How good are you at co-production (really)?
Co-production, or involving people with lived experience of being a ‘service user’, is considered to be at the heart of the project I work on and is being rapidly adopted by the majority of organisations in the health and social care sector and beyond, in some form. I am lucky to have worked on projects that have actually been founded on the knowledge and insights of people with lived experience and I am also considered to be one such person.
As we are all users of services in some form, there is arguably a question mark over where we draw the line between those of us who have had significant experience of multiple issues and therefore often significant professional involvement in our lives, and those who have not. However, this particular debate is not the focus of this article so when I use the term service-user here I mean someone who has had experiences relevant to the organisation in question. In my field for example, it would be people who have experienced severe and multiple disadvantage.
There are also existing debates regarding the differences between what the terms co-production and ‘service-user involvement’ actually mean. For me ‘service-user involvement’ means the inclusion of current and former ‘service-users’ specifically in decisions that effect them.
I see co-production however, as involving all relevant stakeholders including former and current service-users and those with relevant lived experiences, in development and decision-making processes. Making sure that co-production is meaningful however, and done as well as possible, is a significant piece of work in progress. The better we get at it the more we beg the question; What is the logical endpoint of this process? Will traditional organisational structures be turned on their heads, or replaced with something entirely different?
Co-production is arguably an endeavour that categorically disrupts the traditional hierarchies within organisations. I therefore find that when the uncomfortable ‘sticking points’ in co-produced settings occur, it is often where those in power find themselves being asked to examine any limits to the actual value of their own considerable professional experience, experience usually gained rising up through traditional hierarchical ‘top-down’ models.
Other difficult moments may be where those leaders are forced to disclose the limits to their power or the pressures they are under that could perhaps, if examined, even constitute a conflict of interest with the co-produced process that is occuring. If individuals know that certain actions in the organisation must be taken regardless of the perspectives of service-users and other relevant parties generally, then we have potential tokenism regardless of other efforts made to make the co-production process feel truly meaningful.
Often such scenarios can feel very meaningful in other aspects, which is why we need to take care not to hurry to congratulate ourselves just because there are lots of kind faces and gentle voices around the table who look like they are listening very hard to those whose voices often do not get heard. Co-production is about much more than listening, I would argue.
If someone works for years to climb towards the top of a hierarchy and is then asked to participate in an arena that doesn't presume or applaud their authority or expertise, it can understandably be an uncomfortable setting for even the most well-meaning senior manager or decision-maker. That said, I've seen several appear to humble themselves entirely, and when co-production occurs with everyone truly on board, it can be an exciting and productive space to be in. However, I've also been in spaces where it is accepted that all are participating on an equal footing when clearly, at least from my perspective, they are not.
Some of the more obvious examples are when one lone service user is asked to attend a meeting of high level decision makers. There is so much that can be wrong with that situation such as intimidation, the dominance of service-specific jargon, the assumption that one person with ‘lived experience’ represents all and a lack of preparation or understanding of the purpose of the meeting. That is not to mention that ultimately the decision makers present are still exactly that.
Recently however, I have been moved to think about some of the more subtle and less spoken about areas of concern. It seems that even in a space where representatives across all levels, including numerous ‘lived experience’ representatives, are prepared and given equal space to contribute, there can still be issues.
If we think about the purpose of co-production, one would expect that the contributions of lived experience individuals are acknowledged, thoughtfully considered and responded to, that perhaps further conversations develop and then actions are taken based on the ultimate outcomes of such discussions. If this is not what does occur, then those with lived experience who are contributing may as well be in an echo chamber.
Unfortunately, if what is said even by multiple individuals, doesn't fit with decision makers pre-conceived ideals or objectives, then responses by the most well-meaning of those decision makers may not fully acknowledge and prompt an exploration of what is actually being said. Instead, I have observed occasions where the response may be more of a subtle assimilation and re-framing of those voices into vague ‘ideals based’ statements that work, however unconsciously, to artificially unify, or ‘fudge’ the differing perspectives. This seemingly well-meaning act serves to end the discussion rather than raise questions that further explore differing and often, strongly felt views.
If this lack of true acknowledgement and genuine interest is detected by the less powerful and further questioned, then you can find yourself in a game of ‘opinion tennis’ where neither party gets beyond their initial objective of stating their view in order to be truly heard. What is being said by the service user is permitted and supposedly heard, but might never be explored fully to ensure understanding and seek solutions. They may then try to say it another way, receive a similar conversation-closing response, and on it goes..
This could be seen, at it’s worst, to be an insidious form of domination by the powerful, and a maintenance of the traditional status quo. One that, due to it’s subtle nature, all parties could actually be oblivious to. That is perhaps until those that have been disempowered reflect on why they feel frustrated in the aftermath of what, on the surface, appeared to be a very empowering situation.
For the many people with a personal history as service users of being disempowered, due to the decisions and behaviour of those ‘up top’; such negative experiences can also trigger trauma.
Do we have a duty then to ensure that co-production is safe? How can we go about that in a way that doesn't suggest that a ‘tippy toeing’ around those with lived experience is necessary also, which is hardly empowering. I suggest we start by asking the service users.
Subtle and perhaps even unconsciously protective behaviour may actually be some individuals at their most humble and respectful. That is, compared to how they may typically assert themselves. The bottom line however, is that if something is about to be signed off on, or, there are pressures from on high to see a project through to it’s end regardless; it is not going to be easy to welcome and embrace an open-minded thrashing out of identified glitches and potentially game-changing perspectives on already embedded processes.
It is understandably very tempting to re-package what is being heard with words that suggest we are all on the same page anyway and, ever so gently and respectfully of course, bat those perspectives back.
There may also be others present who are subordinate to such decision makers and so feel compelled to more or less back up their seniors position in a similarly inoffensive style. This could arguably go equally for lived experience representatives also I suppose who may for example, side with each other regardless out of loyalty. There are many possible underlying dynamics that may go unnoticed depending on power, allegiance, organisational and personal agendas and so on.
There may also just simply be a poor quality communication, for no obvious or conscious reason. The results, or rather lack of results, may still be the same.
If there is a good and independent facilitator present, one would like to think such situations would be less likely to occur. Perhaps then there is a call for co-production facilitator ‘experts’? As well perhaps as a set of guidelines and agreed commitments to try to ensure a meaningful and healthy process?
For as long as we are working within the traditional mould of ‘meetings’, it seems that without an impartial facilitator at least, there is a risk that it is the decision makers who will take the lead ultimately, however gentle their demeanour. They are free then to decide what is ‘reasonable’, what conclusions are ultimately drawn and what actions will or wont be taken.
I have been to many meetings where the most senior person in the room chairs and steers the discussion. Sometimes this is because there are specific things they want to find out. A facilitator could better ensure that there was no ‘cherry-picking’ from the feedback but there is a question of how to be sure that a facilitator wont bring their own bias into the space. They are potentially in a powerful position and we all have our blind spots. Is it always about sitting in a room anyway, or about stepping into each others worlds?
In my experience it can sometimes be that both ‘sides’ are guilty of thinking that co-production is a forum for putting opinions forward and expecting one ‘side’ to automatically trump the other without discussion. As a staff member as well as someone with lived experience of professional involvement in my life, I am aware that there need to be real conversations so that each demographic can properly understand each others perspectives and constraints.
For example, when I have conversations with the people we work with about what they would like to see in our service and explain the ways in which their desires are sometimes difficult for us to manifest and why, they then consider those reasons and sometimes reformulate their view to find a solution that is viable and desirable to everyone. Genuine open communication encourages respect and unity and better ensures the formulation of appropriate solutions.
It is therefore unhelpful for people to be forming opinions and making recommendations in silos. I am not talking about idealising compromise or meeting in the middle either however. I am talking about radical transparency, a shared understanding of where we are all coming from so we know exactly what we are dealing with and can look to solutions that are actually viable, which may include coming together to challenge those who ultimately determine such ‘viability’.
If we are serious about getting co-production right then I believe we need to move away from just throwing everyone together in a room with good intentions and hoping for the best. We need to develop best practice, then reflect, consult and continue to develop that practice with an open end.
When I say ‘we’, I do of course mean we service users, we people with lived experience, the decision makers and those at the bottom of the organisational hierarchy too, in particular, the frontline staff. The voice of frontline staff who have the closest relationships with service users and find themselves implementing the decisions made, have been deeply undervalued until recently. They too have to find their way of being heard.
Of course there are new systems emerging in this area that appear to transcend much of these difficulties. Community-based, mutual support projects such as Camerados Living Rooms do as much as they can to eschew traditional hierarchical structures and the differentiation between service user and staff. Such egalitarian networks could well be where services are ultimately heading. However, I do not imagine they are without their challenges such as ensuring any funders are happy and the possible formation of unofficial hierarchies for example.
Overall, I feel incredibly positive about the ever more meaningful forms that co-production is taking and the desire for integrity over tokenism that generally pervades. However, if we don't adopt reflective attitudes and become brutally honest about where we could improve, instead of patting ourselves on the back the first chance we get — we will never figure out how truly best to do this, or anything else for that matter. Self-awareness at both the individual and organisational level, is key.
