Jenni McDonald
The Health Foundation (2013, p. 9) describe quality improvement (QI) as ‘a systematic approach that uses specific techniques to improve the quality’ of health care. In recognition of the unsustainable financial and operational difficulties the NHS faces today, achieving high quality and cost-effective care through QI has become a key objective for leaders (Alderwick et al, 2017).

Historically, the health and social care system in the UK was built to serve an era of acute and infectious diseases and not the complex, lifestyle-related, chronic diseases that challenge the NHS today (Realpe and Wallace, 2010). The NHS Five Year Forward View (2014) reflects this and states that the NHS ‘needs to evolve’ to better meet today’s challenges. Chief Inspector of hospitals for the Care Quality Commission, Professor Richards (2016), states that the NHS in its current model, is not capable of meeting the needs of our population.

The idea of co-production is not new, it was first proposed in the USA by Elinor Ostrom in the 1970s. Ostrom identified a disconnect between users and providers of public services and deemed co-production as a term when both of these groups come together to shape the services they consume (Ostrom, 1996). Almost a decade later, Anna Coote, policy director at the King’s Fund, made co-production known to the national health service (NHS) in the UK (Boyle et al, 2006). Since then, the concept of co-production has developed and is now in receipt of national limelight (Batalden et al, 2015). Boyle and Harris (2009) believe that this shift in attention coincides with the realisation that previous health and social care reforms are not fit for purpose.The Next steps on the Five Year Forward publication (NHS England, 2017) anticipated that applying co-production as a QI technique was a positive step towards developing an NHS that is fit for purpose. The Social Care Institute for Excellence (2015) believes that co-production generates improved outcomes and optimal use of available resources.

In the authors’ experience, the word co-production is used commonly in the NHS but they suspect the precise meaning is not fully understood. This may be because there is no one accepted standard definition for co-production. Within a healthcare context, Cahn (2000, p. 34) describes co-production as ‘a way of recognising the patient as someone who can contribute different and essential knowledge to a health-related outcome’. Loeffler et al (2013, p. 23) maintain that ‘co-production is the public sector and citizens making better use of each other’s assets, resources and contributions to achieve better outcomes or improved efficiency’. The National Co-production Network (2018, p.1) aptly define co-production as ‘an approach where people, family members, carers, organisations and commissioners work together in an equal way, sharing influence, skills and experience to design, deliver and monitor services and projects’. 

It is interesting to review the language used by these authors when describing the patient–provider relationship during co-production. It appears this is interpreted differently and varies on a spectrum ranging from patients/citizens ‘contributing’ to becoming an ‘asset’ through to ‘shared power’ and ‘equal relationships’ (Co-production Wales, 2018). Cameron (2018) states co-production has become a buzz word but often used as an umbrella term which incorporates differing levels of patient/citizen involvement.
Malby (2015) believes there are three distinct levels of patient engagement; voice, choice and co-production. The ‘voice’ stage is where patients are asked for their opinion, i.e. retrospective feedback on a patient information leaflet. The ‘choice’ stage is where patients form part of the decision-making in the design of services they consume, and co-production is where patients are equal members of the team who define, problem solve and implement improvements together (Malby, 2015).

The European Pressure Ulcer Advisory Panel (EPUAP, 2014, p. 12) define a pressure ulcer (PU) as a ‘localised injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure or pressure in combination with shear’.

The incidence of PUs is a key indicator of the quality of care an organisation provides (Hope, 2014). For the most part, PUs are a preventable patient harm and therefore prevention continues to be a local and a national priority, as seen in the Department of Health (DH) NHS Outcomes framework 2014/15.

We know that patients with cancer have a higher prevalence of PU compared to the general population (NHS England, Safety Thermometer, 2014), but the research available alluding to why this is the case is scarce (Sankaran et al, 2015).

As part of an American initiative in 2004, the ‘SKIN’ acronym was developed to provide a structured approach to PU prevention (Whitlock et al, 2011). This was introduced to the NHS in 2009 (NHS Wales), being later developed into ‘SSKIN’ in 2011 (NHS Scotland) and ‘aSSKINg’ in 2018 (NHS England). While it is recognised the fundamentals of care to prevent PU remains in ‘SSKIN’, the acronym ‘aSSKINg’ (Assess risk, Skin inspection, Surface, Keep moving, Incontinence, Nutrition, Giving information) further supports clinician actions.
An aSSKINg bundle is essentially a prescription of care at the bedside. It is a tool which guides and documents regular PU prevention interventions (NHS Wales, 2013) subsequently reducing variation in care at the bedside (Healthcare Improvement Scotland, 2011) and, therefore, considered best practice in the UK (NHS Improvement, 2018).


Jenni MacDonald: joining the Royal Marsden late 2017, my eyes were firmly set on the goal — reduce the incidence of hospital-acquired pressure ulcers (HAPU). Having achieved remarkable reductions in patient harm previously in my established career as a tissue viability specialist nurse, I was quietly confident. As I was fully immersed in QI and suitably armed with knowledge of co-production around this time, I decided that this was the approach I would employ. I applied to the Trust’s internal patient and carer advisory group for volunteers and received four responses.

To have four patient representatives on our new working group was really exciting. I have made several improvements previously where I sought patients’ ‘voice’ and ‘choice’ but had not worked alongside patients to co-produce improvements. Out of my comfort zone, suddenly I was not so confident!
Maggie Harkness: I am a retired nurse and was a patient of the Royal Marsden Hospital in 2009, and, although I had exceptional care, I found the experience of being a patient hard. I felt that as a patient I had little choice over the roller coaster of my journey, but now I’m through the other side and I can understand and appreciate why it happened like it did. I became a member of the Patient and Carer Advisory Group (PCAG) and through this I hoped to become involved in projects that help to improve and shape services from the patients’ perspective.

When the opportunity arose for members of PCAG to join members of staff to work together to improve PU prevention, I felt that with my previous nursing experience and my patient experience, I could contribute to the project, which would likely have immense benefits to improve patient care and therefore their experience.

Fiona Stewart: As a patient at the Royal Marsden, I have been an in-patient, for stays of between five and 10 days, on several occasions following multiple surgeries.

Looking back, and with the benefit of hindsight, I now realise I was one of the more fortunate patients — relatively young, otherwise healthy, able to regain mobility within 24–48 hours after surgery, and had a team of friends and relatives to visit me regularly. Pressure ulcers were not an issue for me. However, I was aware that many of my fellow patients were unable to move easily, whether because of their illness or surgery, age or general frailty. For those patients, pressure ulcers were a very real risk, with a potentially serious adverse impact on their health and recovery.

Following completion of my treatment, I joined the Royal Marsden PCAG, where I try to use my own experiences and observations as a patient to help improve the experience of other patients, especially those who may not have a ‘voice’ for whatever reason. An example of this was when we were invited to share our thoughts on how the assessment of pressure ulcer risk and the documentation used could be improved, and how to raise patient awareness generally about the potentially devastating impact of pressure ulcers.
Maggie Harkness: After reviewing many documents, our group created a working document called the ‘aSSKINg bundle’, which both patients and staff could fill in appropriately. I was delighted that we designed a document that was different to all the others, it gives the patients and families a chance to ‘be in control’ of their care instead of it being ‘done to’ them, as it used to be back in the day!
Fiona Stewart: As a patient, I know how easy it is to become ‘institutionalised’ during a hospital stay, and become resigned to having everything done ‘TO’ you, often not knowing why. Being able to take control in some small way of your own well-being and recovery is very empowering for a patient.

It was good to learn that patients would be actively encouraged to complete the aSSKINg bundle themselves, if they were able to do so, following the initial risk assessment and so be involved in their care plan and prevention of PU.

Maggie Harkness: I do think staff and patients or even the patient’s carer working together to do the care and helping to fill in the document makes it more likely to be kept up to date and a joint effort. If there came a point that the patient was unable to complete their part, this could easily be filled in by the nurse caring for them.

It is written with wording that patients can understand, and this can be empowering for the patient as they don’t have to keep asking their nurse what certain words/terms mean. Patients will feel that they are taking more control of their own care when at times, I know, it feels like you are ‘swimming against the current’.
Fiona Stewart: From our very first meeting, it was clear to me that a whole range of healthcare professionals were involved in the project, including nurses, dieticians, physiotherapists and occupational therapists, each with a particular interest in one or more aspects of preventing PU and all keen to be involved in the new document. It was great to see that the new documentation was written in easy-to-understand language, and laid out in a clear way. Great emphasis was placed on the role of the healthcare professionals to not simply explain the risk of pressure ulcers to the patient, but also explain what they were looking for on the skin, and why they were proposing certain actions. This approach means that the patient (and where relevant their carer) will understand what is being asked and why, and, more importantly, can become involved in monitoring themselves, and know the importance of, for example, changing position regularly and eating well to prevent pressure ulcers.

Jenni MacDonald: After the first few meetings I became more relaxed in the new environment of co-production. There was a great deal of excitement around what we were doing and many different staff groups. I was initially worried that our patient representatives would not be given the space to share their opinions or ideas. I soon learned that patient representatives have an equally big voice, and for that I was grateful.
Maggie Harkness: The group met regularly, and I felt that my opinions and suggestions were taken on board by our chair, Jenni MacDonald. A new draft of the document was soon presented to us all with our changes applied. We would then meet again and discuss whether the suggestions previously made were appropriate. The document still contained the conventional information required, such as the Waterlow score and a body map diagram for any skin damage to be indicated, but also encompassed other areas such as nutrition, type of mattress used, other pressure-relieving devices ordered or in use, and, most importantly, information given to the patient as to how to prevent any tissue damage from occurring. The next part of the document was very in-depth — if any patient had been unfortunate to develop skin damage, this would have been recorded along with repositioning of the patient and at what time, so that other staff caring for that patient on subsequent shifts, could clearly see what care had been given and would be required later on. It also provided a record to the patient and their family/carer that care had been given accordingly.

Fiona Stewart: This was a fascinating and worthwhile project in which to be involved. All the healthcare professionals worked well together and, in particular, really listened to the suggestions and comments of the patient representatives.

The draft documentation was revised quickly and accurately, taking account of all comments and amendments discussed in the meeting and then re-circulated for approval.

The project moved to completion swiftly, without losing momentum, and the documentation was piloted without delay on the wards.
Maggie Harkness: I was unfortunate to develop pressure damage as a patient as a result of prolonged surgery, but working on this project helped me to understand why it happened, how it would have been communicated to the team caring for me, and what can be done to prevent or at least mitigate the development of tissue damage to any other patient in the future.

The ultimate part of this project was being involved in the making of the aSSKINg training video, which is to be used trust-wide to education staff about how to use this document. By being filmed and telling ‘a small part of my story’, although briefly, it did bring back some of the emotions that I had felt while undergoing treatment, but it made me feel extremely proud that I can be of some help in preventing another patient from developing pressure damage.


Realpe and Wallace (2010) state that for co-production to be truly embodied, power in the system must be transferred from healthcare provider to the citizen/patient. Malby (2016) recognises that redefining this relationship is a ‘daunting task’ for the NHS.

Fiona Stewart: The filming of a video to explain the Royal Marsden’s approach, with direct comments to camera from many of those involved, including two of the patient representatives, was an imaginative and novel idea — certainly not one that I have come across before. I feel sure that this video will educate and inspire healthcare professionals who assess and monitor the risk of pressure ulcers. It will also help patients, like me, understand the risks ourselves, make us feel safer, more involved in our own care, and even empowered to take part in the monitoring process ourselves.
Maggie Harkness: If a project was to come up that had just some of the elements of the work collaboration that this initiative had, I would be extremely grateful that my opinion was sought and proud to embark on the work required, as I know how useful to the wider patient population a new and more in-depth working document has in advancing patient care.
Jenni MacDonald: Relinquishing control goes against the internal grain. As senior nurses, we are experienced in and have become accustomed to leading/chairing and guiding conversations, projects and groups of staff to ensure optimal outcome of the time spent. By ‘letting go’, I allowed staff/patient representatives the space to innovate and I was able to observe the blurring of traditional role boundaries towards sharing each other’s ‘assets’ and achieving ‘equal relationships’. Batalden et al (2015) believe that blurring of roles between and within staff and patient groups is a prerequisite to co-production. Retaining strongly defined role boundaries is known as a barrier to improvement in the NHS (Health Foundation, 2015). Having achieved this, I was however left wondering about where accountability lay for our group’s creations? How much letting go is too much?
I tried not to draw my own conclusions and be aware of my hidden assumptions (Camillus, 2008), which was more difficult than I had envisaged as my previous experience clouded my objectivity. I began to question whether a fear of shifting control or hidden assumptions are responsible for the lack of adoption and spread of co-production in the NHS?

Fortunately, our final aSSKINg bundle is richer than I had ever envisaged, and has been designed like no other I have seen. This outcome is a direct result of being co-produced and I would recommend this QI technique to my colleagues.


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