April blog post – some ideas on co-production

Dear All

Below are some bullet point type notes relating to the final discussion at St Catherine’s on 17 February. Do let me know via email if you’d like to add anything or change anything.  It’s great that the seminar has generated much interest. Since February I’ve been contacted by a number of people/organisations who are interested in getting involved in order to take this initiative forward. More on this later.

I want to write a little here about research and co-production because it is very much an emerging paradigm. Generating knowledge co-productively challenges accepted research practices. The researcher no longer defines clear objectives but instead engages with stakeholder groups in a dialogical process. Whilst University researchers normally adopt a linear approach to research, co-production requires an expanded view of research which blurs traditional boundaries whilst being open to uncertainty and ambiguity. While some may see this approach as unfocussed, I see it as a driver for research which is thoroughly interrogated, socially useful, and, crucially, co-productive. A colleague recently expressed the view that I should have started with clearer ideas about co-production at the outset. But, stating clear ideas about what co-production should be at the beginning would in itself be irreconcilable with co-production. The seminar series is about developing a position on co-production whilst at the same time (however imperfectly) enacting co-production. My only non-negotiable when I wrote the proposal for the ESRC was that co-production is not the same as patient and public involvement, it is about power-sharing, and power-sharing requires new approaches to professionalism. Otherwise, for me it’s a journey.  If anyone thinks this sounds like the road to nowhere, I say ‘watch this space’…

Just one other thing, I shall be developing a book proposal for an edited collection. I’ll be circulating more information on this in the summer, but you might want to start thinking about the possibility of contributing a chapter.

Pamela Fisher, April 2016

Key Words: Power – Space – Peer Support

 Research power imbalances

Dichotomy of paid and unpaid work in a context of shrinking budgets

Unpaid service users/researchers               paid professional researchers

Imbalances in the legitimacy/status of different forms of knowledge (experiential, personal, lived experience, and professional)

People are expected to ‘inhabit’ one ‘role’ or another: either service user, volunteer/peer support worker, paid professional

Co-production involves parity of esteem for all type of knowledge/’roles’

This requires external voices to ‘raise hell’. Reform cannot be achieved from the ‘inside’ only

Community

 Asset based approach, based on community wellbeing. Should involve multiple partners across core services/economy working towards the promotion of wellbeing with a focus on the prevention of mental distress and the development of resilience

 Many resources in the community (800 organisations in Kirklees), but recognition that ‘the community’ can be a hostile as well as enabling. More opportunities in community than anything a service can offer.

 More blurring of roles needed: ‘allow people to give back when they are well’. This is a feature of Recovery Colleges.  Peer supporters also need peer support

Investment in education needed in volunteer and peer support ‘roles’. Recovery colleges are harnessing the expertise and skills acquired through lived experience

ZIP (Leanne) and commissioning training for co-production

Flexibility of using services when needed rather than being ‘service user’

Co-production of commissioning is working in some CCG’s – particularly Leeds. The environment needs to be right for this. How can co-production in commissioning be facilitated?

Key questions: How is the ‘right’ environment created? What forms of governance are required to ensure that service user perspectives are incorporated?

Protected/shared ‘recovery’ spaces required in order to develop the capacity for co-production?

Education, Training and Workforce

Accountability requires service user and peer-led governance

“People with power please listen!”

Commensus – Community Engagement and participative process at UCLAN

Education, Training and Workforce

Professional training didactic, little space for critical political thinking

Involvement of service users is tokenistic rather than core to education and training

Professionals are generally reluctant to share power: a need for some ‘unlearning’ before they are able to facilitate co-production.

Collaborative risk training involving service users, peer support workers, professionals is needed

Ian McGonigle and Kim Woodridge and others have developed resources, but these are under-utilised.

More formal representation of service users required as unionised workers, but this also raises risks.

Need to resist power without becoming what you are resisting (need to consider theory on how power reproduces itself in new forms)

Co-production is a methodology applicable to all age groups, including children

Do we need something similar to Schwartz round in mental health?

Ward rounds

Can be overwhelming for service users and professionals

More space for the wards needed for the facilitation of better conversations in order to overcome boundaries between ‘roles’

Space a recurring theme;

  • To talk
  • To feel safe
  • To think
  • To innovate
  • To do things differently
  • To help blur roles/demarcations

A significant body of theoretical perspectives on space

Need to introduce theory on democracy/citizenship into the area of mental health

Project TOGETHER provide training for peer support workers and ward staff.

Drug and alcohol addiction/Recovery

Services have moved from statutory to third sector, and models have been developed which could have wider application in mental health

Values developed around mutual aid and an asset approach

Recovery approaches developed within build on the idea of Patricia Deegan

Co-production in commissioning very important

Use of digital/social media to facilitate co-production

The Voicebox’: simple to use technology which hosts stories

Inappropriate gatekeeping of people’s perspectives

Digital media may mitigate the tendency to find out what people want but only report ‘safe’ ideas

Maybe ‘let go’ of some approaches to defining research questions, and allow themes to ‘emerge’ directly from service user voices. However, difficult to secure funding this way in current context.

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Talking about co-production…

At the second seminar at the Collaborating Centre for Values Based Practice (St. Catherine’s College, University of Oxford) on 17 February 2016 we recorded some ‘talking head’ interviews with Gemma Stacey & Phil Houghton from the  Critical Values Based Practice Network, Mick McKeown of Comensus, and Tina Coldham of The Social Care Institute for Excellence.

Some really interesting insights here.  We’d like to hear your thoughts, either by tweet using #esrccopro or by contributing to the blog.

ESRC seminar ‘Enacting co-production’ at St. Catherine’s College, University of Oxford on 17 February 2016

ESRC seminar ‘Enacting co-production’ at St. Catherine’s College, University of Oxford on 17 February 2016

 First of all, many thanks to all participants for an interesting and stimulating day. Your level of engagement was great, and your commitment to co-production and social justice very evident. Thanks too to the Collaborating Centre for Values-Based Practice for providing us with such a lovely venue and lunch.

The programme was full – arguably too full – but, that said, I wouldn’t have wanted to have missed any of the papers which were all great. Throughout the day power was a theme that emerged time and time again.  Addressing imbalances of power goes to the core of co-production, and space (in different forms) seems to be important for resisting power. I was heartened by a message I received from one of the participants who commented on our final discussion at the end of the seminar, ‘To me, it felt very much like the safe, shared space we were talking about towards the end’. This suggests that we were enacting co-production – not merely talking about it.

Here are some brief reflections on the presentations.

Introduction

(Click the links to download presentations)

Bill Fulford introduced the day’s proceedings with an overview of the work of the Collaborating Centre for Values-Based Practice at St. Catherine’s. Bill addressed the relationship between values-based practice (VBP) and co-production, pointing out that VBP is now being applied in the traditional bastions of evidence-based practice (EBP), notably surgery. Bill suggested that a balance is required between EBP and VBP, highlighting that this involves dissensus.  Dissensus is a decision-making strategy which respects and acknowledges people’s differing values. This contrasts with the usual organisational/institutional approach of seeking consensus. Bill explained the significance to co-production of the 2015 Supreme Court Judgement in the case of Montgomery v Lanarkshire Health Board. Following this ruling, doctors must now ensure that patients are fully aware of the risks (and alternatives) involved in any proposed treatment. This constitutes a new departure in how informed consent is implemented.

Following Bill’s contribution, I gave an overview of some of the salient points which arose in the first seminar.  Perhaps the key message in this was that co-production involves blurring traditional boundaries which separate the personal from the professional, the sharp distinction in roles between professionals, service users, peer support workers and informal carers. Equally, co-production requires a new approach to research which is more tolerant of ambiguity and uncertainty.  This view is expressed in the recently published N8/ESRC report N8/ESRC Knowledge That Matters: Realising the Potential of Co-Production. 

 The presentations

Some really important raised here which reflect the need to embed co-production in a broader social/civil movement. Sarah Carr drew on Cahn’s work ‘No more throw-away people: the coproduction imperative’, eloquently highlighting the need for external pressure in bringing about reform in mental health care.  Without external political pressure, organisations and institutions adopt or, more accurately, co-opt emancipatory terms such as co-production, applying them as an adroit strategy to perpetuate the status quo and existing power relations. The legacy of Goffman’s total institution is maintained, turning people into aliens and alienists. In brief, Sarah’s paper pointed to the necessity of not entrusting organisations to reform themselves, arguing that internal reform requires external pressure – hell-raising.

Peter Ryan followed Sarah by outlining the key principles and values of co-production based on power and control, reciprocity, an asset perspective, social capital, and redefining work.  The values identified by Peter appeared to resonate with just about everybody. What Peter subsequently provided was a really well thought through systematic framework for promoting co-production.  Peter’s model incorporated all levels of a system, from commissioning and organisational processes down to the micro level of everyday interaction. Partnership is key to the goal of creating a system which empowers people to look after themselves.  Peter presented a detailed and really helpful action plan for implementation.

The last presentation of the morning was by Ruth Allen who spoke engagingly about the need to re-imagine professionalism with co-production at the centre. Emphasising that professionalism should be developed through a synergy of personal and professional learning, Ruth argued against the traditional model of detached professionalism.  As Ruth put it (taken from the film ‘An ecology of mind’ by Nora Bateson), ‘A role is just a half-assed relationship’. This distinction between role and relationship summed up the views of many of us who believe that authentic relationships are central to co-production. Ruth’s presentation argued for systemic change and for greater sensitivity among professionals who can unwittingly inflict minor injuries in everyday interactions.

In the afternoon, Gemma Stacey’s and Philip Houghton’s paper (co-authored with James Shutt) representing the Critical Values Based Practice Network, was based on a study which investigated co-production or, more accurately, its tendency to be absent, in ward rounds. The paper critically interrogated how the exercise of power – a recurrent theme throughout the day – meant that patients were often not even routinely informed about their treatment and care. In co-production with patients Gemma and Philip have developed a guiding framework to enable busy professionals who may have their minds on target and efficiencies to enact shared-decision making/co-production. The model, developed by the Critical Values Based Practice Network, involves a practical step-by-step approach towards the three ‘i’s: being informed, being involved and being influential. Many commented on the usefulness of the model, suggesting that it might be adapted for contexts other than ward rounds. Lots of food for thought here.

The final presentation was by Ms Keeble who provided an insightful view of co-production in action by speaking about the development of the Bristol Co-production Group, initially formed to co-produce a change in mental health assessments. The Group, which was co-produced by Laurie Bryan (service user lead); Lu Duhig (carer lead) and Bill Fulford (academic lead) is based on ‘three keys’. These are: 1) active participation of the service user and carer; 2) a multidisciplinary approach and 3) strengths, resiliencies and aspirations of service users and carers. Among the valuable lessons that emerged from Ms Keeble’s presentation is the insight that the journey or the process of working towards co-production is an important as the destination. In other words, co-production is a learning process for everybody.  The positive outputs achieved by the Bristol Group include publications and the development of educational materials for mental health nursing students. The Group evidences the productive power of dissensus.

And finally

Overall, the day provided an opportunity to share ideas both on and in the spirit of co-production and, once again, thanks to all participants.

In my next blog I’ll post a list of points which emerged as a result of your reflections in groups.  These points will be used to develop a focus for future research collaborations and applications.

Pamela Fisher

Montgomery Judgement

Bill Fulford speaks about a new legal departure towards co-production

 Bill Fulford (Click to download Slides) introduced the day’s proceedings at the second seminar of ESRC series Re-imagining professionalism: towards co-production with an overview of the work of the Collaborating Centre for Values-Based Practice at St. Catherine’s College, University of Oxford. Bill addressed the relationship between values-based practice (VBP) and co-production, pointing out that VBP is developing strongly in bastions of evidence-based practice (EBP), notably surgery. Bill emphasised that EBP and VBP are partners in clinical decision-making (VBP ‘links the science of EBP with people’). At the heart of values-based decision making is dissensus.  Dissensus is a decision-making strategy which respects and acknowledges people’s differing values. This contrasts with the usual organisational/institutional approach of attempting to enforce consensus. Bill referred to the recent (2015) Supreme Court Judgement on consent in the case of Montgomery v Lanarkshire Health Board. This strongly endorses co-production. It specifies that for consent to be legally valid: 1) clinicians (of any kind not just doctors) must engage in ‘dialogue’ with their patients, to the point that, 2) they have sufficient understanding of the risks and benefits of the options available such that, 3) their individual values are ‘taken into account’ in the decision made. This judgment marks and gives new legal weight to established principles of person-centred decision-making (as in the GMC’s ‘Good Medical Practice’ for example). It shows the extent to which principles of co-production are becoming more influential not just in mental health but across health and social care as a whole. The Collaborating Centre will shortly be announcing a conference on the Montgomery Judgment: Lady Hale, one of the Montgomery judges, is a Keynote speaker.  (Hold the date, Friday October 28th.)

Seminar 2 Format

Please note the second seminar is now full. Should you wish to be put on the waiting list for this seminar please email esrc-co@leeds.ac.uk .

9.30 Registration (with tea and coffee available)
10.00 Bill Fulford, welcome and introduction to the collaboration between the Centre for Values Based Practice, St Catherine’s College and the Leeds University initiative on co-production. Pamela Fisher, summary of key points arising from seminar one. Housekeeping and scene setting

10.30 Presentation by Sarah Carr and Peter Ryan of the University of Middlesex. Sarah is an Associate Professor of Mental Health Research, Middlesex University and an independent mental health and social care consultant and researcher. Sarah is Co-Chair of the National Survivor User Network (NSUN) and uses her lived experience of mental distress and service use in all her work. Peter Ryan is an expert in mental health. He is currently establishing a research centre for co-production in collaboration with Sarah Carr at the University of Middlesex.

11.15 Café style discussion based on presentation
11.45 Facilitated feedback, questions and discussion of arising themes
12.15 LUNCH
1.00 Presentation by Ruth Allen followed by questions and comments

Ruth is Director of Social Work for South West London and St George’s Mental Health Trust and a Research Fellow at St George’s University of London. She is Chair of the national Social Care Strategic Network for mental health which promotes effective social work leadership in mental health and former Chair of the Mental Health Faculty of the College of Social Work.

Presentation by Philip Houghton, Gemma Stacey and James Shutt
Philip Houghton is a clinical psychologist with a particular interest in the impact of power on individuals and systems, both within and outside of the mental health systems.
Gemma is the Academic lead of the Critical Values Based Management Centre, University of Nottingham. Philip is a Clinical Psychologist and Practice Leader of the Critical Values Based Management Centre, Nottinghamshire Healthcare Foundation Trust.
James Shutt is the service manager of POhWER. Coming from an advocacy and voluntary sector perspective, he is interested in the lived experiences of people with mental disabilities.

2.00 Identification and discussion of key points arising from presentations and discussions

2.30 Round table discussion introduced by presentation (10 mins) by Ms Keeble.  Ms Keeble uses mental health services. She is a founder member of the ‘Bristol co-production group’ which has grown from its original brief to produce many collaborations, including the partnership teaching of mental health nursing students

3.30 Summary of key points and emerging focus for research applications and outputs

4.00 Additional Networking opportunity

Seminar 2: Enacting co-production

Seminar 2: Enacting co-production is to take place on Wednesday 17th February at St. Catherine’s College, University of Oxford. Speakers include Dr Ruth Allen, Director of Social Work for South West London and St George’s Mental Health Trust and a Research Fellow at St George’s University of London, Dr Sarah Carr, Associate Professor of Mental Health Research, Middlesex University, Dr Philip Houghton, Clinical Psychologist and Practice Leader of the Critical Values Based Management Centre, Nottinghamshire Healthcare Foundation Trust, Ms Keeble, founder member of the ‘Bristol co-production group’, Professor Peter Ryan, an expert in mental health, Dr Gemma Stacey, Academic lead of the Critical Values Based Management Centre, University of Nottingham.

Please email esrc-co@leeds.ac.uk to request a place at the seminar.