El desafio de la co-produccion

8/9/2019 El desafio de la co-produccion

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THE CHALLENGE OFCO-PRODUCTIONHow equal partnerships between

professionals and the public arecrucial to improving public services

David Boyle and Michael Harris

DISCUSSION PAPER


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PART 1: THE CRISIS OF REFORM IN PUBLIC SERVICES 2

Co-productionchangesallthis.Itmakesthe

systemmoreefcient,moreeectiveandmore

responsivetocommunityneeds.Moreimportantly,

itmakessocialcarealtogethermorehumane,

moretrustworthy,morevaluedandaltogether

moretransormingorthosewhouseit.Phil Hope MP, then Minister of State for Care Services, March 20091

Thepublicbecome,notthepassiverecipientso

stateservices,buttheactiveagentsotheirown

lie.Theyaretrustedtomaketherightchoicesorthemselvesandtheiramilies.Theybecomedoers,

notthedone-or.

David Cameron, January 20072

Weshouldnotallbesupplicantsatthestatemachine,butenabledtotakechargeoourhealth.

Nick Clegg, The Liberal Moment, 20093


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EXECUTIVE SUMMARY 3

Thereisnodoubtthattheideaoco-

productionhasarrivedintheUK.

Policymakersareusingthetermintheir

speeches,anditisincreasinglyappearingin

Whitehallstrategydocumentsandthink-tank

reports.

Thisisimportantandexcitingorthoseouswho

havebeentryingtoshapeanewconversationalong

theselines,arguingthatthekeytoreormingpublic

servicesistoencourageuserstodesignanddeliver

servicesinequalpartnershipwithproessionals.

Thetimeseemstohavearrivedortheideathat

theusersopublicservicesareanimmensehidden

resourcewhichcanbeusedtotransormservices

andtostrengthentheirneighbourhoodsatthesame

time.

Thereasonorthisinterestissimple.While

policymakersmightnotalwaysbeableto

acknowledgeit,previousapproachestothereorm

andimprovementopublicserviceshavelargely

runtheircourse.Insomeareas,theyhaveproduced

importantimprovements,certainly.Butourpublic

servicesaceanunprecedentedsetochallenges:

increasingdemand,risingexpectations,seemingly

intractablesocialproblemsand,inmanycases,

reducedbudgets.Reormcantconrontthese

challengeseectively;radicalinnovationinpublic

servicesnowneedstomoveromthemarginsto

themainstream.Thequestioniswhatanalysisandprinciplesshouldinormthisradicalinnovation.

Asweargueinthispaper,co-productionasa

newwayothinkingaboutpublicserviceshas

thepotentialtodeliveramajorshitintheway

weprovidehealth,education,policingandother

services,inwaysthatmakethemmuchmore

eective,moreefcient,andsomoresustainable.

Thereisanemergingco-productionsectorintheUK

whichisenormouslyvitalandinnovative,eveniit

isnotyetquiteawareoitsel.Itisacrucialaspectotheemergingdebateonlocalismandmutualism

inpublicservices.

Thedifcultyisthat,asalwayswithnewideas,co-

productionisotenusedlooselytocoverarange

orelatedconcepts.Thereisnoagreeddefnition,

noraremanypeopleyetclearaboutwheretheidea

cameromoritsullimplications.Weareinthe

earlystagesounderstandinghowco-productioncantransormmainstreampublicservicesand

yetthereisanunderstandableurgencyamongst

policymakerstofndnewapproachesthatwork.

Thisisthenapotentiallycreativemomentorpublic

services,aswellasadangerousone.

Thisisthechallengeoco-productionitprovides

astrongcritiqueoexistingapproachestoreorm,

butitrequiresastrongeragreedunderstandingand

evidencebaseinordertomakearealimpactinpolicy

andinmainstreampublicservices.

Thispaperprovidesthebasisorbothabetter

understandingandastrongerevidencebaseor

co-production.Giventhecurrentdiversityouses

otheterm,thispaperalsoexplainswhatco-

productionisnt.Itdemonstrateswhy,properly

understood,co-productionlookssettocreatethe

mostimportantrevolutioninpublicservicessince

theBeveridgeReportin1942.Itdiagnoseswhy

publicservicereormisstalled,andwhyaradically

newapproachsharingthedesignanddelivery

oserviceswithuserscanbreakthislogjam

andmakeservicesmoreeectiveorthepublic,

morecost-eectiveorpolicymakers,andmoresustainableorallous.

Onepaperdoesntprovideallotheanswerswe

need.Inthespiritoco-production,urtherprogress

inthisareaneedstobebasedontheideasand

experiencesopublicserviceproessionalsandthe

communitiestheyworkwith.Thispublicationmarks

thebeginningoapartnershipbetweenthene(new

economicsoundation)andNESTAtodevelopthe

evidencebaseonco-productionworkingwithand

learningromrontlinepractitionersinparticular

andromthistodevelopproposalstopromoteamorepositiveenvironmentorco-productioninour

publicservicesandinpolicymaking.

EXECUTIVE SUMMARY


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CONTENTS 4

CONTENTS

Part 1: The crisis of reform in public services 5

Part 2: Why efciency isnt effective 9

Part 3: What co-production is 11

Part 4: How co-production works 13

Part 5: What co-production isnt 16

Part 6: Getting more for less 19

Conclusion: Next steps for co-production 22

Endnotes 24


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PART 1:

THE CRISIS OF REFORM IN PUBLIC

SERVICES


When William Beveridge laid thefoundations of the welfare state morethan six decades ago he called it a

revolutionary moment in the worlds history a

time for revolutions, not for patching.4 AnnaCoote and Jane Franklin have described ourown time in similar terms.5 Britains welfare statewields massive power and inuence over theshape of society and the fortunes of the countryas a whole. But through 60 years of peace andplenty, it has not managed signicantly to narrowinequalities of income or health or to strengthensocial solidarity. Neither, in general, has thewelfare state successfully tackled the underlyingreasons why problems emerge in the rst place.Now it also has to cope with the implications ofenvironmental degradation, an ageing societyand a dysfunctional global nancial system.Something has to change.

The reason our current services are so badly-equipped to respond is that they have largelyoverlooked the underlying operating systemthey depend on: the social economy of familyand neighbourhood (what has been called thecore economy, for which see below). We canno longer rely on continuing economic growthto provide enough nance for public services,or on pseudo-market mechanisms to make sure

they are efcient. Because the nancial systemis unreliable, markets cant tackle inequalities,and because unchecked growth puts the planetat risk. If we are to avoid a massive decline in thescope and ambition of our services, we need anew idea to reshape them.

Our public services have become constrainedby the New Public Management of centralisedtargets, deliverables, standards and customerrelationship management software, whichhas narrowed the focus of many services and

often undermined the relationships betweenprofessionals and patients, or between teachersand pupils. Contrary to the hopes of manypolicymakers, articial divisions between differentcategories of users, between professionals and

clients, and between different service budgets,have all served to make the system more inexiblethan before.6 If we are to make sure our publicservices are signicantly more effective, we need

a signicant new idea to reshape them.

This is the background to the emergence of co-production, and explains why its advocates areusing it to free up the concrete structures andprocedures of public services to make them moreeffective and cost-efcient. It also explains whysome policymakers are looking back to the pre-Beveridge welfare state for solutions, learningfrom mutual institutions and local self-helporganisations which provided the backbone towelfare before the Second World War.

Welfare settlements since 1945

While capitalist economies delivered growthand prosperity, the social democratic analysisat the time was that they also producedsocial inequalities. The dening idea was thatwelfare had to soften the relationship betweeneconomy and society, to redistribute wealth andopportunity, by mitigating social inequalitiesproduced by industrial production. This providedthe framework for so-called cradle-to-gravesocial security, and universal, free health and

education systems.

This was designed to tackle social class inequality,but it relied on full male employment, a familywage and womens commitment to home andfamily. The same assumptions were reected inthe way the services worked, where professionalknowledge and judgement went largelyunchallenged, and where people were happy totrust expert advice and care.

This went hand in hand with a deep distrust of

informal knowledge, as well as uncertainty andscepticism on both sides of the political divideabout the role of self-help, mutual aid, and socialnetworks.


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The new conservatism

This pattern was followed by Conservative andLabour governments alike, until the ThatcherGovernments began to prioritise economicgrowth more emphatically over social and

economic equality. The new approach wasalso informed by the continuing pockets ofdeprivation, and what came to be known as thedependency culture which many conservativethinkers believed had grown up around thewelfare state.

There was a parallel challenge to the power ofprofessional knowledge, and people came to beseen as consumers, with voice, responsibility anda right to choose. This was used to justify greaterprivate provision of public services, and the new

contract culture and search for efciencies someof them real, some of them just moving costselsewhere which has followed.

The third way

Since 1997, the New Labour welfare settlement,or third way, has shaped policy and practice inthe UK. Distancing itself from the old left and thenew right, it was based on a pragmatic adaptationof both, and an attempt to reconcile oppositionalinterests across society.7

To critics, this now seems like a highly centralisedmodel. It meant investing greater resources andthen using targets to direct these resources athigh-prole aspects of performance in publicservices, motivated by the need to makesignicant improvements in services in a shorttimescale.

But this approach has failed to tackle thestructural inequalities that are fuelling the demandfor services, instead borrowing from aspects ofthe communitarian tradition in the US but without

providing enough local responsibility to build newsocial networks capable of taking some of thestrain. It has also largely ignored mutual solutions,adopting the rhetoric of consumer choice withoutbeing able to provide it in a meaningful way.Despite the use of market pricing, and increasedinvestment, demand on the system has continuedto rise.

Our prevailing economic difculties are forcing are-think of all these assumptions. Any approachwhich continues to rely on increased investment

seems unlikely to be feasible in the currentcircumstances. Also, by failing to confront thecauses of deprivation and need, New Labourfailed to distinguish its approach sufciently fromwhat went before. But this is not just about the

current economic crisis; studies like those of theNHS by Derek Wanless, and by similar expertsin Sweden, agree that it will be a huge taskto sustain universal welfare systems based ontaxation unless we build in better encouragement

for self-help.8

However there is a more fundamental problemwhich is barely being addressed at a policylevel, in part because of the lack of radical newapproaches in welfare inherent in the third wayapproach. We have created a broad welfaresystem that is more inexible than it needs tobe, employing staff who are in effect rewardedfor their devotion to systems instead of theircommitment to effective relationships with thepublic, a system which has become excessively

risk-averse, and has yet to develop the levers itneeds to enable more effective communities.Services have been re-organised in ways that arenot effective for what they are trying to achieve:as the systems designer Jake Chapman put it,we are using systems that can deliver a parcelor a pizza, but which are not very effective atdelivering health or education.9

We also now face a series of linked problemsacross public services which affect their ability tochange. These include:

Marginal choices: The choice agenda has beenat the heart of policy towards public servicesfor most of the past three decades, but there isincreasing doubt about whether it has succeededin delivering what people actually want.

First, there are some services that are not reallysusceptible to choice most obviously, policingand justice. Second, the reality of provision hasoften failed to live up to the rhetoric of choice.In education, in effect it is schools which choosepupils, and many parents nd themselves outside

any catchment areas. Where service managershave delivered choices for service users, it is alltoo often the choice between almost identicalsystems usually large, technocratic hospitals orhuge schools delivering largely identical curricula.

Third, and most importantly for this discussion,where choices are possible, it has frequently beennecessary to prize open the relationships betweenprofessionals and the people they serve in orderto deliver it. Delivering this narrow kind of choicehas meant cutting the link between people and

local schools or GPs, often in the name of morepersonalised services, when the one choice thatso many people want in their public services acontinuing and respectful relationship with asupportive professional is less and less on offer.


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In this way, choice can represent the failure ofempowerment, rather than its realisation.

Centralised decision-making: Control bycentralised targets has overwhelmed efforts

to innovate in many public services. It hasalso introduced highly complex and expensivecompliance and auditing regimes, which oftenprovide misleading data. Goodharts Law explainsthat numerical data used as a target will tend tobe inaccurate.10

This particularly applies to services delivered bythe voluntary sector. One former member of theBristol drugs action team complained that he hadto keep his eyes on 44 different funding streams,nine different grids and 82 different objectives

imposed on him by managers, funders and thegovernment. Before he resigned, he reckonedthat he and his colleagues spent less than 40per cent of their time actually tackling drugsissues. He compared his management regimeto a kind of addiction: Monitoring has becomealmost religious in status, as has centralised

control,he said. The demand for quick hits andearly wins is driven by a central desire analogous

to the instant gratication demands made by

drug users themselves.11 The target regime hasdelivered an illusory control to the centre, basedon inaccurate data which, from the perspectiveof the challenges we now face, is actually hugelyinefcient (see Part 2).

Narrow outputs: The spread of internal marketsand a growing contract culture has meant thatthe ambitions of many public service agencieshave been narrowed to specic outputs.12 This hascorroded the added value that public servicesused to create, just by being present and visiblein the local neighbourhood. It has also leftthem more vulnerable to the constant ow ofdemand, and without incentive or means to reach

upstream to nd ways of tackling the causes ofthe problems that threaten to overwhelm them aswell as their clients. The commissioning processhas often limited the pool of potential biddersfor public services, excluding small businessand local organisations, and has encouragedmergers between major suppliers, underminingcompetition and raising costs. The combinationof these factors has undermined the tradition ofinnovation in public services, and undermined theability of frontline staff to change the way theywork to make themselves more effective.

Corroded relationships: The huge investmentin public sector IT (over 70 billion in the pastdecade) has tended to subordinate the humanskills of frontline staff to software, and has

often locked in the inefciencies in services.13These have been projects which reduce, dene,standardise and control, and set processes inconcrete. They also undermine face-to-facerelationships that so often make the difference

between success and failure. The inevitable, ifunintended, consequence of the governments

reliance on computer databases, wrote JillKirby of the Centre for Policy Studies, is thatthe tracking of information is replacing personal

interaction between professionals in which the

sharing of information is mediated by human

contact.14 If relationships between professionalsand clients are part of what makes changepossible, then management systems thatundermine these are likely to make services moreexpensive to run. They are driving in the wrong

direction.

Prioritising processes over outcomes: Twofactors have increased activity in public servicesin ways that are unrelated to serving the public.One has been that many public service contractsare organised so that contractors are paid peractivity (for example, patient processed orcall handled), no matter whether those peopleneeded processing, which enormously increasesthe process without useful objectives. Thesystems analyst John Seddon claims that theproportion of calls to local authorities that arethe result of failures elsewhere in the systemmay be as high as 80 per cent, and other publicservices deal with failure demand of over 40 percent.15 Yet there is no incentive for contractorsto reduce this. Payments to hospitals are alsoarranged to encourage episodic treatments andre-admissions, rather than seemless and effectivecare. The split between front ofce call centresand back ofce processing, encouraged bysuccessive government reviews and by the AuditCommission, has tended when combined withcomplex targets to multiply busyness in services

at the expense of those who rely on them.

Manufactured demand: The increasing use ofconsumer language has encouraged people tobehave towards public services as they wouldtowards any commercial supplier. Equally, byfocusing entirely on peoples needs ratherthan what they can contribute services havetended to disempower their users and havedone little to prevent needs arising in the rstplace. The combination of these factors hasadded to demand, particularly when access to

professional help is rationed to those who aredeemed most needy. Since services largely ignorepeoples abilities, their continuing need has oftenbecome their only asset in their battle for help.Responsibility and recovery has to be postponed


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indenitely or even suppressed for fear thatsupport will be removed. This can be seen in thecase of Employment Support Allowance (the oldincapacity benet) where peoples fears aboutlosing support is a powerful motive for preventing

change, but it affects other services too. In thesecircumstances, demand will inevitably rise.16

These issues lie at the heart of the current crisisin our public services. The existing underlyingmodel of public services offers what is in effecta minimal choice between similar institutionsand methods of delivery, and undermines therelationships between frontline staff, their clientsand each other which allow people to use theirstrengths to make a real difference. This is likelyto lead to less successful organisations, more

mistakes, less imagination and more simplication.

This is directly related to rising costs. If humanrelationships are removed from the delivery ofpublic services in the name of efciency eitherbetween professionals and users or betweenusers and friends and neighbours then thisundermines innovation, exibility and learning,and the ability of any public service organisationto achieve its objectives creatively and effectively.

As we will see, co-production has emerged asa critique of the way that professionals andusers have been articially divided, sometimesby technology, sometimes by professional andmanagerial practice, and sometimes by a spuriousunderstanding of efciency. It provides analternative way for people to share in the designand delivery of services, and contribute their ownwisdom and experience, in ways that can broadenand strengthen services and make them moreeffective.


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PART 2: WHY EFFICIENCY ISNT EFFECTIVE 9

All eyes are now focused on the budgets forpublic services, with suggestions that theNHS alone will need to nd savings of 15

billion to 20 billion over the next few years (andhealth is likely to be one of the favoured services,

given cross-party pledges not to cut funds in thisarea).17 Yet the focus on efciency savings is notnew. Since Peter Gershons 2004 review of publicsector efciency, annual targets (of between 3and 10 per cent) of cashable savings have beendemanded from public sector budgets. Gershonhas been superseded but the core objectiveremains. Efciency has become the driver ofpublic service reform.18

Government expects local public servicecommissioners to put efciency dened in anarrow nancial sense at the heart of publicservice contracting, to be achieved throughmarket mechanisms, shared centralised servicesand mimicking private sector discipline. WhilstGershon suggested that savings would releaseresources for the frontline, evidence suggeststhat this kind of short-term nancial efciencytends to squeeze out the broader considerationsof positive social and environmental outcomes even though these might be crucial to makingservices more effective and so cutting costs in thelonger term.19

Contracting-out services based on this narrowmodel can also have the inadvertent effect ofpreventing more cost saving, because contractsare based on payments for activity, which giveslittle incentive to provide cheaper or moreeffective alternatives. Contracts also tend toobscure actual costs behind a veil of commercialcondentiality.

HM Treasurys guidance denes value for moneyas the optimum combination of whole-of-lifecosts and quality (or tness for purpose) of the

good or service to meet the users requirement.The Treasury Green Book goes on to emphasisethat value for money is not the choice of goodsand services based on the lowest cost bid, butthat wider social and environmental costs and

benets for which there is no market price also

need to be brought into any assessment. Yet inreality, resources tend to be understood solelyas public sector nances or the public purse.This means that people and natural resources

are neglected. The only inputs that are countedare those with nancial value. Through this lens,the efciency ratio demands a focus on pricereductions or cost savings.

The danger in this cost-efciency game is thatit creates a race to the bottom in public serviceprovision. Shorter-term horizons are fed byever narrower outputs. This trajectory becomeseven more problematic in current nancialcircumstances. Many proposals to save moneyassume that services will remain essentiallyunchanged doing the same thing, only tryingto do it more cheaply rather than focusing onfar-reaching reforms that prevent needs arisingand provide better outcomes. If public servicesare to become genuinely better and efcient,they must focus on maximising positive outcomesdened in terms of public benet, rather thanmerely minimising costs, and move upstream totackle problems before they become critical. Weneed radical innovation so that public servicescan make real inroads into tackling prevention,reducing demand for expensive critical services.It is here that substantial future savings will be

found. Yet the current narrow focus on efciencyinadvertently undermines that possibility.

The current model for public service reformfocuses attention on easily costed and easilydelivered changes, siphoning attention andmoney away from preventative interventions,which are often more difcult to model. Yet thereare difculties measuring success in terms ofnarrow efciency on the basis of outputs alone,which can be extremely misleading. It is quitepossible for agencies to deliver services that meet

a wide range of process targets yet still fail toimprove outcomes for those they are supposed tobenet.

In 2007-8, the Public Administration Select

PART 2:

WHY EFFICIENCY ISNT EFFECTIVE


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PART 2: WHY EFFICIENCY ISNT EFFECTIVE 10

Committee looked at public services and thethird sector. They agreed with the new economicsfoundation (nef) that added value is exactly whatthe state should be looking to achieve in society.They urged public service commissioners to look

at the costs and benets of the wider effectsof any service, rather than just at the outputsdescribed in the contract. This would not onlymake services more efcient; it would make themmore effective too. They said:

The critique calls into question the entire

direction of public service reform, with an

emphasis on easily measurable nancial

efciency over harder-to-measure indicators

of effectiveness particularly those of wider

social and environmental benets. Their [nefs]

suggestion of a new model for measuring theeffectiveness of services certainly warrants

consideration at the centre of government and

beyond.20

This may not be an easy shift to make, but giventhat only a tiny proportion of public spendinggoes on prevention, or on creating the socialnetworks that can insulate people from futureproblems the present balance of spending iscertainly not efcient. For example, as a TotalPlace pilot area Birmingham has measured whereall the public money is spent over the same area,and has found that less than 2 per cent of healthspending goes on preventing ill-health.21

Despite recognising this fundamental inefciencyin where money is spent, reformers also run upagainst the narrow service-focused efciencymodel in trying to make savings, for example inrelation to where savings accrue. Jason Lowther,director of policy and delivery at Birmingham CityCouncil, has said: Parenting classes have beenshown to work, and for every 1 spent by council,

4 comes back to public sector. But only 1 of this

comes back to the council itself, so we spend 1 tosave 1 thats OK, but not exciting. And the other

partners get 3 back, for no action. So we are

starting to have conversations about how we can

get more payback.22

There are also some major barriers to progressthat can only be addressed nationally. Onebig stumbling block is the timeframe overwhich success is currently measured. Lowtherrecognises that the existence of short-termnancial horizons, make expenditure impossible

if savings are only accrued in several years time.So we need to talk to the Treasury about looking

longer can we look over a three or ve year

period, or 10 or 15 year periods?23

While co-production can compete nanciallyagainst the other services in current narrowefciency terms, we need to be able to bringbroader objectives onto the balance sheet beforethe full value of the approach is going to be

recognised, counted and costed.


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PART 3: WHAT CO-PRODUCTION IS 11

Akey challenge for the next 12 months is towork with practitioners and the public togenerate a description of co-production

that captures the value of the approach, butis informed by and directed towards practical

application. For the purposes of this paper we willuse the following working denition:

Co-production means delivering public

services in an equal and reciprocal relationship

between professionals, people using services,

their families and their neighbours. Where

activities are co-produced in this way, both

services and neighbourhoods become far

more effective agents of change.

Our welfare state has improved the lives ofmillions of people over the past three generations.But it has not, generally speaking, made peoplehealthier and more self-reliant, as the BeveridgeReport suggested it would. As we have seen,far from a gradual reduction in costs anddemands for services, the very opposite has beenhappening. The co-production critique suggeststhat the conscious or unconscious maintenanceof service users as passive recipients is not just awaste of their skills and time; it is also the reasonwhy systemic change doesnt happen.

When people are never asked to give anything

back, and when the assets they represent areignored or deliberately side-lined, they atrophy.The fact that social needs continue to rise is notdue to a failure to consult or conduct opinionresearch, or even a failure to nd enoughresources. It is due to a failure to ask people fortheir help and to use the skills they have. Thisis a key insight from the idea of co-production.Co-production theorists suggest that this isthe forgotten engine of change that makes thedifference between systems working and failing.24

The central idea in co-production is that peoplewho use services are hidden resources, notdrains on the system, and that no service thatignores this resource can be efcient. Thepeople who are currently dened as users,

clients or patients provide the vital ingredientswhich allow public service professionals to beeffective. They are the basic building blocksof our missing neighbourhood-level supportsystems families and communities which

underpin economic activity as well as socialdevelopment. This was the insight of the humanrights lawyer Edgar Cahn, who developed theidea of co-production into a practical propositionfor public services (see Part 4). Cahn uses theanalogy of a computer, which runs powerfulspecialised programmes, all of which rely on abasic operating system without which they cannotindividually function.

In the same way, our specialised services dealingwith crime, health or education, rely on anunderpinning operating system that consistsof family, neighbourhood, community and civilsociety. The economist Neva Goodwin calledthis operating system the core economy.25 Theconsequences of failing to recognise and supportthis core economy are all around us: isolation,time poverty, low levels of trust, engagementor social infrastructure. Just as we have beenresponsible for free-riding on the environmentbecause its value was hard to establish, we havebeen blind to how important the core economy is.

Models of public service reform that fail to value

the core economy and help it to ourish, relyingmore on price signals and narrow legal contractsof service delivery, are part of the problemrather than the solution. Co-production suggestsways we can rebuild and reinvigorate this coreeconomy and realise its potential. It suggests thatpublic services need to be turned inside out, sothat they can rediscover the human resourcesand remake the social networks that reducedemand on professionals and support publicservice interventions to succeed. This meansthat we must unleash the huge wasted resource

represented by the recipients of services, andtheir families and neighbours.

Co-production shifts the balance of power,responsibility and resources from professionals

PART 3:

WHAT CO-PRODUCTION IS


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PART 3: WHAT CO-PRODUCTION IS 12

more to individuals, by involving people in thedelivery of their own services. It recognises thatpeople are not merely repositories of need orrecipients of services, but are the very resourcethat can turn public services around.26 Co-

production also means unleashing a wave ofinnovation about how services are designed anddelivered and how public goods are achieved, byexpecting professionals to work alongside theirclients.

Co-production is central to the process ofgrowing the core economy. It goes well beyondthe idea of citizen engagement or service userinvolvement to foster the principle of equalpartnership. It offers to transform the dynamicbetween the public and public service workers,

putting an end to them and us. Instead, peoplepool different types of knowledge and skills,based on lived experience and professionallearning.


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PART 4: HOW CO-PRODUCTION WORKS 13

Co-production emerged in the socialsciences nearly four decades ago. The ideawas rst articulated by the 2009 Nobel

prize winner for economics, Elinor Ostrom, andher team at Indiana University, who coined the

term co-production in a series of studies of theChicago police in the 1970s. Ostrom was trying toexplain why the wholesale adoption of centralisedservice delivery through large institutions wasless effective than people had predicted.27 Sheneeded a word to convey what was missing whenthe police abandoned their close involvementwith the public on the beat, and became moredistantly involved in patrol cars: it was thatelement of successful policing that only membersof the public could provide to make sure servicesworked. It was Ostroms team who denedco-production as the

process through whichinputs used to produce a good or service are

contributed by individuals who are not in the

same organisation.28

What began as an academic denition wasdeveloped into a practical agenda for systemchange by Edgar Cahn.29 Cahn used co-production to explain how the time dollars andtime banks that he originated could be used totransform public services, initially in health. Oneof the early applications after that was his TimeDollar Youth Court in Washington DC. The youth

justice system in the District of Columbia anarea where half of the majority black populationunder the age of 35 was in prison, on parole or onprobation had been in a state of near collapse,forced to dismiss rst and second offencesbecause of case overload. The youth court aimedto turn this around by recruiting young offendersthemselves to help combat crime.

If you are a young person arrested for the rsttime for a non-violent offence in Washingtonnow, the chances are that you will be arraigned

not before a judge but in front of a jury of otherteenagers, who will question you, judge you andsentence you. The sentence will include servingon a jury yourself.30 The ultimate purpose is todeliver a youth justice system that not only helps

to prevent criminal behaviour, but also changessome of the conditions that cause it in the rstplace, and it does so by engaging young peopleas advocates of good behaviour.

In 2007, the youth court dealt with 80 per centof all rst-time offences in Washington. Therecidivism rate for youth court participants isonly 17 per cent, about half the average in themainstream juvenile system. There is a similarsuccessful model in Jefferson County, Wisconsin.

Co-production approaches are emerging in theUK in both the public and voluntary sectors, evenin the justice system. Preston in Lancashire hasbeen developing a UK youth jury approach. In2009, the Nacro Centre for Restorative Justice/Preston Peer Panels won the Justice team awardfor tackling youth crime. The project started inSeptember 2007, and already more than 80 caseshave been successfully concluded, affecting some250 victims. The team has now extended theproject with the Street Law programme, whichoffers training to young people as part of theircontract, allowing them to become peer panelmembers and addressing areas of concern in theirown lives. Adult versions of this approach are alsobeginning in the UK with the Community JusticePanel in Chard.

The charity Scope has been pioneering the ideain the eld of disability equality. CSV has beenpioneering it in volunteering. Mind and otherorganisations are using the idea in the HumanGivens approach to mental health. The CitizensAdvice Bureaus ROTA project trains prisonersto support other prisoners. Many schools areinvolving parents deeply in co-producingeducation (but many are not).

Co-production ranges from programmes that areaimed specically at prevention, like the Nurse-

Family Partnerships, which support rst-timemothers and children in low income families bypartnering them with registered nurses until thechild is two, with a core purpose of coachingthem into a sense of capability and encouraging

PART 4:

HOW CO-PRODUCTION WORKS


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them to support each other.31 Co-production alsoincludes programmes that give responsibility backto service users, like KeyRing, which supportspeople with learning difculties to live in theirown homes by embedding them in mutually

supportive local networks.32

It also includes programmes to use the knowledgeand experience of users, like the Expert Patientscheme in the UK, where patients with long-term health conditions teach others about theexperience, which has so far involved 50,000people.33 Or programmes to provide for mutualsupport, like the Shared Lives scheme (formerlyknown as Adult Placement) that pair up disabledpeople and those with long-term problems withfamilies. Shared Lives has done this now for 30

years in 130 schemes across the UK, in such a waythat caring becomes a joint activity between thepeople and the families they live with.

Co-production can work in existing structures,like the Learning to Lead programme that beganve years ago in the Blue School in Somerset,where pupils join teams which take responsibilityfor aspects of running the school, or makingchange happen outside it. Learning to Lead isnow working in ten secondary schools and isbeginning to work in primary schools too.34

Alternatively, it can begin to turn the existingstructures upside down, as it has in Taff Housing,a housing association with over a thousandhomes in some of Cardiffs most disadvantagedhousing estates, where tenants earn credits byvolunteering time to help deliver the services ofthe housing association. They can spend thesecredits through a partnership which Taff havenegotiated with Cardiffs leisure services, CardiffBlues Rugby Club and the Gate Community ArtsCentre, which accept credits earned by tenantsinstead of cash to use their services.

The effect of this, where it happens, is a hugeshift of focus for public services. No longerobsessively looking inwards to targets andprocedures, but increasingly looking outwards tolocal neighbourhoods to create supportive socialnetworks, seeking out local energy where it existsto help deliver and broaden services, and seeingclients for what they can do, not just what theyneed. The idea is that, by working alongside thepeople they are supporting, public services candramatically increase their resources, extend their

reach, radically transform the way they operate,and be much more effective. Co-productionmakes strengthening the core economy ofneighbourhood and family the central task of allpublic services. This means:

Recognising people as assets, becausepeople themselves are the real wealth ofsociety.

Valuing work differently, to recognise

everything as work that people do to raisefamilies, look after people, maintain healthycommunities, social justice and goodgovernance.

Promoting reciprocity, giving and receiving because it builds trust between people andfosters mutual respect.

Building social networks, because peoplesphysical and mental well-being depends onstrong, enduring relationships.35

Co-production is the model by which publicservices can begin to prevent social problems likecrime and ill-health, understanding that this isonly possible by providing a catalyst for citizensto broaden the range of what they already door can do in the future. It means public servicesbuilding mutual support systems that can tackleproblems before they become acute. It meansencouraging behaviour that will prevent theseproblems happening in the rst place, andbuilding the social networks that can make thispossible. It means public services reshapingthemselves to build the supportive relationshipsthat can help people or families in crisis carry oncoping when they no longer qualify for all-roundprofessional support.

What holds these projects together, apart fromsharing the term co-production, is that theyare all ways in which patients, pupils, parents orservice users are being asked to do something,to give back and to help deliver the service. Thisgenerally means providing mutual support, whichin turn strengthens the delivery of effective public

services, but it can mean delivering other aspectsof services not those which require professionalskills, but the aspects of services dependenton broader human capacities. Co-production iscertainly about effectiveness, but it is also abouthumanising services or, as Elizabeth Hoodlessfrom Community Service Volunteers puts it,broadening and deepeningthem.36

Co-production is about mobilising the hugeuntapped resources that people represent,in and around schools or surgeries, but also

prisons, probation centres, housing estates,social work. What they all have in common isthis shift in attitude to the users of services. Thisis how Dr Abby Letcher describes the impacton mainstream practice that the Community


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Exchange had on her own health centre outsidePhiladelphia:

It is a fairly radical change, and it does

challenge peoples ethical and professional

sense. But it has transformed the way we

practise medicine. It has stopped us seeing

our patients in terms of us and them, as if we

were just service providers to people who are

classed as needy. We are no longer looking

at them as bundles of need, but recognising

that they can contribute, and when you see

people light up when you ask them to do so,

it changes your relationship with them. The

culture has changed. The relationships are

different, deeper and more therapeutic than

they are in the usual doctors ofce.37

This is why, properly understood, co-productionrepresents a fundamental reshaping of publicservices, and in practice the reforms must beginwith the way services are commissioned.

Commissioning co-production

In 2006, the London Borough of Camdenlaunched an innovative experiment to focus theircommissioning of services towards outcomes,rather than just counting the numbers of peoplegoing through services. Working closely with thecouncil, local providers and service users, nefdeveloped a model that allows commissionersto take account of those broader effectsthat so often get excluded, both social andenvironmental.38 It was initially applied to a mentalhealth day care service, and it meant that thosebidding for the contract were also asked how theywould achieve wider training and employmentoutcomes, improved physiological well-being,more community participation and better socialnetworks. In fact, the tender specied that:

We would encourage providers to adopt themodel of co-production whereby services are

planned and delivered in mutually benecial

ways that acknowledge and reward local

lay experience while continuing to value

professional expertise. Service users should

be regarded as an asset and encouraged to

work alongside professionals as partners in

the delivery of services Real and lasting

changes are possible with approaches that

build or strengthen social networks and in

turn motivate people to learn about and

exercise their powers and their responsibilitiesas citizens. Networks of friends and families

should also be considered positive co-

contributors to success in this approach.

The winning tender was a consortium of Camden-based third sector organisations, MIND inCamden, Holy Cross Centre Trust and CamdenVolunteer Bureau, a mainstream volunteeringorganisation. The consortium advocated a co-

production approach to running the service,which uses time banking and peer supportapproaches to create a mutually supportivenetwork of people around the service.

By treating service users and the wider KingsCross community as potential assets, rather thanas passive recipients, the consortium deliveringCamdens day care services has been ableto leverage previously invisible or neglectedresources the capacities and knowledge ofservice users and the wider community itself,

who provide support to each other, anythingfrom advice to gardening and lifts. It has enabledthe consortium to focus on the broader social,environmental and economic aspects of theservice, as well as to focus on preventative workthat encourages independence and inclusion inmainstream community activity amongst thosedealing with mental health issues.39


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PART 5: WHAT CO-PRODUCTION ISNT 16

There is no agreed denition of co-production,but we must still be careful how we use the term.For example, the Australian post ofce recentlyused the term to describe the way people lived upto their responsibility to put the postcode on their

letters. This is not co-production in the sense thatwe mean it here.

Much of the ofcial discussion about co-production shows only partial awareness ofwhat it means, where it came from and how itworks. Even the Cabinet Ofce, which broke newground to promote the idea in mainstream policydebate, dened it too broadly as establishing

a partnership between citizens and government

to tackle a social problem.40 Co-design andother forms of asking the advice of users may behelping to create space for co-production, butcan lack any continuing involvement in delivery.41

Similarly, when communities or users organiseprovision with no involvement from publicservice professionals, whilst this is a very valuableintervention, it is not co-production. As the tablebelow demonstrates (Figure 1), co-productionoccurs in the critical middle ground when userand professional knowledge is combined todesign and deliver services.

PART 5:

WHAT CO-PRODUCTION ISNT

Responsibility for design of services

Responsibility

for delivery of

services

Professionals as soleservice planner

Professionals andservice users/community asco-planners

No professional inputinto service planning

Professionals as sole

service deliverers

Traditional

professional serviceprovision

Professional serviceprovision but

users/communitiesinvolved in planningand design

Professionals as sole

service deliverers

Professionals andusers/communitiesas co-deliverers

User co-deliveryof professionallydesigned services

Full co-production

User/communitydelivery of serviceswith little formal/professional

Users/communitiesas sole deliverers

User/communitydelivery ofprofessionally

planned services

User/communitydelivery ofco-planned orco-designedservices

Self-organisedcommunityprovision

Figure 1: User and professional roles in the design and delivery of services

Source: Adapted from Carnegie Trust (2006), Commission for Rural Community Development Beyond Engagement and participation, user andcommunity co-production of services. By Tony Bovaird, Carnegie Trust.


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The table helps us to see more clearly whatco-production isnt (or rather, what elements inisolation are insufcient for full co-production). Toexpand on a few examples:

Co-production is not consultation: Co-production depends on a fundamental shift inthe balance of power between public serviceprofessionals and users. This is what makesimproved effectiveness possible. It goes along way beyond the blizzard of consultationso favoured by government over the pastdecade.42 It is the antidote to the idea that weendlessly need to ask peoples opinion, beforehanding the service back to the professionalsto deliver, since people will be involved indelivery as well. Nor is it all about user-

management of organisations, important asthat might be, because that can only appeal toa small proportion of those who would needto be involved.

Co-production is not volunteering: Co-production is certainly about activity andgiving time. It emphasises mutual support andnetworks of relationships rather than a clearlydened demarcation between providers andreceivers. But it requires a new generation ofmutual exchange for everyone, not just morevolunteers ministering to ever more passiveneedy individuals on the fringes of publicservices, whilst the professionals continue withbusiness as usual. The transformative powercomes when people who are usually on thereceiving end of volunteering or services areinvited to help. The volunteering infrastructurein the voluntary sector is under huge strain,so it seems likely that if co-production isto emerge effectively it is going to happenthrough the public sector. Indeed, redeningthe mission of the public sector is central toco-production.

Co-production is not individual budgets:

Such budgets may be vital, but on their ownthey are not the realisation of co-production,especially when they ignore the need forsupportive social networks. The organisationIn Control makes a distinction betweenindividual budgets and what they call self-directed support, in which money is only oneasset which people can draw on. Personalbudgets were never intended to replacerelationships with market transactions. But

when they are used by policymakers insteadof rebuilding social networks, then theoutcome can be that recipients will have lessmoney and less condence than before. Bythemselves, individual budgets can entrench

the ineffectiveness of the consumer modelof care: they can encourage users to buysolutions or consume passively, rather thanhave an active stake in devising and deliveringtheir own solutions.

By contrast, co-production goes beyond these inthe following respects:

1. Co-production has the capacity to transform

public services: Co-production has to bepotentially transformative, not just forthe individuals involved, but also for theprofessionals who are struggling to put itinto practice and for the system as a whole.Public service workers will need to changethe way they think about their role and how

they operate and the people they have cometo know as users, patients or clients whowill now become their equal partners; theyneed to change their attitudes, prioritiesand training. They need to move from xersto facilitators. Public services and welfaresystems that are delivered in this way arelikely to be more participative, by denition,as well as more equitable, responsive andcreatively designed and delivered. And,because the people who are supposed tobenet from them will have a strong andtangible stake in them, they are more likely tocommand wider public support.

2. Co-production promotes equal participation:

Co-production has to have equalityat itsheart. It can only be true to its principles ifit is backed by measures to make sure thateveryone has the capacity to participate onequal terms. This is partly because it fostersequal partnership between providers andusers of services, and affords equal valueto different kinds of knowledge and skills,acknowledging that everyone has something

of value to contribute. It is also because, inorder to be effective, it must enable everyoneto participate, not just those who are alreadymore able, articulate and socially advantaged.Hence developing co-production forcesus to think about the underlying causes ofinequality and how these can be tackled,and embrace very different ways of framingparticipation. This is going to mean changingthe perceptions and the approach of manypublic service professionals.

3. Co-production is essential to buildingsustainable public services: Co-productionhas to be aboutsustainability. It is a methodby which public services tap into theabundance of human assets, enabling them to


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ourish and expand, and then bringing theminto play complementing and augmentingthe publicly funded resources of the welfarestate, which will be scarcer over the nextfew years.43 By helping to prevent harm and

constrain demand, co-production can helpto safeguard public resources for meetingneeds that cannot be prevented. In this way, ithelps to guarantee the long-term viability ofessential public services.

4. Co-production must have a key role to

play in commissioning public services:

Co-production can play a signicant role indeveloping service innovations when servicesare commissioned in the right way. This is theantidote to narrowing down public services

to contracted outputs, which dont justimpoverish the service which is delivered, butcan often impoverish the neighbourhood inwhich they are delivered.

As noted earlier, narrow deliverables leave outthe real value that public service institutionsused to provide44 and are far from the worldclass commissioning standards that theDepartment of Health amongst others arelooking for. When commissioners build co-production into the commissioning cycle, andtry to procure co-produced services, theyenable providers and users of services toplay a much more important role in designingand delivering services that work, as CamdenCouncil did for their mental health day careservices contract. As a result, they managedto keep the most important ingredient of anypublic service people at their heart. Thismeant that their model of delivery includeddirect beneciaries, their families and thewider community, as real resources built intothe service design, making the service not justbetter value for money, but better for those

involved.

For these reasons it is clear that co-productioncant be a bolt-on innovation. It fundamentallychanges the way public services are delivered,with the objective of reducing need, rebuildingthe social infrastructure and shifting the balanceof power.


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PART 6: GETTING MORE FOR LESS 19

Since the bank bail-out of 2008, it hasbeen clear that the public sector in allcountries, but especially in the UK was set

for an urgent bout of belt-tightening. Even beforethe nancial crisis, it was clear that the rapid

increases in spending enjoyed by services such asthe NHS for most of the decade would come toan end. And now we know all too well that futuregovernments will have a huge task to returnthe nation to anything approaching a balancedbudget. We have seen that co-production hasa vital role in making our public services moreeffective. It is also important to demonstrate therole it can play in making them easier to run in theage of public sector retrenchment.

It is no coincidence that the most innovative andsuccessful examples of co-production have arisenin places where problems seem most intractableand everything else has been tried. This suggestspublic services can be more cost-effective oncethey are built around co-production, becauseco-produced services work better. They will becost-effective not necessarily because they costless though they can do but because theyproduce more effective outcomes, because theyinsulate people against ill-health, or help peopleto acheive better outcomes than most servicescurrently do.

There is considerable evidence that co-productionhelps to prevent people getting ill, increases theirwell-being, and involves those who are seldomheard in society.45 Co-production is designedto prevent needs arising in the rst place, bymaintaining and improving the quality of peopleslives and extending the opportunities as well asthe capabilities of individuals and communitiesto look after themselves. It helps people to buildstronger social networks.

National surveys of psychiatric problems in UK

adults show that the most signicant differencebetween this group and people without mentalhealth issues is social participation.46 If you havea restricted social network, made up of three orfewer close friends and relatives, this is a major

predictor of mental health problems in the future.Co-production builds these supportive networksaround people and services as its central purpose.This brings a double prize of maintaining well-being and saving money.47

Another major reason why co-produced servicesare more cost-effective is that they bring inextra resources, in the form of help, support andeffort from clients, their families and neighbours.These non-monetary resources are ignored inthe current model of illusory efciency, mainlybecause no price is attached. Their effectiveuse demands major reforms to the structures ofour services, effectively turning them inside out.But the possible resources available are hugeand their contribution is critical. We also havesome evidence of the cost savings because keyelements of co-production have been evaluated.These include:

Delivering better outcomes: Nurse-FamilyPartnership programmes in the US have beenevaluated over 15 years. They were found toreduce child abuse and neglect by 48 percent, arrests of the children as teenagers by61 per cent and incorrigible behaviour by90 per cent. This would have a huge impactif taken to scale; it translates into benetsworth ve times the investment and a saving

in public spending of about $41,000 per childinvolved.48

Preventing problems: The Jefferson CountyTeen Court in Wisconsin engages youngpeople along similar lines to the youth courtin Washington. Each child they deal with whois not processed through the mainstreamcourts saves the local justice system $11,510.This is partly from avoiding the basic costs ofgoing through the ofcial court system, butthe Teen Court has a highly successful record

of reducing re-offending (only 7 per centcompared to the usual 30 per cent) whichbrings major savings to the public purse.49

PART 6:

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PART 6: GETTING MORE FOR LESS 20

Bringing in more human resources: TheShared Lives services which link disabledpeople with families, or people with otherlong-term difculties, offer good value formoney because they deliver high quality

support at a relatively low price. Costs andoutcomes can vary substantially betweenindividuals, but the average potential savingsfor a person in Shared Lives instead ofconventional supported living for people withlearning difculties can be as much as 995 aweek.50

The impact in terms of additional resourcesis potentially huge. In 2008, Scotland had681,573 pupils in publicly funded schools. Ifeach of these young people contributed an

hour a week whilst at school (on average 39weeks) to their school or local communitylife, in the way that young people do withinLearning to Lead schools, this would meanan extra 26.6 million hours to grow the coreeconomy and contribute to citizenship at thesame time.51

During one week in 2007, nearly 300,000adults in England received person-centredservices delivered by organisations in theindependent sector, funded by social services.If each of them gave back three hours supportto someone else in similar circumstances, inthe way that KeyRing schemes support peopleto do, over the course of one year this wouldgenerate an extra 900,000 hours of valuablepeer support, enabling professionals to deploytheir time differently.52

Encouraging self-help and behaviour change:

Changing peoples behaviour to improvetheir health is an area that is receiving moreattention. One review of the best evidenceidentied four aspects of intervention as

effective: using an educational component;providing continued support after the initialintervention; family involvement; socialsupport from peers or lay health workers.53Of these four, professional staff are probablyonly best placed to deliver the rst aspect.To intervene across the four aspects, theywill need to work alongside families and localcommunity networks to draw on their skillsand resources. Behaviour change, such aslosing weight or giving up smoking together,especially when facilitated through a GP

surgery, can make a huge difference.54

Thereis a potential 16 billion to be saved fromtreating illnesses which can be prevented bymore exercise.55

Supporting better use of scarce resources:

An analysis of the Expert Patient programmeshowed that it reduced visits to GPsconsultations by 7 per cent and to A&E by16 per cent, saving between 27 and 58 per

avoided consultation, before prescriptioncosts, and 84 for each patient diverted fromA&E.56 The gures for a disadvantaged areasuch as Newham in south-east London arespectacular, with half the patients reducingtheir visits to hospital. As many as 45 per centof participants reported increased condencethat symptoms would not interfere with theirlives and 38 per cent had reduced severity ofsymptoms four to six months after completingthe course.57

Growing social networks to supportresilience: Social networks are very importantfor excluded groups; national surveys ofpsychiatric morbidity in adults aged 16-64in the UK show that the most signicantdifference between this group and peoplewithout mental ill-health problems is socialparticipation.58 The evaluations of time banksin medical settings in the USA also showhealth improvements.59 The rst of these,Member to Member in Brooklyn, was launchedin 1987 by the Elderplan health insurancecompany, and it has beneted them nanciallyto such an extent that it has been extended tocover the whole of New York City.60

Improving well-being: About 16 per centof adults and 10 per cent of children areaffected by mental health issues such asdepression or anxiety. The NHS spends 13billion a year on treating mental health issuesand their complications. Co-productioncan have a major impact on peoples well-being, improving outcomes and moderatingdemand.61 Evidence from the Foresight Mental

Capital and Wellbeing Report suggests thatachieving a small change in the average level

of well-being across the population would

produce a large decrease in the percentage

with mental disorder, and also in the

percentage who have sub-clinical disorder.62

All these examples demonstrate that co-producedservices can compete nancially with existingpublic services, whilst delivering additionalbenets such as prevention of problems,sustainable outcomes, increased resilience and

the generation of additional capacity.

Why then are they not already the target formajor investment? First, because the benets ofthis kind of investment which works across the


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usual departmental boundaries often accrueto somebody elses budget. Second, becausethe mainstream public service efciency agendafocuses its energy on reducing costs in the short-term, and nds it hard to deal with non-monetary

resources to build long-term effectiveness. Ashas already been noted, now is not a time forpatching. It is not acceptable that these out-datedaccounting limitations are allowed to continue torestrict services abilities to innovate, particularlyat this time of crisis within our public services.


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CONCLUSION: NEXT STEPS FOR CO-PRODUCTION 22

Co-production is part of a much broadershift that is emerging across all thesectors, and most obviously in those

fractures between public and private, or betweenpublic and voluntary. This has been described

by the innovator Robin Murray as the new socialeconomy.63

Murray describes this as different from the oldmodel based on production and consumption.Instead it uses distributed networks to sustainand manage relationships, blurs the boundarybetween producers and consumers, emphasisesrepeated informal interactions such as care andmaintenance, and derives from a strong senseof values. Murray argues that the conditions arebeginning to emerge that are likely to acceleratethis social economy, because of a combination ofsqueezed resources and growing social pressuresfrom obesity, diabetes, an ageing populationand many other problems. He also explains howit requires capital, methods and skills to moveforward on any scale.

Murray writes about the extraordinary spirit ofinnovationthat is emerging behind this neweconomy, with the sense of a pressure cooker,as the new ways forward are held back bysclerotic systems and scarce resources. The samepressure cooker is apparent in the emerging

political argument about mutualising the publicservices, with all three main parties articulatingrather different locals of local services with usersin charge. Murray suggests three directions forchange for the social economy as a whole, andthese are a useful guide to the next steps for co-production too.

The rst is to reconstitute the state: co-productionrequires new kinds of organisation and structureto move forward on any scale, not just to allowthe experiments to grow, but to take the co-

production reform to scale. This means a new,exible, local and personal shape to publicservices that are not possible using currentinstitutions. These are emerging around existingservices and beginning to change mainstream

services from within. We must use the state toremake society, said Conservative leader DavidCameron.64 But the essence of co-productionis more radical than this: it is also about usingsociety to remake the state. Our task is to speed

this process along.

The second is to learn from successful networks.This doesnt just mean virtual networks, buthow human networks have been used to tackleintractable problems, like the way the micro-lenders Grameen Bank in Bangladesh madelending possible to the poorest, and how theBoston-based charity Partners in Health wentabout tackling multi-drug resistant TB in LatinAmerica.65 Both of those are clear examples of co-production in practice.

There are important implications for the shape ofservices in the future. We need to help servicesturn themselves inside out, so that they are farless inclined to look inward to processes, targetsand rigid standards, and instead look outwards,involving their users to build new mutual networksthat are able to stem the tide of demand. The newsocial economy is the context, and co-productionis the application of these general trends to publicservices. That means borrowing from the successof extended schools to create extended surgeries,extended hospitals, extended housing estates,

each one over-lapping to some extent, in order toprovide the kind of interlocking, human servicesthat actually reect the needs and capacitiesof their users. It implies that using services willmean embarking on a reciprocal relationshipwith professionals, and with other users andneighbours, that will help you but will also helpthem recover and learn. It means that every casealso re-builds local relationships.

The training of professionals must also change, sothat they are able to operate in a far more exible

way. We need to look again at the question ofrisk. Decision-makers and politicians in particular,are going to have to address the shortcomings ofthe Beveridge settlement by looking at their ownapproach, which remains caught in the habit of

CONCLUSION:

NEXT STEPS FOR CO-PRODUCTION


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CONCLUSION: NEXT STEPS FOR CO-PRODUCTION 23

providing for the needs of grateful constituents.

Murrays third direction is to understandinnovation better: we urgently need to look athow these ideas evolve in practice. Generally

speaking, the co-production sector is not yetaware of its own potential. With the launch ofthis publication, nef and NESTA are launching aconversation between these pioneering peopleand institutions, so that they can learn fromeach others experience and nd out what worksin different service areas. We aim to give thisrevolutionary new sector a clearer voice and buildbridges between practitioners and policymakerswho are desperately in need of a new approach topublic services.

Together, we will be approaching some of the keyissues that stand in the way of mainstreaming co-production in the UK. These include setting out abetter working denition of co-production, andidentifying areas of public services especiallythose facing intractable problems or over-demand where co-production could have the biggestimpact.

It also means:

Identifying appropriate measures: The cultureof targets, standards and best practice tends tocount against innovation, and innovation which isdesigned to impact on more fundamental aspectsof service delivery is particularly vulnerable. Whenthere are economic difculties, those experimentsoutside the core targets and standards tendto suffer rst. A central weakness of targets isthat they set prevailing practice in concrete andprevent services from evolving to tackle theirkey problems. We need to nd ways to createthe conditions for co-production to take root,like the commissioning experiment in Camden.Re-shaping a public sector organisation along

co-production lines should earn exemption froma range of targets and specications with a fargreater emphasis on outcomes measurement.We are intending to use this project to make thispossible.

Tackling the accounting problem: Any innovationwhich hopes to make public services morepreventative faces the same problem with the waythe public sector organises its accounts: savingsaccrue somewhere else in the system and thereare few mechanisms to link them together, which

means it is hard to justify them in the rst place.There are conceptual and research problemsbehind this which still need to be solved. We willbe working with practitioners to draw togetherthe evidence already available, and to look more

closely at the costs and benets of mainstreamco-production.

Tackling the fear of reasonable risk: Thereis already a problem about some categories

of claimants being involved in co-production.People on Incapacity Benet take a risk withtheir benets when they take part, in spite ofthe obvious advantages. New health, safety andsafeguarding regimes make it next to impossibleto involve people with any kind of criminal history.The Independent Safeguarding Authoritys vettingand barring scheme (VBS) poses a real threat tothe effective peer-led co-production methods wewant to see ourishing.

Ive got the sort of criminal record that means

the VBS will certainly vet and bar me, wroteMark Johnson in The Guardian. Yet its my

criminal record that makes me particularly

qualied to work with young offenders. Its my

years of drug addiction that give me a special

understanding of addicts. Its the changes Ive

made in my life that offenders and addicts

want to hear about. A prison governor told me

I can have more effect on his inmates in 30

minutes than he can in three years.66

Developing and testing practical models: Thosealready experimenting with co-production aredeveloping experience in a number of differentgeographical and service settings. Over the nextyear we will support practitioners to identifywhat the common practical skills and conditionsare that enable co-production to ourish, builda library of existing experience, and developsupport and advice for others who are intendingto develop co-production activity. We will alsowork with practitioners to develop the toolsneeded to generate further evidence of the valueof this work.

The opportunities are huge, but there plenty ofremaining barriers to creating the conditions forco-production. It is going to be our job to helparticulate them, and provide some potentialsolutions, over the next 12 months, in a series ofevents and publications. If you are workingon co-production practice, research or study,we invite you to join us. If you would like moredetails please contact Julia Slay at nef:[email protected]


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ENDNOTES 24

1. Hope, P. (2009) Speech at conference on Putting People First: OneYear On. 25 March 2009.

2. Cameron, D. (2007) Speech. 29 January 2007.

3. Clegg, N. (2009) The Liberal Moment. London: Demos.

4. Beveridge, W. (1942) Social Insurance and Allied Services. London:HMSO.

5. Coote, A. and Franklin, J. (2009) Green Well Fair. London: neweconomics foundation.

6. These three characteristics of different phases of welfarephilosophy in the UK have been partly borrowed and adapted fromCoote and Franklin, ibid.

7. See for example Blair, T. (1998) The Third Way. London: FabianSociety.

8. See Wanless, D. (2002) Securing Our Future Health: Taking a Long-term View. London: HM Treasury; and Financedepartmentet (2004)Langtidsutredningen. Stockholm: Financedepartmentet.

9. Chapman, J. (2004) System Failure: Why Governments Must Learnto Think Differently. London: Demos.

10. The best description of Goodharts Law (Any observed statisticalregularity will tend to collapse once pressure is placed upon it

for control purposes.) is in Hoskin, K. (1996) The awful idea ofaccountability. In Munro, R. and Mourtisen, J. (Eds) Accountability:Power, Ethos and the Technologies of Managing. London: Thomson.

11. Parker, S. and Heapy, J. (2006) The Journey to the Interface.London: Demos.

12. Ryan-Collins, J., Sanlippo, L. and Spratt, S. (2008) UnintendedConsequences. London: new economics foundation.

13. See estimates in Craig, D. and Brooks, R. (2006) Plundering thePublic Sector. London: Constable and Robinson.

14. Kirby, J. (2009) The Reality Gap. London: Centre for PolicyStudies.

15. Seddon, J. (2007) Systems Thinking in the Public Sector.Axminster: Triarchy.

16. Cahn, E. (2001) No More Throwaway People: The Co-production

Imperative. Washington DC: Essential Books.17. Bunt, L. and Harris, M. (2009) .The Human Factor: How

Transforming Healthcare to Involve the Public can Save Money andSave Lives.. London: NESTA.

18. Ibid.


20. Public Administration Select Committee (2008) Public Servicesand the Third Sector: Rhetoric and Reality. London: HMSO.

21. See Jellinek, D. (2009) Prevention is Better than Cure. GuardianPublic, 28 October 2009.

22. See www.guardianpublic.co.uk/total-place-prevention-health

23. Ibid.

24. Cahn, E. (2001) No More Throwaway People: The Co-productionImperative. Washington DC: Essential Books; and Stephens, L.,Ryan-Collins, J. and Boyle, D. (2008) Co-production: A Manifestofor Growing the Core Economy. London: new economicsfoundation.

25. Goodwin, N., Nelson, J., Ackerman, F. and Weisskopf, T. (2003)Microeconomics in Context. New York: Houghton Mifin.

26. Stephens, L., Ryan-Collins, J. and Boyle, D. (2008) Co-production:A Manifesto for Growing the Core Economy. London: neweconomics foundation.

27. Ostrom, E. and Baugh, W.H. (1973) Community Organization andthe Provision of Police Services. Beverly Hills: Sage Publications.

28. Parks, R.B., Baker, P.C., Kiser, L., Oakerson, R., Ostrom, E., Ostrom,

V., Percy, S.L., Vandivort, M.B., Whitaker, G.P. and Wilson, R. (1981)Consumers as coproducers of public services: Some economic andinstitutional considerations. Policy Studies Journal. Vol. 9, No 7.,Summer, pp.1001-1011.

29. Cahn, E. (2001) No More Throwaway People: The Co-productionImperative. Washington DC: Essential Books.

30. Time Dollar Institute (2003) Time Dollar Youth Court AnnualReport 2003. Washington DC: Time Dollar Institute.

31. See www.nursefamilypartnership.org

32. See www.keyring.org.

33. See www.expertpatient.co.uk

34. See www.learningtolead.org.uk.

35. This list is adapted from Cahn, E. (2001) No More ThrowawayPeople: The Co-production Imperative. Washington DC: Essential

Books.

36. Quoted in Stephens, L., Ryan-Collins, J. and Boyle, D. (2008) Co-production: A Manifesto for Growing the Core Economy. London:new economics foundation.

37. Interview with David Boyle, June 2009.

38. Harrington, R. and Ryan-Collins, J. (2009) Users as producers:innovation and coproduction in Camden. In Parker, S. (Ed.) Morethan Good Ideas. London: IDeA.

39. Ibid.

40. Horne, M. and Shirley, T. (2009) Coproduction in Public Services: ANew Partnership with Citizens. London: Cabinet Ofce.

41. Bovaird, T. (2007) Beyond Engagement and Participation: User andCommunity Co-production of Services. London: Carnegie Trust andCommission for Rural Community Development .

42. There is an excellent hierarchy of different kinds of co-production inNeedham, C., (2009) Co-production: An Emerging Evidence Basefor Adult Social Care Transformation. SCIE Research Brieng 31.London: Social Care Institute for Excellence.

43. See also Coote, A. and Franklin, J. (2009) Green Well Fair. London:new economics foundation.


45. Seyfang, G. and Smith, K. (2002) The Time of Our Lives. London:new economics foundation; see also Garcia, I. (2002) Keeping theGP Away. London: new economics foundation.

46. For example Jenkins, R., Meltzer, H., Jones, P., Brugha, T. andBebbington, P. (2008) Mental Health and Ill Health Challenge.London:Foresight.

47. The Government has recognised the importance of preventative

strategies as essential for the future sustainability of the NHS; seeDepartment of Health (2006) Our Health, Our Care, Our Say: ANew Direction for Community Services. Norwich: TSO.

48. See www.nursefamilypartnership.org

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49. DallAsta, R., Lemoine, P., Riggs, B., Rushmer, E. and Shager, H.(2005) Jefferson County Teen Court: A Cost Benet Analysis.Jefferson County, Wisconsin: Delinquency Prevention Council.

50. NAAPS/IESE (2009) An Evaluation of the Quality, Outcomes andCost-effectiveness of Shared Lives Services in South East England.Liverpool/Oxted: NAAPS/IESE.

51. See http://news.bbc.co.uk/1/hi/education/8048127.stm

52. Community Care Statistics 2007-08, Grant Funded ServicesEngland.

53. Workshop on Changing nutrition behaviour to improve maternaland fetal health, 4 July 2008, The 1st Summer Nutrition Workshopof the International Society for Developmental Origins of AdultHealth and Disease, at the University of Nottingham, in associationwith the Nutrition Society, Physiological Society and Early NutritionAcademy. Paper written by Baird, J., Cooper, C., Margetts, B.M.,Barker, M. and Inskip, H.M. from the Food Choice Group, Universityof Southampton.

54. Darnton, A. (2008) GSR Behaviour Change Knowledge Review:Overview of Behaviour Change Models and their Uses. London:Government Social Research.

55. Bunt, L. and Harris, M. (2009) The Human Factor: HowTransforming Healthcare to Involve the Public can Save Money and

Save Lives. London: NESTA.

56. PSSRU (2007) Unit Costs of Health and Social Care. London:PSSRU.

57. Leatherman, S. and Sutherland, K. (2007) The Quest for Quality inthe NHS: Rening the NHS Reforms. London: Nufeld Trust.

58. Jenkins, R., Meltzer, H., Jones, P., Brugha, T. and Bebbington, P.(2008) Mental Health and I ll Health Challenge. London:Foresight.

59. Lasker, J., Baldasari, L., Bealer, T., Kramer, E., Kratzer, Z., Mandeville,R., Niclaus, E., Schulman, J., Suchow, D. and Young, J. (2006)Building Community Ties and Individual Well Being: A Case Studyof the Community Exchange Organization. Bethlehem, PA: LehighUniversity.

60. Metropolitan Jewish Health System (2003) An Evaluation ofElderplans Time Dollar Model. New York: Metropolitan JewishHealth System.

61. Boyle, D., Clark, S. and Burns, S. (2006) Hidden Work: Co-production by People Outside Paid Employment. York: JosephRowntree Foundation; also Boyle, D., Clark, S. and Burns, S. (2006)Aspects of Co-production: The Implications for Work, Health andVolunteering. London: new economics foundation.

62. Foresight Mental Capacity and Well-being Project (2008) MentalCapital and Wellbeing: Making the Most of Ourselves in the 21stCentury. London: Government Ofce for Science.

63. Murray, R. (2009) Danger and Opportunity: Crisis and the NewSocial Economy. London: NESTA.

64. Cameron, D. (2009) The Big Society. Hugo Young Memoriallecture. 10 November 2009.

65. See Yunus, M. (2003) Banker to the Poor: The Story of theGrameen Bank. London: Aurum Press. The Partners in Healthexample is in Kidder, T. (2003) Mountains Beyond Mountains: The

work of Dr Paul Farmer. New York: Random House.

66. Johnson, M. (2009) Middle-class voices hush up a criminal waste ofresources. The Guardian, 21 October 2009.


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T Lb C-prCT

Our public services face unprecedented challenges, made more urgent by the

impact of the current economic crisis. Traditional approaches to public services

reform are unlikely to provide the answers we need.

NESTA is applying its expertise to nd innovative ways of delivering our public

services. More effective solutions at cheaper cost will only come through ingenuity.

Our Public Services Innovation Lab is trialing some of the most innovative solutions

and bringing them to scale across the countrys public services.

Co-production is a new vision for public services which offers a better way to

respond to the challenges we face based on recognising the resources that

citizens already have and delivering services alongside their users, their families and

their neighbours in partnership with the public. Early evidence suggests that it is an

effective way to deliver better outcomes, often for less money.

This paper is the rst publication from a major project between the Lab and nef

(the new economics foundation) to increase the understanding of co-production

and how it can be applied to public services. We have established a network of

pioneering frontline workers from across the UK who are using co-production to

engage citizens and improve services, and will use these insights and evidence to

promote a more positive environment for co-production in our public services and

in policymaking.

nef is an independent think-and-do tank that inspires and demonstrates real

economic well-being. We aim to improve quality of life by promoting innovative

solutions that challenge mainstream thinking on economic, environmental and social

issues. We work in partnership and put people and the planet rst.

www.neweconomics.org

nef (the new economics foundation)


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NESTA

1 Plough Place London EC4A [email protected]

www nesta org uk

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