E Summary and Conclusions

In recent decades, co-production has become one of the cornerstones of public policy reform across the globe. With the explosion of interest in understanding and facilitating citizen/user participation in the provision of public services, co-production now encompasses a variety of different phenomena, contexts and levels, and it is studied by a variety of disciplines that employ a variety of approaches. Nonetheless, a growing chorus of scholars and practitioners has called into question current attempts to define and delimit co-production. They argue that it is a poorly defined and formulated concept. It has become one of a series of ‘woolly words’ that risks becoming an empty signifier. This troubling development can perhaps be considered normal when different disciplines with different approaches attempt to reach a common generic definition and understanding. Moreover, many states are actively attempting to expand the scope of coproduction to include civil society and volunteers for policy reasons. However, neither the rapid growth of the field nor the political efforts to enlarge the scope contribute to clarifying this key concept. Much of the growing confusion could be resolved by separating various approaches into different schools. Comparing the three schools of study, each with a unique understanding of this phenomenon, can contribute to understanding this development. They include a political science/ public administration, input/output model; a business administration, a value chain approach; and a service marketing and management, cocreation approach. This implies that there is no single, unique or correct definition or approach to the study of co-production in public service provision.

Co-production in public services and patient participation in healthcare have different origins, focus and definitions. Patient participation in healthcare faces a familiar variety of terms and understandings to describe the need for and forms of patient participation in healthcare. However, much of this seems to focus on individual patient participation rather than collective co-production. An emphasis on either the consultative or the collaborative on both the individual and organizational side of health literacy, on the diversity of patients and their needs or on the hurdles to co-production all seem to suggest a similar conclusion.

This overview of co-production in public services and healthcare reveals that there is a myriad of terms, concepts, definitions and perspectives of this phenomenon. There is no single dominant approach, but rather a number of clusters that suggest the existence of different schools of coproduction in public services in general and, most likely, in healthcare as well. While this underlines the ambiguity of co-production as a concept, it also means that there is no right or wrong approach to studying coproduction or putting it into practice. Rather, these diverse perspectives often reflect the underlying cultural, social and political values of researchers and practitioners. However, it is also indicative of the paradox of co-production. It can either refer to individual and aspirational values in relation to patient participation or to collective co-production with a more transformative capacity.

Much of the literature on patient participation in healthcare is aspirational. It focuses on individual patients and describes the relationship between clinicians and patients as a meeting of two experts, each with their respective knowledge and skills. This challenges the traditional relationship between them, and it requires patients to become experts in their own circumstances and therefore capable of making decisions and having control as responsible citizens. This literature puts heavy emphasis on the ability and agency of individual patients, but it seems to ignore the shortcomings of many patients in this respect and, therefore, the importance of social support for facilitating both their agency and ability. Chapter 7 on patients and Japanese healthcare explores the contribution of membership in health co-ops to promote the agency and ability of individual patients to achieve health literacy and well-being, together with others.

At the same time, much of this literature also implies a change in the role of the professionals from being the fixers of problems to facilitators who find solutions by working with their clients. This underlines the importance of front-line staff. When co-production is transformative, there is a relocation of power by the development of new joint mechanisms where professionals and patients collaborate in the planning, delivering and management of healthcare. Two chapters in this volume consider those mechanisms in greater detail. Chapter 6 explores the relationship between work environment and service quality and demonstrates how staff satisfaction is related to improved service quality. Chapter 9 discusses the impact of governance models on staff control and influence, as well as possibilities for promoting a multi-stakeholder approach to healthcare. Chapter 8 is devoted to the tasks performed by volunteers, which can either be essential or complementary to the core tasks of the professional staff. Chapter 10 compares the perspective of the staff, patients and volunteers on the social values of their hospital, and documents the unique profiles of the three hospital groups in this study.

Considered rogerher, rhe chapters in this volume allow us to compare and contrast two widely different approaches to co-production (i.e. as- pirational and transformative co-production). The former focuses on individual interactions between patients and professional healthcare providers and it promotes incremental change. The latter demonstrates a more collective, transformative approach to promoting patient participation in healthcare. However, this study also shows that these two different approaches can satisfy different healthcare needs. Therefore, the patients’ evaluations of the hospitals serving them show that they appear equally satisfied with the service they receive. Thus, both the aspirational and transformative approach has its advantages, and hopefully, they can learn from each other.

Finally, before presenting the Japanese data, it is important to clarify my own understanding of co-production, since it guides much of the text in the remaining chapters in this volume. As a professor of political science and public administration, I build on the role played by citizens in the provision of publicly financed services - regardless of whether the provider is public, private, NGO/NPO or a social enterprise. Therefore, the focus is on service delivery and the role played by citizen/service users in providing such services for themselves and others and, eventually, in modifying them to better suit their needs and improve the service quality. This perspective adheres more to the public administration and public management school of study than the value chain or service-dominant approach of business administration. I trust that readers of this volume will see what unique insights this perspective reveals about co-production and patient participation in healthcare. I trust that the journey will be both enriching and rewarding in terms of new knowledge and insights gained from studying co-production and Japanese healthcare.

 
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