Co-producing the next AHP strategy for England

In England, allied health professions (AHPs) form the third largest clinical workforce in the NHS and are professionally autonomous practitioners educated to a minimum of a degree-level standard. Alongside diagnostic and therapeutic radiographers, AHPs comprise 13 other professions: art therapists, dietitians, drama therapists, music therapists, occupational therapists, operating department practitioners, orthoptists, osteopaths, paramedics, physiotherapists, podiatrists, prosthetists and orthotists, and speech and language therapists¹.

AHPs provide system-wide care to assess, treat, diagnose and discharge patients across social care, housing, education (early years and schools), criminal justice, the independent and voluntary sectors. Through adopting a holistic approach to health and care, AHPs can help manage patients' care throughout the life course, from birth to end-of-life care. They focus on prevention alongside improving health and wellbeing to maximise people's potential to live full and active lives in their family circles, social networks, education/training settings and the workplace¹. 

Five years ago, the AHPs into Action: Using Allied Health Professionals to Transform Health, Care and Wellbeing (2015/16–2020/21) strategy was published, highlighting the transformational capabilities of AHPs on patients, the public and communities². The development of the strategy was groundbreaking in its stakeholder engagement approach and, at the time, it was the largest crowdsourced strategy in northern Europe, capturing a variety of stakeholder voices, including those of patients and the public. Crowdsourcing, first described by John Howes in 2006³, is the practice of obtaining input into a task or project by enlisting the services of a large number of people, usually online. Positives of crowdsourcing are the ability to bring together a community of people around a common cause and undertake deeper engagement with this community⁴.

Such was the far-reaching legacy of AHPs into Action² that the need to further develop the strategy was mandated in the NHS Long Term Plan⁵. Thus in 2020, the office for the Chief Allied Health Professions Officer (CAHPO) for England announced that a second updated strategy would be commissioned. From the onset, co-production with patients and the public would be central to the development of this work, which was published in June 2022⁶.

Co-production is an approach to decision-making and service design rather than a specific method in practice. It means that those who are affected by a service are not only consulted but are part of the conception, design, steering and management of services. Co-production with patients is a critical commitment made by the NHS Long Term Plan⁵. For diagnostic and therapeutic radiographers, the importance of working this way is also captured in the College of Radiographers professional document Patient, Public and Practitioner Partnership within Diagnostic and Imaging and Radiotherapy: Guiding Principles⁷. This commitment has been further emphasised in the College of Radiographers Research Strategy 2021-26⁸. (This article uses the words “patient” and “the public” to describe anyone accessing health and care as these are the terms most commonly used by the profession).

However, it is not just enough to seek to co-produce. It is equally important that we consider who is part of our co-production activities. As noted by Russell, Fudge and Greenhalgh (2020)⁹ , this activity in a research setting will often attract a certain type of individual – white, middle-class, retired males. Hence a small minority may be offering the voice for a majority. The following outlines how the development of the next AHP strategy for England took an inclusive approach to gathering and incorporating the voices of people who access health and care services and those who deliver these services, all of which happened against the backdrop of the uncertainty of a global pandemic.

The first consideration when setting up the project was the construction of the project team. The team consisted of two staff members from the office of the CAHPO, two members representing the crowdsource platform supplier and the third author of this article, Rob Moriarty. Rob has lived experience of accessing 24-hour care through a personalised care package and is also a trained NHS England and Improvement (NHSEI) peer leader. Rob has acted as a critical friend throughout this process. Of course, the project team could have recruited any person with lived and learnt experience, but the Peer Leadership Development Programme aims specifically to develop knowledgeable, skilful and effective advocates on a national and regional level with an ethos that co-production should be a long-term route¹⁰.

Developing the next AHP strategy for England was commissioned before the Covid-19 pandemic and was, therefore, designed to include several regional face-to-face workshops to support the crowdsourcing element. However, as lockdowns in England continued in early 2021, the digital platform became critical to collating stakeholders' views. This approach raised the challenge of how the project team would ensure that the work results would not be skewed, based on the crowd being sourced⁴. Thus, recruitment of a diverse patient and public voice to the crowdsource, alongside the platform accessibility, became top priorities for the project team.

The project was split into three online conversations hosted by Clever TogetherLab Ltd¹¹. The platform was open 24 hours a day, seven days a week. Those engaged with crowdsourcing could add contributions in several ways. For example, they could add their ideas, comment on other people’s ideas or cast votes. Those accessing the crowdsourcing platform were anonymous, as were their contributions. The first conversation was with patients and the public in England, asking them to share how they would like health and social care delivered by the 14 AHP professions (March 2021). The second conversation was with AHPs to understand how they could support the ideas generated by patients and the public in phase one (May 2021). The third (final) conversation involved patients, the public and professionals challenging the views from the previous two conversations to agree on the themes to be included in the final strategy (July 2021) (Table 1).

_{Table 1. AHP strategy development: engagement activity}

Across the three conversations, more than 3,200 registrants made 21,000 contributions (ideas, comments, votes), representing 500 English postcodes. The data (ideas and comments) were thematically coded from the ground up to identify the key themes of the conversation. Votes were analysed to understand which ideas had the strongest support (adjusting for the length of time a contribution was visible). Finally, data triangulation with national policy and strategy was made to produce the final document. Although AHPs into Action² used crowdsourcing in a groundbreaking way, the approach adopted to prioritise patient and public consultation for the development of the second strategy was considered the first of its kind in health and care strategy development in the UK.

There were 1,200 people who identified as individuals accessing health and social care for the online activities. Of all of those who engaged, 17% identified as non-white British with representation in each ethnicity category. For comparison, 2011 census data from the Office for National Statistics (ONS) showed 18% of people identifying themselves in this category¹². There was representation across all age groups and staff pay bands up to senior manager level. Some 7% of participants identified as non-heterosexual, while 2019 ONS figures estimated that 2.7% of people aged 16 years and over identified as lesbian, gay or bisexual (LGB)¹³. Some 10% of crowdsource participants indicated they were disabled. We heard from all 14 AHP professional groups and across the AHP community (students, the support workforce and registered staff). We also heard from other health and social care professionals, including dentists, social workers, medical doctors and psychologists. Data saturation was achieved for each of the phases.

To ensure the project team did not exacerbate health inequalities and miss the voice of key groups, additional measures were taken to ensure inclusion and to support access. Three separate workshops were carried out in partnership with the organisation Working with Everyone (WE)¹⁴, ensuring the voice of underrepresented communities was captured. WE is a not-for-profit company that prides itself on being independent. All WE directors, employees and volunteers have lived experience of social harms and marginalisation and members are selected for their personal, professional knowledge and expertise. These specific workshops included those who experienced homelessness, those from the travelling communities, migrants, refugees, people who use drugs (currently or formerly) and those who have experienced the criminal justice system. The WE team ensured those participating had access to laptops and wireless broadband to support the online workshops conducted using Microsoft Teams. It also guaranteed those participating were compensated for their time. These workshops were critical to developing the strategy because they ensured that people who were often not included in research could share their views. In total, three workshops were undertaken between February and July 2021.

The project team also worked with the following NHSEI teams and groups:

• Personalised Care Strategic Co-Production Group.
• Patient and Public Participation Team.
• Age UK Older People Sounding Board.
• Learning Disability and Autism Advisory Group.
• Voluntary, Charity and Third Sector Partnership Team.
• Children and Young People Forum.

These groups contributed to various aspects of the work. With regards to the digital accessibility of the platform, several groups considered what the text and images on the crowdsourcing platform meant to them and how we could then pitch our digital platform to meet the needs of multiple audiences. A suggestion by another group led to the project team buying an accessibility software extension for the third and final conversation. This had an array of tools, including a webpages translator. The learning disability and autism team supported the design of easy-read versions of the consultation details and the consultation questions. Of course, there were accessibility challenges even with these changes, hence adjunct online workshops were also run with a number of these groups.

Several ad hoc local events were also initiated and hosted by AHPs across England with local people and communities during the third online conversation in summer 2021. The data gathered from these workshops were also analysed, themed and the results merged with the crowdsource. The themes generated from all these activities were forwarded to the NHS Assembly¹⁵ in September 2021 for comment. The NHS Assembly brings together a range of individuals from across the health and care sectors at regular intervals to advise the NHSEI board on delivery of the NHS Long Term Plan⁵.

We acknowledge that there are numerous models of co-production available. However, for this work we have adopted the model proposed by Roper, Grey and Cadogan (2018)¹⁶ to support the life cycle of this strategy. For this model, co-production happens when co-planning, co-design, co-implementation and co-evaluation intersect. Here a co-production approach sees health and care stakeholders involved in leading, defining a problem, designing, delivering the solution and evaluating the outcome. Just as the strategy development has ensured co-planning and co-design, the implementation of this work will require co-implementation and co-evaluation between people, the AHP community and wider health professional groups.

AHPs into Action presented a visionary strategy that has served the AHP community over the past five years. At the onset of being mandated by the NHS Long Term Plan⁵ to further develop AHPs into Action², the CAHPO’s ambition and commitment has been that the life-cycle of the strategy captured the voice of the people and communities who access health and care across England. The methods used throughout the development of the new strategy² ensured we represented a diverse voice, including voices from underrepresented communities. We have included people who access health and care services from the very beginning of this work. It is their insights that have shaped the strategy content.

As we move to the implementation phase over the next five years, it will be critical to maintain our work with people and communities. We are calling on all AHPs, including the diagnostic and therapeutic radiography community, to consider their role as co-producers at an individual and provider level.

Janice St. John-Matthews is a Diagnostic Radiographer and 2021/22 CAHPO Clinical Fellow.

Suzanne Rastrick is CAHPO for England.

Rob Moriarty is a Consultant, University Associate Lecturer, Peer Leader and a member of the NHSEI Strategic Co-production Group. He has lived with a high-level spinal cord injury for more than two decades and, being completely wheelchair dependent, he self-manages his 24-hour care through a range of personalisation schemes that enable him to live independently.

References

1. NHS England and Improvement. The 14 Allied Health Professions. 2022. Available at www.england.nhs.uk/ahp/role/ Accessed 9 January 2002.

2. NHS England. AHPs into Action. 2016. Available at www.england.nhs.uk/wp-content/uploads/2017/01/ahp-action-transform-hlth.pdf Accessed 3 January 2022.

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5. NHS England. The Long Term Plan. 2019. Available at www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ Accessed 6 January 2022.

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7. The College of Radiographers. Patient, Public and Practitioner Partnerships within Diagnostic Imaging and Radiotherapy: Guiding Principles. 2018. Available at www.collegeofradiographers.ac.uk/patient-advisory-group/patient-advisory-group/patient,-public-and-practitioner-partnerships-with Accessed 14 December 2021.

8. The College of Radiographers. The College of Radiographers Research Strategy 2021-2026. 2021. Available at www.collegeofradiographers.ac.uk/research-grants-and-funding/cor-research-strategy Accessed 20 December 2021.

9. Russell J, Fudge N, and Greenhalgh T. The impact of public involvement in health research: what are we measuring? Should we stop measuring it? Research Involvement and Engagement, 2020, 6 (63) https://doi.org/10.1186/s40900-020-00239-w

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11. Clever Together. About Clever Together. 2022. Available at https://clevertogether.com/ Accessed 5 January 2022.

12. Office for National Statistics. The 2011 Census for England and Wales. Available at https://www.ons.gov.uk/census/2011census Accessed 21 December 2021.

13. Office for National Statistics. Sexual orientation statistics. 2019. Available at www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/sexuality/bulletins/sexualidentityuk/2019 Accessed 23 December 2021.

14. Working with Everyone. Working with Everyone: who are WE. 2022. Available at https://workingwitheveryone.org.uk/ Accessed 11 January 2022.

15. NHS Assembly. About the NHS Assembly. 2022. Available at www.longtermplan.nhs.uk/nhs-assembly/ Accessed 5 January 2022.

16. Roper C, Grey F, Cadogan E. Co-production: Putting Principles into Practice in Mental Health Contexts. 2018. Melbourne: University of Melbourne. Available at https://healthsciences.unimelb.edu.au/__data/assets/pdf_file/0007/3392215/Coproduction_putting-principles-into-practice.pdf Accessed 29 December 2021.