Constraining co-creation? An ethnographic study of Healthwatch organisations in England

Why it matters

Over the last decade, health and social care systems in England have increasingly been organised around the idea of collaboration. New integrated care systems, for example, prioritise partnership over competition as the main approach to managing, coordinating, and improving healthcare. These systems are intended to include patients and the public along with health and social care providers.

The principles of co-production and co-creation are central to the potential of collaboration in coordinating and improving health and care. Described as the “joint effort of citizens and public sector professionals in the initiation, planning, design and implementation of public services” (Brandsen et al., 2018), co-production and co-creation have attracted a great deal of interest and have much promise. They are increasingly seen as a means of transforming public services with renewed energy and bold ideas. Evidence of their impact on the organisation, delivery, and outcomes of public services, however, is limited. With this study we aimed to advance understanding of how co-production and co-creation are realised in practice by studying Healthwatch organisations – bodies responsible for championing the voice of patients, service users and the public in local health and care systems.

Our approach

The study, led by colleagues at King’s College London, used ethnographic methods to examine the role of Healthwatch in five local health and care systems over several years. The Healthwatch organisations were selected to ensure our sample included diversity in their size, structure and organisational approach, and in the characteristics of the local areas they worked in. We worked with these organisations for around a year and a half, observing their activities, talking to people involved, and examining documents relating to their work.

What we found

The Healthwatch organisations we studied often worked closely with their wider health and care systems. They were keen to demonstrate the impact of their work and the value they added by bringing the views of the public to bear on health and social care. They varied a lot  in their size and capacity, which affected the scale and impact of the work they could undertake.

While several Healthwatch organisations could point to examples of the impact of their work, there were also limitations on the types of activity that were welcomed by their local systems. Specific, focused input into objectives that were commonly agreed by other organisations in their local health and care systems were highly valued; contributions that were more challenging (for example, which were not compatible with policy direction) were less welcome.

People working in the Healthwatch organisations themselves often had an implicit sense of what would be acceptable in their local systems and what would not. This influenced the nature of the contributions the Healthwatch organisations made in the first place, so that more radical ideas tended not even to be discussed – even when such ideas appeared to be well supported by some sections of the public.

The result was that while the work of co-creation did indeed create value for health and care systems, it tended to relate to less controversial, more conservative ideas. The transformative potential of co-creation that some academic theorists have suggested, and the melting pot of perspectives and ideas it is claimed to offer, were less evident.