'Power on Power' 

For the second day of Co-production Week Scotlabd we have a blog post by Gerry Power, Director of Integration, The Health and Social Care Alliance Scotland.

As a student Podiatrist undergoing training in the late 1970’s the suggestion that shared decision making and joint responsibility for care should be at the centre of the clinician/patient relationship would have produced confused looks from my tutors. Back then we operated very much within a solely hierarchal model of clinical care with patients being viewed primarily as passive recipients of care, wholly dependent on the training and expertise of professionals.

It is arguable whether this position has significantly changed in the 40 years since I first embarked on my career in healthcare. Indeed, to paraphrase Jeremy Taylor writing in 2014 … whilst the aim of giving people a stronger voice in decisions about their own health and care has been an explicit policy goal for more than 20 years it still feels like an aspiration rather than a programme of action, with reality lagging behind the rhetoric.  

I would argue that some of the main reasons for the lack of progress in overcoming the power imbalance between practitioners and citizens lie both in the vested interests and established ways of doing things within some health and care institutions and professions but also in how some of us as citizens lack the motivation and capacity to manage our own health and care effectively.

Recalibrating the ‘scales of power’ does require Health and Care organisations and professionals to cede power but at the same time citizens need to be willing and able to engage in and accept greater responsibility for co-producing and self managing their own care.

Numerous attempts have been made in recent times to challenge long held attitudes to health and wellbeing.  In Scotland, government policy has provided a strong platform on which to build citizen empowerment supported by a number of national initiatives supporting self management and asset based approaches. Whilst these and similar initiatives have resulted in many fine examples of shared decision making and co-production they tend at best to be localised to specific geographical areas, clinical departments or groups of individual practitioners and citizens. At worst they take the form of one off projects which stall when the funding runs out. This somewhat piecemeal approach is inadequate if the desired transformation in health and social care is to be achieved, as Coulter (2012) put it “… one off initiatives, although well intentioned, and often hard fought are not enough to create the fundamental shifts in power and practice that are required…”

So, is a seismic change in societal and institutional thinking required to challenge prevailing attitudes and realise the vision of a model of care based on the principles of reciprocity and mutuality? Possibly, but I don’t think this likely any time soon! What we can’t afford however is any reduction in the drive to continue the incremental push towards a model of shared responsibility for our health and wellbeing.

Taking back some of the power and responsibility for our own health and wellbeing is however as challenging for us as individuals as ceding power is for institutions and professionals. 

We therefore need to work on two fronts; investing in engaging, educating and empowering citizens to take more ownership for their health and care whilst at the same time developing a professional and institutional model committed to partnership work.

In closing I would therefore refer readers to the conclusions and recommendations of the 2014 Kings Fund publication by Foot et al (2014, pp 54-58). In this the authors call for a new compact between citizens and services recognising that in balancing power, rights and responsibilities for our health and wellbeing ‘… all parties need support and tools to develop the confidence and skills to behave in new ways …’  

Foot et al (2014). People in control of their own health and care – The state of involvement. Available at: www.kingsfund.org.uk/sites/default/files/field/field_publication_file/people-in-control-of-their-own-health-and-care-the-state-of-involvement-november-2014.pdf (accessed 27 October 2017)

Taylor J (2014) ibid pp 6-7