Do you remember playing with Lego as a child or with your children? Let me give you a good reason to use LEGO at work to trigger your imagination and redesign your services the way LEGO did a couple of years ago.

Governance International has shown me that it is worth exploring new scenarios in which public service providers enable and skill up service users to help themselves and empower local communities to harness their knowledge and expertise to solve ‘wicked problems’.

The 50+ case studies in their Good Practice Hub show the wide range of co-production approaches all over the world. They demonstrate that co-production can either achieve improved outcomes or better value for money. Often it does both.  The Co-Production Explorer developed by Governance International highlights innovative co-production models so that you can design a new vision for your service. At the same time, it helps you to build on existing pockets of co-production in your service to link the present with the future.

Ignoring the imagination unleashed by co-production is almost like accepting the inevitability of future failure. Once again, don’t read on if that really is what you think is acceptable - but I certainly don’t.

Be honest - you probably need to save budget? Guess what, co-production can help with that, too. Co-production champions are refreshingly unwilling to accept that offering ‘less’ is the only path. Even with financial constraints, it is possible to do better.

Perhaps you might not expect a well known company to use co-production approaches? Well, read this Toy Story about Lego’s transformation.

Lego is now so popular that there are 62 little coloured blocks for every person on the planet but few people are aware that the family-run business nearly went bankrupt in 2004. From being an amazing start-up in the economic depression in the 1930s and experiencing a fast expansion in the 1960s Lego started to suffer losses in a fast changing toy market in the late 1990s. Kids simply preferred to play video games and playing with Lego was not cool any more. As a portrait of the Lego company in the Guardian states, in January 2004 the company reported a record deficit of £144m.

According to the brilliant analysis in Tim Kastelle’s blog on the Innovation Lessons from the Rise, Fall, and the Rise of Lego, its economic downturn was due to three factors:

1. Poor overall management.  As LEGO reached its crisis point in 2003, everything was going wrong.  Its financial control was very poor, and it had lost touch with what customers wanted.  Furthermore, even when people who loved LEGO reached out to try to contribute ideas, the firm was fairly arrogant in ignoring this input, believing instead that they knew best.
2. Lack of strategic focus.  In all of the pre-2003 innovation efforts, LEGO was obsessed with novelty – with doing new stuff.  But they were so far removed from understanding what their customers wanted (or even who they were), that these new ideas failed to create value.  They thought that the power was in the brand – so they launched things like LEGO TV series.  But really, the power was in the bricks – it was refocusing on this that started to turn the firm around.
3. Disconnection from customers.  Many of the misfires prior to 2003 were the result of not understanding what kids wanted – most of the new products were based on assumptions about this, not on feedback from the customer base.

Does this sound familiar to you? Do you think that your commissioners know their clients – or what they need?

If not, continue to read the Lego story. Of course, as Lego is a private sector business not everything may be transferable to a public service context but in my view the LEGO transformation shows the potential of co-designing services with people using services.

Tim Kastelle describes in his blog how LEGO discovered co-design as a method to drive product and service innovations:

Shortly after LEGO released Mindstorm, the enthusiastic community of adults that love LEGO, hacked the software.  After a great deal of thought, instead of shutting down the hackers, LEGO embraced them.  This then led to further collaboration with the community. It was this community that drove the overwhelming success of the product:

Instead of taking a year to find two potentially big growth opportunities and then invest significant resources to develop them, the front-end team would align with entrepreneurs who were already working on nascent but promising projects. Within a matter of months or even weeks, the team would use the LEGO Group’s know-how to help these entrepreneurs test the market, make necessary revisions, and test again. The idea was to avoid making bet-the-firm mistakes by launching a series of low-cost, low-risk experiments, which would increase the odds that one might grow into a runaway success.

LEGO also discovered that the key to its success was harnessing the ideas of its end customers – children!  Lugnet, a Lego user community, works with users to co-design models, even using open source design software to create shared visions from different cities. This virtual community even tackled problem solving and design - for fun! Children are enabled to create their own designs making them co-designers of their own dreams. Lego now incorporates public feedback into its heart, soul and philosophy, contributing to its choices, designs and decision-making on new products.

In the end, it was its new strategic focus and this new collaboration with customers which turned the company completely around. As a result, five years after reporting its biggest ever loss, Lego was reborn and reported a net profit soaring to 32% to DKr1.35bn and sales up a healthy 18.7% for 2008 (source: http://www.theguardian.com/lifeandstyle/2009/mar/26/lego-billund-denmark).

Are there any bells ringing yet or light-bulbs flashing inside your head? There should be…!

The transformation of Lego is the starting point for imagining how co-design can not only create ’improvements’ but can transform a whole organisation and its relationship to its clients and local communities.   

The many forms of co-design that Lego adopted illustrate the tremendous potential of harnessing the ideas and skills of people using services. And, as I’ve experienced in my career in public services, one ‘co’ leads to another ‘co’, involving clients and communities as part of the process, starting from co-commissioning, all the way to co-design, co-delivery and co-assessment.

Scotland has an amazing wealth of case studies to learn from – just look into the publication 

Co-Production of Health and Social Care in Scotland. But there is also an increasing number of local authorities in England and Wales such as LB of Lambeth, Stockport MBC, Surrey County Council and Swansea Council which have embarked on a co-production journey. What a difference it would all make, if even more service providers and commissioners adopted these ideas.

So we do some good things in the UK already – but don’t we now have a golden chance to harness fully the opportunities offered by co-production?

USA basketball legend Michael Jordan famously gave what I consider to be one of the best motivational quotes of all time:

“I can accept failure, everyone fails at something. But what I cannot accept is not trying”.

Now ask yourself honestly, why don’t you get in some Lego for the next senior management or team meeting and ask your colleagues to design an alternative service delivery model based on co-production? It’s obvious – what LEGO could achieve, you can do too!

Everyone thinks innovation is great, everyone thinks working with the public is great. But how do you actually get this to happen? My colleague Tom Hoy has shown how it’s possible. Check out the next Made in Lambeth weekend make-a-thon to see how he’s helping create an alliance against violence, stopping pay day loans, and creating a brand identity for a local Brixton paper. Made in Lambeth now gets people from across the local community contributing and doing stuff. Most of the work is done in an amazing 48 hours.

But what about creating change within the council? Recent research in the sector has shown that the majority of council officers think innovation is one of the answers, but feel pace is far too slow.

So what can you do? Do you need to spend millions on branding, fancy buildings, and lots of experts? Do you need to launch more initiatives? I’m sure that could help. However, in Lambeth, we’ve gone back to basics. We’ve shared our ideas about what really seems to create a buzz on the ground. We’ve look at what captures our imaginations. Some of it is rational, some of it unexpected.

My colleagues Giles Gibson and Sue Sheehan have been baking delicious cakes. Sue is famous for her lemon drizzle, and Giles for his chocolate brownies. I have been pouring the tea. We find that it’s enough to get people talking and coming up with ideas and plans. We’ve also found that many of our colleagues love baking, and we have been able to capitalise on this tradition of sharing.

We decided the most important thing was talking to people, listening to their ideas, and giving them practical support. Money was rarely a barrier to coming up with ideas. Instead of using external designers, we found an artist amongst our council colleagues, and we designed our own promotional materials and worksheets. We produced all of these within seven days, from start to finish. Get in touch if you want to see what we came up with.

We have a letter from our Chief Executive Derrick Anderson, supporting each team to see what they can do over 30 days over the month of October. The idea is to help people try something new. We know that there is too little risk taking, too little experimentation and sometimes people need explicit support to try something new. We now have a dozen teams, with ideas ranging from re-launching an unused kitchen in the town hall, to involving residents in carrying out environmental inspections in their neighbourhoods, to growing and sharing vegetables in GP surgeries. We are supporting them in overcoming any barriers they encounter. At the same time, we are developing an in-house school of innovation, based on creating networks within the organisation, and working with local residents.

But we are not spending money on new buildings, or fancy prizes. We are working on the basis that people enjoy collaborating to solve challenges, and make life better. We find a little piece of cake and a cup of tea can go a long way.

This blog has been written by Governance International Associate Ajay Khandelwal, email: Ajay.Khandelwal@govint.org

Learning from a bike crash in Belgium

I recently travelled to Belgium for a cycling weekend.  I was showing off by riding over some cobbles when I crashed.  Luckily, one of my friends was carrying a portable medical kit, and promptly put on some latex gloves, cleansed my wounds, and administered industrial quantities of pain killers.

I was promptly re-installed on my bicycle, until I decided to call it a day and managed to find a local train station.  Just as I was about to board the train to Brussels a local handyman offered me a lift to the local Accident and Emergency Department. I was pleasantly surprised to be seen after a few minutes.

I was then bandaged up by nurse and doctor, and given a tetanus injection.  The only problem was that my cycling kit was splattered in blood and sweat, and I didn’t have any spare clothes with me.  It was a Sunday in rural Belgium and all the shops were shut.  I used my powers of persuasion and managed to leave wearing a crisp white nurse’s outfit.  Over the last few years I have spent a lot of time thinking about the role of patients in health care innovation, but this wasn’t exactly what I had in mind!

My recovery in the UK

In 2012, I had predicted that many of us would become much more active in our managing our own health care.  I argued that many people would seek out knowledge and expertise from their peers, and online, as well as consulting their doctor.  Well, this crash gave me the chance to put my ideas into practice. 

When I returned home, I sought advice from internet forums and my cycling friends about the best way to treat “road rash”, as we cyclists call abrasions caused by hitting the road.  But in the end, I decided I need help from the experts, and I went to a local “NHS walk-in centre.”  My walk-in centre in Peckham, South London was lot busier than rural Belgium. It would be more accurate to call it a “walk in and sit down for a while” centre, but once I was seen, the nurse who saw me gave me her full care and attention as she changed my dressing, and we shared some stories about our lives, in the fifteen minutes we spent together. 

The help of this nurse, who I saw every few days after this, was crucial in aiding my recovery.  This reminded me of how important it is that clinical staff and patients work together to achieve real outcomes together. There is a real risk that this human relationship, which requires compassion and genuine empathy, is often neglected in modern health systems and innovations. Indeed, Darian Leader has uncovered evidence that the majority patients visit their GP due to psychological distress, rather than for any medical reason.    

Need for a new form of collaboration between patients and clinicians

Nevertheless, the interaction of the patient and clinicians is an area that is ripe for change.  Genuine co-production between clinicians and patients can provide opportunities for better outcomes, experiences and improved efficiency.

 A number of organisations and individuals have been grappling with the question of how patients and clinicians need to work together.  The King’s Fund has argued that the UK needs to unleash a wave of innovation to find new ways to relate to patients in managing their health care conditions. The blogs from patients and experts on Time to Think Differently make the point that clinicians need to find out what patients want, and show why patients need to take more responsibility for their own care.

Often, this can be achieved through very small changes in conversational approach.  For instance, a London based GP reports that she is much more likely to start with “What are we working on today?” rather than “How are you today?”  Her experience was that the result of this shift is that patients are much more thoughtful about their own role in managing their long-term condition. The Health Foundation’s Co-creating Health Programme, has provided clinicians support to rethink about they work with patients with long-term conditions.  A key finding has been that patients respond constructively to jointly set agendas around how best to manage their care. 

Over the last few years I have been talking to clinicians, commissioners and patients around the country about how they can work together more closely as part of the NESTA People Powered Health Programme.  We set out with the idea that co-production was a marginal approach in health care, but we wanted to find out if it could produce real results if it was scaled up.

We need to test and try out creative new approaches

We worked with Professor Chris Drinkwater and GP Dr Guy Pilkington to support doctors to provide “social prescriptions” – linking patients to local activities to give them a sense of purpose and meaning.  We talked to commissioning manager Nick Dixon about how to help adults move out of inpatient psychiatric care and find support from peers who were in recovery themselves.  We worked with colleagues in Leeds to think about how to create multi-disciplinary teams that helped people with many long-term conditions.  We listened to clinicians and service users about how to use group consultations for individuals experiencing chronic pain.  We worked with a primary care centre in Earl’s Court to think about how to get patients to benefit from nurse coaches, and join a time bank to support other patients. My overall experience was that whilst there are many powerful political and professional barriers to giving patients a greater role, there are also interested clinicians and commissioners who are willing to try new ideas and develop new approaches. 

One such co-production champion is Paul Ballard, Deputy Director of Public Health of NHS Tayside. He has been heavily involved in the drive to embed co-production within all areas of work, including the design and implementation of a new Health Equity Strategy. This will imply a much stronger focus on asset-based approaches and behaviour change: As Paul states, “… during this process I have extensively used the Co-production Star which has proved to be an excellent resource to support our co-production work”.

Co-production offers a financial solution

Not only is there a moral case for co-production, there is also a financial case.  If we were to reshape the health service, so that it had a whole range of support for patient groups, peer to peer support, alternatives to medical care, new forms of medical consultation, and other co-produced forms of health and well-being, we could realise savings of at least £4.4 billion or 7% of the NHS budget.  This doesn’t always require the most expensive medicines, equipment or buildings. But it does require the public and professionals to show the will to re-think and re-imagine what the future of health care looks like. 

If you are interested in exploring how to think creatively about how to bring together clinicians and patients to co-produce healthier outcomes check out our co-production case studies and do get in touch.

'When you first asked me about skills I said I had none because I never did very well at school. But then you asked me how long I'd lived here and what I know about my neighbourhood then I realised I have lots of skills, yes lots.'

The UK charity Skills for Care started its work on community skills development, as a way of building community capacity or social capital, in 2008 as the seventh principle in the principles of workforce redesign. This stated that if social care was to be successful in developing personalisation, commissioners would need to develop a better understanding of the skills that exist in a local community.

In 2009 Skills for Care commissioned 'Only a Footstep Away' as an evidence review of the role of skills development in building community capacity. We published this report in 2010, and made a commitment to test out in action the theory that a more explicit focus on 'skills' as part of community development might lead to different outcomes for people with social care or support needs living in a particular community. In late 2010 we published a 'practical guide to neighborhood workforce planning and community skills development' and established 14 pilot sites to test our model. 

We found that creating an explicit conversation about skills as part of a community development model had profound and multiplying effects. For example, a food bank that couldn't understand why people removed the fresh vegetables from their allocations and didn't take them home found out through skills analysis that most of the people who used the food bank did not know how to cook fresh vegetables. So they taught people how to cook and saw improved nutrition. Indeed, people used all the food they were given and saw the food bank as a positive socialisation opportunity. As a matter of fact, two people fell in love with cooking and went on to take a vocational course in cooking at their local college.

We found that the model could work in multiple settings. For example, a provider could use the model to assess the skills of local businesses in enabling people with learning disabilities to access their services (whether that was banking, transport or retail). If the provider developed training for these local businesses, people using care and support services felt more able to use local businesses unaided, and felt more integrated in their community. The model has been used by a shire county to develop community cohesion, by a parish council to set up a skills bank, by a village residents association, and a borough council as part of a public health campaign. The model has been adopted in affluent areas such as a Royal London Borough - and in less affluent areas with high unemployment. In each case a focus on skills in its broadest sense has brought people together to share and develop those skills in many different ways.

In 2012 we published an independent evaluation of the community skills approach. We dropped the concept of 'neighbourhood workforce planning' as we found the term 'community skills' can capture the whole model, which is essentially: 

Talk to people about what skills they have and what skills they need to learn or develop. Then give people the opportunity to acquire those skills.

Skills can refer to a range of knowledge and experience - from knowing where not to go at night in a particular neighbourhood, to knowing how to fix a shed, or being able to talk to people, to formal or practical skills - or knowing what an 'app' is!  Skills do not have to be about formal training or qualifications.

Everyone has skills - everyone can share those skills with others.

So what are we doing now? 

We are working with some of the original sites to ask - 'what value comes from the community skills approach? How do we realise that value?'  Again, we are defining value more broadly than just in economic terms and looking instead at how value is added on multiple dimensions.

We have also set up two new work streams building on the earlier community skills programme. These new work streams are focused on the concept of 'Skills Around the Person', with one work stream applying this in an end of life context.  'Skills Around the Person' requires a model that explores what happens if social care assessment or person centered planning are substituted with by an explicit conversation about skills. Finding out what skills the person needing support has and needs to learn. Finding out what skills people (paid and unpaid) have and need to learn to support themselves. Then, doing something to address those skills needs for new skills and seeing what difference they make to people's lives.

In the early days projects testing this work for us have begun to share reflections and experience. The projects are saying things like: 

• We need to change the assessment model we've brought in. It doesn't work.
• People get this?
• This is real culture change.
• Is it honestly that simple? 

Perhaps the best example how to put 'Skills Around the Person' in practice is the situation when people come to end of their lives. People at the end of their lives have skills to offer others and skills they need to learn. What if a person at the end of their life needs assertive skills to make sure they can remain in control of the decision-making about their care and support? By having an explicit conversation about the skills that people need and coaching them to get those skills will they and those around them be better able to stay at home as long as possible and have a good death?  As with the previous programme of work, the 'Skills Around the Person' model is being independently evaluated and will report in spring 2014.