On 18 November we hosted a round-table discussion around the first RED paper, Health:Co:creating services. The notes in this entry are an account of the ideas and comments that came out of that event. Further comment or elaboration on any of these ideas is welcomed.

Health: Co-creating services
RED paper 01 Launch - 18 November 2004 4pm @ Design Council

Hilary Cottam and Charles Leadbeater opened this event with an overview of the paper and the thinking behind our project (for more detail see our paper Health: Co-creating services).

Chris Yapp - Microsoft Ltd
Co-creation within health is not so radical - sufferers of chronic asthma have been co-creating in their self management for some time however lack of accountability within the system means that professionals are not involved in this. What does professional accountability mean for this notion of co-creation? At present professionals are accountable to their industry only.

Chris Powell - BMP DDB Needham Ltd
What self-management programmes already exist in chronic disease?

Tony Elson - Department of Health
The issue is can we overcome the resistance to co-creation that will be inevitable amongst professionals? This requires a changing culture of leadership. We will need to bridge the gap and work with leaders in the industry who have the power to prevent co-creation.

Pam Garside - Independent health consultant for RED Health project
We must be careful not to focus on poor people only. Disabled people, particularly the mentally disabled, are also a key opportunity group for improvement through co-creation.
There will be obstacles within the medical profession concerned with 'doing the right thing'. Structures are easy but changing the attitudes of professionals is difficult.

Alasdair Liddell - Independent health consultant
The conceptual ideas are exciting - the question of whether this is happening already is somewhat irrelevant because we are talking about a different process of engagement. The issue then is how to shift the way in which people characterize their health problems.

Ravi Gurumurthy - Hammersmith & Fulham Council
A package of healthy activities with reward incentives to tackle the externalities is good but essentially individualistic. Is it possible to establish the social networks that exist around chronic conditions around healthy living? We need to be aware of the extent to which this would require active citizen participation.

Richard Eisermann - Design Council
All our examples of co-creation are a based electronically based. People who are socially/economically disenfranchised will also be electronically disenfranchised so we will need analogue solutions as well.

Helen Bevan - NHS Re-design Team
The biggest thing design thinking can give is the ability to think forwards instead of backwards. The NHS knows what works but has problems with making that happen. Design thinking needs to be made mainstream to steepen the adaptation curve.

Helen McCarthy - Researcher for RED health project
There is a question around aspirations that needs to be considered. Unhealthy things like smoking and rich extravagant foods used to be aspirational as synonymous with 'success'. Healthy lifestyles and fitness are now becoming more aspirational with similar associations. The problem with aspiration is that it sets people up for failure. So we need to think clearly about the impact of failure and how to manage failure when talking about health aspirations.

Patrick Towell - Simulacra Media
Behaviour change is the definition of learning. The role of design in this is how information flows from experts to non-experts to instigate that change. The language used by health experts at present is not effective in stimulating behavioural change.

Karen Jochelson - Kings Fund Policy Institute
A retrograde perspective - regulation has been successful in a wide range of health issues - what is the potential for regulations for healthy living?

Robin Murray - Design Council
Our partners have demonstrated that within the health industry there is real drive for change and improvement. There is, however, a dark area between what the professionals are trying to achieve and bringing the patients on-board to make it happen - it is a tricky interface. In trying to get people to work together on this the question of whether the state has a role is important - we think there is potential for the state to create a 'space for collaboration'.

Harry Cayton -Department of Health
1. We have not spoken about the distinction between co-creation and co-production. There are examples of the latter in the NHS but not so for true co-creation.
2. Carers and the Carers movement and other examples have been invented by patients - people with long-term conditions not doctors. Experience shows that professionally led self-help groups are a contradiction and end in failure
3. These examples show that although it is always a high risk activity in handing power back to the people, it is critical for professionals to do so.
4. Professional accountability? The Royal College of Physicians is investigating what it means to be 'professional' for doctors? Traditional view is that professionalism comes through autonomy, knowledge (and power through knowledge) and altruism etc.
The new model will see professionalism based on how doctors conduct relationships with:
 knowledge
 colleagues
 patients
 society

Charlie Leadbeater - Independent thinker & author
There are 2 sets of questions here:
1. How much can we evolve the current system?
2. What should the new model look like?

To Ravi Gurumurthy - Self-help is marketable - Tupperware parties, Anne Summers parties, Weight-watchers etc The question is can we take self-help examples in health and make them as big as e-Bay?

To Richard Eisermann - Analogue examples are available - Grameen Bank

To Helen Bevan - Steepening the adaptation curve is most possible through viral change rather than institutional change - text messaging

To Karen Jochelson - Regulation certainly has it's applications but not across the board and not in isolation. Can we create a regulatory framework that allows change from the bottom up?

To Helen McCarthy - the question of the side effects of aspirations is interesting and needs to be considered further.

Change will be in the centre of gravity away from hierarchical model of professional knowledge to one where professional knowledge is needed and valued but only called upon when needed.

Where is the leadership? In communities and Local Government Authorities.

Hilary Cottam - Design Council
1. Yes, regulation is important as are some aspects of traditional health services - there will always be a need for hip replacements. It is important to recognise that the system we are proposing is neither bottom-up nor top-down.
2. How do we create an environment where everyone feels empowered to make the changes that suit them?
3. It is a question of individualism v collective and where are the roles?

David Kester - Design Council
We are obviousy talking about more than just a matter of wealth distribution.

Andrew Goldberg - Medical Futures
No-one has mentioned the issue of the media and what role it has to play in changing behaviour. To consider user demand we must look at the enablers and motivators and for these we should seriously consider what the media offers.

Michael Scott - Department of Health
1. co-production v co-creation - this needs more investigation to define the distinction between the two.
2. important to make the distinction between health and healthcare
3. health project? there are many routes into good health that will never be recognised as part of a health project as they are not health driven
4. pilots are valuable but how do the problem is not with good pilots it is with implementation on a national scale.

Charlie Leadbeater
The issue of motivation is largely one of framing. We need to look to non-health organisations and institutions to provide the motivation as it needs to be broader than just through the NHS. It is interesting to consider that vanity is a strong motivator in many health issues.

Samira Ben Omar - Hammersmith & Fulham Primary Care Trust
When talking to users about their self-management the question of practicality is often overlooked. With many pilot schemes there is not enough focus on the process involved in coming to that point as this is what really engages the user.

Aisling Byrne - Oxfam
So often these pilots are working within systems that are effectively working against this process - perhaps the solutions need to come from outside the system to fully realise this process of engagement.

Hilary Cottam
In Bolton we have seen that in many cases the patients are in denial.
We are looking for a process and a set of principles rather than a 'pilot' to implement - the process and principles will be utilised in different areas and within different frameworks.

Ed Mayo - National Consumer Council
Legal Aid now considered a gravy train, once it is started it is very difficult to stop. Another are the chocolate barons and soft drink companies who are now battling for their interests.
Need a semi-regulatory semi-voluntary system of steering consumer choices. Can we work with a constituent of users that are already trying to solve their problem.
Emphasis on social justice.

Nigel Edwards - NHS Confederation
The distinction between health and healthcare is a difficult one. The US provides examples of incentivised insurance where health promotion through benefits or prizes is not working.

Tony Elson
The design ideas being used in Kent and Bolton should feed into the white paper.

Charlie Leadbeater
There is a tendency to think that these are win/win opportunities. However these are challenging questions and the test of success will be bringing about change without being heavy handed. The discussion has outlined the importance of design to this debate - changing the design of systems and platforms sis key to changing the institutions. A question that was asked frequently in writing the document was whether change should be:
- inside out
- outside in
- from outside
What do the attendees think? approx 70% outside in and 20% inside out

Hilary Cottam
It is critical for us to keep this debate going - we are open to any comments and / or suggestions and ideas for co-created services.
www.designcouncil.info/red

CATEGORY: HEALTH PROJECT