Introduction Co-production and Japanese Healthcare

This chapter introduces the concepts, theoretical considerations and model building necessary for successfully undertaking a project on Coproduction and Japanese Healthcare. Key theoretical concepts include work environment and toxic workplaces, co-production, governance models, multi-stakeholder dialog, social values, public administration regimes and organizational logics. It discusses the steps and phases of this project. The methodological considerations result in an analytical model of work environment and service quality in Japanese healthcare.

A Contemporary Healthcare Challenges

Healthcare in Europe and most other developed countries is now facing a complex and partly contradictory mix of challenges. Fiscal strains combined with a New Public Management (NPM) agenda have resulted in cutbacks and calls for improved efficiency in public-funded health and eldercare. This development is a significant contributor to the growing concern about service quality in healthcare, while other developments such as increased demand due to an aging population and an increased level of individualization of services also add to the mix. The proposed solutions to these challenges in European healthcare help to illustrate the severity of the problems. One solution suggested by market proponents is to further increase efficiency so that the existing resources can cover more care with better quality. The problem with this solution is that many European countries already have some of the most streamlined healthcare sectors in the world, and there is probably a limit to how ‘efficient’ one can make healthcare services while maintaining acceptable levels of service quality. Another possible solution would be to increase public funding, but most European countries already have the highest taxes in the world. Thus, given these alternatives, a key issue for the future of healthcare in Europe is to find a way to provide high-quality' services to a greater number of patients at an acceptable cost.

A different kind of solution is reflected in the growing interest in and practice of public participation in healthcare. A decade ago, the World Health Organization (WHO) maintained that there were basically three ways or mechanisms to channel public participation in healthcare governance: ‘choice’, ‘voice’ and ‘representation’. ‘Choice’ mostly applies to individual decisions in selecting insurance providers and/or services. ‘Voice’ tends to be exercised at the group or collective level for expressing public or group views. 'Representation' implies a formal, regulated and often obligatory role in the process of healthcare governance (2005). Co-production can combine all three: choice, voice and representation, by actively engaging citizens in the provision of public services, including healthcare (Pestoff, 2008, 2009). Ten years later, the WHO broadened its perspective by adopting a ‘Global Strategy on People-Centered and Integrated Health Services’. It recommends five closely connected steps: 1) Engaging and empowering people; 2) Strengthening healthcare governance and accountability; 3) Reorienting healthcare through models that prioritize primary and community care services and the co-production of health; 4) Coordinating services and 5) Creating an enabling environment (World Health Organization, 2016). Calls for greater public participation in the National Health Service (NHS) were recently reiterated in the United Kingdom. Hudson argued that public and patient engagement in healthcare is ‘an idea whose rime has come’ (2014), while the Office of Public Management states that ‘co-production is the new paradigm for effective health and social care’ (Alakeson et al., 2013).

The purpose of this project is to explore the possibility to address the challenges facing healthcare in OECD countries from the perspective of greater staff autonomy and more user participation. The idea that the patients can play a more active role in the provision of their own healthcare services is grounded on an expectation that it may result in high-quality services without adding to the costs for the public sector, or perhaps even reduce these costs. Healthcare is a highly professionalized service sector, and most healthcare sendees are provided by medical professionals without much involvement by patients or their relatives. The hypothesis to be tested by this project is that a significant part of healthcare services can be provided by professionals and patients acting as ‘partners in a continuing process of inquiry’ Fotaki (2009, 2011), where the two parties co-produce the service by mutual contributions of information and treatment. This partnership can take many forms and should naturally fit the individual patient’s needs and abilities. However, information asymmetry between the professionals and patients, as well as patient uncertainty, will decrease through their communication and joint efforts to improve the health of patients. This is done in equal measure by professionals teaching patients about health issues and patients providing detailed and operable data on their conditions in order to reach an informed opinion of what ought to be done about it. The ideal outcome of this interaction is better, more individualized care, active and more satisfied patients and better use of existing or additional resources in terms of patient input. Patient inputs can vary in form and be can limited to providing information or be extended to taking responsibility for simple selftests and keeping a journal. This partnership between professionals and patients can also take collective forms.

Vamstad (2014) argues that there are two potential paths to high quality individual social services at an acceptable societal cost: quasimarkets and co-production. Innumerable volumes have been written about the advantages and disadvantages of quasi-markets, as well as their costs and benefits. In contrast, co-production is a less well-known and understood alternative for achieving similar important social goals. In England, the NHS has recently promoted several pilot projects related to the co-production of health and social care (Alakeson et al., 2013). These projects seek to unite the ‘lived experience of individuals with the learned expertise of professionals to improve health and well-being’ (ibid.). The NHS focuses on encouraging greater public participation at the individual level, where individuals and professionals work together to reach decisions and achieve improved outcomes. However, coproduction also takes place at the group or collective level (Hudson, 2012). Individual co-production often promotes customized and personalized services, while collective co-production emphasizes collaboration and collective participation in healthcare.

Moreover, this project is premised on the assumption that service quality and work environment are closely interrelated or linked to each other. An employee who has tossed and turned all night worrying about work related problems, who feels tired and exhausted when they wake in the morning, who displays typical stress symptoms, who dreads the idea of going to work because they have little or no control or influence on the what, when, why, where and how of their daily routines, who has little chance to learn new things or advance at work - such an employee will not provide as good quality service as one who has the opposite experience and feels good about their work. Likewise, a client who experiences an unhappy, stressed or disgruntled service professional will not experience as good service quality as one being served by an employee with the opposite feelings. This project hopes to shed more light on the importance of such mechanisms for the relations between the staff and their clients and on how this is reflected in service quality in healthcare.

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