each team member to share their biggest success around another statement, ask each team member to think about what they do that is working/not working around each statement.
  • With other managers, for example as a practice group or as part of an organisational development programme

 

Please email me if you would like a copy of the checklist (helen@helensandersonassociates.co.uk) and please share your ideas of how we could put them into practice.

 

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Can ‘Parents of Disabled Children’ and ‘Professionals’ have true working partnerships?

 

Today’s guest blog takes us to co-porduction and parents of disabled children, by Joe Whittaker.

Coproduction is not, or should not, be limited to health and social care: we hope that by looking at other sectors aiming to practice coproduction we can identify similarities and learn lessons. This week’s blog is from Joe Whittaker, an academic who has worked for years in further and higher education, and who acts as an advocate for parents and disabled people, as well as being the recently – retired chair of the Alliance for Inclusive Education (ALLFIE).

“You have to love your own baby becos everone says they are a nusance”

Sally age 8

A parent of a disabled child will get whatever support they believe the child requires in school – IF it matches with what the professionals are prepared to offer. If you require something different ,’the parent’ becomes ‘a problem’ to ‘the professionals’.

This parent may be a medical doctor, a police officer, a plumber, a lawyer, a home carer, an MP, even an education inspector but, in their role as a parent of a disabled child, who is challenging the professional narrative, their place in the hierarchy is determined as ‘ less than’ the professional. The more articulate and assertive a parent is, in support of their child, the more they are seen – and have been described – as “bloody awkward”, “too pushy”, “in denial”, “neurotic”, “deranged”,”obsessed”, “too emotional”, “aggressive”, “irrational”, “too involved”, “unhinged” and “unrealistic”. These are just a few of the labels given to parents who expect something different from what the professional has to offer.

This is the context from which local authorities have, for many years, called for partnerships between ‘parents and professionals’. It is indeed a laudable aim. It is however my assertion, based upon 35 years of advocating with parents of disabled children, that there is a systematic devaluation of a parent with a disabled child, particularly when the parent is challenging the narrative of the professional.

Meaningful partnerships are based on equality for the parties involved. In particular those with power to provide service, the professionals, have to learn to listen more effectively to those denied power, the parents. I assert that disputes occur when there is a failure to listen to parents, particularly when a parent does not accept the professional decision.

Does this mean that parents are always right about their child’s support requirements and the professional should always accept the parents’ narrative? Such an assertion is clearly absurd and unhelpful to both parties. It is as inappropriate as assuming the professional always has the answer.

Let us however, consider the two parties in this context.

Professionals :

*        Have a salary.

*        Have an entitlement to travelling and subsistence expenses.

*        Have an entitlement to contracted working hours.

*        Have an entitlement to their access requirements being met.

*        Have access to administrative support.

*        Have access to line management support.

The list is illustrative: these items are, however, part of the typical working conditions that have been struggled for and established over many years and should be robustly protected and enhanced.

For a parent to be in partnership with a professional there has to be a reciprocal practice. Parents, I argue, to be engaged in partnerships with professionals at meetings and other joint enterprises :

*        Should have their access requirements met e.g:

Payment for attendance plus travel and subsistence expenses.

Support for childminding.

Support for other dependants.

*        Should be fully involved in deciding appropriate times, dates and locations of meetings.

*        Should be fully aware of the agenda for each meeting, prior to meeting.

*        Should have administrative and mentoring support from the host organisation.

  • In addition, if the parent is involved or invited to deliver any training, they should be reimbursed accordingly, in line with professional fees.

 

The above are prerequisites, they do not guarantee partnerships. Only when parents feel they are being listened to by professionals, will parents be likely to be open to making their valued contributions, which in turn results in greater confidence from both parties. If such an environment can be created this is more likely to result in openness, transparency and honesty, followed by consensual and constructive discussions. This then provides the real opportunity for power-sharing relationships to evolve and from which all parties benefit.

 

 

 

Co-production – the hallmark of a person-centred organisation

 

Last week I (Helen) was speaking at the Hospice UK conference in Liverpool explaining why I think it is important that we know what matters to both patients and colleagues. I don’t believe that you can expect colleagues to work in a person-centred way, in health or social care, unless they are also supported in a person-centred way. This is why the whole notion of person-centred organisations is critical – being person-centred has to be system-wide, and not simply an expectation of staff. This made me wonder if it is also true for co-production?

Co-production does not stand-alone. There must be a correlation between valuing and investing in co-production, listening and responding to staff, and working in partnership with stakeholders. You would therefore expect a person-centred organisation to have both a culture of co-production with people who use its services, empowerment with colleagues, and partnership with stakeholders, so that everyone is working together to create change.

If co-production is hallmark of person-centred organisation, what would we see? This would mean that people would have comprehensive and clear information about what is possible and what is available to them. The organisation would need to know how everyone makes decisions and communicates them, and, where people do not have capacity to make decisions themselves, advocacy was available and that decision-making always remains in the best interest of the individual. As well as leading decision-making in their own lives, people using services would have opportunities to influence how the organisation develops, and to co-produce change.

If this is important to an organisation – would they declare it? Do you know of any organisation that is explicit about co-production in it’s mission or values? In this series of blogs we have heard definitions of co-production from different voices, and there is a clear sense that the term ‘working together’ just does not address the issues of power that co-production demands.

I went back to some earlier work I had done with Stephen Stirk on creating person-centred organisations, and looked at some of the examples of mission, vision, and values that had impressed me then. Looking at them now with fresh eyes, there is little that you would recognise as an ethos of co-production. Except this one, from support provider, Certitude;

Certitude believes that true and proper involvement begins with people being involved in decisions on the most fundamental elements of their support: who, what, how, where and when.

Certitude also believes in the importance of listening, valuing and acting upon what people are telling us through these decisions. The quality of our organisation depends on our ability to listen and shape our services as a result of what people tell us.

How we ensure that everybody we support is involved in decisions about their own life therefore forms the basis of our involvement strategy. Without this, meaningful involvement at any other level is not possible.

Our strategy also seeks to ensure that those who want more involvement in the way the organisation strategically develops have opportunities to do so.

It is an ambitious strategy; we will be able to evidence the following:

  • Everybody is involved in decisions about their own life.
  • Those who want more involvement in the way the organisation strategically develops have opportunities to do somission

Thinking about co-production as central to what we would expect of a person-centred organisation is changing how I work. I am often asked to support organisations to develop one-page strategies, that describe what success means to them and how they are delivering this. This is where I can start to have the discussion about co-production, and encourage explicit statements of how they support people to direct their own lives, and co-produce change. Please share any mission statements, values statements or strategies that are explicit about commitments to co-production, it would be excellent to have examples to share.

Breakthrough – co-production in practice

As this series of blogs progresses a number of themes and trends are emerging, not least from those which are constructive in their criticism, and here I , Lorraine, want to take one of those themes and illustrate it with a particular example. In a recent blog Bernard Leach flagged up the notion of uneven balance of power as a potential block or problem, and indeed there are many and complex reasons why this is the case. However, if it is recognised then this imbalance can be addressed and the context and conditions that support and maintain that imbalance can be tackled, leading to real change.

In Manchester July 1st 1998 marked a significant development in relation to disability, employment and training: this was the launch day when the culmination of several years of planning and hard work came together to mark the full operation of a new initiative called Breakthrough UK Ltd., the setting up of which was a prime example, from twenty years ago, of coproduction in practice.

This came at a time when many local authorities across the country were taking on board equal opportunities issues in a big way and in Manchester local disabled people had pressed hard for disability to be included alongside race, gender and sexuality as the major areas being addressed, and the local authority had responded positively. Employment and disability was one of the issues considered via equal opportunities structures, with local, segregated provision being looked at critically. Disabled people on the Manchester City Council (MCC) Equal Opportunities sub- committee argued that this was in fact provision which maintained disabled people in low- paid work with little chance of promotion or advancement, and that MCC should redirect the money to more appropriate provision. To cut short a rather long political story, over several years this proposal was agreed as a way forward – with a major plank of this strategy being to set up a new company, controlled by disabled people and completely independent of MCC, to develop and deliver more appropriate employment support.

To be sure, this was a huge project: it required commitment and partnership working from local disabled people’s organisations, the local business community, and the local authority – and these were by no means always readily forthcoming! It required reallocation of existing budgets (always hotly defended) and new funding; it required trade union input over transfer of staff; it required HR and legal advice, as well as advice on charity and company law, and the knowledge around putting in place the structures, policies and procedures needed to get a ‘start up’ off the ground. It needed commitment, and a willingness to change from all those involved – which must be demonstrated most clearly by those in a position to ‘make things happen’ (or indeed, those who can stop things happening), and they must be proactive in that demonstration. It is a given that ‘nobody likes change’ which is why it is so important that reluctance is identified and tackled, that vested interests are challenged, and that a ‘willingness to let go’ is not only supported but encouraged.

But most of all it required that disabled people and their organisations were recognised as equally valid partners by those others involved.

The establishment of Breakthrough was the design and delivery of a joint aim from very different directions. It would not, could not, have happened if those who held held the power, who were the decision makers had not been prepared to encourage and support the initiative and to ‘let go’ where needed.

And look, just look, at what coproduction can achieve.

 

Embedding Co-Production in Health and Care organisations

Bernard Leach has been involved in the disabled people’s movement since the early 1980’s. He is a member of the C4CC Co-production group, and here he shares his reflections on the NHS Expo 2015 held in Manchester.

This was one of the popup university session at the NHS Expo and was led by Ceinwen Giles, cancer survivor. Like other successful sessions it was bBernardased around small group discussions where you could actually get to meet and discuss with other people. This was important to me as the overall NHS Expo experience was pretty alienating. Men in suits and glossy stalls and salespeople, everyone with a lanyard and a badge. Being retired I’d forgotten what these things were like.

Anyway, back to the co-production session. There was an excellent presentation by Amir Hannan (a General Practitioner, Board member for Tameside & Glossop CCG leading on Long Term Conditions and Patient Engagement & Empowerment) about the cultural change needed by clinicians and managers to fully commit to public engagement – lots of training on learning to listen and to trust patients (not straightforward).

“why” until you reach the underlying source of the problem. The question was what stops co production from working? Lots of interesting stuff came out of this. First of all was an observation that the term “co-production” wasn’t that helpful. Whereas “patient involvement” is fairly self-explanatory, the term “co-production” has to be explained and strikes many people as tokenistic, trendy jargon leading to a cynical and hostile response based on how previous initiatives had failed.Then on to the best bit of the session where Ceinwen used the Five Whys tool. This says that when a problem arises, simply keep asking the question

Out of the small group discussions a range of ideas about blocks and problems arose:

  • Uneven power relationships between professionals and other (voluntary groups, volunteers, users, patients). Doctors are generally revered.
  • Uneven access to resources – who hold the purse strings?
  • Cynicism or even hostility based on previous initiatives.
  • Not all patients want or are interested in co-production. There are others who want to be involved but can’t do so for whatever reason.
  • Imbalance of perceived expertise – GPs might feel – “why should I, who has studied for 10 years listen to someone who has had a condition for 10 weeks?
  • Doctors can be surprisingly insecure and touchy about feedback (especially if it is critical). They want to be liked and can be fearful of criticism.

It was agreed that a change of culture was needed in the move away from a purely medical model to an understanding that patients and carers had valuable contributions to make. A move from a target based culture to a values based one. People with long term conditions have skills and resources that can be unlocked, but doctors have limited time and resources to access them. The evidence from places like Tameside & Glossop (in Greater Manchester) is that when training in such skills is given across the board, the benefits become immediately apparent. All in all, a very thought provoking workshop.

Operating Rules and World-Views

UnknownA Google search on co-production reveals six books, and one of these is Co-production and Personalisation in Social Care, by Susan Hunter and Pete Richie, (Jessica Kingsley Publishing). I am keen to read as much as I can, and if you have book recommendations, please share them.

This book was on my summer reading list and I must confess to a degree of bias, I am a fan of Pete Richie’s clear, values-driven thinking and writing, so out of the 6 books on Google, I started here.

Susan Hunter and Pete Richie introduce the idea of operating rules for co-production, and explain how these rules emerge from a ‘distinctive world view’. They argue that co-production can only be successful and sustainable when this world view is consciously adopted. Without this, co-production is in danger as being seen as a technical bolt-on to an existing service system.

This table, from page 17 of their book, is a helpful step forward to describing what needs to be in place – some rules around co-production, and the philosophy or world-view that underpins it.

 

Operating Rules

Underpinning world-view

People who rely on services involved in defining the problem as well as developing and implementing solutions

Recognising that different people interpret situations differently, hold different values and have different investments in a solution, and seeing the goal as securing a shared commitment to action rather than enforcing a single right answer

Tensions and differences between stakeholders discussed openly

Recognising that the interest of professionals and agencies are not identical with those of service users, and that saying one thing to people’s faces while writing something else in a report is almost always in the interest of the professionals rather than the person served

Focus on quality of life issues not just clinical or service issues

Humility about the role of services in people’s lives, and honest awareness of quality and limitations of what is delivered

Engagement of people who know and like the person

Seeing people as part of a social network: and valuing the contribution of friends and family as much as that of professional staff

Use of ordinary language and settings as deliberate strategy to reduce power differences

Recognition of the games that people play to enhance distance and retain power

Engaging the wider community, and viewing this as a resource not a threat

Looking in from ‘out there’ as much as looking out from ‘in here’

A focus on gifts and capacities rather than deficits

Actually believing that everyone has something to offer society

 

We have published 6 posts now on co-production, are we getting any closer to what it is yet, and how do you know it when you see it? 

 

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