Joining the Dots: Who is helping who? Co-production and professional boundaries within social care services

In this piece Joining The Dots, Nick Andrews discusses the true nature of co production and how good support is founded in, and reflects back, the kind of relationships that Martin Buber called “I– thou” not “I- it”.

Nick is a social worker, a teacher and currently the Research and Practice Development Officer in the Wales School for Social Care Research at Swansea University

by Nick Andrews

I have been working in education and social care for thirty years, and have seen various new initiatives and buzz words come and go, whilst the fundamental principles of humanity remain the same. ‘Co-production’ in its truest senses is grounded in these principles. However, as with the concepts of ‘personalisation’ and ‘reablement’, there is a real danger that the term ‘co-production’ is misused for hegemonic purposes to cover up what is essentially a cost cutting exercise. Under this scenario, individuals and their communities are expected to take on more responsibility for their own well-being whilst the machine of impersonal and ‘professionalised’ public services carries on as it always has done, albeit it with a few less staff employed. In my opinion, this would be a travesty and missed opportunity to restore warm humanity as the driving force for public services, not compliance with increasingly centralised and de-personalised processes and systems.

One of my favourite quotes by the theologian Martin Buber is ‘all real living is meeting’. Please note that Buber’s understanding of the term ‘meeting’ is much richer than the idea of putting a group of people together in a room or placing nurses and social workers in the same office, which is commonly assumed to result in integrated practice. I am sure many people will share my experience of being in meetings where no one actually met, where each person had their own agenda and the purpose of the meeting was to get this across – to win the argument. For Buber, ‘meeting’ is about genuinely connecting with other people and being changed in some way by the process. In order to explain this process, he talks about two ways of relating to people and the world, which he calls ‘I-It’ and ‘I-Thou’. In ‘I-it’ relationships, the person is detached and unaffected. In ‘I-Thou’ relationships, the person is attached and vulnerable.

Rupert Higham, Lecturer in Educational Leadership, UCL Institute of Education also eloquently points out that dialogue is more than just talking together:

“Dialogue, is valuing the other person as if they really matter and seeking out and learning from the
differences between us”. It is deeply caring and relational.

Tom Kitwood, in his seminal book Dementia Reconsidered – The Person Comes First (Kitwood 1997), talks about his experience of seeing how people living with dementia were dehumanised through receiving emotionally detached task based care:

“A man or woman could be given the most accurate diagnosis, subjected to the most thorough
assessment, provided with a highly detailed care plan and given a place in the most pleasant of
surroundings – without any meeting of the I-Thou kind ever having taken place” (Kitwood 1997)

By contrast, I believe that genuine co-production facilitates and nurtures the development of ‘I-Thou’ relationships between all parties, which in so doing begins to challenge the prevailing understanding of professionalism and professional boundaries. ‘Who is helping who?’ as well as ‘what counts as knowledge and whose knowledge counts?’

A few years ago I co-ordinated a Joseph Rowntree Foundation funded action research project which focused on the use of evidence from their programme A Better Life, which identified 7 challenges for services working with older people who have high support needs. One of these challenges was ‘We must create opportunities for older people to give as well as receive’. This simple statement flew in the face of the experience of many older people involved in the project, who were often seen as passive recipients of well-intentioned care and support. A highlight of our research was the involvement of one man with dementia (Andrews and Beer 2019) who said at the start of the project:

“Listen, I am nobody, only my name and what I have done… I would like to be involved and I would like to help you all. I can give you advice, but I think it is better not to involve me in this . . . because of my age and my failure in memory whatever . . . because of my uselessness”.

Whilst diligently cared for by staff in the day centre he attended, no one recognised his need to give as well as receive. I am pleased to say we went on to write a children’s story book about his life as a Strang the Strong, a strong man, who had spent much of his life raising money for charities. He decided to write his book as an anti-bullying resource, which was subsequently shared with primary school children. He had become a strong man because of being bullied at school and his closing words in the book were:

‘Now I am sharing my memoirs with you, and I want you to know. . . . You can be whomever you want to be. You do not need to listen to those that say you are weak. Strang says “STAY STRONG.”’

He also became the star of the show at the end of project national conference where he signed copies of books for delegates.

The A Better Life programme also identified that ‘all good support is founded in and reflects meaningful and rewarding relationships’ and that ‘often it is the simple things that bring the most pleasure (and the lack of them can bring a sense of sadness and loss) and services do not always seem to be very good at delivering ‘the ordinary’. (Blood, 2013 p13). Whilst balanced reciprocal relationships enhance well-being, emotionally detached and compliance focussed task based care often excludes ‘the ordinary’ of give and take, as noted by Edgar Cahn:

‘The world of helping others in need is now built around one-way transactions…. and with the best of intentions, one-way transactions often send two messages unintentionally. They say: “We have something you need – but you have nothing we need or want or value.”’ (Cahn, 2000).

Through many focus groups and learning events involving older people, carers and frontline staff, I have been struck by how many people feel that current regulation and guidance is risk averse, restrictive and at worst destructive of human relationships. For example, workforce regulation states ‘the inappropriate use of touch is not permissible’, rather than ‘the appropriate use of touch is fabulous and to be encouraged’. This is a particular issue for people living with dementia, who often have to express themselves and connect with others through feelings and emotions. Frontline staff talk have talked about feeling guilty when they do little kind things (what we have come to call ‘undercover kindness’) that are not written in the Care Plan or receive small gifts of appreciation. Older people can be ‘told off’ (in the name of health and safety) for pouring tea for others in day services, and carers have been made to feel that they no longer have a role when the person they love goes into a care home.

At the heart of co-production is an understanding that everyone has something to contribute and that exchanging these contributions is enriching for everyone concerned. I am reminded of the work of Jean Vanier, who established the L’Arche Communities in learning disability services. Vanier did not see his role as caring for people with learning difficulties, but rather sharing his life with them and being open to receive and learn from them as much as to offer them support.

I remember one of my earliest experience of working in social care services. It was 1984 and I had started my first job as a residential support worker in a children’s home. I thought I was the ‘sorted one’ who was employed to help others. I worked hard to form good working relationships with staff and children in the home, but one boy, who had experienced a lot of hurt in his life, kept his emotional distance. As anyone who knows me well can tell you, I am not gifted in DIY or anything that involves fixing something mechanical. One day, I was trying to repair my bicycle (I did not drive at the time) and was getting nowhere fast. The boy walked past me and said ‘I’ve got a book about repairing bikes, do you want to borrow it?’. I am pleased to say that I took up his offer and our friendship took off from that day. He is now a happily married 43 years old who lives on the other side of the country, but we still keep in contact via Facebook and phone and offer each other support and encouragement whenever we can.

Jean Vanier once said, ‘I am struck by how sharing our weakness and difficulties is more nourishing to others than sharing our qualities and successes’. This is an important message for social care practitioners and agencies. We need to open our ears, our eyes and our hearts to the people we work with, which might involve sharing our vulnerabilities and concerns and allowing ourselves to be changed by genuinely ‘meeting’ with them in truly co-productive relationships.

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