Co-production for Integrated Care

“Medicine's ground state is uncertainty. And wisdom - for both patients and doctors - is defined by how one copes with it.” 1

I think the health discourse has begun to move. Move from the acceptance or expectation that a healthcare professional does something to the patient or for the patient. To one where both the patient and healthcare professional co-produce health in partnership. In other words a move where medicine is done ‘to’ an individual, to a working ‘with’ relationship.

When we talk about co-production it can, at first, seem a complicated idea. In essence it means to make together. It extends upon the idea of professionals working together across work or organisational boundaries, a model I became familiar with in my social care career. It brings into the conversation, in a meaningful way, the individual, group, or community as equal partners in the planning, implementation and evaluation of their health and well-being.

For this to happen will require an examination of our roles as patients and professionals in relation to health, education, culture and politics. It embraces an idea of a more active form of citizenship. It will require us to acknowledge and act together upon the affects of impoverishment on peoples health and well-being as a consequence of economic, social and cultural inequality.

It can seem the most difficult conversation to begin. From a professional point of view the active engagement of patients and carers in the co-production of health would seem the least effective or even wished for way to work. It will require healthcare professionals to examine some of the values and assumptions that underpin their practice. It will prove a challenge, given the inherent status, power and control that comes with the role.

I hear the same repeated themes in my conversations with patients and carers about what they want from healthcare professionals. They want to feel included as far as possible in the important decisions about their healthcare choices. They want to feel the benefits of a team of professionals who work with the patient in the patient's best interest.

As I did when I worked in my various roles for social care and continue to do so now in my work with students and healthcare professionals. One must engage in a ongoing dialogue to answer some simple questions:  ‘Who do you work for?’ and ‘Who's needs do I / we meet when I / we make an important decision about an individual's or a communities health needs?’

No one said that the work of healthcare in the 21st century will be easy. It will require healthcare professionals to explore the difficult discourse of uncertainty with patients, carers and fellow professionals. It will require the learning and practice of complementary skills with the same dedication given to the clinical skills learnt as part of  medical training. Skills such as facilitation, care-coordination, care-planning, and advocacy, among others.

When I worked with the Darzi fellows in 2014 as part of the PCC from Leeds talking about coproduction I left the events buoyed by the passion and energy I witnessed. I felt hopeful that the health professionals and leaders of tomorrow will continue to work, advocate and value the knowledge, skills and experience that patients and carers bring. Not just to manage their own health needs but for the co-design and development of our health services.

1.  Atul Gawande. Complications: A Surgeon's Notes on an Imperfect Science.  2nd ed. London: Profile Books; 2008.

Message to the Darzi 6 - Gil Scott Heron and Clinical Leadership

I wrote the following message to the Darzi 6 Fellows at the beginning of their PG. Cert. in Clinical Leadership. The theme for the day was an exploration and discussion on:

What helped me to learn to be effective in complex social systems?

I took part as one of a group of ‘wise visitors’ who shared experiences from their respective careers and then discussed with the fellows the ways in which we had managed to negotiate the complex of people, systems and processes one finds in organisations.

On the train journey home I began to reflect on all things I wish I could've said had we had more time. So, to make amends I quickly wrote down those things and sent it to Duncan Ross, one of the facilitators on the day to share with the Fellows. Here's what I wrote: 

‘Things I didn't say but would have liked to.’

I would, first of all, like to say how much I enjoyed meeting you all on Friday. Toward the end Duncan asked if we, the visitors, had any other thoughts that we hadn't had a chance to speak about. It seems to happen all to often that when one leaves an event as stimulating this that many questions and reflections arise afterward but too late to communicate at the time.

I recognised from the questions and discussion I had with the two tables I sat with just how many demands you face day to day. Your passion showed that you will grasp the nettle of these challenges and affect a positive and lasting change.

So, if you will allow, I would like to offer some of my thoughts on the question above. I hope it may prove, if not helpful, a spur for your reflections on the day and this experience.

I ought to add a caveat. I offer these reflections in the spirit of Message to the Messengers by the late great Gil Scott Heron.  Gil Scott Heron (poet, author and musician)  known as the ‘Godfather of Rap’became most active in the 1970's and '80's.

Message To The Messengers speaks to the rappers of the 1990's and rap music in general. In his poem Gil advises the new generation of hip hop artists to remain conscious of the past. To respect the elders that went before and a map to avoid the pitfalls inherent within the music industry.

Diane mentioned the accumulated wisdom present in the visitors when she introduced us. In a similar vein, Gil's message expresses his hard won wisdom and best hopes for the next generation as they make their way in the world.

The following reflections I noted down on my journey home to Yorkshire on the train. I trust that you will examine them in the spirit that I offer them. Or you could just listen to Message to the Messengers:

 

Thoughts and Reflections

 

Systems and process's can disguise what happens in health organisations and agencies. Namely, the day to day process of people engaged in complex face to face relationships, interdependent upon reciprocal and mutual benefits.

Often times it seems, we can find ourselves in uncharted territory where we must draw the map as we go along.

Our ability to navigate depends on our interpersonal skills to negotiate and cooperate. To work with knowledgable, skilled and experienced local people on the ground who can help.

Our interpersonal skills need to foster helpful conversations that seek and affirm the good. To find those things that we all share in common.

Know that the process is dynamic and emergent. One must become agile and nimble, embrace the unknown and let go the idea of always having or taking control.

Think about your core values. Examine them. How do they affect your behaviour, your attitude and communication style.

Be generous. With your time, with yourself, with others.

Get comfortable with the unfamiliar. With different people and places, where alternate ideas and ways of being exist. You just might learn something. You will, without a doubt, come away richer for it.

Your role and title, be it manager or leader, describes a series of knowledge, skill, and function sets. As we used to say in our team, ‘Management is a function not a status.’

If you don't know, don't bluff. Ignorance, if embraced can become a strength. That doesn't let you off the hook. Once again, in our team, if you didn't know something then go find someone who does and ask for their help, or find out for yourself.

In other words you either know, or don't know, and if you don't know you engage in finding out. Ignorance gifts you the greatest invitation to learn something. In the process  you will develop yourself, meet unique characters and get to travel to interesting places.

Find and nurture your voice, your way of being. Become adept at using different modes and mediums of communication while you remain true to yourself.

When things go wrong, and they will, respond with integrity. Take ownership and never seek to cast blame because:

People can and do make mistakes, 'to err is human.' You will make mistakes.

Systems and process's can and do fail, 'if it can go wrong it will go wrong.'

Don't confuse the two points above. The first needs support. The second requires attention.

There's a difference between having a plan and planning. Plans become fixed, difficult to adapt and slow to respond. Planning makes room for contingency, builds in flexibility and nimbleness to respond.

As the professional in the relationship don't become the barrier, either to others or yourself. Many of life's barriers start and remain inside people's heads.

Change happens all the time. At the micro level (teams and individuals) and macro level (organisational structure, systems and process's) .

Within teams individuals come and go, have significant life events and mature as characters. Organisations must adapt to local, national and international policy agendas. Both individuals, teams and organisations must respond to crisis and breakdowns.

I wish you all well on your respective journeys. It was a pleasure to meet you. If you go away with anything then I hope at least I may have introduced you to the work of Gil Scott Heron.