Over the last few years, co-production has increasingly become a more prominent term used by the UK health service to describe partnership working with patients. Community nurses, because of the nature of their role, already work in some form of partnership with the patient, as in most circumstances they are a guest in a patient's home. Nevertheless, how far does this partnership extend and is it co-production? Co-production has been defined by Boyle and Harris (2009) as vehicle for ‘delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours’. Co-production has been linked with various tangible benefits; these include developing greater trust between the healthcare provider and the patient (Palmer et al, 2019), being more considerate of a person's needs and the patient becoming more empowered in making decisions regarding their own health (Turnhout et al, 2020), with more choices being provided to the patient (Cramm and Nieboer, 2016). Co-production was first conceptualised in the 1970s by Eleanor Ostrom and her colleagues at Indiana University in the US (Ostrom, 1978; 1996). She looked at how police officers in Chicago were becoming more detached from people's lives, leading to less trust in the police by the local community. Accordingly, the police were witnessing a reduction in engagement with the local community and this was causing an impediment to tackling crime and anti-social behaviours.
Ostrom discovered that these barriers between the police and the community were largely because of the police increasing their use of car patrols, rather than the more traditional foot patrols to police the neighbourhood. Walking the beat allowed the police opportunities to formally engage with the community. Ostrom argued that the police needed the community as much as the community needed them and this mutual need was described as co-production. Since Ostrom's work, co-production has been seen as a way to engage with stakeholders across multiple sectors, including healthcare. Historically, the NHS made little mention of patient choice or patients being a part of planning the delivery of a service, except for the choice of GP practice (NHS, 2019). The NHS was set up by the state and, for the first few decades, remained largely in the control of the state, with the state taking a paternalistic approach and acting on behalf of the people. However, after a series of cultural changes during the 1960s ideas of individual freedom and choice began to disseminate into other areas of public life, with more pressure for greater personal involvement in decision making across a broad spectrum of public services, including community care (Michailakis and Schirmer, 2010; Allyn, 2016). As time progressed, it became a legal requirement, instead of an expectation, to consult with service user groups.
However, no policy document really set out in clear terms the nature of the consultation and, in those documents that did mandate choices for patients, the choice was often restricted to set parameters. Nevertheless, a series of policy consultations and recommendations in recent years has led to further ideas about how this choice can be exercised. Consequently, co-production began to be examined as a vehicle for patients to have more involvement in their own care, rather than being a passive bystander. Policy led the way; however, co-production soon became part of the statutory law framework. The Care Act 2014 statutory guidance states:‘When an individual influences the support and services received, or when groups of people get together to influence the way that services are designed, commissioned and delivered’.
Of course, ‘influences’ in the statutory guidance is different from some of the definitions of co-production, which is viewed more as an equal partnership, however there is a statutory requirement for the service user to be involved in all aspects of the service, including those offered in the community as part of a nursing service. Legal case law also acknowledges co-production, upholding the right for a competent patient to be provided with an alternative choice of pathways when discussing treatment and care (Montgomery v Lanarkshire Health Board, 2015), although this choice will always be dependent on financial considerations and the availability of expertise. Yet giving patients more choice may also be seen as part of the political agenda in seeing patients as more of a consumer of care. In the Department of Health and Social Care's (DOH) consultation document Greater choice and control (DOH, 2011) patients were to be offered a choice of five providers for elective treatments, which included approved providers from the public and private sectors. Later, the DOH's consultation paper Liberating the NHS: no decision about me, without me (DOH, 2012) called for increased shared decision making between the patient and clinicians, and decisions of care without involving the patient to be discouraged. Further choice for patients was strengthened in the passing of the Health and Social Care Act 2012 that expanded choice beyond elective treatments. More recently, the Health and Care Act 2022, under sections 78 to 81, while not specifically mentioning co-production, stated that ‘the regulations must make provision as to the arrangements that NHS England and integrated care boards must make, in exercising their commissioning functions, for enabling persons to whom specified treatments or other specified services are to be provided to make choices with respect to specified aspects of them’.
Co-production, despite legislative and policy directions, can be a real challenge for the community nurse. Not all patients will understand the need for co-production or may feel unable to partake in a more equal partnership. However, Vahdat et al (2014) put forward a few factors that may assist a healthcare practitioner, including the community nurse, with the participatory process; this includes the community nurse being able to listen to the patient and their needs, providing comprehensive and simple to understand information regarding the patient's care. Being open to listening to patient choice, even if it goes against medical and nursing advice, is essential in creating good partnership working. It is part of a community nurse's legal and professional duty of care to ensure that they are empowering patients to make decisions for themselves. However, having adequate time from the employer is also necessary to ensure that this happens. In the current climate of increasing costs and fewer resources, it is becoming more of a challenge for clinicians to meet the various policy diktats and directions.
Co-production, therefore, has its challenges. First, it is not a term that is always understood by patients or staff and genuine working in partnership with patients is difficult in a resource-scarce NHS (Holland et al, 2019). Some patients may not want to be in a partnership with their healthcare provider. Instead, they would rather the community nurse informs them of the right options for them. This view was acknowledged by Batalden et al (2016) who suggested that some patients would prefer to look to the doctor or the nurse to provide solutions. Palumbo and Manna (2018) also identified levels of knowledge or understanding of the patient of their own health to be vital, to facilitate successful co-production. This includes a certain level of health literacy. Health literacy also requires the patient to be interested, and indeed willing and able, in having an increased involvement in the management of their own care. Co-production therefore may not be universally applied, sometimes because of patient abilities, but also because of the various resource issues that continue to be a constant struggle in the NHS. Increasingly patients are less likely to be passive recipients, instead wanting more information and options in respect to their own health. Co-production is an ideal vehicle to allow for the delivery of enhanced information exchange and, with a working together ethos, this can lead to some productive relations. There will be challenges and these do need to be recognised. However, some of these challenges may not be insurmountable and an increased use of co-production will become more evident if those who are responsible for the dissemination and implementation of policy have more meaningful discussions with those on the frontline of care. This will lead to more examples of co-production and further research, especially in the nursing context. Small steps, such as changing terminology, can help.
Co-production as a method of ensuring an equal partnership is almost impossible, rather co-production needs to be framed in a way to recognise that the community nurse will begin the co-production journey with their patients often as unequal partners. Support and guidance must be made available to the patient, so that at a later stage they do become a more equal partner in their own care. However, expecting this outcome from the offset is unrealistic and impractical. Co-production, in its purist form, is an impossible feat, but with some pragmatic approaches it can increase the involvement of patients in making informed decisions and plans about their own care. The community nurse is the ideal professional to assist with the process.