News and Comment

Coproduction: the new paradigm for effective health and social care

Thursday 4 April 2013

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Vidhya Alakeson, Director of Research & Strategy at the Resolution Foundation introduces OPM’s recent paper – Coproduction of health and wellbeing outcomes: the new paradigm for effective health and social care – which she co-authored.

Over the last decade, a range approaches has been introduced into the NHS and social care that recognise the central importance of individual priorities and preferences in the effective management of long term conditions. Whether the original Year of Care pilot in diabetes or Nesta’s People-powered health programme or personal health budgets, each initiative seeks to unite the lived experience of individuals and the learned expertise of professionals to improve health and well being. Given that each has been developed largely independent of the others, it is tempting to see them as competitors. But in this new paper, we argue that far greater value could be generated by combining them into a portfolio to transform local health and care systems.

Although they have their differences, the initiatives described in the paper have more in common with each other than they do with the wider health and care systems in which they sit. First and foremost, they are rooted in a commitment to coproduction – the idea that individuals and professionals work together to reach decisions and achieve improved outcomes. To realize this goal, they require significant change in culture and practice. Clinicians have to be willing to facilitate decision-making and share risk – things that they are not trained to do. Individuals and families can no longer remain passive, but have to actively take part in decisions about their own care. While not everyone will want this level of involvement, more do than is commonly imagined. The personal health budget pilot in Dorset is just one example where more people wanted the choice and control on offer than NHS staff initially assumed.

Central to the change of practice and culture that coproduction requires is a change in the care planning process to enable a more equal exchange. Research to inform the Year of Care diabetes pilot found that, although 95 per cent of people had diabetes checks at least once a year, fewer than half discussed ideas about the best way to manage their condition with their doctor and even fewer discussed their goals or agreed a plan for the coming year. A more equal exchange requires that care plans are no longer documents written by clinicians on behalf of individuals. Instead care planning becomes an ongoing process in which power is more equally shared. The Co-Creating Health programme found that training could improve the engagement of both clinicians and individuals in self-management.

Alongside these similarities, the differences between the initiatives described in the paper are not insubstantial. The core difference lies in their scope –the dimensions of a person’s life on which each initiative is focused and the breadth of services they aim to mobilize. While shared decision-making has tended to focus only on care and treatment decisions and look for solutions within the healthcare sector, personal health budgets take a whole person view and solutions can be found in any sector, including commercial services available to all, such as gym memberships and weight loss classes. As a result, personal health budgets embrace a broader understanding of the nature of evidence than shared decision-making which relies on a more traditional clinical evidence-base.

But there’s an advantage to these differences. They mean that each initiative has its own strengths and can operate in conjunction with others. For example, an individual with diabetes may work on a plan with his GP using the Year of Care approach to care planning, may attend an Expert Patient group to improve his overall self management and have a personal health budget to manage his weight and mental health problems related to his diabetes. If he becomes unwell and ends up in hospital, his inpatient team would use shared decision-making to ensure that his priorities continue to be part of the decision-making process. Putting these different coproduction approaches together in this way is more likely to transform local health and care systems.

For this reason, the paper proposes testing the impact of a portfolio of coproduction approaches in a number of trailblazer sites, starting in places where progress has already been made in shifting culture and practice to support collaboration. The risk of not adopting a portfolio approach is that each initiative grows only slowly, stymied by the dominant culture around it. Despite a growing body of evidence to support shared decision-making in healthcare, for example, its take up has been slow. The best way to take coproduction to scale in health and social care may be to combine forces and adopt a portfolio approach that is better able to challenge business as usual.

Both the full report and Executive Summary of “Coproduction of health and wellbeing outcomes: the new paradigm for effective health and social care” are available for free download