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Co-production in healthcare education

Sharing power – Tipping the balance

The School of Health Sciences at the University of Nottingham had a long-standing reputation for working in partnership with members of the public. People contributed to teaching and assessment in innovative ways and the School regularly jointly produced publications and co-presented at conferences. The investment and commitment to public engagement was reinforced when an external review was commissioned by the school management board in 2015. The resulting recommendations and final report outlined a public engagement strategy and agenda for how we could improve and build upon our activity and work – towards an ethos which supported co-production:

The practice of co-production will become a normal, embedded part of the School’s culture and structure; furthermore, it will become part of our shared discourse.

A governance structure for ‘accountability and communication’ which included three new groups, was established and work took place to enact the report recommendations and strategy. One public member stated:

We didn’t really start our involvement to become rich, but to make meaningful contributions and to help get service users and carers issues and opinions included.

What difficulties were there in implementing co-production?

In terms of power-sharing, the new structure created improved opportunities for people sitting on the three groups to have a real say. However, in practice, meaningful co-production was perceived to be compromised by cultural and hierarchical barriers to communication and information sharing.

In 2018, to comply with employment law, the majority of public engagement activities were re-categorised as ‘Voluntary’ with remuneration intended to cover expenses only; the activities termed ‘Co-production’ were to be hourly-paid short-term project work.

The organisation redefined the terms of engagement for members of the public.

This led to members of the public not feeling valued as equals, and the contribution they had made to the quality of healthcare education and the school’s reputation over many years was perceived to be unrecognised.

The powerful reaction of the service users and carers group which ensued, came as a challenge to the organisation’s power. As well as being experts by experience, their professional and community roles had equipped them with expertise in advocacy, political activism, social justice – and the practice of co-production. The group gained the support of academic staff and brought on board the university’s trade union which ratified and powerfully advocated concerns and initiated a formal process of industrial action.

What has helped create change towards implementing a co-production approach?

With the prospect of industrial action and potential reputational damage, there was an organisational impetus to work to address the concerns of the public members.

In late 2018, six months on from the issuing of the new proposals, this was achieved in an open meeting with senior managers.

The senior leadership actively listened and attempted to understand the source of discontent. A sense of respect was engendered and managers present openly acknowledged their error in how the new arrangements were devised and presented to the members of the public.

Over the next three months, a more equitable governance structure was developed which reflected the views of members of the public. This was ratified by the School management board and a Public Engagement Steering Group, with significant representation from members of the public, was set up.

What are the main strengths in the approach that has been taken?

Facing challenging conversations: The open meeting uncovered the varied motivations to support the public engagement agenda, which at times were in conflict and resulted in challenging conversations. Where some were motivated by a desire to bring to life the principles of person-centered care for healthcare students, others were concerned with professional governing body requirements and student satisfaction outcome measures. Conversations were uncomfortable because they exposed the inherent power imbalance within the interactions, and the underlying cultural barriers to co-production were laid bare.

Active listening: Consensus around a way to move forward was enabled by the various parties actively listening to one another, accepting criticism, being willing to compromise and work constructively together towards a solution.

Transparency: An honest and transparent environment was created which permitted the varied motivations to be discussed and a shared understanding to be created. Motivations were different, the end goal was the same: the best-quality educational experience for the students, for them to impact positively on healthcare practice.

What have been the main outcomes of this experience?

Where previously the organisation’s decisions were informed by minimal consultation with the public members, there is now an active commitment on both sides to respect the experience and expertise of the other, ensuring that ongoing developments and decisions are based on much wider mutual agreement.

Under these circumstances power lies not with one part of the organisation or the other but within the relevance and validity of the discussions and the actions that can be derived from these.

Such mutually shared power can fit comfortably within or alongside existing power structures, and/or challenge and inform them. What will be most important is that the honesty and transparency continues.

What advice would we offer to others?

Questions and learning for others embarking on co-production within healthcare education and other large ’hierarchical’ organisations:


  • What are the different understandings within the various layers of your organisation of what ‘co-production’ really means and really entails?
  • What are the different understandings of power and how do they manifest in your organisation’s culture? For example:
    • Power To – using power to ‘enable’ and advocate
    • Power Over – relations of dominance and the exercise of authority
    • Power With – collective approaches, working together and mutual empowerment
    • Power Within – developing inner resources and empowerment and a sense of ‘self’. (Thompson N 2007)
  • What are the cultural barriers to, and what professional and personal threats are posed by, power sharing?


  • Power is personal and drives the human need for identity. However, this positive drive to belong to a ‘tribe’, to align and identify ourselves with certain groups, can easily lead to separateness, exacerbate division and create a ‘them and us’. Being mindful of how this process can bias and disrupt communication, alienate and disempower others – including those perceived as power-full, is key.
  • Stakeholders – the parties involved need to be transparent and honest about their differing agendas and motivations in promoting public engagement and co-production.
  • The challenge of practising co-production and power-sharing involves self-awareness and courage – a willingness to ‘put your head above the parapet’ – to ‘be seen’ and to face discomfort.
  • Power is an element of human relationships, which is neither good nor bad in itself – power relations are everywhere and it is necessary to be aware of their force.
  • Reciprocity’ and empowerment: Viewing co-production as ‘a meeting of minds’ which is mutually beneficial and empowering is key. Empowerment is not a simple matter of power being ‘handed down’ from those perceived as power-full or empowered, to those perceived as power-less or disempowered – this is a paternalistic and mutually disempowering position from which to view the process. Empowerment is co-created, flows both ways and benefits all involved.