‘Co-production’ can be interpreted in many ways, but is generally understood as the process of consulting and including the public in designing and changing the services they use. The practice—which originated in the disability and mental health rights movements—advocates for an equal relationship between the people running services and those who use them.

While co-production can be applied to many NHS projects, including the design of new services and the reconfiguration of existing ones, the term is increasingly being prefixed with ‘meaningful’, in an attempt to move beyond what many see as performative efforts to apply the concept.

“Co-production is often seen as tokenistic because people suspect a decision was already made before engaging with the public,” says Dan Wellings, senior fellow at The King’s Fund. True co-production, he says, requires a different way of working. “It’s not a technocratic solution,” he says. “You have to let go and realise that the answers to some problems might not lie in the system, but in communities.”

There are four pillars to effective co-production, according to Isaac Samuels, chair of the National Co-Production Advisory Group and an advisor on co-production to several NHS bodies:

To enable a “reasonable” conversation, Wellings says, the parameters within which the co-production team is working should be set early on. Staff must be upfront and honest with the co-production group about what can and can’t be co-produced, he explains, depending on the budget and other factors, and about what decisions have already been made.

“This might be a conversation about who’s best placed to provide services on mental health for young people,” he says. “The answer might not be the NHS provider, but a community organisation, for example.”

A group of researchers and family carers working with Warwick University recently collated their learnings into a ‘toolkit’ for co-producing research projects with family carers of people with a learning disability. The seven ‘golden rules of co-production’ they came up with are just as relevant to service providers, the team say.

Joanna Griffin, a psychologist and research fellow at Birmingham University, who worked on the project, says: “People talked about being brought onto a project at the end when everything has been decided already, which felt tokenistic. They emphasised the importance of having lived experience experts from the beginning.

“They also talked about wanting to feel like an equal partner in meetings, which includes not using jargon or acronyms, or people’s titles,” she adds.

The toolkit also highlights the need for researchers and service providers to be sensitive to the fact that people are often talking about difficult and personal subjects, and to not push them to talk beyond what they’re comfortable with.

To effectively tackle health inequalities, services must also engage with people from minority ethnic communities or those living in the most deprived areas, who are often systematically excluded from decision-making processes, explains Wellings.

“Sometimes you know some groups will be disproportionately [more] represented than others, but if you’re really going tackle health inequalities, you need to engage the groups of people that services often refer to as ‘hard to reach’,” he says.

Isaac Samuels says experiencing ‘meaningful’ co-production felt like being an equal partner in shaping his own care. “At the individual level, co-production can be as simple as a clinician asking, ‘What works for you?’ rather than assuming they know,” he says.

“For me, that made all the difference when I was involved in a mental health project. Staff didn’t just consult me, they listened, adapted appointments around my life, and acted on what I said.”

Fiona Flowers is head of practice improvement at campaign and advisory group Think Local Act Personal and was the lead for developing Making It Real, a co-produced framework setting out the principles of good care, which is used by the Care Quality Commission and many other NHS organisations.

Flowers says the keys to effective co-production are trust, good relationships and a willingness to make mistakes along the way.

“If people know we’re coming from the right place, we can learn and improve together,” she explains. “A lot of the fear around co-production comes from people worrying about saying or doing the wrong thing, but at the heart of it, it’s really just about being human with each other—and that’s what people value most.”

According to a review of research by NHS England, managers and leaders have a crucial role in the co‑production process. Leaders must ensure that co-production is systemic, and that requires culture change at strategic, operational and individual levels, explains Flowers.

Co-production isn’t new, but how it should be embedded in NHS services is still being discussed and digested. There are some pockets of good co-production in the NHS, Wellings says, where people are fundamentally trying to change the way they work in a meaningful way. “But it still feels like the exception, rather than the norm,” he says. “Where this work is done really well, it can lead to genuine transformation in how services are provided.” //