What we talk about when we talk about coproduction in mental health

The following is the text of an opening speech given by Mark Brown at ‘Creativity in Coproduction’ conference at the King’s Centre Norwich on September 26th 2017

The first thing I want to tell you about coproduction is it’s really, really hard.  It’s something that exists in theory far more than it exists in actuality.  If you get away from using coproducton as just a description for an approach to making thing happens you have to think about what coproduction actually means.  Coproduction means ‘making together’.  It sounds simple.  From childhood we learn to play cooperatively, to all muck in to make something bigger and more enjoyable than what we could have made on our own:  a glorious image of carefree imagination and harmonious satisfaction.  But if we think back to childhood with slightly less rosy glasses we’ll also remember the fallings out, the arguments, the feeling of being picked last for the team, the kid who always took their ball back and went off in a huff if they didn’t get to be captain, the ridiculous longstanding vendettas and tearful recriminations when the games fell apart or someone didn’t follow the rules that everyone else had agreed on.

Working together on things is amazing, but it’s also difficult because working together is a bit of work in itself aside from the actual thing you’re trying to create.  Coproduction can be amazing when it works, but as we’ll hopefully hear and experience today, making it work is half of the battle.

As is the way with many ideas that are thrown about in health and social care, coproduction is an idea that originally came to prominence as a solution to a particular problem then somehow broke free of that original problem and, like a story that is passed from person to person; from campfire to campfire, it lost its origins and turned into something that stood on its own. Lost in the telling, the original problem became obscured and the business of turning coproduction into a training course or an academic paper or call to arms began.

So where did coproduction come from and what problem is it trying to solve?  To understand that we’re going to have to go on a journey, back, back, further back.  Back to a time when men smoked pipes and ignored women and an entire country was still reeling from a great blizzard of destruction and rock ‘n’ roll hadn’t even happened…

Where did coproduction come from?

 

Our conception of public services in the UK really has its beginning in the postwar period with the founding of The Welfare State.  The experience of the war and of war planning had given the UK a taste for big ministries creating things for the common public good.  It was the high point of the dream of planning and standardising everything.  For a while people were over the moon, because suddenly they were getting to access for free things like healthcare and support which hadn’t been open to all previously.  In a world where there was still rationing and where streets in cities still looked like smiles with missing teeth, people were grateful to the clever people who met their needs or at least this was what the public myth told us.  The reality was that there were always people who failed to get their needs met or who didn’t have choices or didn’t feel able to escape from what other people felt was best for them.  People with mental health difficulties often fell into that category.

This is the way with such ideas in health and social care: they turn from something that people do to a thing in themselves.  We end up calling for more coproduction or we end up training people in the idea of coproduction or we end up suggesting coproduction is the solution to all ills.  In reality, coproduction is something messy, glorious, frustrating and disappointing all at once.  In the past seven or eight years coproduction has been something that has been suggested as a solution to all of the challenges that we face in health and social care.  No money?  Coproduction!  Service unpopular?  Coproduction!  Not sure what to do next? Coproduction!  Certain what to do next but not sure if people will like it?  Coproduction!

Originally, coproduction was suggested as a solution to a very particular problem.  Public services, of which mental health support and treatment can be one, were seen as being transactional.  People who were paid designed and delivered services based on research and people who weren’t paid but did need a service consumed what the clever people made.  This was based on a model of public services designed at the time when rational planning was all the rage; where people who smoked pipes and had slide rules in their pocket would look at all of the available evidence and data and decide what people needed and then people were grateful for what they got.  People using a service turned up, took whatever the clever people had developed and then went away again.  Bish bosh. Jobs a good ‘un.

Two forces created the idea that there might be an alternative to this centrally planned world; one from within professions and public services and one from outside.  Inside services people began to wonder if they were indeed getting the right end of the stick about what people wanted.  Why, when we do all of this hard thinking, does it seem like people really don’t like or appreciate what we’re trying to do for them?  What is it we’re missing?  The conclusion that some people came to from within public services was that, perhaps, they didn’t know everything.  One thing they often didn’t know was what it was like to receive a service designed on their behalf by someone who didn’t face the same pressures and challenges that they did.  Public services had spent a lot of time people asking whether people liked things via consultations and involvement of the public; but that still didn’t seem to translate into things that did what people really wanted them to.  By the 1970s, many professionals across health and social care were beginning to wonder what gave them the right to wield such power.

At the same time, over the same period time, people began to examine more carefully whether the services that were being provided really were in the interests of those whom they were provided.  People became more critical of the ability of those designing and running services to define the reality and lives of those who received them.  Across health and social care patient groups sprang up.  In mental health The Scottish Union of Mental Patients was first established by mental patients at Hartwood Hospital in July 1971 when a group of people began to seek better treatment and conditions.  In 1973 The Mental Patients’ Union was founded by people who used Paddington Day Hospital.  These groups tended initially to want to exert pressure on the powers that be to improve standards and remove bad practices.  As time went on, such groups grew and evolved.  Some wanted to be left alone to develop their own solutions and their own services and projects.  Others wanted to change the public sector services that existed.  The charity sector in mental health ranged from being able to include these demands to being completely against them.

So from within services you had people wondering how they might make better services and projects that would really meet the needs of people in ways that didn’t tell them to ‘sit down, shut up and take what they’re given’ and from the side of people who used such services you had people who were increasingly confident in the idea that they knew better than professionals what they and others like them wanted and needed.  Coproduction in its purest sense is like the secret lovechild of those two different trends; people who design and work for services and people who want better ones getting together to make something new happen that wouldn’t have happened in quite the same way if they hadn’t hooked up.  It all sounds simple doesn’t it?  A glorious Mills and Boon romance.  But, like every good love story there must be obstacles along the way.  And, crikey are there some obstacles.

Danger! Risk and reward ahead

In a perfect version of coproduction, people would come together spontaneously, easily decide what they were trying to make and then get on with making it, carrying on until everyone was finished and everyone felt they had made the contribution they wanted to make.  There wouldn’t be set end point from which the project began. Somehow, as if by magic, people would find each other and have all of the right skills and resources to create a magical new thing.  We, however, live in the real world.

One of the first obstacles to coproduction is power.  Some people have control of resources and some people don’t.  Some people are paid for their time and some people aren’t.  In the perfect idea of coproduction people from different disciplines, with different experiences, come together as equals to work on building new things. But there are always constraints to this.  In most coproduction projects someone has already set the initial direction of travel.  From the beginning the project is trying to get to a particular place or has already decided what the particular problem is to be solved.  So, sometimes, it isn’t possible for coproduction to really be completely defined by the people involved in the process.  Some people in coproductive activities will have more power than others.  If a professional has managed to convince their boss that the project they are working on should be done in a coproductive way, that professional will have to answer to their boss, or their funder, or the government.  Even if it becomes apparent for everyone working on the project that the thing they’re working towards won’t be useful when it’s finished because it’s not the thing that people really need, they’ll have to finish it.  In lots of coproductive situations I’ve seen people try to do a really weird thing: they try to avoid doing the thing they’d be good at because they think that is something that gives them power that might make others uncomfortable.  I’ve seen professionals avoid talking about how things in services really work, even though that’s vital knowledge for the coproduced project to work.  I’ve seen people avoid talking about what they know other people want because they’re worried that means that they aren’t doing a useful thing in coproduction.  I’ve seen people from all walks of life ignore their previous experience when coming up with ideas because they’re worried that they’ll break the coproduction spell by pointing out everyone isn’t equal.  In coproduction how we differ from each other is important and making best use of it more so.

Another obstacle is personal resources.  Sometimes when we have a problem we don’t have the resources or the will to be involved in developing our own solution to it.  Sometimes what I want is a transaction.  What I want when my mental health is suffering is a service I can use that is ready for me to use.  At that point I can’t be involved in a twelve month process of designing a service to suit me.  Even if I could, I might try to make that service into one that would be perfect for me at that point without thinking about other people who might need to use it.  Not everyone has the same capacity to be involved; or might need extra help and support to contribute.  Good coproduction works out what it needs to make a project happen and then works out who is best to do what bits.  It’s about finding out how useful you can be to making that project work.  This can be hard for many of us when we’ve had experiences where people have told us that we’re no use to anyone or where we’ve felt rejected or ignored.  Coproduction is the job of making something new, but it’s also an emotional experience and an experience of getting to know and work with people we might never have expected to work with.  This can be difficult for people who work with services and for people who don’t.  It can be hard to learn to trust each other.

A further challenge in coproduction is responsibility and respect.  For many of us who have been users of services and tried to change them our experience has been one of being ignored or spoken over or belittled by people with more experience or what feels like a higher social position than us.  This can make us very good at entering into consultations or meetings and being very clear and very strident about what we don’t want to happen but less used to working with what we do want to happen.  For many professionals, even with the highest of intentions, it can feel challenging to step out of the safety of your professional role and to take part in something more collaborative.  For anyone in a coproduction project, respect for each other and responsibility to the project is vital.  Setting the contract for how you’ll work together is a huge step towards actually getting something you’ll all be proud of out of the process at the end.

A further thorny issue is to whom the final product of a coproduction process belongs.  Coproduction is about sharing ideas and sharing work and making something happen that wouldn’t have happened in the same way if different people had been involved.  If it’s coproduction everyone involved will have made it what it is; but too commonly those on one side of the professional divide get to carry the work forwards and those on the other side get left behind.  A good coproduced project will be thinking about what happens after the process is finished and how everyone involved might profit from what has happened.  I know we’re all doing it for the good of humanity because we are all saintly and have huge hearts; but we also need something for ourselves too so that we can be replenished or rewarded or recognised.

The final issue is working out what is actually good to coproduce.  When I put my bins out I’m happy that the bin people take them away.  I don’t want to meet with them every week for six months to work out exactly how it should happen.  Similarly, if I’m having heart surgery I don’t want to coproduce my surgery with a group of non surgeons who reckon they know what might work.  I do however want the information I’m given and the pre and aftercare I receive to be coproduced by a coalition of people who’ve been through that surgery and professionals who know how the system works.  Knowing why you’re working together and knowing why this is the thing to be working on is vital to ensuring what you make together useful to other people.

Coproduction isn’t magic: it’s people and processes

Coproduction is about power, purpose, respect, responsibility, resources and knowing what will happen next.  Today is about hearing from people who been there and done that and already have coproduced the t-shirt.

Coproduction isn’t easy.  It’s not made any easier by giving it a mythical status or a magical power.  Coproduction is making things together.  It must make good things and it must be a good way of being and working together.  Coproduction is an investment for anyone who takes the risk of taking part.  Being involved in coproduction makes us vulnerable and powerful at the same time.  It’s easy to forget that we are all glorious, complicated, amazing, confusing creatures filled with our own vanities and insecurities and powers and surprises.  We might be keen to be involved in coproduction because we want to change the world; but we have to be prepared for the experience to change us.  Making things together in mental health in an equitable and inclusive spirit requires many qualities of us.  It requires generosity, it requires diplomacy, it requires, and this will sound a little sappy, love and respect for each other.

Coproduction in mental health challenges us to make the things we want to see in the world together.   Coproduction is about putting our values into action and making things that work by making processes for working together that work.

We can’t just say what we’re against or what we’re for. We have to do.

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.

 

 

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One Response to What we talk about when we talk about coproduction in mental health

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