Consumers, Citizens and Co-production

Gerry takes another look at the historical origins of co-production and how it informs our approach to health and social care.

In my last ALLIANCE viewpoint I reflected on the importance of co-production as part of Sir William Beveridge’s original blueprint for the NHS and social care.

In making his vision a reality Beveridge asserted the need for individuals to rise above personal interests and ‘stand together’ to improve the lot of everyone in society.  Beveridge recognised that achieving this aim would require an immense act of ‘national unity overriding the interests of any class or section’; a task which he thought attainable due to the unique sense of solidarity engendered by the world war in which the nation as a whole was then engaged.  The deal therefore was that the state would provide comprehensive healthcare and a level of ‘social assistance’ with individuals, as part of the social contract, participating in a system of collective citizenship where everyone contributed and benefitted.

In the 75 years since Beveridge, the role of the ‘citizen’ in respect of public services has varied from passive recipient in the early days of the welfare state to consumer under the market tenets of New Public Management.  Increasingly however, the role of the citizen as co-producer is recognised as the means of responding to the challenges of increasing demand and austerity as well as addressing the perceived democratic deficit in the planning and provision of health and social services.

Scotland has largely rejected the most stringent aspects of market ideology in the governance of its public services, yet in broader society consumerism is rife and this itself impacts on the perception and expectation of roles in the relationship between citizens and public services.  If we leave aside the enormous contribution that carers, volunteers and the third sector make to the health and wellbeing of our society this begs the question – does an appetite exist in our society today for individuals to act, as Beveridge put it, in the ‘common interest of all citizens’ or in other words as citizen co-producers rather than simply passive consumers of health and social services?

Malby and Turbitt in their 2011 Guardian article illustrate that that the social contract envisaged by Beveridge remains relevant in our consumer age i.e.  ‘… Co-production and self-help are the best options we have for improving public services.  Both would be much easier in a world where we were all citizens and co-owners.  The NHS needs a rich, mature relationship with patients who perceive themselves as citizens, who feel an intrinsic responsibility not only for their own health but towards others who need help …’

Whilst there are many fine examples of co-production both at individual/practitioner level and in the co-design and commissioning of public services, I would submit that we have some way to go before we live in the world aspired to by Malby and Turbitt.  We are also fortunate not to face a national crisis of the magnitude of a world war that might unite us around the step change necessary to produce this paradigm shift in the short term.  So given this, how do we progress towards a more citizen co-produced health and social care system?

As suggested by Loeffler and Hine-Hughes we need to ‘… focus strategically on the areas where co-production is likely to work best and be the most cost effective way of achieving outcomes …’

Pestoff suggests two factors are important in determining these areas of strategic focus; the ease with which citizens can get involved in public service design and provision and the importance or salience placed on the service by the citizen?

Ease of service access depends on things such as availability of information and transport, location, and opening times whereas salience reflects the degree to which the service impacts directly on the day to day lives of a person and their loved ones.  The more vital a service is to an individual’s life the greater the motivation to engage in co-producing it.  In this respect Pestoff distinguishes between enduring and non-enduring services. Enduring services, associated with the management of long term conditions, require that those with lived experience of a condition i.e. in the role of service user or carer, combine their knowledge, skills and resources in a continuing relationship with those who have professional expertise in order to achieve the best possible outcomes over the longer term.  Such exchanges offer opportunities for co-production on a collective basis due to the solidarity engendered by shared health challenges and interest.

To my mind citizens today are willing to act as co-producers rather than passive consumers, albeit conditionally.  Where there are common challenges to overcome and benefits to be achieved from collective co-operation then citizens will engage in co-production with one another and public service providers.

Whilst consumerism is pretty well rooted in our 21st Century society, shifting the balance towards a more co-produced health and social care system is not impossible.  It is however incumbent on policy makers and strategists to focus on and invest more keenly in promoting citizen co-production in those service areas in which longer term relationships make its success more likely.

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