Good practice in the co-production of commissioned services within adult social care

Good Practice by Ron Mader

Project title

Good practice in the co-production of commissioned services within adult social care


Skills for Care Workforce Development Innovation Fund

What are the aims of this project?

The aim is to evaluate whether the involvement of stakeholders in review and co-design of a modified Direct Payment Support Service for Disability informs changes in the design of the service and removes barriers to accessing payment.

How will the research be carried out?

Developmental evaluation is being used, which produces real-time or close to real-time feedback, allowing stakeholders to use the learning within the lifespan of the initiative to adapt principles of practice (Quinn Patton 2015). We will collect information to inform the approach to co-production, the ability of co-production to identify issues with the existing service, and the creation of a Direct Payment Support Service (DPSS) model that contains solutions to enabling people to feel more in control of direct payment.


Due to be completed in April 2017.

Who is undertaking the research?

Disability Sheffield Centre for Independent Living

Project Lead: Emily Morton

School of Health & Related Research

Lead Evaluator: Janet Harris

How are stakeholders being engaged?

Disability Sheffield Centre for Independent Living is a membership and user led organisation, run and controlled by disabled people. Service users, workers, managers and commissioners will be engaged in identifying barriers to using the payment scheme and generating solutions together. Participatory approaches are being used to involve everyone in reflecting on the process of co-production, including

  • Ability to create a level playing field, where the voice of different types of stakeholders is represented
  • Ability to facilitate dialogue and reflection across diverse people and groups
  • Transparency in collecting information and showing people how it is going to be used
  • Involvement of stakeholders in decisions about how to use information to inform service development
  • Ability to negotiate conflict and resolve issues

What will be the outputs from the study?

A model for the service which enables people to be more in control of managing their payments.

A good practice guide on using co-production to inform user-centred commissioning.

Workshop at Public Health England Annual Conference

The Public Health England Annual Conference is fast approaching.  This year Sarah Salway will be joining colleagues from the Race Equality Foundation, UK Health Forum and Institute of Health Equity to deliver a workshop within the Improving Quality of Lives track of the conference. The workshop will look at how health inequalities work can be better integrated with work that addresses the equity and diversity agenda. The conference takes place at the University of Warwick and booking is still open here.  Come and find us on Wednesday 14th September at 12:25pm.

Why is progress on race equality so slow in the UK?

Why is progress on race equality so slow in the UK? 

By Sara Hodgkinson & Sarah Salway

A new report from the Equality and Human Rights Commission highlights widespread racial inequality and warns that failure to tackle this deep-rooted disadvantage will exacerbate societal divisions. EHRC Chair, David Isaac, noted that the report exposes a ‘very worrying combination’ of a post-Brexit rise in hate crime and long-term systemic unfairness and race inequality.

Along with ethnic inequalities in employment, education, criminal justice and living standards, the EHRC report also highlights health and healthcare inequalities. The report confirms that, despite an apparently strong legal and policy framework, barriers to high quality healthcare persist for people of minority ethnic identity.  This apparent inconsistency between national policy and local reality was the motivation for our recent research project that looked into the role of healthcare commissioning organisations in delivering equal access to health services for minority ethnic groups in England.  We wanted to find out why progress towards race equality is so slow in the UK.

Healthcare commissioning is the process of planning, procuring and monitoring health services to effectively meet the health needs of the population. Between 2010 and 2013, we carried out a large-scale study to examine healthcare commissioning in England which was, at that time, predominantly carried out by Primary Care Trusts. The study included case studies, stakeholder workshops, and interviews with professionals.  We spent a large amount of time talking to people as they went about their jobs, observing the work of the organisations and reviewing the documents produced.  We wanted to find out whether and how ethnic diversity and inequality is considered within health commissioning in the UK.

We found that minimal attention was being given to ethnic diversity and inequality within healthcare commissioning.  Three key themes emerged from the research, suggesting why this might be.  First, minority ethnic health inequality is not a high policy concern.  Despite racial inequality in England remaining a hot topic both within the media and in academia, there appears to be a lack of discussion and action at policy level to effectively address the matter.  Few national resources include any consideration of ethnic diversity or equal access to services for minority groups and there is no performance monitoring related to this agenda.  Marginalisation of minority ethnic health was found to be consistent at national and regional level and, while some areas of good practice were identified at local level, the work tended to be piece-meal and without broader impact.

Second, we found widespread uncertainty among policy makers as to whether inequality is even really an issue.  Some senior leaders were unconvinced of the existence of inequalities between ethnic groups, despite a growing body of evidence to the contrary, others did not view such inequalities as a priority.  Without acknowledgement of the issue and its importance, ethnic inequalities in healthcare will continue to be overlooked at all levels.

Finally, interviews and case studies pointed to a lack of clarity at policy level as to how ethnic diversity and inequality should be addressed within the national health system.  Limited data on patterns of ethnic health inequalities, together with a lack of understanding of the subject among senior leaders and the tendency of some managers to blame minority groups themselves for poor access to services, were also important barriers.  Minimal understanding – both of the issue and of how to address it – undermines people’s confidence to act, resulting in the problem being downplayed and overlooked.

Our study primarily highlights obstacles to ethnic equality in healthcare in England, though we did find some factors promoting positive work.  Importantly, we found that action on ethnic diversity and inequality was rarely prompted by national directives but was rather driven by committed individuals who championed the issue locally.  Such individuals did, however, struggle to maintain momentum without clear leadership on the issue from local managers or central government.  Good work remained siloed and was often short-lived.

How, then, can equality in healthcare access be improved?  Our study suggests the need to enhance the skills, confidence and competence of individual managers and commissioning teams and to improve organizational structures and processes that support attention to ethnic inequality. However, it is also clear that greater political will and clearer national direction is required to produce the widespread system change needed. Our conclusions therefore mirror those of the recent EHRC report which calls for a ‘comprehensive race equality strategy’ that goes beyond the current ‘patchwork of initiatives’, is underpinned by good data, and monitors progress against clear targets.

The full report of our study can be found here and our recent paper in Social Science & Medicine can be found here.

Communities in Control

Big Local

What are the aims of this project?
This study aims to evaluate a Lottery-funded initiative – the Big Local – that aims to give residents in disadvantaged neighbourhoods a bigger say over what happens and how resources are used to improve their local area.  Big Local is run by Local Trust and is taking place in 150 communities across England over the next 15 years.

Why is this important?
Past research suggests that low control may be a fundamental cause of inequalities in health. However, we know little about how to support greater control, particularly at the level of communities. We also need to know more about how and why control impacts on health and its social determinants. The Big Local presents a great opportunity to learn more about effective ways to support greater control by communities.

How will the research be carried out?

There will be two phases. Phase one involves:

  1. Detailed case studies across 10 Big Local sites and analysis of quantitative data to describe the neighbourhood contexts and early experiences in different places.
  2. Interviews and document analysis at national level to describe how the Big Local intervention is expected to work.
  3. Design of methods to evaluate the impact of Big Local on health and wellbeing in the longer term (Phase two).

 Timeframe: January 2014-March 2017

Professor Jennie Popay of Lancaster University leads our team of researchers from LiLaC,  Cambridge, Exeter, London School of Hygiene and Tropical Medicine, FUSE and Sheffield.  Here in SPHR@Sheffield we are currently conducting case studies in two Big Local sites in Yorkshire.

How are stakeholders being engaged?
In case study sites residents are consulted on the conduct of the study and in some areas Community Researchers are directly engaged. Local advisory groups provide critical commentary and findings will be shared widely as they emerge. Local Trust guides and supports the work.

What will be the outputs from the study?
Resources for public health practitioners and local neighbourhoods will be produced, focusing on:

  • The links between collective control and health inequalities;
  • Factors influencing public health actions in low income neighbourhoods;
  • Lessons about community engagement/empowerment;
  • Small area monitoring systems;

Presentations and papers from the project will be listed here.

Find out more here

A New Politics for Health – Moving Forward from the Ottawa Charter

Friday September 2nd, 9.00 for 9.30 -12.30pm Pemberton Room, Regent Court Sheffield, S1 4DA

Thirty years ago, the Ottawa Charter for Health Promotion generated worldwide interest in a new public health movement. This was based on the promotion of healthy public policies, healthy environments, inclusive public services, community action and individual skills. Thirty years later we better understand how politics and public policy affect health but we’re still battling for health equity.

In partnership with Birmingham City University and The Equality Trust, the Politics of Health Group is marking the Charter’s 30th anniversary with a one day national conference in Birmingham on the 23rd November 2016. Here. we’ll develop a new charter for health: The Birmingham Health Charter. We also want to inspire and encourage those campaigning now for a better, healthier future, and building a stronger coalition to address the causes of health inequality.

We’re inviting people working in Sheffield and the wider region to share their ideas at a pre-conference event. We’d like to make sure that good practice and innovative ideas from our region are heard at the national event through a participatory workshop. Book your place for the free Sheffield event here.

Book your place at the national event here. The conference fee is £50 waged (£40 for an early bird booking), free for unwaged.

Inequitable access to services for older people

Funded by the NIHR School for Public Health Research as part of the Ageing Well Programme of research.

What are the aims of this project?

The project investigates the extent to which older people receive inequitable access to effective and cost-effective health interventions, both clinical and public health. A range of conditions and health interventions which are effective in both younger and older people will be examined.

We will focus on the potential impact of interventions in older populations on inequalities in health outcomes. We will explore how such inequalities arise and seek to identify ways to intervene to prevent them.

Social inequalities in health among older populations seem to be widening and this work package will explore one potentially important cause with a view to identifying ways to reduce such inequalities.

Why is this important?

It is important because the health of older people will be adversely affected if they fail to receive health interventions which improve the quality and quantity of life. Moreover, age-discrimination is something which has been found fairly extensively in the past, but should not be occurring now, not least because recent age-equality legislation has been introduced.

How will the research be carried out?

A number of sub-studies are being undertaken. Currently, the research carried out in ScHARR includes two sub-studies:

  • A literature review of existing published evidence about inequality in access to health interventions in older people:
  • A study using existing data on utilisation of smoking cessation services in older people.


From November 2013 until March 2017

Who is undertaking the research?

In Sheffield

Sarah Salway, Nick Payne, Melanie Rimmer, Hannah Jordan

How are stakeholders being engaged?

  1. Stakeholder consultation events; and
  2. Engagement with PPI representatives on the ScHARR SPHR Advisory Group.

What will be the outputs from the study?

  • Presentations at scientific conferences:
    Early findings were presented at the British Society for Gerontology Annual Conference in Newcastle, UK in July 2015.
  • Publications in Journals

Reports and presentations to lay audiences including stakeholders

Criticality and the welfare commons for health equity













By Liz Such, Katie Powell and Julie Balen

Those looking for new ways to address contemporary social injustices might be heartened to read Fiona Williams’ recent think-piece in the Social Policy Association’s Social Policy Review (27). Her brief history lesson, on the origins of critique in social policy, reminds us how research can form an act of resistance to social injustices, of which health inequity is a part. Using inspiration from the feminist, disability and gay rights movements among others, Williams proposes a framework for critical social policy that might underpin wider contemporary resistance to injustices. The piece wasn’t an easy-read and it felt sometimes that the ideas were bouncing around but it certainly inspired deeper thinking about how health inequity can be challenged through research that harnesses contemporary forms of resistance. The piece raises some important questions about the sort of claims that can be made to support action to reduce health inequity

At the core of Williams’s framework are two concepts: ‘criticality’ and the ‘welfare commons’. Criticality refers to a view to the future that goes beyond criticism and critique: “While criticism is a mere descriptive identification of what an author disagrees with, critique attempts to deconstruct the underlying beliefs, claims and unexamined partiality in any given phenomenon, to point out omissions and injustices. Criticality, however, goes beyond this; it is forward-looking, it looks to political spaces for intimations of transformations” (p106). As such, criticality involves the creation of an imaginative space that enables practices of resistance through the articulation (rather than prescription) of alternatives to current practices and power configurations. For researchers and practitioners working in the field of health equity, this approach has the potential to shift the focus of action beyond mere description of established patterns of inequity towards a reimagined future. As Burowoy warns, academics need to be wary of the ways in which such practices can perpetuate their own privileges (Buroway 2005).

Williams’ call for criticality echoes Graham Scambler’s (2015) rallying cry to sociologists urging a search for alternatives to the current pattern of relations underpinning financial capitalism and growing social inequality in the UK. Criticality in social policy, Williams argues, has already contributed to a better understanding of the “multivalent forms of resistance” – recognising for example that resistance might involve redistribution of resources and recognition of the experiences of particular groups (which might be conceived as finding a ‘voice’ for marginalised groups). It has also, she argues, identified the “multi-layered nature of welfare settlements” (the different modes, practices and discourses for example that might be associated with welfare). Finally Williams draws attention to the work of criticality in social policy in uncovering the “multi-level nature of welfare” – recognising the interdependency between micro, meso and macro processes shaping injustices.

Welfare Commons refers to the reclaiming of public resources that have been subject to commodification over the last century: “land, water, space, time, creativity, public services, care” (p.95). The concept refers to a renewed democratic purpose that promotes communal and shared ownership of these resources. Recent examples of this in relation to health equity can be seen in organised campaigns that seek to resist neo-liberal pressures to shrink the welfare state, such as the “Save Our NHS” and anti-austerity campaigns.

The mobilisation of resistance however according to Williams, “stands on a knife edge” (p.95). The global expansion of neo-liberalism, disaffection with mainstream politics and the commodification of core resources such as care, education and health are superpowers in the struggle to claim resources for the common good. Williams draws on examples from her research into the organisation and implementation of care work to show how criticality and the welfare commons might be used to identify common issue areas – and sites for resistance – within a range of social justice areas. Investigating the ecological, financial and social reproductive systems affected by the issue of care among ageing populations, Williams identified three common themes: recognition, rights and redistribution.  Recognition of care as work, supports for the rights of carers as workers and redistribution of the resources needed for caring provide a framework for action that cuts across movements mobilised around the needs of workers, disabled people and migrants.  These concepts, she argues, help to unify the resistance across a range of causes – finding common ground and connections in the fight against injustice.

Health equity work and research with health equity at its core can be seen as allied with both criticality and the welfare commons. Equity is a future imagining of health locally, regionally, nationally and globally and resistance to inequity is evident in research and practice. Equitable health is a question of recognition, rights and redistribution that is articulated as an aspiration in local, national, regional (e.g. EU) and global (e.g. WHO) strategies. Knowing how to do it – to operationalise resistance –  is a more pressing challenge. While ‘everyday inhabitants’ and national and global pressure groups are voicing a challenge to the commodification of resources, it is beyond their gift to mobilise their mass reclamation. Researchers working in the field of the social determinants of health frequently scratch their heads as to how to effect change in the context of existing structural constraints. Williams framework would suggest that what is needed is to create conceptual coalitions “across progressive groups” (p.103) active in civil society to identify interdependencies between areas of resistance. This could include organisations that contest welfare cutbacks, health privatisation, environmental degradation, and racism and discrimination for example. An idea also supported by Scambler (2015) who has called for “a coming together of activists for change.” Any developing collective spaces of resistance, however, must include and empower the people who bear the brunt of the pervasive processes of exclusion. Equity in academic practice, as advocated by the Politics of Health Group(2015), seems likely to support the search for conceptual alliances.  For Williams, it seems this dialogue presents the prospect of alliances that can offer effective resistance to social injustice and can help to create transformative alternatives of the future. It seems crucial that these coalitions can present their claims with one – louder and more coordinated – voice.


Burawoy, M., 2005. For Public Sociology. American Sociological Review 70(1) 4-28. doi: 10.1177/000312240507000102

Politics of Health Group (2015). Health Politics as if People Mattered 2. Good Practice in Academia. Retrieved December 2, 2015 from

Scambler, G., 2015. Triggers for social change. Retrieved December 2, 2015 from

Williams, F., 2015.Towards the Welfare Commons: contestation, critique and criticality in social policy, in Z. Irving, M. Fenger and J. Hudson (eds) Social Policy Review 27 93—111.


Image by Steve Rhodes under a Creative Commons License