Paul Corrigan, during one if his typically engaging presentations at the end of our first People Powered Health all-locality event on Tuesday 11th October, drew on the words of Antonio Gramsci to express the kind of spirit that he feels the six projects will need as they embark on a journey ‘to take coproduction from the margins to the mainstream.’ Paul made the point that successfully tackling the kinds of barriers that the projects are likely to face over the next 18 months will require, in Gramsci’s words, ‘pessimism of the intellect, optimism of the will’. In other words, projects should predict and plan for the worst, while at the same time hoping for and expecting the best. It was a fittingly thought-provoking motto with which to conclude a day which had presented both daunting challenges and exciting possibilities for the enterprising and ambitious people gathered in the room.
It has been a gruelling summer for the sites, as we gradually whittled down the applicants for the People Powered Health programme from a staggering 108 initial applications, to the final six: Calderdale and Huddersfield Foundation Trust, Lambeth Living Well Collaborative, Leeds Community Healthcare NHS Trust, Newcastle Bridges Commissioning Consortium, Stockport Metropolitan Borough Council and NHS Kirklees, and Turning Point (you can read more about the projects and their proposals here). Through three different stages, applicants were asked to defend their ideas, test and interrogate their own thinking, and demonstrate that they were adequately motivated and equipped to be part of the programme. Those who attended Tuesday’s event thus seemed visibly more relaxed than they have been in recent months – even managing a joke or two – because their place on the programme is now official and secure. At the same time, we are all aware that the really hard work has yet to begin. There is a long road ahead, and yet everyone in the room demonstrated a keen desire to share, learn, and work hard to realise their goals. It was nice to see, during the ‘project mingle session’ that kicked off the day, that there are already friendships and alliances forming between different sites, and an overall atmosphere of co-operation and mutual support.
Coproduction inspiration: Making coproduction real
After the sites had had the chance to get to know more about one another and the work that they are each doing, we held a ‘coproduction inspiration session’, in which four practitioners of coproduction were invited to share their experiences and answer questions about how coproduction might work in concrete, everyday, practical contexts. What exactly does ‘building on people’s assets and capabilities’ really mean? How does ‘facilitating rather than delivering’ work in practice? How is it possible to build a peer support network?
Alison Paule spoke about Paxton Green’s Timebank scheme, which works alongside Paxton Green GP clinic and consists of a network of about 300 people exchanging time and skills at the same time as building new relationships, gaining confidence, and becoming more active and integrated in their communities. From helping out with the shopping to doing people’s gardening, members of the Timebank donate one hour of their time in exchange for one credit, which can then be ‘spent’ on support from other local people when needed. It was clearly a popular and successful model, from which hundreds of people benefit, but what were some of the issues and practicalities involved in running it? How did people find out about and join the Timebank? What happened when they registered? How was the network of people managed? How many staff did it take to run it? Did social media play a role in helping the members to stay in touch with one another? With 10 years of experience of working in Timebanks, Alison was well-placed to answer the many questions that attendees had about what a Timebank might look like. One concern that was raised related to the issue of safety and accountability – were there any safety implications around introducing new people to one another, and could the Timebank be held accountable for them? It was heartening to hear that, in her ten years of working in Timebanks, Alison had never heard of any such problems – and in any case, the Timebank is only in effect an intermediary, supporting people to connect to one another through mutual and reciprocal relationships, and cannot be held responsible for what happens beyond that. Someone else wanted to know how GPs viewed the Timebank – were they supportive of the concept? Again, it was positive to find that, in general, GPs were receptive to the Timebank, and happy to encourage their patients to join it. Lack of time was however the main barrier to GP engagement, but Alison’s team were taking the right steps towards overcoming this, through for example attending the weekly staff meetings and enlisting the support of the nurses and receptionists at the Paxton Green clinic to be as active as possible in promoting the model.
We also heard from Bill Mumford, CEO of the disability charity MacIntyre, which has developed a new recruitment, training and staff development strategy to ensure that interactions between frontline staff and people who access the charity’s services increase choice and control; Mike Wright, who works for Keyring, a charity which works with people with disabilities to support them to share their skills and talents with each other and their communities, and Alex Kenmure from Camden Council, which has developed an Outcome Model that has enabled a major shift in commissioning and procurement in the Council. All of them had interesting, unique and inspiring angles on the power and potential of coproduction, and the issues involved in making it work.
What are the barriers to success?
So what will it take to make the People Powered Health programme successful? In the middle part of the day, we ran sessions with the sites on the importance of learning from their experiences of implementing the programme, taking lessons from the successes, failures and challenges that they encounter, and gathering sufficient evidence of impact to build a strong and robust business case. The sessions raised a number of concerns around the likely difficulties that sites will face in capturing the multiple outcomes of their work. How is it possible, after all, to measure the effect of increased patient self-esteem, the impact of which is most likely to have health, financial and social benefits? And what about the benefits that might arise some way down the line in a different part of the system - such as reduced reliance on the criminal justice system or social services? There is very little precedence for this kind of impact measurement in a healthcare system that until now has been characterised by a narrow focus on the medical outcomes of care and treatment.
Paul Corrigan took the baton at this point, and finished the day by facilitating a discussion about the barriers that stand in the way of taking coproduction to scale, at both a system and project level. Some of the likely barriers discussed included:
- The language barrier, particularly between patients and professionals – how will it be possible to communicate the principles of coproduction to patients, and to motivate and inspire them to embrace its principles, deconstructing the more abstract and academic thinking that underpins co-production in a way that makes sense to them?
- Cultural and attitudinal barriers, especially with regard to what constitutes a ‘service’ – different people, from both professional and public spheres, may have different values attached to what they feel a service should offer
- Fear of loss of change and abandonment, particularly from patients and their families and carers
- A fragmented healthcare system that operates in siloes and currently has limited integration with other services, such as the community and voluntary sector
- A commissioning framework that is set up to ‘commission services’ rather than to ‘generate value’
- The time factor – even if everyone can be convinced that coproduction is the right thing, the transition to a different kind of model is likely to take a lot of time
- Changes in the NHS, which could aggravate risk averse behaviour and uncertain leadership
And yet even as we discussed these challenges, there was a discernible tone of positivity in the room. The two commissioners in the group – Lambeth’s Denis O’Rourke and Stockport’s Nick Dixon – testified to the appetite for change amongst commissioners in the face of a system that is clearly not working. At other tables, people were having discussions about whether inequalities in the NHS are really as entrenched as we think they are – perhaps we need to place more trust and confidence in people and communities to seek out and embrace the kind of help and support that will improve their lives. Indeed, Paul emphasised that the point of the exercise was not to paralyse everyone with a sense of inevitable failure, but to have a clear picture of the barriers that may arise during the course of the People Powered Health programme, so that we can both pre-empt and begin to think of solutions to overcome them. It was interesting to observe a discussion about barriers giving way to this emergent and defiant sense of optimism: perhaps these challenges were not so insuperable as once thought. Paul Corrigan’s closing words were these: ‘The world is full of movement and change. If you are feeling stuck it’s because you are not looking at it correctly.’
It felt as though everyone left the event feeling hopeful and excited about the task that lies ahead of them, and a sense that – with hard work and the right kind of support – coproduction can and will be taken to scale.
To read more about the People Powered Health programme, follow this link to NESTA's website.