Co-producing the behemoth – NHS Wales

Now here’s an interesting thing…fresh from his appearance in the code of the Social Services & Well-being Act, the glorious Edgar Cahn pops up again in our Health Minister’s introduction to Prudent Healthcare:

The idea of co-production is today one which is widely and approvingly quoted. That is not to say that everyone uses the term in an identical way. Here in Wales, the dominant strand is that which draws on the highly-influential work of Edgar Cahn. At its ethical core lies the notion of reciprocity – the give and take which creates the social bonds that hold us together in a common life and which relies, for its vitality, on the innumerable individual encounters in the services we use. The purpose of those encounters has to be emancipatory – always aiming at fostering and promoting the autonomy and capacity of the individual, rather than undermining it.

Prudent Healthcare is intended to save the NHS in Wales. It is based on five principles.

  1. Do no harm
  2. Carry out the minimum appropriate intervention
  3. Only do what you can do
  4. Promote equity on the basis of clinical need …and
  5. Remodel the relationship between user and provider on the basis of co-production.

Principles 1 to 4 focus on the behaviour of health professionals and on a medical model of health. The application of these principles will certainly encourage a more thoughtful and effective use of resources, including staff resources. This is clearly important. But it’s simply not enough. Despite their merits, these principles on their own will not lead to equality and shared responsibility – the core ambition of Prudent Healthcare.

It’s possible to work with each of these first four principles and still retain existing power relationships – internally, with partners, and between those who provide healthcare services and those who use them. The NHS can become more prudent and yet remain compliance-focused and bound by risk-adverse systems, many of which actually undermine human relationships.

Only principle 5 ensures culture change, refocusing on people and relationships, and embracing the social model of health in all its complexity.

And only principle 5 offers the possibility of transforming the NHS from an organisation which treats ill people into an organisation which works in equal partnership with citizens to improve the health and well-being of all of us.

  • Co-production will increase the ability of NHS staff to do no harm and to carry out the minimum appropriate intervention, since they will become aware of the needs, hopes and assets of patients, and the community assets, formal or informal, which might be available to support them – and the NHS.
  • And if the workforce are included in the co-production approach, decisions about what you can do will be based not simply on established clinical hierarchies, but on the equally vital skills and attributes of communication, building trust, empathy and compassion. In other words, they will be based on all of the capabilities and potential that staff possess.
  • Co-production also offers the possibility of ownership, engagement and buy-in – from staff, statutory and third-sector partners, communities, patients and citizens. Mark Drakeford concurs:

This sense of shared and joint decision-making is the opposite of the cold managerialism which has played its part in the history of social democracy, as well as being the dominant strand amongst the privatising and marketising right. …Co-production is achieved by amplifying the collective voice of users as well as by the choices each of us makes. No user of public services ought to be left as an isolated individual but should be enabled to link with others. We have given insufficient attention so far to the contribution that third sector, user-led, organisations can bring to the practical delivery of the co-production principle.

There’s another reason why we should place co-production at the heart of Prudent Healthcare – the need to align culture and practice across both health and social care. Co-production and personal outcomes underpin the Social Services & Well-being Act, and will be embedded in the regulations and code of practice. The Welsh Government intends to make personal outcomes the foundation for integration, and the cornerstone of regulation, assessment and improvement in social care. Speaking at the National Social Service Conference in July 2014, the then Deputy Health Minister said:

We must make our commitment to a new relationship with people a reality… looking not just at what they need but what they can contribute, building on people’s strengths and abilities… and involving people in the design and delivery of services. The National Outcomes Framework sets the foundation.

Integration requires the NHS to make a similar hearts and minds commitment.

An assertion. If we collectively rise to the challenge of co-production, it will increase the impact of the other principles of Prudent Healthcare. If not, we risk business as usual, albeit with some additional tick-box tasks. At worst we risk the collapse of the NHS. 

So best we collectively rise!

This post is taken from an essay in the Prudent Healthcare e-publication which was launched today. ‘Co-producing the NHS: putting people in the picture’.

A link to Mark Drakeford’s introduction is here:


About Ruth

UK National Teaching Fellow, Founder of Co-production Wales (All in this Together), co-pro trainer and consultant, working to make co-production 'the way we do things' in Wales. And having a ball!

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