Embracing disagreement in research co-production

Co-production, at its simplest, involves the providers and users of services working together to find a collective solution or outcome. It has gained traction as a means of enhancing and evolving patient and public involvement (PPI) in health and social care.

Although interpretations of and guidance on co-production vary, it is generally regarded as a values-led approach in which researchers, patients and the public share power. Differences among guidance documents are subtle. I was a co-author of the National Institute for Health and Care Research’s guidance on co-producing a research project and in this we identified five key principles:

• sharing power, in which the research is owned by those working on a project
• including all perspectives and skills, whereby the research includes all people who can make a contribution
• respecting and valuing the knowledge of all those working together on the research, as everyone is of equal importance 
• reciprocity, so everyone benefits from their input
• building and maintaining relationships, to ensure that people are valued, their potential is unlocked and power is shared.

Principles can give us a framework and guide our work. But it’s by applying the guidance that we add experience, practice and nuance. In this way we can enrich the guidance and the advice that we provide. 

Allowing disagreement and dissenting voices in co-production

Co-production is not all consensus and harmony, however. And what the guidance is less explicit about – although it emphasises dialogue, reflection and flexibility – is the importance of allowing and enabling disagreements and dissenting voices. 

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Having disagreements, discussions and arguments is all part of the creative process, and we need to embrace them. Through dissent and debate we can often improve what we produce and the knowledge we create. People are usually mature enough to know that we do have to move forward with a project and make decisions, and to know when to pick their battles. The skill is creating the right environment – a safe environment – within which people feel they can disagree. 

So, what can we do to create this environment? 

Here are four tips:

1. Collectively develop a “ways of working” document that sets out rules or principles for how all parties will work together. This gathers people together to negotiate and agree a set of statements. In addition, you can include statements that encourage people to recognise that it’s OK to disagree. I always include a statement about disagreeing agreeably. It is important to challenge and disagree – as long as it is done respectfully. 
2. Develop good relationships. If you have long-term, established relationships with people, it can often (although certainly not always) be easier to work through differences of opinion or nuances in approach. People are used to each other, respect each other and feel comfortable about disagreeing and sharing opinions. Obviously, though, many projects bring together people who don’t know each other for a short period of time. In an ideal world, it would be useful to have events or get-togethers before the project to help develop relationships. Consider events that involve people stepping outside their roles to get to know each other. 
3. Organise reflective sessions. Create a space where you can have open and honest discussions about how the group is working. Are we being true to the co-production principles? Are we creating spaces in which people can express an opinion? If not, what can we do about it? Within these spaces, it is important to emphasise the importance of people being able to express their views and to disagree. These sessions can be recorded and written up briefly – one or two pages, almost like a blog – to share with the whole group. Reflective sessions are safe spaces for people to air their views and thoughts, debate, discuss and argue, agree disagreeably and then work out a way forward.
4. Play devil’s advocate. Sometimes, in a group setting, people will be reticent about disagreeing through fear of upsetting others or appearing stupid by going against the consensus. Here, I think someone like the PPI lead on a project can proffer an alternative view. (The PPI lead is someone who has responsibility for managing and overseeing all PPI activities on a project.) This may: a) give someone else the confidence to speak up; and b) ensure that alternatives are discussed. Of course, the devil’s advocate doesn’t have to believe in the alternative view.

The guidance, in my opinion, focuses a lot on sharing power and working together, with an emphasis on developing relationships and moving towards a consensus on decision-making. But debate is also part of developing and improving our projects, plans and products. It’s time to embrace the role of disagreement and embed it within the co-production process.

Gary Hickey is head of Agora Digital Centre in the School of Healthcare Enterprise and Innovation at the University of Southampton.

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