Voice, Choice and Coproduction

Voice Choice and Coproduction[1]

A couple of meetings and the twitter feed from the HSJ summit showed me that NHS leaders are still struggle with what patient / service user and carer voice is for. Patient Leaders are now attending gatherings in the NHS to think about futures; or NHS England Board meetings; or Trust Boards open with a patient story. Sometimes service users are involved in co-design processes, and sometimes in prototyping. Boards know they need to engage patients as stakeholders. In my view the language of patient, consumer, and service users are used extensively, but not always with purpose. We just aren’t sure what relationship we want with patients – passive supplicants to expert will; or citizens – owners and supporters of the NHS and our expertise, and partners in the future of NHS services.

There are four distinct places that citizens play an active part in the NHS, through three types of relationships. I argued previously that these have their basis in different policy ideologies in terms of importance http://www.theguardian.com/healthcare-network/2012/mar/21/nhs-reform-radical-approach-co-production, but even so as a healthcare leader and manager these categories help work out what work you should do/ might want to do with citizens.


This is perhaps the hardest as it contains two very different places that citizens should have a voice.

  1. As owners. The NHS belongs to citizens, they pay their taxes for it and the NHS is accountable through parliament and through their Boards to local citizens and communities. As owners they should have a say in strategy, priorities and reviewing impact. Here citizens should be powerful in determining direction and strategy with the health system. As a public service upholding civic society’s values, this is both critical in terms of governance but also as an intervention in society itself. It helps society determine the health care it wants, and the values it supports. In fact ethical decision making at board level also requires a full engagement with the context. http://www.cihm.leeds.ac.uk/wp-content/uploads/2014/05/Ethics-Inquiry-full-report-for-WEB.pdf
  1. As users. Citizens as partners in the provision of their own care, are a powerful partner in feedback and reviewing impact. Often we find professionals have partial sight of a service user’s journey, and that partial sight means they can’t see the whole experience. It means they can try and ‘fix’ the wrong thing with knock-on effects that don’t benefit the user. Working with service users to discover their experience across the whole, and getting feedback on quality, access and experience helps professionals improve their practice. Here citizens are giving feedback to professionals for the areas of treatment and care where they are responsible.


Here we are in the territory of consumerism and markets, where people make individual choices, and those choices drive up quality. Ideologically it relies on the model of excess supply. It can also be shared decision-making, where as a service user you make choices of treatment options, (although others argue this is coproduction as together the professional and user choose a course of action that requires user co-delivery or compliance). At the less dogmatic end of interpretation it means treating people as if they could walk away, with respect for their views, opinions and behaviours. Acting as consumers we have no regard for, and no sight of, any unintended consequences of our choices, or any knock-on effects. It is wholly individualism. In the Barriers to Choice review https://www.gov.uk/government/publications/barriers-to-choice-public-services-review David Boyle argued for choice for vulnerable people to give them some power over their health and health service. He found that:

  • “Somewhere around half the population are currently choosing, but the difficulties vary between different services.
  • There is strong public support for being able to choose, but still around a third of the population find it difficult.
  • People are generally happy with their service once they get it, even if they had no choice.
  • The biggest barriers are a combination of access and information.”

So it can also be seen as a way to share power with citizens, but at present even though this exists vulnerable people are struggling to have access to choices.

Overall its an individual not a collective model of engaging citizens tied into ideologically at present, the notion of competition and individualism


I find that citizens can be actively participating in some elements of coproduction, but rarely the whole. Coproduction means more than co-designing a pathway with some local citizens, it means together (co) deciding what the issue or problem is that needs changing, agreeing together what the change should be (co-design), bringing citizens into the delivery of that change (co-deliver) so that their brilliant resourcefulness, passion, and energy can be part of the future, and then together evaluating whether what you have tried out actually works (co-evaluate). Here are some definitions:

Co-production – people who use services contribute to the production of services. Needham, 2009[2]

“[co-production is] about broadening and deepening public services so that they are no longer the preserve of professionals or commissioners, but a shared responsibility, both building and using a multi-faceted network of mutual support” Stephens et al 2012[3]

“Co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours. Where activities are co-produced in this way both services and neighbourhoods become far more effective agents of change” Boyle and Harris 2009[4]

I was talking with a colleague and friend who had been part of Coproducing Leeds as a probation officer. This was a programme in Leeds that helped lead to the re-commissioning of all drug and alcohol services in the City.

It also changed people’s lives, and lead to partnerships that have endured to secure amazing change – see Altogether Better’s latest evaluation report http://www.altogetherbetter.org.uk/evidence-and-resources (maybe I’ll come back to them in a future blog as their work is significant for the future of primary care). Their bid for Big Lottery funds started in Coproducing Leeds. Anyway, back to my friend. He was saying how years after we started (and finished) our work, he is seeing the impact of it in new areas as they too try to solve historically intractable problems. It showed me that building capacity through coproduction just sticks – for a long time. Our co-evaluation was at the end of the small funding (70K if your interested, but a lot more ‘in kind’ from citizens), http://www.cihm.leeds.ac.uk/wp-content/uploads/2014/03/The-Story-of-Coproducing-Leeds-Dec-2013.pdf but it seems the impact is still happening. In Coproduction you have a shift in power from hierarchies to partnerships and networks that include citizens as active contributors.

So perhaps its helpful to have a look at these options for citizens and healthcare leaders.

For me, there is no future for the NHS if it doesn’t move beyond consumerism and feedback to the more powerful models of citizens as users and coproducers.


Have a great week and catch up when I’m back. This blog is courtesy of a 4.5 flight hour delay!

Walk Easy as they say where I’m going


[1] With thanks to Prof Mike Dent for these categories. Mike Dent Majda Pahor , (2015) “Patient involvement in Europe – a comparative framework”, Journal of Health Organization and Management, Vol. 29 Iss: 5, pp.546 – 555

[2] Needham C, Carr S. 2009 Research briefing: Co-production and emerging evidence base for adult social care transformation. Social Care Institute for Excellence. March.

[3] Stephens L Ryan-Collins J Boyle D. 2012. Coproduction: A manifesto for growing the core economy. New Economics Foundation, London p10

[4] Boyle D and Harries H. 2009. The Challenge of Co-Production. How equal partnerships between professionals and the public are crucial toimproving public services. NESTA. London. p6

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