Co-production

"Co-production is a simple idea: it's about individuals, communities and organisations having skills, knowledge and ability to work together, create opportunities and solve problems."

Co-production is an approach to partnership between people who rely on services and the people and agencies providing those services.

It is underpinned by a belief that people with disabilities and their families, and older people are in the best position to determine their own needs and goals, and to plan for the future, to whatever extent they want to.

Co-production can take place an individual level, service and system level.

Person centred thinking and planning is an example of co-production in action at an individual level.

 

Papers and Articles

Using 'Planning Live' to develop support plans with Gemma and Kirstie.
My Way Derbyshire is a partnership project between Derbyshire County Council and MacIntyre, it provides facilitator support for young people who are in transition to adult life. The My Way facilitators work to make a support plan and help find different options with young people about where they might live, who they may live with, what they might do during the day and how this can be done flexibly and in the way that works best for them. This is Gemma and Kirstie's story of the work they did with a facilitator from My Way, to create their support plans using a process called 'Planning Live'. Through this they created a strategy that will enable them to move out of residential college, and live together in their own home with the support they need.

To read this paper see the downloads box on the left.

 

Personalisation - Don't just do it - co-produce it and live it!

This guide has been co-produced by a small team of people working together over a period of four months to capture what 'co-production' means and how we'll know it's happening with older people who need support in their lives. The team included older people, strategic leads/senior managers in three local authorities and representatives from HSA and NDTi.

To view this guide see the downloads box on the left.

 

Design Teams.

A Design Team is a group of people who design an event. They are a cross section of the potential participants and work together to clarify the purpose of the event and create a structure that will achieve the purpose.

To view this guide see the downloads box on the left.

 

Co-production in practice
What are we learning?
byTony Bennett, Sam Newman, Helen Sanderson

Introduction

In 2008 the Department of Health commissioned two pieces of work which were to be "co-produced" by which they meant that the work was to be carried out as a genuine partnership between Council social services staff and disabled people, their carers and families.

Each piece of work was also to be co-facilitated with a citizen leader playing a key part in the planning and delivery of the events.

The two pieces of work were:

• Outcome Focused Reviews - this work is now complete and the work published here: http://www.dhcarenetworks.org.uk/Personalisation/PersonalisationResources/Type/Resource/?cid=5625

• A common Resource Allocation System (RAS) framework - this work is ongoing.

The two pieces of work were different in scope, reviews had 8 councils represented, with 3 disabled people and 2 family carers; resource allocation had 18 councils and 8 disabled people and carers. Tony co-facilitated the Outcome Focused Review project with Helen, and the RAS project with Sam. Co-facilitation, with an experienced citizen leader and a consultant working together, and co-production with citizen leaders and Councils, were new experiences for each of us. We wanted to record and share what we have learned through this short paper of practical suggestions for others involved in co-production.

We have not gone into the definitions or theory of co-production, these are covered in several papers, instead we share the practical lessons we have learned in preparing for events, and facilitating them. We begin with the learning from the Outcome Focused Reviews work, and then the issues and lessons from the RAS work. Co-production in practice.

What we learned about co-production in practice through the Outcome Focused Reviews work.

Event Set up and Design. As we said in the introduction, the Putting People First Team commissioned both of these pieces of work, with the explicit intention that they were co-produced and co-facilitated.

Many people believe that co-production requires at least one third of the group are disabled people, carers or family members. This work was designed to ensure that a third of the participants would be citizen leaders. In the Outcome Focused Reviews work, there was nearer 50% citizen leaders and 50% council staff. In the RAS work there were less citizen leaders - around 25%. The Putting People First team appointed both facilitators separately and convened a meeting for the facilitators to co-design the sessions.

Co-facilitation with a disabled person, carer or family member was a key element to this co-production. It was crucial that both facilitators have the necessary skills and experience to play a full part in the facilitation. We were selected as facilitators for this event through a process of tender or application and interview.

Facilitators

• It is vital that both facilitators share an understanding of the social model of disability, and use language that reflects this. The "medical model" language still in regular use is deeply offensive.
• Both facilitators need to co-design the event, and this is even more powerful when participants (a couple of citizen leaders and council staff who will be part of the event) are involved in the design as well, through a 'design team'.
• The facilitators need to have a clear understanding of how they will work together, by discussing how they see their roles, what they bring to this work (their particular skills and interests) and what support they will need from each other. At the reviews events Tony and Helen talked explicitly about what each expected of the other, and the RAS events Sam orchestrated the days and gave specific time bound tasks to other facilitators.

Participants

• Having the right people, by which we mean people with varied skills and experience which equip then to offer a useful contribution - mere inclusion is just the same as "consultation" - tokenism. This applies equally to council staff and disabled people. In these pieces of work we invited citizen leaders who had participated in a citizen leadership course and who were active in contributing to local and national developments. We invited councils who had expressed an interest in developing reviews or RAS.
• Ensuring a broad spread of disability and experience - what is a burning issue to one may be of little or no consequence to another. In these projects, there was a dedicated administrator support. A dedicated administrator supported the logistics of the events (including access requirements), and Tony took responsibility for ensuring that the citizen leaders had the information and any support that they needed before the work began.

Logistics and budget

• Equal contribution requires that everyone is paid to attend. Council staff are salaried and you must pay citizen leaders to attend, as well as their expenses, which might include Personal Assistant costs.
• It is important to pay attention to logistics, communication and access, and identify someone to take responsibility for this.

Before the events - what we learned about co-production in practice

Once people had been invited to be part of the work, and the co-facilitators had developed the design, making sure that the initial events were successful required thinking carefully about access and communication.

 

Access and communication

It is very important to really understand access requirements and ensure that the venue does too.

• Don't assume - a motorised wheel chair is very different to a self-propelled one, and access ramps etc. may not necessarily be adequate. Double check access requirements, are the disabled toilets really accessible? Is the dining room wheelchair friendly? Is an inductive loop installed and working? Is it tested? Equally, don't make assumptions about people; council staff may also have access needs.
• Working with partially-sighted or blind people means paying attention to differing requirements in the way that material is presented to them in terms of font size, shape and text colour. Again, it is important not to make assumptions and to ask directly what people need. At a recent event that Helen was doing she knew that one person was visually impaired and prepared all the posters for the event with a yellow background, as recommended by the RNIB. She did not realise that for this particular person, yellow was the worst colour background, and when Helen learned this, she managed to get all the posters redesigned with the person's preferred blue background.
• People with access requirements at these events appreciated Tony contacting them to re-assure them that we had accommodated their requirements.
• Continue to work with access issues throughout the events, by asking people if there is anything else they needed and problem solving issues. We found out the reception at the venue used for the reviews work was inaccessible for wheelchairs and people using wheelchairs then had to check in separately in the foyer. We talked with the hotel to make them aware of the difficulties this posed, and their duties in this area. We discussed this with the citizen leader who uses a wheel chair people and considered changing hotels, but ultimately the citizen leaders who used a wheel chair suggested that we stayed.
• Plan your start and finish times, and ensure that you have adequate breaks. In the reviews work we agreed the times and lengths of breaks with participants. Tony negotiated the optimum start and finish time with people before the events, taking into account access and travel times, and the amount of time that we needed to do the work!
• Enable everyone to fully participate by sharing a clear agenda beforehand that helps people to prepare. In the reviews work we used an agenda format giving the questions that we wanted to ask at the event and what we wanted people to think about before hand. The agenda format is in the appendix.

At the events - what we learned about co-production in practice

• Include everyone right from the beginning by using an opening round. It is typical practice to get people to introduce themselves, and in the reviews work we asked people to choose a postcard (from the 50 spread out on the floor) and use that to introduce themselves and what good co-production meant to them. We talked to the group member with the visual impairment about whether and how we could make this work for her beforehand. She asked us to describe a selected of post cards to her, and she chose the ones that resonated with her.
• At the reviews events we found it helpful to have a poster of the purpose, agenda, rules and roles (meeting map) up to help everyone to know where they are in the agenda and how the agenda relates to the purpose of the session. The RAS events had a much larger attendance, but we always outlined the content of the day, and what would be expected of people.
• Agree specific ground rules at the beginning with the group that include paying attention to access issues. In the reviews group we agreed that we would all say our names every time we spoke in the main group, at the request of the group member who has a visually impairment. At the end of the first day we reviewed the ground rules with the group to see how we were doing in practice and whether there were any that people wanted to add.
• Adapt facilitation techniques to make them work for everyone. In the reviews work we used a process called a 'card call' where people write on cards and then the whole group clusters them. Rather than not using this approach because someone had a visual impairment, we talked with her about how we could make the process work for her.
• Make sure that everyone is included. At both events we were quite clear that everyone had an equal voice. Occasionally, where relevant, we included PA's in rounds. Some great contributions came from people who were not directly invited to the events - in one case a supporter became an integral and valuable member of the team.

Getting feedback

In the smaller reviews group we were able to use "rounds", where everyone was given the opportunity, and expected to comment on the current issue, we also used this method for feedback. At the RAS events we asked people to write on two cards what had been good about the day, and what could have been better. We collated, published and acted on this feedback.

 

Work between sessions

• Work between events - ensure that everyone has a role to play, at the RAS events where councils were to test material, we involved the disabled people in creating a framework for that testing by which they would measure the councils work. We called it "what a good testing phase would look like".

 

After the events - what we learned about co-production in practice

The outcome from the Outcome Focused Reviews event was a report. We worked with the group to think about how everyone wanted to be involved in putting together the report.

• We agreed the potential content areas (based on our earlier work on 'success') for the report and wrote these on a board.
• We asked everyone to think about whether they wanted to/had the time and energy to contribute to writing. This was not an expectation, but an offer to the citizen leaders. Some people wanted to write up stories, another citizen leader wanted to have a first go at the introduction
• We wanted everyone's contribution, and were clear what was going to happen next, when people would have a chance to review the material, deadlines for comments, and where the overall editorial responsibility was.

Some of this learning was echoed in the RAS work, however, the different nature of the work, the number of people, and the percentage of citizen leaders, led to further learning about building consensus and leadership.

 

What we learned about co-production in practice in the RAS work

Getting two councils to agree something can be difficult, so co-producing some complex products related to the creation of personal budgets - with all the passion that goes with it, with 18 councils - some experienced, some not, and also in genuine co-production with disabled people was a huge though rewarding challenge. Here are some thoughts on reflection near to the end of the RAS programme.

 

Sort out the leadership

• Culture is powerfully established through leadership. We did not get our co-produced leadership right to begin with. In hindsight this was partly to do with how we were commissioned - separately, with little negotiation or introduction, but also about our own relative lack of experience in relation to co-production. It needed us to make mistakes, reflect, take criticism, and experience some real pressure to deliver in order to create a model of co-produced leadership that really reflected our commitments to joint work. In order to successfully deliver a co-producing environment in the room we had to model and reflect that in the way we led the sessions together.

 

Model a new relationship

• Our work was about shifting power, and creating new relationships between 'the care system' and disabled people. If we were really committed to this then we had to model it in the way we worked together. For the most part we did our significant work in three working groups all with representatives of both councils and citizen leaders. Our constant commitment was to minimise the times when we were not 'acting out' our commitment to co-production and joint work. However we did take one or two opportunities to give time to citizen leaders to agree some key messages that they wanted to give to councils - for instance in the way that councils were , as part of the programme, going to test the materials we were designing together In this way we established a relationship where disabled people 'directed' public servants - a dynamic we were seeking to support in the materials we were designing.

 

Positive discrimination

• The reality of the world, and the social care system as a component of it is that things are not equal, disabled people are not listened to properly, individuals don't always get to make the key decisions about their lives. Therefore it was ok to to a bit of rebalancing every time we met. From the third session onwards after the saying 'hello' to each other we always started by inviting one or more of the citizen leaders to remind us all why this is important and to ground the work we then did throughout the day in someone's real experience of what counts as respectful social care. This led to some fantastic materials that can be used again - both in written, spoken, and DVD format.

 

Don't be afraid of the dots

• We worked hard at establishing good relationships between council employees and disabled people through the way we worked around tables, mixed people up in groups, and had a constant reminder about the agenda we were all committed to. In addition, given the relatively short period of time we had to work in, and the huge challenge to produce useable materials at the end of the programme, sometimes we had to 'cut to the quick'. The group learned together that sometimes in order to reach consensus we could not continue for ever individually articulating a range of views. Also it was clear that some people were really keen to speak and be heard and others were less so, but still wanted to contribute. We used a facilitative technique on a number of occasions which consisted of identifying some key issues (sometimes those that in between sessions were clearly exercising people given the contributions on the web page), working on them in co-production groups to explore potential solutions, strengths and weaknesses, and then displaying choices on boards so that people could hear about them, read about them, and then indicate through placing their 'dot' where their favoured position lay. We didn't over use it - usually reserving it for issues where we felt we had talked the issue out and needed to move to a conclusion, or where a smaller working group wanted to take direction from the whole group, or where it was absolutely necessary to make a decision in order to move on. We didn't call it 'voting' as this only produces winners and losers. What it did enable us to do was visually display where the feeling of the whole room was - and this shaped the solutions that the working groups thenh adopted. Of course we had a numbers issue in that there were often about 40 council employees in the room and 8 citizen leaders. We adopted a methodology that displayed when a 'dot' was from a council and when a 'dot' was from a citizen leader. Because we were not voting, and it wasn't first past the post wins, this technique only added to the information that was available, and the scoring process revealed to the whole group the aggregated views of everyone, and aided us in reaching reasonable conclusions that would carry support.

 

Lots of informal loops to check understanding

• We made mistakes where we assumed consensus and co-production too early in the journey. Councils are grooved into the concept of 'meetings' with the accompanying often unwritten rules and expectations. We Co-production in practice 9 learnt quickly that it was not ok to work in co-productions groups, think we had a reached a conclusion, write it up and post it on our web space as work agreed by the group. Several 'loops' of checking things out, confirming that the decisions that the 'author' wrote up were in fact correct representations of where people were at were necessary.

 

Time

• Good co-production takes time! We were being constantly reminded that we were working at a pace that had the potential to threaten real co-production. Working together, ensuring real dialogue and real understanding, and making sure that people have multiple opportunities to check out with each other what they really mean, and that we are happy with the positions we reached takes time.

 

Allowing argument

• We had some lively debates - not just between council employed staff and citizen leaders - but between all possible combinations. Culturally we are not necessarily skilled at allowing constructive disagreement which can result either in a 'pretence' of consensus, or outright destructive argument. We had to learn how to allow and encourage disagreement, acknowledge difference, not force the pace towards consensus.

Constant opportunity to debate, discuss, disagree find consensus - on line presence

• One of the things we did without really knowing why we were doing it was establish a private on line space where people could continue to debate between meetings, where documents could be posted for comment and where people could ask questions and seek clarification from each other. This turned out to be a vital component of our system to support co-production. It allowed people to at their own pace to internalise documents, ideas, debates, and contribute. Nobody was excluded from the possibility of inclusion in this, in contrast to our one-off events where complexity of time, physical environment, audio and visual issues can all conspire against good inclusion.

 

Build personal relationships

• Some of what we learnt is just plain good common sense. Quickly building good personal relationships - both between facilitators and citizen leaders, and also between all participants in the way that sessions were facilitated were very lucrative and wise investments. The evening before each session where some of us met in the local pub not do work but just to get to know each other a little really helped.

 

Pay attention to language

• Language is absolutely vital. The 'council environment' has its own language, assumptions and culture. Some of these had to be vigorously challenged, un learnt, and re thought.

 

Nail colours to mast - again and again

• We quickly became aware that there were some key commitments that were non-negotiable and needed to be confirmed and reconfirmed if citizen leaders were going to trust in the process. Hence it was important to visibly and publically re-assert commitment to the social model of disability, to citizenship, to the concept of human rights and self determination for all people. It was impossible to do this too much.

 

Conclusion

The two pieces of work taught us a lot about what it means to co-produce work in practice. We have shared the very practical details of setting this up through the Outcome Focused Review work, and how the challenges of building consensus and establishing leadership were managed through the RAS work.

We learned that the proportion of disabled people and carers in the room is significant, and that careful attention to how we work together benefits everyone. Our most powerful experiences were the benefits of working together, hearing all views, negotiating differences and ultimately, achieving a much richer, and better outcome for everyone.

About us

Tony Bennett
Tony cared for his father who had Alzheimer's disease, was involved in the individual budget pilot programme, and has gone on to deliver training, and facilitates events around the agenda of transforming social care.
www.carben.co.uk

Sam Newman
Sam is the director of the personalisation programme at OLM Group. Sam had a career in social services, has worked with InControl, and currently contracts for work again supporting the transformation of social care.
www.olmgroup.com

Helen Sanderson
Helen leads HSA a development, training and consultancy team focussed on person centred approaches, support planning and review. Helen also designs and facilitates events for the Department of Health and local organisations. www.helensandersonassociates.co.uk