Varieties of co-production in public services: time banks in a UK health policy context

Abstract

Time banking is a third-sector initiative that enacts principles of co-production and offers a model with which to understand how users can become actively involved with professionals and other stakeholders in the delivery of public services. This article explores possible lines of tension between principles that underpin time banking practices and principles informing the health policy field in the United Kingdom. We develop a framework rooted in the logics approach to critical policy analysis with which to track shifts in conceptions of co-production at three nodes situated along the full length of the public service chain: (1) service provision and distribution; (2) service delivery; and (3) service governance. Our analysis reveals discrepancies in the way co-production principles can be defined, interpreted, and linked to broader notions of social justice: recognition-based interpretations with a transformative accent, and choice-based interpretations with an additive accent. We conclude that the health care regime, if understood as a ‘regime of choice’, will invariably prove to be a rather inhospitable environment for time banks, whose co-production principles are much more in tune with what we call a ‘regime of recognition’.

Keywords:

• time banking
• co-production
• healthcare
• choice
• recognition
• logics

Acknowledgments

We would like to thank Alan Finlayson, Steven Griggs, Alan Hansen, David Howarth, Aletta Norval, Karen West and Adam Wright for their feedback on previous versions of this article. The article was originally presented at a panel on ‘Logics of Critical Explanation’ at the Interpretive Policy Analysis conference in Cardiff in 2011. We extend our thanks to all participants in that panel who commented on the article. We also thank the anonymous referees for their very helpful and productive comments in revising it for publication.

Notes

1. These policy documents include: Department of Communities and Local Government 2008; Department of Health 1998, 1999, 2000, 2002, 2003, 2004a, 2004b, 2005, 2006, 2007a, 2008a, 2008b, 2010a, 2010b, 2010c; Her Majesty's Government 2009; Her Majesty's Treasury 2002, 2004, 2005, 2007; Her Majesty's Treasury and the Cabinet Office 2006a, 2006b, 2007a, 2007b.

2. See Dixon and Mays 1997, Talbot-Smith and Pollock 2006, Paton 2006, Pollock 2005, Needham 2007, NEF 2007, Powell 2007, Greener 2008, 2009, Hunter 2008, Greener and Powell 2009, Ham 2009, Wainwright and Little 2009, Leys and Player 2011, Mays et al. 2011, Speed 2011.

3. See, for example, Ostrom 1993 1996, Alford 1998, 2009, Cahn 2000, 2010, NEF 2001b, 2008b, 2011, Powell and Dalton 2003, Cahn and Gray 2004, 2010, 2012, DEMOS 2004, 2006, 2007, Boyle 2005, Brandsen and Pestoff 2006, NEF and Joseph Rowntree Foundation 2006, Bovaird 2007, OPM 2007, Compass 2008, Needham 2008, Dunston et al. 2009, NEF and NESTA 2009, 2010a, 2010b, Loffler 2010, National Development Team for Inclusion 2010, Bovaird and Loffler 2011, Fotaki 2011, Governance International 2011, Pestoff et al. 2012.

4. We note here how the opposition additive/transformative shares a family resemblance with the opposition interactionist/constitutive as elaborated by Sheila Jasanoff (see, generally, chapters 1, 2, and 12 in Jasanoff 2004). Jasanoff (2004, p. 12) invokes co-production primarily as a ‘cognitive frame’ with which to conceptualize the relation between science and society in the knowledge production process and so tends to operate at a more ‘meta’ level than in our case where the notion of co-production is invoked by the subjects engaged in the practices under study. Nevertheless, although our field of inquiry tends to run more along the ontological-normative axis rather than the ontological-epistemological axis, we feel that this is largely a difference of emphasis, since our overall perspective shares with Jasanoff the centrality attributed to the constructivist and performative dimension of practices, including the practice of studying practices.

5. The Office of the Third Sector (part of the Cabinet Office) funded TBUK for a good part of the 2000s (personal communication Martin Simon, ex-chief executive, TBUK).

6. For partial exceptions see NEF 2002a, 2002b, 2004, Simon 2003, NEF and Young Foundation 2006, Seyfang 2006a, 2006b; for a take on health policy reform and community economies more generally, see Healy 2008.

7. Unlike New Labour's flagship policy initiatives such as Sure Start and the Child Trust Fund, interest in time banking has been largely confined to think-pieces and commissioned think-tank reports. Despite making available some limited funding and enabling legislation, time banking made appearances only at the margins of New Labour official government policy discourse.

8. Examples of logics-informed policy analyses include Griggs and Howarth (2013), Wright (2012), Clarke (2012).

9. For a more detailed elaboration of the three logics (parsed out as social, political, and fantasmatic logics) see Glynos and Howarth (2007, pp. 133–164).

10. There is also one further substantive document on co-production, produced by Compass, another left-leaning organization (Compass 2008). This document is illuminating because it seeks to emphasize in a more explicit manner the political and democratic potential of co-production, including time banking. For the sake of completion, we note also that we have yet to find any other organization, especially from other positions on the party-political spectrum, which can be said to actively promote time banking. Having said that, there is a degree of overlap and indeed contestation regarding the role of volunteering which has long been championed by the right as a means of promoting civil society involvement in the delivery of public services. It is interesting to point out, however, that there is considerable normative resistance to adopting the volunteering tag by time banking advocates, a view elaborated and reiterated in the documents of advocate organizations. We note the reasons for this later.

11. The epigraph to the co-production manifesto (NEF 2008a) makes this aspirational dimension explicit in quoting Edgar Cahn: ‘Family, neighborhood, community are the Core Economy. The Core Economy produces: love and caring, coming to each other's rescue, democracy and social justice. It is time now to invest in rebuilding the Core Economy’. Time banking can assist in this revolutionary task because it helps us ‘recognize the hidden assets that public service clients represent … [thereby making] public services into engines that can release those assets into the neighborhoods around them – and to do so even when public sector budgets are severely constrained whilst avoiding people becoming cynical about the role and motivation of the state’ (NEF 2008a, p. 14).

12. The view that the professions appear to be an obstacle to progress is something time banking advocates share with many policymakers, though for different reasons (e.g. fiscal reasons, as opposed to reasons linked to the type of professional–user relation).

13. According to a special exemption secured early on from the government, the exchange of work for time credits does not jeopardize welfare benefits eligibility.

14. For a similar contrast in the domain of law between relationality and discreteness, see Ian Macneil's Relational Theory of Contract (2001).

15. The construction of this graph involved a simple frequency count of the terms ‘choice’ (and its derivatives, such as ‘choose’, ‘choices’, ‘chosen’, ‘choses’, etc.) and ‘quality’ (and its derivatives, such as ‘qualities’) controlling for obvious things like ‘inequality and inequalities’ taken from all health white papers (and some other landmark documents such as the Next Stages review) within the relevant time period. Frequency counts were totaled and then converted into a percentage of the total document word count to produce comparative data for the graph.

16. Although political and fantasmatic logics play an important role in the process of instituting, challenging, and defending particular regime norms, the focus of our article is restricted largely to the process of characterizing the regime as a function of these social logics.

17. All these choices were understood to be delimited within strict, centrally determined tariff-based systems. For example, patients only had a choice of provider subject to the constraint that the provider offered the same procedure at a pre-determined tariff. If the provider were to charge more for that treatment than the NHS, then that provider would be deemed ineligible as a choice option.

18. It is worth noting how the focus there was on the range and quality of available services to choose from rather than the character of public service delivery as such.

19. http://www.youtube.com/nhschoices#p/search/0/24wnbFW4Cbo.

20. In characterizing the health care domain on the whole as a regime of choice we do not claim to have identified all relevant social logics, nor do we claim to have named and described them in the best possible way. We see our intervention as one among several possible interventions that can shed light on different aspects of such a regime.

21. In this framework, time banks would appear as one among many providers of public goods competing for world-class commissioning tenders and for the budgets of individual users. One notable success in the context of commissioning is the Holy Cross Centre Trust in Kings Cross London. In collaboration with mental health charity MIND and Camden Volunteer Bureau, the center provides Mental Health Day Services throughout the borough of Camden. The consortium bid for the tender to provide these services and was successful, setting them up in 2007. This relative success is indicative of the sorts of spaces that might be opened up for time banking activities within a world-class commissioning context.

22. Just as time banking as a practice, again partly due to its relatively novel status, is still quite open in the articulations it may forge, challenge, or reinforce, so too we find we have to remind ourselves about the dangers of presenting the government's position as overly monolithic, especially since there are a whole slew of relevant actors with an interest in civil society initiatives, each representing one or another departmental or sub-departmental agenda.

23. In a more recent White Paper Communities in Control (Department of Communities and Local Government 2008), there appears to be some recognition that more local and popular forms of accountability will need to become part of the overall package of health service production and delivery (Department of Communities and Local Government 2008, p. 92), but it is not clear how this more collective and democratic impulse will square with the shift toward greater personalization. Within the NHS, co-production now appears in a number of contexts, most notably through the NHS Institute for Innovation and Improvement where it is offered as an approach to decision making within the Patient Experience Network of the NHS. Co-production is listed in conjunction with participatory appraisals and budgeting, deliberative opinion polls, citizen juries, open space discussions and time banking. The dominant context in terms of how these options are presented tends much more towards additive rather than transformative representations of co-production (NHS n.d.); similarly, a non-governmental organization (NGO) – the National Development Team for Inclusion (NDTI) – commissioned by the UK Department of Health produced a co-production guide in 2010, aimed at older people's services which draws very much from an additive model.

24. Thus NEF seeks to maintain a distinction between human and monetary assets. While it does not want to negate the latter, it does warn that individual budgeting runs the risk of entrenching what it calls ‘the ineffectiveness of the consumer model of care by encouraging users to “buy solutions” rather than have an active stake in delivering (or “producing”) their own solutions’ (NEF 2008, p. 16; see also NEF and NESTA 2009, p. 17). Consumerism and co-production are likewise contrasted in terms of short-termism versus long-termism. A tactical awareness on their part, however, may account for the way that NEF appears to background the role of co-production in enriching and bolstering the democratic experience of citizens. Insofar as it talks of the shared responsibility of service users and professionals, NEF (2008a, pp. 10, 13) appears to want to focus almost exclusively on co-producing services, rather than co-producing collective decisions affecting service delivery. But this may be because talk of co-producing collective decisions sits uneasily with the recent push toward greater personalization of public services through individualized budgets.

25. Bovaird's (2007) typology of co-production, for example, differentiates between co-delivery and co-design. As a further example, consider Governance International's (2011) co-production model, comprising four elements: co-commissioning, co-designing, co-delivering, and co-assessing. Or consider the threefold distinction co-production, co-management, and co-governance (Pestoff 2012). Consider too a relatively recent effort by the Department of Health to explore different approaches to, and legal framework for, co-production across a wide range of contexts, drawing also on the work of, among others, NEF and Governance International (Department of Health 2010c).

26. A further line of inquiry might involve considering how the recognition and choice paradigms we have identified relate to different political economy strands informing the Labour, Conservative, and Liberal democrat parties, respectively. Finlayson (2012), for example, identifies four such strands in the Labour Party (Polanyian, Keynesian, Schumpeterian, and Schumacherian), each of which can be said to stake out a distinctive position, and thus relation to, these regimes.

27. Our analysis has been focused primarily on policy documents and on documents of advocacy organizations. As we have already noted we are aware that these documents tend to project an image that need not match the concrete practices they purport to describe. We may find, for example, that concrete health care practices and community economy practices can be better characterized as partaking in other sorts of regime, regimes of care (see Mol 2008), a regime of libertarian paternalism (Thaler and Sunstein 2008), a regime of self-sufficiency, or a regime of wellbeing.

28. Within a logics approach, ideological processes are understood in terms of ‘fantasmatic logics’, drawing on the psychoanalytic concept of fantasy (see Glynos and Howarth 2007, Glynos 2008, 2011a, 20011b, 2012, Chang and Glynos 2011, Glynos et al. 2012). The concept of fantasy has been invoked in the context of health policy (e.g. Fotaki 2006, 2009, 2010, Gabriel 2008, Holtzman 2010), but also in relation to other domains of public policy (e.g. West 2011, Clarke 2012, Wright 2012, Kolvraa 2012, Griggs and Howarth 2013).