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Public services-inside-out

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T
his report is about real stories of reform,
led by people who work in and use public
services. The examples included in this
report didn’t rely on expensive consultants,
troublesome IT systems, or grand blueprints drawnup
in Whitehall departments and Westminster think
tanks. They depended only on the commitment and
creativity of frontline workers and members of the
public who wanted better services.
In spite of this – or more likely because of it –
these examples represent a radical new approach
to public services. They embody what has come
to be known as ‘co-production’: public services
that rest on an equal and reciprocal relationship
between professionals, people using services, their
families and neighbours. They exist today not as
promises in pamphlets or manifestos, but as real
services serving real people more cheaply and more
effectively than traditional approaches.

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  • 1. PUBLIC SERVICESINSIDE OUTPutting co-production into practiceDavid Boyle, Julia Slay and Lucie Stephens
  • 2. PART 1: THE CRISIS OF REFORM IN PUBLIC SERVICES 2
  • 3. EXECUTIVE SUMMARY 3EXECUTIVE SUMMARYT his report is about real stories of reform, who wanted to know more, or who felt they were led by people who work in and use public already doing co-production. Often they were services. The examples included in this working in the most difficult circumstances, outsidereport didn’t rely on expensive consultants, the mainstream or ‘tolerated’ in the corner of majortroublesome IT systems, or grand blueprints drawn- public service organisations. Since then we haveup in Whitehall departments and Westminster think been working with a community of practitioners totanks. They depended only on the commitment and learn from their experience. In the space of just acreativity of frontline workers and members of the few months this community has grown to over 100public who wanted better services. people. Their insights, challenges and successes are at the centre of this report. They have shownIn spite of this – or more likely because of it – us how co-production can be applied across a hugethese examples represent a radical new approach variety of public services to achieve cheaper, betterto public services. They embody what has come outcomes.to be known as ‘co-production’: public servicesthat rest on an equal and reciprocal relationship From family nurse partnerships to parent-runbetween professionals, people using services, their nurseries, community-led justice to patient-ledfamilies and neighbours. They exist today not as recovery from brain injuries, the examples herepromises in pamphlets or manifestos, but as real demonstrate six main themes. These includeservices serving real people more cheaply and more recognising people as assets and building oneffectively than traditional approaches. their existing capabilities, establishing mutual responsibilities between professionals and theThis is public services inside out – innovation that public, and supporting people to support each other.overturns the conventional passive relationship Based on these examples, co-production is strongestbetween the ‘users’ of services and those who when it embodies all six of the themes highlighted inserve them. As we enter a period in which cuts and this report.savings will be made from on high, these examplespoint to the possibility of a different approach: These practitioners might be surprised to findbetter, cheaper services created from the ground up themselves at the forefront of a radical newby those who know public services the best. approach to public services. They have been developing new approaches ‘because it makesThis is the second of three reports on co- sense’ or simply because ‘it works’. Based on theirproduction from a partnership between nef (the practical experience, they have recognised thatnew economics foundation) and NESTA. The first services need to be founded on new partnershipsreport, The Challenge of Co-production, published with the public, whether students, those inin December 2009, identified the problems in supported housing, living with a long-term illness ortrying to reform public services from the centre. It experiencing a mental health problem – and that thepointed to the exhaustion of improvement efforts partnership could be a one-to-one relationship or athrough a so-called ‘New Public Management’ of community of mutual support.seemingly endless institutional re-wiring, targets and‘efficiencies’ – especially in the face of long-term But in bringing these services to life, thesechallenges such as an ageing population and a rise practitioners are realising a vision that isin debilitating health conditions. It also explained increasingly shared across the political spectrumwhy co-production offers the possibility of more – of public services that are designed aroundeffective, and so truly efficient, public services. the public, that are better at building people’s capabilities to be productive and healthy citizens,We have been inundated with messages from people and so are more efficient, effective and sustainable.
  • 4. EXECUTIVE SUMMARY 4The evidence here suggests savings of up to sixtimes the investment made in new approaches – andof course better outcomes for the public.It would be tragically counter-productive if, inthe coming context of cuts, policymakers were todefend traditional approaches in public services atthe expense of these new, better approaches. Now isthe time to think about how co-production can moveinto the mainstream of public services.The first task is to understand the challenges facedby these practitioners as they have experiencedthem. As detailed in this report, these includedifficulties in securing support from existingfunding and commissioning, traditional approachesto audit and accountability in public services, anddeveloping the professional skills required to bringthese approaches into the mainstream.But the fundamental and provocative issueunderlying all of these barriers is that co-productionis sometimes blocked because it takes seriouslythe current political rhetoric about ‘devolvingpower’ and ‘empowering communities’ – becauseit challenges the costly but conventional model ofpublic services as a ‘product’ that is delivered toa ‘customer’ from on high, and instead genuinelydevolves power, choice and control to frontlineprofessionals and the public.The second task, then, is to identify how policyneeds to be radically rethought to support thewider spread of co-production, and what ‘achievingscale’ means for services that are inherently local innature. This will be the focus of the final report inthe series.
  • 5. CONTENTSCONTENTSPart 1: Building on people’s existing capabilities 6Part 2: Mutuality and reciprocity 9Part 3: Peer support networks 12Part 4: Blurring distinctions 15Part 5: Facilitating rather than delivering 19Part 6: Recognising people as assets 23Part 7: Challenges, conclusions and future work 28Endnotes 34
  • 6. PART 1: BUILDING ON PEOPLE’S EXISTING CAPABILITIES 6PART 1:BUILDING ON PEOPLE’S EXISTINGCAPABILITIESAltering the delivery model of public services from a deficit approach to one that provides opportunitiesto recognise and grow people’s capabilities and actively support them to put these to use withindividuals and communities.O ne of the consistent features of that build on what people can do, rather than only successful co-production is that those trying to fix what people can’t do, makes for a who have been receiving services are subtle change in the way people see themselvesexplicitly told that they have something to give and everyone else. That was the original ideaback, to other people or to services themselves. behind Family Nurse Partnerships, which began in New York, Memphis and Denver in 1977 (asThe trouble is that traditional public services don’t the Nurse Home Visiting Program), and whichusually allow them to. The social theorist David has developed into a programme now runningHalpern describes how he offered to help other in 20 states of the US.2 It has been so successfulparents with children who needed the regular that President Obama has announced that theand rare treatment that he had learned to give his initiative will be a prime recipient of his 2010son. There were few enough people around with health budget, to be rolled out across the US.3the skills he and his partner had developed, andhe was willing to give other parents in the same The programme – like so many of the other storiessituation an occasional weekend off by helping in this report – emerged out of an intractableout. But there was no mechanism in the NHS for situation. The early years psychologist David Olds,anyone to take up his offer. Not only this, but now Professor of Paediatrics and Preventativesuch offers of support to others are often labelled Health at Colorado University, was increasinglyas ‘risky’ – built on an implicit assumption that frustrated by the damage he saw inflicted onpeople are dangerous to other people, rather than children in their first years by parents who wereassets to be used for the public good. very young, very poor or badly-educated – often in intractable situations themselves, with fewThere are many co-produced services that financial or psychological resources.come up against this barrier; Family NursePartnerships is one of them. In the UK they have The idea that children bonding with parents innot yet developed a mechanism for this personal the first years of life actually turns the brain on isreciprocity either, except informally – though they much more recent. Dr Olds was feeling his wayhave explicitly done so in the US – but the civil towards this when he developed his approach toservant in charge of developing the idea in the support the relationship between young mothersDepartment of Health has noticed the same thing: and their children. The mothers, mainly vulnerablewhen you put co-production into effect, people first-time teenagers, are matched with nurses whowant to give back.1 visit them regularly, sometimes weekly, helping them build a relationship with their babies, and“I remember one mother sent a text to a nurse improving their self-esteem and confidence tosaying she was in the pub watching a mother operate in the world.trying to breast feed her baby,” said KateBillingham, who is in charge of the UK version of Nurses work in partnership with these youngFamily Nurse Partnerships. “She said I really want mothers and form long-term, consistentto tell her she’s not in engagement mode.” relationships which start during pregnancy and last for the first two years of the child’s life. TheThere are many examples, also, of mothers nurse can support the mother in any way whichchanging the way they deal with their own is needed: it could be providing guidance onchildren because they have learned from their nutrition and healthy eating, building up thedaughters, who are themselves going through the mother’s capabilities in breastfeeding and literacy,Family Nurse process as young mothers. passing on information on sexual health and contraception, or linking into local employmentWhat seems to be happening here is that services support services.
  • 7. PART 1: BUILDING ON PEOPLE’S EXISTING CAPABILITIES 7Some of the operating principles of Family “I had a meeting with David Olds, and listening toNurse Partnerships are crucial to its success as his stories contributed to the weight of evidence,”a model, and the approach can be scaled out to she said. “I was very impressed with the depth ofnew mothers without compromising the most his respectful approach to families. I thought he’dimportant elements of the programme. For really got it. It was clear that it would work prettyexample, the strict relationship ratio means that quickly, just listening to the nurses talking aboutnurses never work with any more than 25 families their work and watching them help transformat any one time. They don’t so much surround situations on the ground.”them with services, as engage with the abilitiesthey find in the broader families they are working About 3,000 families in the UK have now beenwith, and their neighbours, in order to show involved in a family nurse partnership, and – overwhat kind of behaviour works with the children – the three years this has been working – it hasteaching as much by osmosis as by instruction. begun to bring about deeper changes to the way nurses think about their work.In practice, the nurses provide models for arelationship between parent and child, and these “We have had to look more closely at whatoften cascade through the family. engagement means – what a purposeful relationship means between a nurse and a client“I remember hearing about one visit, when that can really make change happen,” said Katethere turned out to be fourteen people in the Billingham. “When you get it right, it enablesroom,” said Kate Billingham. “That was fine and you to have what would otherwise be incrediblyemotionally refreshing, but at the next visit, difficult conversations. We have come tothey were all there again.” This level of willing understand this about behaviour change. Peopleengagement is rare in so many types of services have what they need within them. People can onlyfocused on intervening with potentially vulnerable change themselves.” Family Nurse Partnershipspeople. It also represents a number of resources supports through the vital one-to-onethat nurses can connect with to develop the relationships the approach provides, and buildssupport networks needed by the young mother. on the capacity and capabilities of young mothers to achieve preventative long-term effects.Dr Olds has been extremely cautious aboutclaiming anything he can’t prove. The result is a Among the positive side-effects of thisbattery of evidence that shows that the Family approach is that the nurses spend much moreNurse interventions from birth in the US carry on time supporting each other’s work, and Katehaving effects on people up to the age of 28, and Billingham and her team have tried hard to makethat the cost savings to the public purse can be their systems work mutually and horizontally, evenhuge. In the very early years, it impacts on levels though they are within a government departmentof child abuse and neglect. It changes the way that sometimes sees things more vertically.mothers behave – there is less smoking, betternutrition, fewer infections and better emotional “It is a mutual experience all round,” she says. “Itand behavioural development for the children. But is as much about the client giving back to theit also seems to have an impact on the lives of the nurse as it is the nurse giving to the client. It is notmothers – less welfare dependency, for example. about sending someone out to assess you. It isCrucially, it also reduces children’s involvement about what your heart’s desire for your baby andin crime and anti-social behaviour later in life.4 yourself is, and how we can achieve that together.”These indicate the impact of sustained behaviourchange. The prestigious medical journal The This is one of the repeated themes through co-Lancet has identified only two programmes as production in public services. It starts with thecapable of reducing maltreatment and child client and what they really want, rather thanabuse: the Family Nurse Partnership was one of trying to fit them neatly into specific servicethem. packages or predetermined outcomes. It is about relationships, not about ‘services’. The emphasisThe UK Department of Health went through a is on celebrating progress – and they are currentlysimilar crisis of confidence in early years policy looking at how they can accredit parents whoin 2006, and scoured academic papers for any have completed the programme.programmes with a proven track record of impact.Family Nurse Partnerships was the only one that It can be very satisfying for professionals tostood out. Kate Billingham was then Deputy Chief work in this way: “It is deeply affirmative seeingNurse and was asked to test out the idea in ten people’s reactions,” said Kate Billingham. “That isplaces in the UK. The idea caught on fast. when it is about seeing what is possible in people,
  • 8. PART 1: BUILDING ON PEOPLE’S EXISTING CAPABILITIES 8not about their risks, problems or deficits.” central role in their education and communities, and supports them in identifying what they areOne of their long-term goals is to build mutuality passionate about and enables them to use theirmore explicitly into the programme, so that skills to act upon it.parents can begin to support each other more.This would bring it more into line with the The approach pivots around a model of student-community of mutual support that co-production led groups, a school council, and schoolachieves, but many of the other features are community council development plans. Whilealready in place. These are equal relationships student councils are becoming increasinglybetween professionals and clients, designed to popular in schools, they are rarely managedbuild up people’s capabilities, whatever they entirely by students themselves and even fewerhappen to be. are developed to the extent that the Learning to Lead approach achieves.The evidence coming from the US is that theFamily Nurse Partnership idea can also save The whole school community is involved fromsignificant amounts of money. For every $1 the beginning of the process, and the model isinvested, research shows that between $2.88 and kept going through teams formed and managed$5.70 is saved from future public expenditure directly by students. These can range fromacross health, criminal justice and social support fundraising teams, to dyslexia support andservices, and the savings are greatest for those ‘beautiful school’ teams. Teams are supported bydefined as ‘high-risk’. It was identified as the most link teachers and staff, but are independent incost-effective child welfare and home visiting their activities and management – students canprogramme in a study by Washington State invite a teacher to one of their meetings, in orderInstitute for Public Policy.5 to draw on their particular knowledge and skills, but students are trusted to plan and manage theirMany of these cost savings come from effectively activities with a high degree of autonomy.cutting child abuse and neglect. But the overallcosts of running the programme are saved by the The school community council provides a tool fortime the children are four through reduced health developing students’ control over their education,service use, reduced welfare use and the increased and in piloted schools often has a membershipearnings of the mother. The biggest long-term of over a quarter of the total student populationsavings are because both mother and child tend – significantly higher than student councils allow.to be less involved with the criminal justice system. The teams work collectively to produce a five-These are indicators of significant change that year school community council developmentimpacts across a lifetime and between generations. plan which is integrated into the school’s development plan and provides a meaningfulThe estimated cost per child in the UK of the space for students to contribute to the activitiesfamily nurse intervention is about £3,000. This and strategies of the school and local community.compares to £15,000 average public expenditure Learning to Lead shifts the view of students fromfor children with troubled behaviour.6 This is a sometimes troublesome and disengaged groupthe kind of financial evidence that lies behind who come in to receive an education, to a vitalthe decision to aim for 70 partnership sites in asset whose co-creation of their own education isthe UK by 2011, although not yet a complete absolutely critical to achieving a strong academic,mainstreaming. The point here is about what can pastoral and social foundation.be done when you work with what people can do,rather than simply looking at them as bundles ofneeds with service solutions and costs attached. Gloucester Enablement Lead Programme In South West England a social services teamOther examples of building on people’s existing which worked with disabled children, and theircapabilities in co-production activity include: families, transitioned away from the traditional model of social service delivery and moved towards a new approach. Action plans andLearning to Lead7 desired outcomes were co-produced with“We don’t just have our say and then nothing families, making the entire approach much morehappens,” said John Dixon, a school council collaborative. The team goals and roles weremember in a Learning to Lead school. “We turn restructured, and placed much more emphasisour plans into action. After all, the school is here on facilitating with the families, rather thanfor us.” Learning to Lead is an approach which ‘delivering’ something to them.provides a forum for young people to take a
  • 9. PART 2: MUTUALITY AND RECIPROCITY 9PART 2:MUTUALITY AND RECIPROCITYOffering participants a range of incentives which enable people to work in reciprocal relationships withprofessionals and with each other, where they have mutual responsibilities and expectations.W hen the phone call came in the middle Scallywags is still affordable for nearly everybody. of 2005 to ask if she could save It costs just £2.50 an hour, significantly lower than Scallywags, the last parent-run nursery comparable childcare provision in London. Thisleft in the UK, the key question Debbie Bull asked is because what makes Scallywags unusual, andherself was whether such a thing was possible what makes it a prime example of co-productionany more. It was founded in 1992 by a group of in practice, is that the parents do lots of theparents who have long since moved on. work. They don’t just manage it and take the decisions – this isn’t just about self-managementThere had been numerous parents who got – it is genuine mutualism in practice. They are thetogether in the 1970s and 1980s to run their own decision-makers but they are also a critical part ofnurseries, usually glorified crèches. There are the staff.parent-run nursery schools in Scandinavia. Butin the UK, these have tended to run out of steam The crisis that Debbie took on in 2005 was partlyonce the children of the original group are old because of a slew of new Ofsted and early yearsenough to move onto primary school. regulations, which seemed to be impossible for models which were not ‘conventional’ toIn the UK, by 2005, there were screeds of comply with, and partly because of the need tolegislation on child protection, on education, on move premises. Debbie was working elsewherehealth and safety and a great deal else besides. in London at another nursery in Hackney as aThat was certainly enough to sink most mutual nursery nurse. It isn’t quite clear why they askednurseries projects, and it very nearly sank her to take over as a full-time manager, but sheScallywags Parent Run Nursery in Bethnal Green, clearly had the reputation of enjoying workingEast London. with parents.Then there were the parents. How do you manage “The remaining parents still wanted to beall those competing requests, needs and egos, involved.” said Debbie. “They didn’t want to justespecially when the parents are actually the drop their children off somewhere. They wantedbosses? The conventional wisdom was that such a the values of the nursery to carry on, but theyposition was a potential nightmare for any nursery needed leadership and they needed new parents.”manager, caught in the tension between inflexibleregulation and parental choice. But Debbie didn’t In the event, Debbie took over and Scallywagsagree. closed for half a term to move premises and get ready. She took all the paperwork away,“There are teachers who say it’s too challenging looked at all the new regulations, looked at theto work alongside parents,” she says. “But it’s not. policies which had been developed because ofIt’s nice and it’s fun.” what the parents actually wanted – a different matter entirely – and organised a framework thatThat is how she came to be the manager of what enabled parents and regulators to meet in theis one of the very few parent-run nurseries in middle. Creating the conditions to co-produce inthe UK, and it is now a huge success. There are a childcare setting required navigating a minefield23 children registered now compared to just six of policy obstacles which, while intending towhen she took over, and usually 16 attending on protect children, had the consequence of pushingany given day – the maximum Ofsted allows in the away the skills and capabilities of parents whospace. There is a waiting list to join Scallywags. wanted to actually take part in their child’s care.But most of all, just when childcare costs are “We were determined to keep the idea of parentssoaring as the increasing regulation starts to bite, coming in and being involved with the nursery, not
  • 10. PART 2: MUTUALITY AND RECIPROCITY 10just as spare bodies but actually doing activities,” at home by parents and brought in. There isshe said, explaining why she didn’t want to be a little recognition that this is a different kindconventional manager who just did everything of model, where the safeguarding is done in aherself. “I didn’t want to come in and just push more traditional way – without having to let thethem away.” food contract out to a professional supplier. The tension is clear, and much of the innovation inNow Scallywags employs Debbie and an assistant, co-production faces a similar challenge fromplus there are three parents helping out at any regulators who struggle to categorise and assessone time. Parents are on duty every fifth day that a genuinely new approach, when people are seentheir child attends, once a week if they are there as much riskier than professionals.full-time and once a fortnight if they are therepart-time. Every session is run jointly between Scallywags is highly unusual in the UK, butparents and paid staff. there are parallels in France and Germany, and particularly in the parent co-operatives in Sweden.The result is that parents can afford to work – Comparisons of the parent involvement in Swedenand there are a many working parents in Bethnal in different kinds of childcare, by the SwedishGreen – but that they also join what is, in effect, sociologist Victor Pestoff, suggest that this kindan instant community. When they are shown of mutual provision is a potential antidote to whataround for the first time, they realise that this is he calls the ‘glass ceiling of participation’. Beingnot your average nursery, but one where they will actively involved in the delivery of childcare leadsbecome co-owners of the enterprise. There are a parents to also become more actively involvedlot of meetings to hammer out people’s different in governance. Parents are not involved inneeds, and it also means that Debbie has to sum democratic decision-making in most other formsup the parents and their capabilities as much as of childcare, but where co-production is the basicshe has to sum up the children, and recognise model parents engage in management decisionshow she can put them to use. too.9 This is not restricted to arms-length involvement in management and decision-taking.“I find myself looking at them and thinking – whatcan they do?” she says. “But it does mean that “Taken together, the work obligation and theirwe have parents who bring a unique experience responsibility for decisions provide them with ato the school. We have artists and musicians, and sense of ‘democratic ownership’ of the childcarea lot of people from other countries. It means facility, not usually found in the other forms ofthat they get life experience from all over, with childcare provision. Parents’ participation in thedifferent and interesting people and different other facilities is restricted primarily to informalskills. It is important for the parents to make their talks in combination with some other channels ofown community; if they are from overseas they influence,” wrote Pestoff. “Only when citizens areoften have no family here and they tend to make engaged in organised collective groups can theyfirm friendships through Scallywags.” achieve any semblance of democratic control over the provision of public financed services.”10 ThisThe key challenge for Scallywags remains this links strongly to the transformational rather thantwin business of satisfying the regulators, even one-to-one models of co-production, and stressesthough they look different from nearly every other the importance of creating a meaningful publicnursery in the UK, and at the same time satisfying space for co-producers to bring their assets intoall the parents. But, as Debbie says, that is part of the delivery of services.the appeal. In fact, the Ofsted regulations leaveroom for the broad idea that parents should What Pestoff argues is that pursuing publicbe ‘partners’. “They are partners here,” says service reform which emphasises “economicallyDebbie, “just a bit more so.” A glance at the 2009 rational individuals who maximize their utilitiesOfsted inspection report makes the challenge and provides them with material incentives toeven clearer. “Children benefit highly from the change their behaviour” tends to crowd out someinvolvement of parents in the day to day running of the other kind of innovations which might beof the group,” it says. “However, some procedures possible, using co-production and reciprocity, andfor safeguarding children are not effective in which – as in the case of Scallywags – help solveidentifying potential risks to children.”8 the problem of affordability, makes members more confident, and hones their parenting skillsThere are queries from Ofsted not just about too.checking out parents, who do all undergo acriminal records bureau (CRB) check, but also Again, it is both an advantage and a key challengeabout the safety of food when it is prepared for this kind of co-production. It looks different
  • 11. PART 2: MUTUALITY AND RECIPROCITY 11to regulators. It seems to involve ordinary parents Tenants earn credits by volunteering their timeto an extent that some officials might believe is to help deliver the services of the housingdangerous. Are the children safe? Are the parents association, for going to focus groups, tenantsufficiently professional to be able to challenge and steering group meetings, being on interviewchildren and educate then? They probably are, panels for Taff staff, writing articles for the Taffand the evidence from Scallywags is that a range newsletter, helping to arrange events and tripsof fascinating people can really enrich nursery for tenants, doing jobs that benefit the hosteleducation. But can a formal, bureaucratic system collectively, like communal shopping or wateringunderstand that? Or will it put so much pressure flowers, creating new clubs or community eventson reciprocal models of co-production to conform linked with Taff or acting as a tenant boardthat it eventually drives them out, as so nearly member. The credits can then be redeemedhappened to Scallywags in 2005? within Taff, for example by ‘paying’ for access to training or computer suites, but also in the widerAll co-production includes an element of community, like the local sports centre and Cardiffreciprocity, both between individuals and public Blues Rugby Club. These opportunities in theservice professionals, who are encouraging them broader local community also help to prevent theto get involved in helping other people as part young women living in the hostel from becomingof their own recovery or treatment or education too separate and isolated from the community– and between the individuals who are involved. networks and resources around them. They areSome projects do this more explicitly. Scallywags now broadening this programme to all theirprovides a financial incentive with the cost of tenants across all their homes and also allowingchildcare offset by parental time contributions; people who aren’t tenants to earn these credits.other projects use a counting system thatmeasures and rewards people’s efforts using atime currency (see Part 6 for more detail). Often Orange RockCorps13these are rewards that are simply excess capacity, Orange RockCorps was founded in 2005, and itslike the sports centres in Cardiff (see below). success as a model of reciprocal giving will this year see it scaled out across Europe. RockCorpsThere are some volunteering purists who identifies the value of people’s time – donateddisapprove of getting anything in return, but to a huge range of community projects – andthe truth is that most volunteers get something in return ‘rewards’ four hours of volunteeringout of their involvement – it just isn’t primarily with a free ticket to a music event where topfinancial and it isn’t at market rates. Reciprocity performers play. In 2009 alone over 5,000 youngin co-production is about making the mutual people dedicated over 21,000 hours of time,responsibilities and expectations explicit, just as which benefitted 41 different charities. The hugethey are in the Scallywags nursery, and triggering success of the programme has shown that allmore opportunities for people to contribute. types of people can become contributors, and hasThese are not one-way transactions between involved people from across the socio-economicvolunteers and recipients but interactions that spectrum. You can only attend a concert if youcatalyse further contributions to the benefit of all. have dedicated time to a RockCorps project, meaning that a reciprocal mechanism supportsOther projects building reciprocity and mutuality the entire process. The challenge for thisalong these lines include: approach is to explore ways in which this one- off contribution and reward can become a more regular option for young people.Taff Housing11Taff Housing is a community-based housingassociation with over a thousand homes in someof Cardiff’s most ‘disadvantaged’ housing estates,as well as specialist, supported housing projectsfor young women. Managers have been workingwith the social enterprise Spice12 to build a co-production culture among some of its young,single, female tenants.The aim is to give them opportunities to bemore active in their hostels and challenge thedependency culture that can quickly develop,undermining their confidence and capacity.
  • 12. PART 3: PEER SUPPORT NETWORKS 12PART 3:PEER SUPPORT NETWORKSEngaging peer and personal networks alongside professionals as the best way of transferring knowledgeand supporting change.O ne of the benefits of improving medical not just what they can’t do – and they build on techniques is that the number of people that. This is a very common theme throughout the who survive serious head injuries is whole co-production sector. “They are all peoplegoing up all the time. So is the number of those like you and me,” says Ben Graham, the residentsurviving strokes. The result is that there is now psychologist there. “They are all people who useda small but expanding group of people who to do a job or who have things to offer. There islive with the after-effects of such conditions – really no excuse for keeping them out of work.”15they get tired easily, sometimes there are othermore challenging side effects to their behaviour Ben Graham is a psychology graduate who– 50,000 people with this experience live in came to Headway East London in 2004. “I wasLondon. interested in doing something a bit different,” he said. “It was the only place offering volunteer rolesMost of our techniques for helping people working with people with brain injuries.”recover from serious head injuries date from theSecond World War when the priority of ‘curing’ There were seven staff then and 25 now, and whatpeople was to get them fit enough to go back attracted Ben – and the other staff who haveto the battlefield. Times have moved on, but our joined him in that period – has been the way thatobjectives for helping people in that category the members (rather than ‘patients’) have beenhave hardly moved at all. The main objective for increasingly integrated into the professional workmainstream rehabilitation is to get people with of the centre. They are helping to run aspectsbrain injuries back into the job market as soon as of the service, mentoring new members, doingpossible – or ‘back to normal’. The main problem assessments or inductions or organising projects.is that, because this often isn’t possible, everyoneis disappointed – patients, professionals and Assessments are an area of clinical expertisefunders. where patients are not usually allowed, but at Headway these are done with a team whichThat approach also begs some key questions. includes a staff member and a member of theHow do you help people rebuild some kind Headway community. As the Expert Patientof quality of life? Or use their skills again? Or Scheme has shown in the NHS, patients are oftenmove on from being permanently dependent on experts in their own condition, but – in this case –medical help when they have experienced such they can also provide vital support to each other.a significant physical change. Most of the non- They have been through a similar experiencemedical provision has gone little further than themselves, after all.day centres, according to one specialist, wherepatients go along, exchange views about how That is the most obvious feature of this kind ofdreadful everything is, and then go home again. co-production. Headway East London certainly recognises and works with their members asBut it isn’t all like that. Headway East London assets, but they are also building peer supportis a charitable operation, a day centre with a networks alongside the professionals as thedifference, which has pioneered a challenging best way of transferring knowledge, andco-production approach to ‘acquired brain injury’, building up people’s abilities. It means differentwhich encompasses the conditions described kinds of relationships between ‘patients’ andabove.14 ‘professionals’. At Headway it has become a common endeavour.The difference about Headway East London isthat, like other co-production projects, they look Ben is in charge of a new project which is pushingat their ‘patients’ according to what they can do, this approach further, which they are calling the
  • 13. PART 3: PEER SUPPORT NETWORKS 13Discovery Project. They have recruited six people apart a bit. We were willing to make mistakes, butfrom their community, all of whom have been things were a bit hair-raising in the early days.”through traditional methods of rehabilitation, havetried going back to work, only to have the job fall The film project is already looking successfulthrough – sometimes more than once. after only three months. Despite having a severe memory impairment, one of the team membersEach of them is now leading small teams, setting has raised the initial money they need to getup a series of new enterprises based at Headway. underway.One of these is organising a documentary as away of launching a new social enterprise to teach “This would never have happened in a traditionalpeople to make films. Another one is organising setting,” says Ben. “It would never have led to thea programme of live events involving disabled setting up of a viable social enterprise. Traditionalpeople. rehabilitation treated him as a patient, and gave him a series of job placements, which he didn’tThis is the cutting edge of an approach which care about. What we are doing is throwing out thebegan back in 1997, led by the centre’s director idea that we can fix people. This man will alwaysMiriam Lantsbury, a former nurse. Ben describes have a memory impairment, but there are thingsthe approach as being based on “intuitive he can do to compensate for that.”wisdom”. The service is now open five days aweek, at the centre in Kingsland Road, with a The trouble with grooming patents for the jobcatchment area that stretches as far east as market is that most employers will not cater forDagenham. About 120 people with brain injuries, employees with complex disabilities. This is notand other volunteers, use the centre every week. necessarily the fault of the potential employers – the world of work is damaging and exhausting forThe subtlety of this approach for the team is that people even without head injuries. Yet these arethis positive approach needs to be tempered people who have something to offer and who willby something tougher. Some people with brain benefit enormously from working.injuries can be aggressive. In some cases the headinjury was acquired as result of a chaotic lifestyle What Headway East London is doing is buildingwhich carries on afterwards. But Headway has on the idea of a network of mutual support, anddiscovered that giving people responsibility can pioneering a way that their members can do twoalso motivate them to control their own behaviour or three days’ work a week, get a salary and stilland make enduring changes. be part of a community where they can provide some support for each other to flourish within“What we have found is that if people are society.motivated, then they can deal with theirchallenges,” said Ben. “If they really care about People with brain injuries often have a big gap inwhat they are doing, they do use the techniques their lives. They may well have been in a hospital,they have learned to control their actions.” spent months in a coma, only to find that the life they knew before had gone. They can becomeHe describes one member of the community hugely isolated.who was often on the verge of physical violence,but who turned out to be very good at greeting One of the side-effects of conventional servicespeople who arrived at the centre. This was one – like mental health or justice – is that people canof those risky contradictions that often seem to become isolated from the very networks theyemerge in co-production. “He is the first person need to recover, whether it is family or supportiveyou meet when you come in,” says Ben. “So you friends. We find where there are co-productioncan’t have him pinning someone to the wall and projects that knit together these kinds of networkthreatening to kill them. But he knows that what of mutual support, they are usually outside thehe is doing is important and the way he behaves mainstream of service delivery.will affect the centre’s future. He can still getstressed or anxious but, because he values being “One of the big problems is that the practicein that role, he has improved enormously.” of co-production leads to ideas and activities that don’t fit with what funders understand toThis isn’t an easy balance to achieve, and it can be ‘rehabilitation’,” said Ben Graham. “So thebe chaotic at first. “It sometimes felt like we were Discovery Programme stands little chance ofstruggling, not sure where we were going with gaining statutory funding as a rehabilitationthis,” said Ben. “But it worked because there venture because Jobcentre Plus have a fixed ideawas an element of being willing to let things fall of what rehabilitation is – a retraining programme
  • 14. PART 3: PEER SUPPORT NETWORKS 14over a number of weeks with a job placement at should be subject to service user evaluations,the end that returns someone to the workplace. to enable the delivery of more effective, andThe idea of an open-ended project that becomes therefore more cost efficient services, and to giveself-financing after an initial investment is way offenders a voice in their own rehabilitation andoutside their box. Of course, we’re not letting that resettlement.”18stop us, but it doesn’t make it any easier.”The benefits of peer support networks have beenrecognised by a small number of professionals,particularly those working with people with long-term medical conditions, but these networks areoften undervalued and unsupported optionalextras to specialist medical services beyond the‘core’ business. What makes them co-productionis the explicit link between these groups andsupportive professionals who are able to respondto and provide appropriate professional supportalongside the peer support that group membersprovide to one another. Anecdotal evidenceindicates that it is actually the knowledge,expertise and support gained through thesenetworks that is among the most valuableservices you can receive. Some practical examplesof developing peer support networks include:Multiple Sclerosis (MS) Society16The MS Society is a charity with elements ofco-production apparent across its services. Itfacilitates a nationwide network of local groupswhich offer services, mutual support and socialactivities for individuals living with and affectedby MS. Local MS nurses are funded by the charityand are often linked into these local groups todeepen the relationship between nurses andindividuals. The society also offers short coursesin self-management of MS as part of the ExpertPatient Programme. Workshops are held forspecific groups, such as young people, whocontribute their time to facilitating workshopswith their peers and are paid a small amount asrecognition of their contribution.User voice17The strapline on the User Voice website is ‘Onlyoffenders can stop re-offending’. User Voice isan organisation advocating co-production as acentral approach to addressing criminal justice.They have organised seminars led by ex-offenderswhich look at the root causes of offending, setup one-to-one peer mentoring programmesbetween successful ex-offenders and existingprisoners, and have recently begun piloting amodel of prison councils to give prisoners alarger and more meaningful role in the decision-making process within prisons. The prisoncouncils model is being piloted in three prisons.Their ultimate aim is that “prisoner programmes
  • 15. PART 4: BLURRING DISTINCTIONS 15PART 4:BLURRING DISTINCTIONSBlurring the distinction between professionals and recipients, and between producers and consumers ofservices, by reconfiguring the way services are developed and delivered.M urder is blessedly rare in the small activity taking part but the work needed to make Somerset town of Chard, but it was one the panels operate – interviews and hearings – of those rare once-in-a-decade murders was done by local people who wanted to takethat led to a unique approach to co-producing part.justice which is now spreading to other parts ofthe UK. This is what makes community justice panels one of the most interesting examples of co-productionThe key player at the beginning was Chard’s local which deliberately blurs the distinction betweencouncillor Jill Shortland, now leader of the Liberal professionals and recipients. The agents in thisDemocrat group on Somerset County Council. It project are the consumers of justice services,was she who made a chance remark to the local the general public, but not just at a distance aspaper about their campaign to have the trial advisors or directors of the operation – takinglocally, rather than send it as far away as Bristol. decisions that paid staff carry out. They are“The real problem in Chard wasn’t murder, it’s the involved as people running the frontline serviceanti-social behaviour and the night time economy themselves, sitting in hearings and deliveringand nobody seems to be brought to book for sentences and doing so very successfully.it,” she says now. A week after Jill suggesteda local justice panel, the paper had received a Part of the power of the panels is that theydeluge of letters which – to Jill’s surprise – were are local, and that local people can takeoverwhelmingly in favour of the idea. “You’ll have some responsibility for justice. They deal withto do it now,” said the reporter. cases sent, not just by the police, but by local authorities and housing associations as well. TheSo Jill sent a more formal proposal to the Home offenders have to accept that they are guilty,Office together with copies of the letters. A otherwise the police can’t divert the case out ofmonth later – backed by the local paper’s the court system. Every case gets an Acceptablecampaign to ‘Bring Justice Home’ – she began Behaviour Contract (ABC), an idea pioneered bythe process of being pushed from department Islington Borough Council, which can last fromto department in the Home Office. “I’m a bit of a three months to a year, and which includes somenag,” she says. “I wore them down.” kind of restorative action.As it turned out, Home Office officials had been The biggest impact of the panel has been onstudying some of the youth courts in the US, but those offences which are classed as minor buthad been unable to develop a workable equivalent which have a corrosive effect on the life of anyfor adults, so they were interested in finding a neighbourhood, anything from tipping over abetter way of dealing with ‘minor’ crimes. After a rubbish bin to GBH, often – but not entirely –great deal of funding applications, and a few small committed by under 30 year olds after too muchgrants, the Home Office agreed to fund a pilot alcohol. It was widely perceived in Chard, as it isscheme, which began in 2005. They attracted in many places, that these minor offences were40 volunteers from Chard in just two days and ignored by the police and courts system. Yet asappointed a co-ordinator, Valerie Keitch. research shows on both sides of the Atlantic, it is often small misdemeanours that attract biggerThe result was called the Chard Community ones and determine the crime pattern over theJustice Panel. It incorporated some of the whole town. They also generate fear of crime. Bybest practice in restorative justice, but what engaging new capacity it has been possible towas genuinely new was the way that it gave tackle these offences at an early stage.responsibility to local people. The co-ordinatorand a professional administrator facilitated the Jill believes that the justice panel works partly
  • 16. PART 4: BLURRING DISTINCTIONS 16because it is well run and partly because it show her the CCTV footage of the evening withexemplifies real community action, “We helped the bottle. Now Pauline works regularly behindprovide a framework for the community to use to the bar and is paid for doing so. What was anmake a difference, and my goodness they have unpleasant alcoholic scrap has been transformedput a lot into it.” by the intervention of the panel into a turning point in somebody’s life.It is also a genuinely different approach to crime– not a raft of new offences, more CCTV and The Community Justice Panel idea has nowoverstretched and centralised policing – but spread to Sheffield and – after one false startthe reinvention of an old idea. “The idea that – across the whole of Somerset. Jill Shortlandcommunities should run their own justice goes claims that at about 5 per cent it has the lowestback centuries,” says Jill. “Every community had re-offending rate of any of the experiments withthis system, but we have consistently lost it from restorative justice in the UK. The false start incivic society for generations. Chard has helped to Wellington, Somerset was partly because of howput it back.” the approach was developed. “I realised that it didn’t work there really because we had just givenTake the example of Pauline (not her real name), them the structure that we were using in Chard,”who was drinking in one of the noisier pubs in said Jill. “You couldn’t just replicate exactly whatChard when she looked up and saw her boyfriend we were doing in Chard. We had to learn fromwalk in with another woman. She had drunk a Chard but develop the approach in Wellingtonconsiderable amount that night, and she dealt with the people there, evolve it that way.”with the incident by smashing a bottle over hishead. It was the kind of rowdy incident of minor The paperwork is now done in Chard andthuggery that happens in many towns on a relationships with the police are organised on aSaturday night, and which seldom comes to court. county basis. The Chard hearings take place at theIn this case, Pauline’s boyfriend refused to press district court, and Wellington hearings at the towncharges, and in almost every other community council. Sheffield uses neighbourhood centres.in Britain that would have been that. But in The Community Justice Panel staff are also allChard she was referred instead to the innovative trained as trainers. Training, one way of buildingcommunity justice panel. After all, Pauline’s on the capabilities of individuals, is always goingbehaviour had not just affected her boyfriend. to be a key factor in projects which blur theThere were the other customers in the pub whose distinction between professional and service user.evening had been disrupted. There was the couplewho ran the pub who had to clear up the blood The original three panels with volunteer membersand glass. There were the police and emergency has now shrunk to just one, though there are moreservices as well. people available if the dispute involves whole families or neighbours. The other change is that,Valerie Keitch, the co-ordinator, visited Pauline as the project has expanded, the proportion ofand arranged a Community Justice Panel hearing. young people going through the panel is muchAt the hearing the chair asked one of the key higher.restorative justice questions: ‘who do you thinkhas been affected by your actions?’ Pauline’s But it turns out that there is some kind of alchemyboyfriend and the pub managers were there too, that happens when young people have to speakand at the end of the hearing, all those involved alongside their parents, said Jill. “Often these aresigned an ‘Acceptable Behaviour Contract’ (ABC), parents who are at the end of their tether. Thewhich Keitch calls “a conference agreement with a young people usually come in quite cocky, andbit of legal bite”. As part of this contract, Pauline usually it is the mother who comes in to supporthad to spend three weekend evenings collecting them. When the mothers answer the questionglasses in the pub, and this turned out to be a ‘what did you think when you first heard this hadtransformative experience. happened?’ it gives them an outlet so that the child can hear – maybe for the first time – whatFrom behind the same bar, and with the their parent feels. You can see they are oftenobjectivity derived from being stone cold sober, taken aback by it.”she was able to watch the behaviour of herfriends and contemporaries under the influence. Jill uses the example of a 20 year old – let’s call“I never would have believed people behaved in him Brad – who went on a drunken rampagethis way,” she told the landlady after one evening. in the town and broke some shop windows. At“I feel ashamed. I am never going to get drunk the hearing, the panel persuaded their oldestagain.” The landlady took the opportunity to volunteer to come and give evidence about what
  • 17. PART 4: BLURRING DISTINCTIONS 17it was like being an older person in the town and the people we are really saving money for are thefearing that kind of violence and disorder. When police and the courts.”Brad was asked if he wanted to say anythingafterwards, he referred back to her. “That lady Other projects that have found ways to blur thecould be my grandma,” he said. “I really didn’t distinction between professionals and ‘users’ ofthink about what my grandma would have said.” services include:A few weeks later, the police officer who hadbrought the case saw Brad on the other side Merevale House20of the street, with about 30 friends. Brad Merevale House is a private residential home forshouted at him to come across and, with some people living with dementia which believes in andtrepidation, he did so. “I wanted to introduce you supports ‘person centred care’. The philosophyto my mates,” he said, and did so. At the end he which underpins their work helps make co-introduced him to two in particular. “Their job is to production a reality by recognising that ‘service’make sure none of us gets wasted,” he said. isn’t always a one-way delivery, but a collaborative endeavour.The sub-text of this kind of co-production,especially with young people, is to find ways that Merevale House has won awards for itspeople can become advocates of good behaviour, achievements, which are based on the valuesas in this case. that “there is no ‘us’ and ‘them’” in the home. Residents take an active role in all the day-to-dayImportantly there is also a local sense that it has activities within the home, from preparing mealsbeen successful, especially from those taking part. to recruiting staff and gardening. The give and“You often start the facilitation panel thinking, take relationship between staff and residentsthis person is never going to change, and then is central to the success of the home; it allowssuddenly the penny seems to drop and they sit residents to take control over their lives andthere and listen,” said Jill Shortland. Evaluation fosters a collaborative and empowering sensesince the panel began shows that the perception of community. This is seen in very basic ways,of the police has improved, especially among for example people set the tables and eat mealsoffenders. While a large minority of the locals said together, rather than ‘staff’ servicing ‘residents’.they were afraid to go out after 5pm before thepanel began, they now say that this nervousness In a publicly funded setting – Merevale House isis just late at night and at weekends.19 privately funded – there might be some public outrage at the idea that older residents living withThere remain problems caused by central dementia are expected to contribute towards thegovernment targets. Because cases diverted daily activities that keep a home up and running.to the panel are not defined as ‘sanctioned But the national awards for excellence Merevaledetections’, they can’t go into the police House has won would suggest otherwise: thatfigures for cases successfully cleared up, which fostering reciprocal relationships and eroding theundermines police support for the whole idea. Jill boundaries between staff and residents genuinelyis trying to persuade the Home Office to start a empowers people. Weekly residents’ meetingsnew category called ‘community sanctions’ which and daily activities also build social support andwill allow the police to count these cases too. focus on using people’s strengths and abilities to create the best possible care environment.The risks that professionals sometimes associatewith the involvement of lay people in justice havenot emerged as a problem. There also seems to Richmond Fellowship/Retain21be no problem in Chard getting volunteers, and Richmond Fellowship employment and trainingthese range in age from 18 to 87. They include services began 20 years ago. In 2008, it beganambulance drivers, paramedics, former naval working with employers and employees toofficers and youth workers. “I am constantly support individuals whose work is affectedamazed at the quality of people who come by their mental health problems.22 The modelforward,” said Jill. is based on preventative services and early intervention. Advisors work with clients in one-to-The key problem is finance. There is no core one sessions, as well as connecting them to peerfunding and most of the administrative time is support groups and peer networks with regulartaken up bidding for grants. “This should not have meetings. The key to this is the equal partnershipto be done by begging,” said Jill. “The money with clients and an explicit focus on facilitatingshould be coming from the justice system because and supporting a client in their own choices
  • 18. PART 4: BLURRING DISTINCTIONS 18and wishes, rather than delivering a prescribed about Size Zero media pressure on young people,service. to be showcased in local secondary schools and running workshops about body image.“Advisors are praised when they can do less forthe individual, and the more they encourage the Once students have completed the Envisionclients to do for themselves,” says Vicky Edmonds’ programme they have the opportunity to join thefrom Richmond Fellowship’s Retain project. Graduate Advisory Panel, where they are involved“Clients can do whatever they wish to do.” in developing the strategy and direction of the organisation. They, along with other ‘grads’ areRetain recognises that clients come to them with involved in hiring new staff, making decisionsvaluable knowledge and skills and experience about marketing, designing flyers and deliveringof their own lives, while their advisors bring workshops, whilst Envision continues to provideknowledge of employment and employment law. them with resources and the opportunitiesBetween the two of them, they ensure clients to help continue making a difference in theirbuild on their own choices. They are now working communities. Envision staff view their users aswith over 1,000 clients. They reject specific time equal partners, and are trained to harness theobjectives for each client. knowledge, energy and enthusiasm of young people and support them in turning their ideasThe focus on choices for the individuals is often into practical projects which benefit the youngat odds with funders’ objectives, which are to set people and the local community.quantitative targets. It was also sometimes hardto change the expectations of staff and clients. “Ifyou’re working with people who have been withina service for a very long time in the residentialarea it’s very difficult to change perceptions,and bring in a new way of working,” says Vicky.“People who have been working within the areaas ‘carers’ are doing work in the old way and it’sharder for them to get a grip on new ways ofworking.”In the same way, people who have been involvedfor a long time expect to be recipients. “This isa huge cultural struggle. But doing as little aspossible for somebody is actually the most helpfulin our service.”Envision23Many of the examples of co-production herecreate a meaningful space for individuals, groups,families and communities to take ownershipof a service, or part of a service, and decidetheir activities and priorities in partnership withprofessionals and supporting organisations.Envision is employed by schools to work withyoung people on environmental, communityand social initiatives – not in the traditionalvolunteering model but with a genuine sense ofcollaboration and control.Co-ordinators at Envision see their role asfacilitators, allowing young people to takeresponsibility for their surroundings, environmentand community. Current groups across London,Birmingham and Leeds are managing projectson climate change, fundraising by selling bakedgoods and organising a gig, organising ‘bike toschool Thursdays’ and making a documentary
  • 19. PART 5: FACILITATING RATHER THAN DELIVERING 19PART 5:FACILITATING RATHER THANDELIVERINGEnabling public service agencies to become catalysts and facilitators of change rather than centralproviders of services themselves.I f traditional services tend towards pigeon- Local Area Co-ordination has a number of holing people according to the needs they elements to it, including individual co-ordination, identify and the available service options personal advocacy, information and advice, familybefore them, many co-produced services start support, building social capital, early interventionsomewhere else – more like: what sort of life does and handing back control. This approach containsthis person want? What does this person feel is strong preventative qualities and over the twoa good life for them? They definitely don’t start decades it has been in place in Australia it haswith the question: what services does this person reduced the number of specialist interventionsneed? needed by disabled people.In Middlesbrough, a range of developments are LAC also aims to make the system lessunder way to put this idea into practice, so that complicated. A local area co-ordinator works asindividuals, families and communities are more a single accessible point of contact in a definedobviously at the heart of everything that happens. local area, supporting between 50-60 individuals (children and adults) and their families in the localLocal Area Co-ordination (LAC) is an community. Co-ordinators get to know people,innovative approach that is at the heart of the their assets and skills, strengths and aspirations,Middlesbrough vision of supporting disabled and the local communities in which they live.people and their families to get a ‘good life’ by They provide and support access to accurate andtransforming existing support and services. Its timely information from a variety of sources.framework is built on the principle that, whileeach individual is different, “the essence of a good They support people to be heard throughlife for someone with a disability is the same as promoting self advocacy, advocating withthe essence of a good life for someone who does people and accessing local advocacy services.not have a disability”.24 They also contribute to building welcoming, inclusive communities, identifying communityThe LAC approach is designed to help people opportunities and responding to gaps in localto stay strong, rather than waiting for them communities. But one of the key areas – and thisto fall into crisis before intervening to fit them is what makes co-production central to LAC’sinto services. Instead, LAC actively works with approach – is that they help people developindividuals, families and local communities to personal and community networks to enablebuild on and share assets and skills, capacities practical responses to their needs and aspirations,and passions to make local communities more and they help people to contribute and sharewelcoming and to value everyone’s contributions. their skills, assets and strengths through these networks.LAC first started in Western Australia in 1988,partly as a response to concerns about quality, Ralph Broad was a member of a communitycost and outcomes of traditional services, based specialist team supporting disabled peopleand from a range of new ideas about how and their families during the implementation ofindividuals, families and communities can make Local Area Co-ordination in Western Australia,a difference. It owes much of its success to the and then worked alongside co-ordinators indrive, contribution and commitment from people the community as part of a community-basedlike Eddie Bartnik, from the Western Australia organisation that provided support. He was alsoDisability Services Commission. It is now also involved in rolling out the idea in Scotland, whereworking across many Australian states, Scotland, LAC was a key recommendation in the nationalCanada, Ireland and New Zealand.25 review of learning disability services.26
  • 20. PART 5: FACILITATING RATHER THAN DELIVERING 20What seemed radical back in 1988 when LAC guide the co-ordinators in the work they do:began is now becoming more widespread, hesays. “Suddenly, rather than assessing people to 1. As citizens, disabled people have the samefind out what they couldn’t do and then thinking rights and responsibilities as all other peopleabout money, resources and how they could fit to participate in and contribute to the life ofinto a service to solve their problem, there was a the community.different discussion,” said Ralph. “Co-ordinatorsstarted asking people ‘what would be a good life 2. Disabled people, often with the supportfor you?’ rather than ‘what service do you need?’” of their families, are in the best position to determine their own needs and goals, and to“Instead of the only discussion being about money plan for the future, whether as self-advocatesand services, it started to be about the range of or supported by advocacy.ways that people could lead the life they wanted,a range of practical ways of getting support and 3. Families, friends and personal networks,assistance to overcome issues and the importance which may include support workers, are theof focusing on keeping people strong rather foundations of a rich and valued life in thethan waiting for people to fall into crisis. Also, community.people started to think about the assets andskills that people had, their personal networks, 4. Support should be planned in partnershipthe contribution the community could make, with individuals and others important to them,and the contribution people could make to the including their family.community.” 5. Access to timely, accurate and accessibleBefore LAC, those who were receiving these information, in a variety of ways, enablesservices talked about feeling undervalued, they people to make appropriate decisions and tocomplained that they were not listened to and gain more control over their lives.were unable to control the life they wanted. Theyfelt they had somehow to fit in with the agenda of 6. Communities are enriched by the inclusionexperts. and participation of disabled people, and these communities are the most important“The system was also really complicated,” said way of providing friendship, support andRalph. “They kept seeing different people and a meaningful life to disabled people andwere assessed over and over to find out what they their families and carers. Inclusion requirescouldn’t do. It was difficult to get information changes in many areas of community lifein an accurate and timely manner and therefore and in mainstream public services, includingdifficult to make choices or take control. transport, leisure and employment.Communities were often not welcoming or hadnothing obvious to offer. Perhaps most tellingly, 7. The lives of disabled people and their familiesthe focus was not on what people had to offer but are enhanced when they can determine theirwhat services and resources were required to fix preferred support and services and controltheir problems.” the required resources, to the extent that they desire. Individuals should be at the centre ofMuch of what LAC is trying to achieve is about decision-making about their lives.changing this. It is about really getting to knowpeople, families and local communities, and 8. LAC enhances support systems. All servicesstanding alongside them. It is about building and support, whoever delivers them, shoulda long-term relationship with people and aim to achieve a good life for disabledunderstanding their vision for the future and a people, should recognise and support thegood life. It is about community building, getting role of families, carers and their supporterspeople information and helping them develop and should be able to demonstrate that thenetworks around themselves. Only then is it about service they give to an individual is available,finding formal services if they are still needed. consistent and of high quality.“Eddie Bartnik has been inspirational in focusing 9. Partnerships between individuals, familieson the range of ways people can gain useful and carers, communities, governments,information to make choices, access what they service providers and the business sectorwant or feel confident in the future,” said Ralph. are vital in meeting the needs of disabled people. Investment in building the capacityLAC is underpinned by ten clear principles which and resources of communities is essential to
  • 21. PART 5: FACILITATING RATHER THAN DELIVERING 21 enable inclusion. support from the LAC was in making the first connections and introductions.10. Disabled people are citizens and have a life- long capacity for learning, development and Ralph Broad is now working with Inclusion contribution. They have the right to expect North, a membership organisation that works to that services and support should respond to promote the inclusion of people with learning their changing needs and aspirations and they disabilities, their families and carers in the North should have the opportunity to contribute to East, Yorkshire and Humber. They are supporting society through employment, public service Middlesbrough Council to develop LAC locally and by other valued means. as a core approach to personalisation and co- production. The first two co-ordinators will beWhat makes LAC so interesting in the UK is recruited by the end of April 2010.the amount of research backing there is forit.27 Some of the key findings include increased “LAC is a way of putting into practice the ideasvalue for money. Costs per person accessing of control, leadership and contribution,” saidthe LAC approach are 35 per cent lower than Carol Taylor, the new LAC development managerthe average support package. LAC also has a 58 in Middlesbrough. “It’s not about doing that forper cent higher take up of people in receipt of people, it’s about supporting people, families anddisability support than other services. This model communities to take leadership roles, to shareof local support proved to be highly effective in and contribute and to make the most of thepreventing people from having to leave their local opportunities that our communities present. It iscommunity or take up unnecessary out-of-home also about doing the hard work of overcomingplacements. Reviews in Queensland, Australia, traditional obstacles, but doing it in partnershipshowed that families were increasingly capable with people who know best – local people.”of continuing care, and increasing independence,self-sufficiency and community contribution.28 Carol, Ralph and the local steering group have spent considerable time, with support from Eddie“Basically, he’s on our side,” one parent told Bartnik and the Disability Services Commission inthe Western Australian Disability Services Western Australia, designing and preparing theCommission in 2005 about their local area co- role, to get it right and keep it true to the coreordinator. “He doesn’t question what we say; he principles of partnership, personal approaches,doesn’t question the validity of my son’s opinions capacity building and citizenship.on anything. He’s there for him and he’s the onlyone who’s there for him. He’s not on the school’s These ideas are not uncontroversial. They provideside, the council’s side. He’s not on anyone’s but a critique of intensive professional help, but anmy child’s side. He’s there for him.” equal critique of the idea that people should somehow be ministered to ‘in the community’What emerges from the research is a story of where they remain isolated. People steeped in thevery individual solutions. One local co-ordinator values of LAC are also sceptical about the new bigused her knowledge of the local community to idea, individual budgets, if they are administeredlink the parent of a child with high support needs in a way that results in people remaining isolatedwith another family in the local area. This meant from each other. The story of the engineer Mikethat the disabled child could be taken to school Hammond, who advertised in April 2008 foreach day in the other family’s vehicle, rather than someone to take his father to the pub twice ahaving to use specialised transport, which had week at £7 an hour, is a symbol of what individualbeen a real problem in the past. budgets could be if we are not careful – where ordinary reciprocal support gets replaced withIn another example, an intellectually disabled expensive market transactions.29woman had become increasingly isolated in anarea she had recently moved to. The local area The approach described relies explicitly onco-ordinator got to know her and found out she personal relationships between co-productionwas interested in crafts and going to church, professionals and clients. There is bound to beintroduced her to a local crafts group where she scepticism about whether this kind of interventionmade new friends who visited her and provided is sufficiently ‘professional’ and can possibly beher with some of the support she needed. She cost-effective. But the evidence of LAC suggestsalso found a valuable role in the church. These it can be, even whilst achieving significantpersonal solutions provided access to a wider improvements in quality of life for disabled peoplecommunity of people and the opportunity of and bringing broader benefit to communities.new friendships with a wide range of people. The
  • 22. PART 5: FACILITATING RATHER THAN DELIVERING 22Other projects that facilitate change rather thandeliver service solutions as an explicit part of theiractivity include:KeyRing30KeyRing is a housing and advisory service forpeople with learning difficulties. There are 899members in over 105 networks nationally (thebiggest is in Oldham). The approach is to set upa series of local networks which each have nineadult members, and one volunteer, each livingindependently, usually within a 10-15 minutewalk of each other. The networks provide mutualsupport, support for independent living, and linksinto other local networks and resources.Volunteers provide regular housing relatedsupport, such as helping to pay bills, organisingmaintenance and other work helping membersconnect into the community. In return theyreceive free accommodation. Once networkshave matured, the support becomes moremutual within the network, and the volunteerrole is reduced as members turn to each other.The volunteer is often perceived as a peer bymembers: in the 2008 floods in Gloucester, thelocal network volunteer’s flat was flooded and allmembers arrived to help clear the rain and debrisaway.Elements of co-production are evident across theservice. It is a members’ organisation driven byand for the members. At least two members areinvolved in the recruitment of new KeyRing staffand members are trustees on the board. Membersalso refer new members and actively increasethe network, shape the development of networksand facilitate network meetings. Critically thenetworks developed are not simply for otherpeople with a learning difficulty, but insteadincorporate a wide range of people from the localcommunity.
  • 23. PART 6: RECOGNISING PEOPLE AS ASSETS 23PART 6:RECOGNISING PEOPLE AS ASSETSTransforming the perception of people from passive recipients of services and burdens on the systeminto one where they are equal partners in designing and delivering services.W hilst this section is a distinct core the skills of those people sitting so quietly in element of co-production in practice, the waiting room will not be able to give lifts to it is also in many ways a critical people, pick up medicines, or visit them whenunderpinning shift in values that makes the other they’ve come out of hospital. But that may notelements possible. The example contained here be the most important idea at the heart of this.demonstrates how patients are now viewed and What makes Paxton Green, and those like it,engaged with as assets by those professionals different from the mainstream is their attitudeworking with them, but it is also clearly a feature to their patients. They recognise that these arein all of the examples contained in earlier sections. people who, whatever health problems they might have, also have huge experience, skills, oftenImagine going along to your local doctor’s time – certainly the human ability to connect withsurgery to learn IT skills or creative writing, or other people. They also recognise that both theto find a friend. Most of these are not usually on prevention and management of someone’s healththe list of services available on the NHS. Nor, you often needs more than a prescription.might imagine, would they be high on the listof priorities for a government looking for public These are important resources which areexpenditure cuts – though giving people lifts to usually wasted – and they may turn out to behospital appointments or collecting prescriptions important economically too. Just as governmentfor people who are too ill to go themselves are departments are seeking out financial assetspretty important health objectives. Yet these are which can underpin services, all these peopleamong the services available at the innovative are clearly ‘assets’ too, and this approach toPaxton Green Group Practice, on the borders of co-production is a result of transforming theSouthwark and Lambeth in south London and perception of people as passive recipients ofthey’re proving to be very good for people’s services and burdens on the system into onehealth.31 where they are equal partners in delivering services.Paxton Green is a seven-partner practice andone of the largest practices in south east Many doctors are aware of the problem that theLondon. It is also one of the latest surgeries patients in front of them don’t really need pills,to use timebanking.32 Timebanking is a mutual but would benefit from a friendly visit once avolunteering approach which enables people week. Having a time bank means they can writeto swap skills with one another, using an equal them a prescription for that and the time bankcurrency of time. One hour of anyone’s time is the will fulfil it, a type of social prescribing that bringssame, whatever the skill they share. It works with mutual solutions. The other important impact isthe basic premise that all of us have something to the way in which this affects the doctors: “Thegive. This means that people who live in the same time bank has broadened the view of how wearea, whether or not they are actually patients at as clinicians see patients,” one of the doctorsthe practice, can now get involved in a range of told researchers. “So patients get some benefitactivities including befriending, visiting, lifts, art, even if we don’t refer them to the time bank.creative writing, meditation, walking and much We consider patients in more societal terms.more besides. As always in timebanking, the The time bank has helped form an identity forkey idea is mutual support: all these services are the practice, and a focus for patients. Patients’delivered and exchanged by other members of groups often fail because they focus too much onthe time bank. illness, but through the time bank we’ve formed a community.”33This is, in short, a broader kind of public service.Surgeries without some kind of system to use What Paxton Green Timebank is doing now is
  • 24. PART 6: RECOGNISING PEOPLE AS ASSETS 24building on pioneering work which began in contacted us because they needed somethingBrooklyn in New York City in 1987 (see end of done.” The growth of the activity by word ofsection) and timebanking experiments beginning mouth – people inviting friends and family alongin a GP’s surgery in Catford. At Paxton Green, – is a strong sign of endorsement of the approachAlison Paule describes one of their ‘ambassadors’, by local people.the team of members who promote thetime bank, who had a long history of alcohol The link with the NHS in West Norwooddependency and unemployment. “He told me provided an instant leveller in Paxton Green, athat ten people had phoned him over Christmas,” neighbourhood with extremes of wealth andsays Alison. “The previous Christmas, he didn’t poverty and includes plush Dulwich Village.speak to anyone for the whole of December. It has Everyone goes to the doctor, after all. As Alisonclearly made a difference to his social networks, recognises, the levelling also comes aboutand he is much more confident and articulate now because everyone is making a contribution,as well. I notice he feels part of the time bank too. “I did a lot of volunteering while I was growingHe says things like ‘what are we doing today?’” up and it always seemed rather a white middle class activity. Someone always had to be doingThe story of timebanking in Paxton Green goes good and someone had to be receiving help. Theback to 2008, when one of the doctors heard timebank drew people in because everyone didabout timebanking and raised the money from the both.”local Primary Care Trust to do something similar.When Alison arrived as development manager in At Paxton Green the paid staff aren’t responsible2009 she set up in a small room in the crammed for getting people to take part in pre-determinedsurgery, which they had to share with pre-natal activities that are seen to be ‘good for them’ butclasses and a range of other activities. There were that they may not want. The ideas for activitiesno computers and no phones so the time bank come from the members, and if none of themstaff looked around the area and moved out into want to organise them, they just don’t happen.a rundown stately home which houses the local Nor do the paid staff hold people’s handslibrary, next to the children’s centre and at the more than a minimum as they embark on newheart of the local Kingswood Estate. “This turned relationships. These are basic human capabilities,out to be a blessing in disguise,” said Alison. “It after all. Paxton Green members were soon takingmeant we had to get out there, do the face-to- walks together, providing IT support, gardening,face stuff and meet people and be where they doing patchwork and a great many other things,were.” as well as the usual support for individuals.Their first clients were referred immediately by “Once there were 20 or 25 members, it suddenlysome of the doctors. They were people with low became a lot easier,” says Alison. “It meant therelevel mental health conditions, including some were a number of people who wanted to join inwho had been recently bereaved. There were with people’s ideas, enough people to take part insome who had been out of work for a long time the activities. People don’t need herding. We wantor people who the doctors felt needed something to create a space where people can come up withto do, either because they lacked self-esteem an idea and start doing it.”so seriously or because they had become veryisolated. It was immediately clear that Paxton The surgery is now just one stakeholder in theGreen’s members were young, mainly under 50, project. They have been joined by 11 other localoften out of work and frequently depressed. organisations, including local public services andThe majority were men. Often they were using more broadly the local Emmaus homeless group,timebanking as a kind of club which supported library and the Dulwich Picture Gallery nearby.them to try new things and develop new skills, Time bank members are now actively involved inand then move on with their life. It offered a all of these. Research into timebanking back inpotential solution to so many people like them, 2003 found they were better able to reach groupsof working age who have become stuck and who would not volunteer, and this appears still toisolated. be true.34The link with the surgery at Paxton Green was The challenge is to break out of the pattern wherean immediate advantage. “People believe in public services are just places where people havetheir doctors,” she says. “If they suggest you join to be passive and grateful, while the professionalsthe time bank, you trust them. But half of the around them can barely cope with the need.members now are people who just heard about “People are used to being patients, especially iftimebanking from friends or posters or who they have chronic problems of ill-health,” says
  • 25. PART 6: RECOGNISING PEOPLE AS ASSETS 25Alison. “But it can be refreshing for them to Another problem is that although it meansknow that, even though they may have long-term broadening the kind of services which candepression, they can still change a light bulb for be provided – befriending or visiting throughan older neighbour. They don’t have to be defined the surgery, for example – these can only beby their illness.” provided on the basis of the willingness of local participants. Every service may be broadenedMany of the basic activities of Paxton Green but they may not be broadened in the same wayare health-related, like giving people lifts to the and how they broaden will reflect local people’sdoctor or hospital, or picking up prescriptions resources and needs. As a result new servicesfor people who are too ill to go themselves. may not be reliably available to everybody andThat is a broadening of what the NHS can do, are unlikely to look exactly the same everywhere.without additional cost, if they use the skills and NESTA’s work on the Big Green Challengeabilities of patients. Some of the social activities indicates that what makes local solutions effectiveare focused on healthy eating, but, as the is their local focus and the ability of groups tomembership grows – it is now over 85 – the range tailor solutions to local contexts. This can causeof activities increases as well. They have quilt- tension, due to the impulse to scale projects up inmaking and creative writing sessions in the local order to achieve impact nationally.35library. All activities are reciprocal with membersoffering their skills in order that others can learn. Most GPs have not yet made this kind of service part of the mainstream. Current examples rely onRewarding people for changing their behaviour pots of grants from central funds in the case ofhas been at the heart of government policy primary care trusts (PCTs) or charitable donors.recently, but the evidence suggests that this These funds and grants tend to be focused onwon’t work as some kind of glorified reward card supporting one narrow interest or needy group.or with unsustainable token financial payments. The whole idea of co-production goes the otherIt will only work if it is embedded in some local way: the Paxton Green Time Bank does not focusscheme of mutual support which people know on narrow segmented problems – which tendand trust, where the results are not levered out to have their neat funding pots – but on broadof people, but co-produced. Fundamental shifts solutions that reflect how people live their lives,in behaviour need to come from people, and be which have fewer obvious sources for funding.both intuitive and self directed in order to effecta sustainable change in people’s patterns and Yet despite this it does seem possible to makehabits. These attitudinal and behavioural shifts it work. There is significant research into howalso need to be supported by organisational and co-production works through timebanking instructural changes which are flexible enough to health settings. Early research on timebankingaccommodate new initiatives and social norms. in a health setting showed that the time bank helped build people’s confidence and self-esteemThe point about the Paxton Green approach by shifting the emphasis from areas where theyto co-production is that it recognises that the are challenged or failing, to activities and skillsrecipients of public services are wasted assets, that they enjoy and can share with others.36 Thiswhose experience, time and ability to care could was confirmed by a similar but larger projectbe put to use – but which generally speaking organised through Lehigh Valley Hospital outsideare not. This is not straightforward; there are Philadelphia, which showed a physical healthpotential pitfalls around health and safety, and improvement among 18.6 per cent of members ofsafeguarding measures such as CRB checks. the Lehigh Community Exchange, a mental healthCo-production examples, including time banking, improvement among 33.3 per cent, and a socialwould defeat their purpose if they monitored support improvement among 51.2 per cent.37every detail of the relationships that result from it.People inevitably let each other down sometimes, Paxton Green has found, in the first year, thatsometimes seriously. The challenge for organisers members who had taken part in their surveyis to encourage participants to deal with this, and felt that their involvement had made them moreto know how far each of them can be challenged, confident and positive. “Just getting myself out ofand to see how much people are changing their my home is a major plus of the time bank system,”behaviour and taking more responsibility as a said one respondent. Another said: “I used toresult. It is in some ways the very antithesis of hang around people who did the same thing dayconventional safeguarding approaches, which is in and day out – and never want to change. Butanother reason why it is hard to slot this approach through the time bank, I’ve been able to changeinto existing public service systems. myself. I’m more able to appreciate the positives in life.”38
  • 26. PART 6: RECOGNISING PEOPLE AS ASSETS 26Of course, these are soft findings, but we also members were allowed to pay a quarter of theirknow that low self-esteem or low well-being feeds insurance premiums with the credits they hadinevitably into other kinds of ill-health and other earned helping neighbours. Many of the servicescosts. National surveys of psychiatric problems provided by Member to Member were beyondin UK adults show that the most significant anything that could normally be offered by adifference between this group and people without health insurance company. Many are also servicesmental health issues is social participation.39 If which money can’t buy anyway. “Often you can’tyou have a restricted social network, made up of buy what you really need,” says Mashi Blech,three or fewer close friends and family, this is a then Elderplan’s director of community services.major predictor of mental health problems in the “You can’t hire a new best friend. You can’t buyfuture. Co-production builds these supportive somebody you can talk to over the phone whennetworks around people and services as its you’re worried about surgery.”central purpose. This brings a double prize ofsaving money and maintaining well-being.40 Member to Member now has more than 10,000That is why Lambeth PCT has been funding the members in Brooklyn, and it was a major featurePaxton Green Time Bank. “It terms of promoting of their recent advertising campaign whenwell-being, I think it achieves this in a number of Elderplan went New York wide. They featuredways,” said Lucy Smith, who leads on well-being their DIY team, originally started as a way offor the PCT. “I have seen it at work first hand and getting husbands involved as volunteers. Theirwe have also carried out a Mental Well-being poster carried a picture of a DIY team member,Impact Assessment and it ticks the boxes on the complete with hat and spanner, with the slogankey issues. We also believe that well-being is ‘Does Medicare send you a friend like George?’.important for health and social inclusion and for ‘Does Medicare lift your spirits?’ asked Elderplan’spreventive work.” advertising later. When the American healthcare industry was plunging into cynicism because ofIdentifying measurable cost savings requires its apparent inhumanity, Member to Member wascontinuing work. It is likely that savings will able to demonstrate a human alternative.emerge largely on the balance sheets of otherservices. Co-housing at the Threshold Centre41Whilst the examples described in this section Co-housing is a long-established movementare largely related to health, earlier sections of people and families who design and createdemonstrate how co-production can work just a housing collective, with an emphasis onas well outside healthcare settings. The following community, sustainability and reviving mutualexamples demonstrate further examples of the relationships in neighbourhoods. The Thresholdbenefits of treating people as assets: Centre in Dorset is a co-housing group which has been working in partnership with the Synergy Housing Association to double local housingElderplan Member to Member Scheme, Brooklyn provision in response to increased demand for co-US housing for older people.Elderplan is run by health insurance companiesin New York and they originally launched their The distinction between ‘professional’ and ‘user’Member to Member scheme as a way of getting was slowly eroded throughout the process of co-their members to look after people who were designing the new homes. Synergy Housing wereslightly more infirm, so that they could stay dependent upon the skills, input and commitmentin their own homes for longer. People earned of the co-housing group, while they provided the‘time dollars’ for the hours of effort they put in, resources needed to create the housing, such aswhich gave them the right to draw down time architects, plumbers, engineers and builders. Itfrom somebody else in the system when they was necessary to work genuinely in partnership:needed it. It was an outline of a mutual support residents’ lived experience of ageing was asystem which measured and rewarded the effort vital asset in this process and enabled themeveryone put in, and utilised key assets in the to design suitable accessibility for those withcommunity. limited mobility, which hadn’t been factored into the initial designs. Residents play an active andTo Elderplan’s surprise, the real health impact explicit role in creating the community in whichwasn’t gained by those being helped; it was in they will all live. The Synergy Housing Groupfact enjoyed by those doing most of the helping. recognised the value the housing communityIt gave them a purpose; a reason for getting out had in co-creating a space which is suited andof bed in the morning. So much so that Elderplan adapted to the community living there – in this
  • 27. PART 6: RECOGNISING PEOPLE AS ASSETS 27case, older people. The outcome is a housingspace which meets a genuine demand and acommunity that is already established by the timethe homes are built.Fureai Kippu, JapanJapan has the second-fastest ageing populationin the world. Fureai Kippu translates to ‘caringrelationship tickets’, and provides a systemfor valuing the hours that a volunteer spendssupporting older or disabled people with theirdaily routines by crediting it to that volunteer’s‘time account’. This is managed exactly like asavings account, except that the unit of account ishours of service instead of yen. The time accountcredits are available to complement normal healthinsurance programmes. Different values applyto different kinds of tasks – for instance a mealserved between 9am and 5pm has a lower creditvalue than those served outside of that time slot.Household chores and shopping have a lowercredit value than personal care.These health care credits are guaranteed to beavailable to the volunteers themselves, or tosomeone of their choice, within or outside of thefamily whenever they need similar help. Someprivate services make sure that if someone canprovide help in Tokyo, the time credits becomeavailable to his or her parents anywhere else inthe country. A strong stimulus to the growth ofFureai Kippu was the powerful earthquake thathit the Kobe area in January 1995. The capacityof the Japanese government during an event ofthis scale was severely limited and a spontaneousgrassroots volunteer movement sprung up inorder to complement the emergency services.At of the end of the year, there were over 300healthcare time account systems operating at themunicipal level, mostly run by private initiativessuch as the Sawayaka Welfare Institute, the ‘WacAc’ (Wonderful Ageing Club) and the Japan CareSystem – all of them seeking to demonstrate thatthese new kinds of innovative credit systemscould provide both more cost effective andmore compassionate mutual care than moreinstitutional forms of care-giving. A surprisingpart of the project has been that members tendto prefer the services provided by people paid inFureai Kippu over those paid in yen because ofthe nature of the relationship. Having this systemin place means that the limited time available byqualified professional staff can be focussed onthe most valuable areas in which they can providesupport, making this paid-for system mostefficient. Fureai Kippu continues to be widespreadin Japan and has also now spread to China.
  • 28. PART 7: CHALLENGES, CONCLUSIONS AND FUTURE WORK 28PART 7:CHALLENGES, CONCLUSIONS ANDFUTURE WORKA ll these examples have their challenges to the mainstream, positioning it as the standard as well as their successes. They show model for public services. We address these in the range of innovative approaches that more detail below, and suggest further work toare already being taken to co-production. Co- address these challenges.production is no longer a theoretical discussion;it is happening but it is not yet mainstream.These examples demonstrate some of the 1. Funding and commissioning co-challenges faced, the regular pressure for funding, production activitythe problems in how regulation is applied andthe structural changes we need to make co- Commissioning with public money looks forproduction work. efficiency and, in an effort to achieve this, tends to apply strict quantitative targets with pre-Overall, the challenge seems to amount to defined roles and narrow outputs for differentone clear problem. Co-production, even in the providers in distinct spheres of activity.most successful and dramatic examples, barelyfits the standard shape of public services or Co-production can be awkward for funders andcharities or the systems we have developed to commissioners, who tend to look for specific‘deliver’ support, even though policy documents objectives and pre-determined outputs generatedexpress ambitions to empower and engage local from a narrow range of anticipated activitiescommunities, to devolve power and increase and evidenced by limited indicators of success.individuals’ choice and control. We still need Co-production looks much messier than this,to answer a major question about how we can often encompassing a broad and multiplemainstream co-production, and to decide whether range of activities which continue to evolve asexisting structures can be modified to enable it relationships develop between professionals andbetter, or if we need new frameworks. The policies people using services. The indicators of successthat shape public services also play a critical role are found in broader outcomes and longer termin making co-production mainstream, and this will changes that often fall across multiple fundingbe the focus of our next publication. streams and are not always easy to measure with current methods. There is, in short, a cultureThese challenges can be grouped into four key clash. Our report suggests that this failure tothemes: encompass what is new and innovative – even when it manifestly succeeds in tackling otherwise • Funding and commissioning co-production intractable problems of public policy – is bound to activity. hold back the development of co-production. • Generating evidence of value for people, professionals, funders and auditors. Lessons learnt Everyone we have spoken to during our research • Taking successful approaches to scale. has had stories to tell about the battle to reconcile their objectives and ways of working • Developing the professional skills required to with the demands of funders and commissioners. mainstream co-production approaches. This makes the work vulnerable and diverts time into fundraising that could be better spent co-The first two are barriers that current co- producing services.produced services face. The second two arepotential obstacles that must be addressed if we For example, because most funders have a veryare going to shift co-production from the margins specific view of what constitutes ‘rehabilitation’,
  • 29. PART 7: CHALLENGES, CONCLUSIONS AND FUTURE WORK 29innovative activities such as those run by questions in the tendering process so that theyHeadway East London are perceived as unproven could understand how future providers would co-and cannot attract financial support as easily as produce services. These included:more conventional support mechanisms, eventhough they are clearly effective. • What role would you envisage for service users in the development and delivery of yourKeyRing’s director of operations said that funding service?is a huge challenge for the organisation: “Whoputs out a tender for a mutual support service? • How does your service identify and mobiliseOur model of combining independent living with service users’ strengths?growing an individual’s social networks isn’trecognised as a service as such by many local • How would the contribution of service users,authorities and commissioners. But it works.” The carers, family, peer group, neighbours and theresult is that KeyRing has to work twice as hard wider community be measured or rewarded?to build relationships with local authorities topersuade them that their model gives disabled They then judged bidders on their responses topeople more control and genuine empowerment, these questions rather than just looking for thewhile offering significantly lower costs than least expensive service provider. Camden is rollingassisted residential placements. out its outcome focus in commissioning across its services, which shows that existing structuresThere are also problems with large grant of local government can be adapted to create afunders, who are focused on particularly ‘needy space for co-production.beneficiaries’ and insist on knowing what afunded programme will consist of in detail overthree years. This often results in pre-determined Areas for further workactivities set up ahead of any real dialogue nef has worked with Camden to support theirwith the people who might become involved. It transition to outcomes-based commissioningactively prevents co-production projects from and its focus on co-production. A briefing onevolving their activities as people learn and this work is forthcoming. We plan to work withchange. commissioners to help them find better ways of commissioning co-produced services.Challenges and barriersEfficiency is not the same as effectiveness. 2. Generating evidence of value for people,Innovative service solutions are often at odds professionals, funders and auditorswith the commissioning structures in place.Peer and mutual support networks, for example, Co-produced services can be awkward forare a strong feature of co-production, but are regulators, because key aspects of other publicnot usually accounted for in commissioning services are missing, such as clear hierarchiesspecifications, either because they are assumed between staff and service users. They are oftento exist already or because they are not nervous about aspects that are absolutely centralseen as important for the services provided. to these projects, such as the provision of homeCommissioning routinely focuses on what people cooked meals for the children at Scallywags. Thiscan’t do, and what types of services are required isn’t done in registered kitchens but at home, byto meet a need, instead of working with people parents who cook for themselves and their ownto build on their existing capabilities and develop children. Concerns about safety mean that pre-solutions – beyond conventional ‘services’ – that prepared meals provided in bulk are seen to beenable individuals to gain the support they want. preferable to parents actively contributing the foods that are home made.Steps forward Public services often rely on strictly definedHoly Cross Centre Trust has been commissioned outputs and targets, whether this is the numberto co-produce mental health day services as part of patients who are seen each day, or theof a local third sector consortium in Camden. number of students achieving A* to C grades, orThis is possible because the London Borough of the percentage of offenders re-offending. ButCamden has begun commissioning for outcomes sometimes these targets seem fundamentally(such as a thriving local community) and has at odds with the nature of the service. How,specified that all services should be co-designed for example, would we quantify the success ofand co-produced. The commissioners included supporting people with dementia, at Merevale
  • 30. PART 7: CHALLENGES, CONCLUSIONS AND FUTURE WORK 30House? In some cases the fear of regulation, These findings demonstrate the wide rangingrather than the actual regulation itself, prevents benefits of one co-production approach. Many ofprofessionals from working more collaboratively. these outcomes necessarily underpin good publicHaving residents with dementia playing an active services but would not necessarily be attributedpart in preparing and serving meals to other to one service or funder.residents and staff on a day-to-day basis might beseen as too high-risk for many staff. Yet elements Similarly, LAC, the Community Justice Panel andlike this create a culture of mutuality at Merevale KeyRing all have ideas about what constitutesand improve the quality of support experienced valuable outcomes and these ideas are developedby residents. in partnership with the people who access support. Identifying an outcome – whether it is independent living, an extended social network orLessons learnt community based restorative justice – starts withMany of the examples here have re-evaluated what is possible to create and build, rather thanwhat success looks like for the people they a deficit process of looking at what needs to bework with. This has a direct impact on how they fixed and delivered.measure their success. It means that traditionalmethods of evaluation are unable to capture thefull benefit of working in this way. Challenges and barriers There is evidence from many of the examplesCurrent rehabilitation programmes for people here that co-production can have a preventativewith a severe brain injury measure success effect. Capturing and accounting for this isby how many are retrained and return to the challenging, particularly when the benefitsworkplace within a set period of time. At may be experienced by a number of differentHeadway East London, success is not linked to stakeholders. Successful outcomes from theemployment rates, but to how people’s lives Chard Community Panel may generate benefitshave changed, and how they can begin to use for other public services, for example by reducingtheir skills and abilities. Given the differing demand for the services as people change theobjectives of these approaches, it is impossible way they feel and relate to one another. It mightto compare their services with more conventional help the wider local community if they becomeones. Yet many organisations that co-produce less afraid of crime. Capturing these effectsservices find themselves needing to fit into the can be complicated and expensive and is rarelyexisting measurement and evaluation models to pursued by funders, leaving services to gatherdemonstrate the value of what they are doing and evidence at their own expense, if at all.get more funding.In many cases, the benefits generated by co- Steps forwardproduction reach beyond a single service area. A What the emerging sector needs are analyticalrecent, intensive study of time banking in the US tools for scrutinising co-production activitiesproduced a wealth of quantitative evidence about in terms of their own ‘theories of change’how it helps improve social, mental and economic (see box opposite). Methods such as Socialwell-being. Return on Investment (SROI), which has been developed by nef, extend cost benefit analysis • One-hundred per cent of all time bank to undertake a broader analysis with a wide members surveyed stated that they had range of stakeholders and capture social benefits benefitted from the time bank, and those alongside economic ones. The Office of the Third with the lowest levels of income reported the Sector is currently developing national support highest level of benefit. for SROI analysis in England and Scotland. • Forty-eight per cent of participants reported NESTA and nef will be working together to improvements in self-assessed physical health, develop a range of tools and approaches for while 72 per cent reported improvements in more comprehensive evidence gathering. This self-rated mental health. will include a review of existing approaches to measurement and evaluation approaches, • Sixty-seven per cent reported increased assessing their strengths and weaknesses and access to health and community services, also drawing together evidence about the and 73 per cent with an annual income under value of co-produced services from a range of $9,800 stated that membership of the time project evaluations. This will help us develop an bank had helped them to save money. appropriate model to capture the full benefit
  • 31. PART 7: CHALLENGES, CONCLUSIONS AND FUTURE WORK 31 Theory of Change A Theory of Change is essentially a description of how a project or service expects to reach a commonly understood long-term goal. It explains how early and intermediate outcomes lead to the resulting long-term goal. This model articulates both the interventions that will bring about the outcomes and assumptions about the process through which change will occur. It often includes a map showing the relationship between actions and outcomes which reveals the often interdependent and complex activities through which change will be brought about.42of co-production. However, it is important to communications, but the bulk of their activityrecognise that, while metrics and indicators of takes place through a national micro-networksuccess are important, it is qualitative evidence with a multitude of project activities takingfrom people directly involved with co-production place locally. Not only does this keep thethat has proved to be the most persuasive for the personal relationships which are so central toorganisations involved. co-production, but also it means that funding is devolved to as local a level as possible. There is a space for control, decisions and action to3. Taking successful co-production be taken locally, and the services can evolve approaches to scale alongside the individuals who would traditionally have been recipients of the service.Many of the organisations and projects wehave worked with are operating at a local level. KeyRing has managed to reach many peopleWhile there are some local authorities who are not by centralising and reducing the schemebeginning to move commissioning models and to a series of deliverables, but by scaling outspecific services towards co-production, it has – seeding small local networks much more widely.yet to become mainstream. Commissioners and The fact that relationships are so important topolicymakers are sometimes worried whether co-production will determine how services arethese examples can be replicated. expanded to reach significant numbers of people.Co-production is personal; it suits smaller At Envision, local education co-ordinators workorganisations and these are mainly in the with individual schools to help pupils identifyThird Sector. Introducing co-production as a their own interests and priorities, a process thatmainstream approach to public services will is unique and highly individualised. The effect isrequire a significant structural shift away from a more engaged and active student population,hierarchical and centralised arrangements, who are able to decide which programmes theytowards flatter and more reciprocal relationships; would like to run, rather than picking from ait will also require a cultural transition away from centrally developed, managed and delivered listdelivering things to people, towards working of ideas or projects. Likewise, the Learning towith people to enable them to help themselves Lead approach is adapted with each school’sand each other. The values that underpin co- population. The key ingredients are familiar, theproduction are essential to its success: for overall structure and principles remain the same,example, co-production often depends on face- but the individual activities and processes areto-face relationships with key practitioners, like a often completely different. This local shaping ofKeyRing volunteer or a local area co-ordinator, to activity develops a vital local ownership whichmake it work. seems important to successful co-production. Organisations that provide nationwide servicesLessons learnt have to stick to some key principles. BarackA few organisations, such as KeyRing, the MS Obama’s recent decision to expand the modelSociety, time banking and LAC, have managed of family nurse partnerships across the US toto scale out their services to a national level. a nationwide programme will require strictMost of these have a central co-ordination adherence to the principles which have madepoint, and people specialising in funding and it so successful as a local model, such as the
  • 32. PART 7: CHALLENGES, CONCLUSIONS AND FUTURE WORK 32guideline that nurses do not work with more than practitioners to develop tools and approaches25 families at one time, and the focus on building to help successful small-scale co-productioneach family’s individual capabilities. Similarly, LAC initiatives to go to scale.has expanded significantly in Australia over thepast two decades, becoming a central pillar ofthe government’s disability support strategy. Yet 4. Developing the professional skillsdespite a huge expansion in the total number of required to mainstream co-productionpeople supported by local area co-ordinators, the approachesmodel still has local support networks of 50-60people, because this is part of what makes it such What is the particular mix of skills that co-a valuable service. production practitioners need? From the examples in this publication, necessary skills include being able to see and harness the assetsChallenges and barriers that people have, to make room for people toExact replication or duplication of a model can develop for themselves, and to be able to use alead to failure. It is not possible for co-produced wide variety of methods for working with peopleservices to be blue-printed and exported to other rather than processing them. This represents aareas. Each of the examples we have described is significant shift away from a culture of caringa product of the particular assets and resources to a culture of enabling. In several examples, itthat are found among the people and places is also important to have local knowledge or todirectly involved. be able to connect with someone who has that knowledge.The service blueprinting approach alsopresents problems because it doesn’t recognisethe structural and cultural shifts involved in Challenges and lessons learntmainstreaming co-production. The initial LAC A big challenge is the often narrow and restrictedexperience of rolling out the approach in one scope of roles within public services, which hasregion found that simply transferring existing led to strictly defined job descriptions that inhibitstaff into new roles with the supporting LAC engagement with activities outside the normalinfrastructure was not enough to guarantee professional remit. The doctors at Paxton Greensuccess. Where this scaling out of activity worked have adapted their attitudes to patients andbest, frontline staff, people who might access their behaviour as clinicians, in ways that mightLAC support and wider communities were more be seen by others as community developmentcomprehensively involved in understanding how work or social care. Yet by having contacts andthe approach worked elsewhere and in developing relationships across the entire community, theya locally appropriate model. are now much better placed to promote and encourage broader health solutions – with clearThe challenge is finding ways in which benefits all round.practitioners can identify the key ingredients andkey principles that the success of an approach Another challenge is the uncertainty that sharingdepends on, for example the relationship ratio responsibility brings, set against a growing culturethat has been kept in place in many successful of safeguarding, blame and risk aversion. Oneexamples. New areas should also be able to learn London borough was asked about citizens playingfrom what others have achieved, and to adapt a bigger part in delivering, or co-producing,them to their local context and make the best use local community safety and policing services:of local resources, if they are going to build an the instinctive answer was it could only lead toinfrastructure that works for them. ‘local vigilante mobs’. It was assumed, wrongly, that inviting citizens to co-produce would replace professional roles. It was also assumedSteps forward that ordinary members of the public couldn’t beCo-production examples need to clarify their trusted to make sensible decisions and that it wasown ‘theory of change’ and the key ingredients therefore too risky to share responsibility withthat make their approaches work. These might them.include the mechanisms by which funding,decision-making and control are devolved to both Even where organisations are open to co-individuals and co-ordinators. It is also important production, there is sometimes a perceptionto be clear what local factors, such as the funding that certain types of users won’t be able toor commissioning, create the conditions for co- co-produce. For example, one London-basedproduction. NESTA and nef will be working with substance abuse organisation is actively seeking
  • 33. PART 7: CHALLENGES, CONCLUSIONS AND FUTURE WORK 33to embed co-production at the heart of its more on facilitation. It also recognises that, whileactivities, but assumes that certain vulnerable professional expertise is vital, this will neverpeople cannot be directly involved. Part of the replace the knowledge that comes from personalchallenge for these organisations is to recognise experience. Real change comes from combiningthe assets, skills and knowledge that such both these sources of knowledge.individuals bring to the service. This is all the moredifficult when service professionals are habituallyexpected to focus exclusively on people’s needs. Steps forward We need to help current and future professionalsOne challenge is not to train citizen co-producers adapt professional practice and performanceto the point that they begin to look like frameworks, learning from those who are alreadyprofessionals themselves, but instead to recognise successfully co-producing services. NESTA andthe distinct contribution that citizens can bring. nef are developing a self-reflection tool with co-Another is to avoid the difficulties experienced production practitioners over the coming months.when Local Area Co-ordination was initially being It will help professionals, programmes and thoselaunched in one region: at this point, the essential who use public services to work out how muchethos was only partially understood by many co-production is already in practice. This tool willof the managers involved, and traditional social also highlight how projects in certain sectors canworkers were sometimes just re-assigned to be succeed in some aspects of co-production morelocal area co-ordinators. Unsurprisingly, not much easily and more thoroughly than others.changed.As the experiences of Headway and Scallywags Where do we go from here?have shown, taking some risks is vital to realising There are genuine challenges in understandingwhat works and what doesn’t. Seeing people as co-production and extending it into a mainstreamassets, and providing a space for them to take approach to public service delivery. Therean active role in running a children’s nursery, are difficult questions that need answers, andor mentoring other patients, is perceived as significant structural and cultural issues whichrisky because we have become used to a strict require careful thought and extensive discussion.delineation between user and professional. But To create the conditions for co-production toco-production, in practice, manages to erode flourish, we shall need policy solutions supportedthese boundaries to the point where the service by changes in practice. In the immediate futurewould fail to function without the input and nef and NESTA will be preparing a document toactivities of both users and professionals. support policymakers and commissioners. If you would like to be part of this debate please contactA model of top-down service delivery lends us.itself to a customer mentality, where servicesare delivered in one-way transactions between Through the second phase of the partnershipprofessionals and recipients. By contrast, co- between nef, NESTA and co-productionproduction facilitates a much more equal practitioners we will be returning to thesepartnership and – in doing so – shifts the balance challenges and developing practical solutions.of responsibility, so that it is more evenly We will be supporting several innovation projectsshared across both parties. Yet this shift is not and testing out new approaches and modelssupported by the management structures and to overcome the challenges this report hasregulatory regimes in which public sector staff highlighted. We will also continue to work withwork. Research conducted by nef for the Joseph the network of frontline practitioners to drawRowntree Foundation found that, in order for learning from its members’ extensive experience.professionals to engage in co-production, they If you would like to be part of the network, beneeded to feel sufficiently engaged themselves.43 informed of upcoming publications and events, or have questions or comments on this report or co-Co-production does not assume, by any means, production more widely please contact Julia Slay:that specialist training and skills are no longer Julia.slay@neweconomics.org.required in public services. Co-productionprovides a mechanism to make best use of theincreasingly pressurised resource of professionalskills while also offering a critique of the way inwhich these skills have been imparted to date.Co-production relies on a distinct ethos and anapproach that leans less on delivery and much
  • 34. ENDNOTES 34ENDNOTES1. See www.cabinetoffice.gov.uk/social_exclusion_task_force/family_ Co-ordination in Scotland.’ Edinburgh: Scottish Executive. Available nurse_partnership.aspx and www.nursefamilypartnership.org at: www.scotland.gov.uk/Publications/2007/03/28152325/72. Goodman, A. (2006) ‘The Story of David Olds and the Nurse Home 28. Chenowith, L. and Stehlik, D. (2002) ‘Building the capacity of Visiting Program.’ Princeton, NJ: Robert Wood Johnson Foundation. Individuals, Families and Communities.’ Available at: www.otbds. org/downloads/publications/LACReport.pdf3. See www.whitehouse.gov/issues/family 29. Boyle, D. (2008) ‘Assets that can’t be bought.’ The Guardian, 16 July4. Department of Health (2009) ‘Family Nurse Partnership: 2008. Information for commissioners.’ London: Department of Health. 30. See www.keyring.org/site/KEYR/Templates/Home.5. Ibid. aspx?pageid=1&cc=GB6. Ibid. 31. See www.paxtongreen.co.uk7. See www.learningtolead.org.uk 32. Time banking was first developed in the US by social innovator8. Ofsted (2009) ‘Scallywags Parent Run Nursery Inspection Report. Professor Edgar Cahn. Time banking is now operating in 22 22 January. London: Ofsted. countries and six continents; see www.timebanks.org/founder9. Pestoff, V. (2006 & 2008) Citizens as Co-Producers of Welfare 33. new economics foundation (2002) ‘Keeping the GP Away: A nef Services: Childcare in eight European countries. ‘Public briefing about community time banks and health.’ London: nef. Management Review.’ Vol. 8/4, pp.503-520; and reprinted in Pestoff, 34. Seyfang, G. and Smith, K. (2003) ‘The Time of Our Lives.’ London V. and Brandsen, T. (Eds) ‘Co-production: The Third Sector and the and Norwich: University of East Anglia and new economics Delivery of Public Services.’ London & New York: Routledge. foundation.10. Pestoff, V. (2009) Towards a Paradigm of Democratic Participation: 35. Bunt, L. and Harris, M. (2010) ‘Mass Localism: A way to help small Citizen Participation and Co-Production of Personal Social Services communities solve big social challenges.’ London: NESTA. in Sweden. ‘Annals of Public and Co-operative Economics.’ Vol. 80/2, pp.197-224. 36. new economics foundation (2002) ‘Keeping the GP Away: A nef briefing about community time banks and health.’ London: nef.11. See www.taffhousing.co.uk 37. Lasker, J. et al. (2006) ‘Building Community Ties and Individual12. See www.justaddspice.org Well Being: A case study of the Community Exchange organization.’13. See www.orangerockcorps.co.uk Bethlehem, PA: Lehigh University.14. See www.headwayeastlondon.org 38. Cooke, A. and Snowden, L. (2009) ‘The Impact of the Paxton Green Time Bank on Mental Well-being.’ London: Inukshuk Consultancy.15. See www.headwayeastlondon.org 39. See for example Jenkins, R., Meltzer, H., Jones, P., Brugha, T. and16. See www.mssociety.org.uk Bebbington, P. (2008) ‘Mental Health and Ill health Challenges.’ London: Foresight.17. See www.uservoice.org 40. The Government has recognised the importance of preventative18. See www.mark-johnson.org.uk strategies as essential for the future sustainability of the NHS; see Department of Health (2006) ‘Our Health, Our Care, Our Say: A19. The Avon and Somerset public confidence survey shows a decrease New Direction for Community Services.’ Norwich: TSO. in local people’s nervousness to go out at night in areas, which corresponds with the introduction of the Chard Community Justice 41. See www.cohousing.org.uk/ Panel; see www.avonandsomerset.police.uk/localpages/public- confidence-survey-results 42. For more information on Theory of Change, see www. theoryofchange.org20. See www.merevalehouse.co.uk 43. Boyle, D., Clark, S. and Burns, S. (2006) ‘Co-production by people21. See www.retain.org.uk outside paid employment.’ York: Joseph Rowntree Foundation.22. See www.richmondfellowship.org.uk23. See www.envision.org.uk24. Bartnik, E. and Chalmers, R. (2007) It’s about More than the Money: Local Area Co-ordination Supporting People with Disabilities. ‘Changing Relationships in the Provision of Social Care.’ Vol. 49, pp.19–38.25. See www.disability.qld.gov.au/support-services/documents/lac- information-paper.pdf26. Scottish Executive (2000) ‘The Same as You?’ Edinburgh: Scottish Executive.27. Government of Western Australia (2003) ‘Review of the Local Area Co-ordination Program.’ Perth: Government of Western Australia; Chenowith, L. and Stehlik, D. (2002) ‘Building the capacity of Individuals, Families and Communities.’ Available at: www.otbds. org/downloads/publications/LACReport.pdf; and Scottish Executive (2007) ‘Evaluation of the Implementation of Local Area
  • 35. The Lab and Co-produCTionOur public services face unprecedented challenges, made more urgent by theimpact of the current economic crisis. Traditional approaches to public servicesreform are unlikely to provide the answers we need.NESTA is applying its expertise to find innovative ways of delivering our publicservices. More effective solutions at cheaper cost will only come through ingenuity.Our Public Services Innovation Lab is trialing some of the most innovative solutionsand bringing them to scale across the country’s public services.Co-production is a new vision for public services which offers a better way torespond to the challenges we face – based on recognising the resources thatcitizens already have and delivering services alongside their users, their families andtheir neighbours in partnership with the public. Early evidence suggests that it is aneffective way to deliver better outcomes, often for less money.This paper is the second publication from a major project between the Lab and nef(the new economics foundation) to increase the understanding of co-productionand how it can be applied to public services. We have established a network ofpioneering frontline workers from across the UK who are using co-production toengage citizens and improve services, and will use these insights and evidence topromote a more positive environment for co-production in our public services andin policymaking.nef (the new economics foundation)nef is an independent think-and-do tank that inspires and demonstrates realeconomic well-being. We aim to improve quality of life by promoting innovativesolutions that challenge mainstream thinking on economic, environmental and socialissues. We work in partnership and put people and the planet first.www.neweconomics.org
  • 36. NESTA1 Plough Place London EC4A 1DEresearch@nesta.org.ukwww.nesta.org.ukPublished: April 2010

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