Human togetherness: the role and impact of citizen-sourced collective co-production in National Health Service (NHS) procurement

Introduction

In 2020, the coronavirus disease 2019 (COVID-19) pandemic (hereafter referred to as “the pandemic”) upended our daily lives placing restrictions on travel, social gatherings at home and even a ban on attending live events. While many employees made the transition to working from home, citizens were also exploring alternative forms of engagement and civic responsibility to deliver a collective response to the pandemic in the UK. Within this sudden cultural shift, designing a ‘new reality’ was a challenging prospect for individuals and organizations alike. Local community projects flourished into initiatives of co-creation, from the resurgence of making video production to cope with anxiety and stress (1); bread making at home (2,3) or new initiatives bringing together local hospitality businesses to support the shielded and most vulnerable (4). This seemingly creative approach created new forms of social experiences and resilience, which sparked change in citizen response on a collective level. Prior to the pandemic, citizen-led initiatives and community-led consultations were typically implemented by local authorities or other national bodies using a “top-down” approach in the development and delivery of public services in local communities. However, there has also been an underlying shift happening where citizens are transitioning from being “passive consumers” into “active producers” (5) described by Alexander and Conrad (6) as the ‘Citizen Story’ (p.39). The power of co-creation triggered by the pandemic and emerged through local communities was then harnessed by public sector initiatives facing national emergency responses for the delivery of their products and services. This report discusses how citizen-sourced collective co-production replaced traditional procurement processes within the management of external resources in the National Health Service (NHS) in the UK. It explores the core components of the citizen-sourced co-production process that enabled the NHS to pivot and overcome disrupted supply chains and unprecedented shortages of scrubs (7). In the following sections, we examine the concept of collective co-production and how it is based on a citizen-sourced approach to procurement in the context of this particular case study, which showcases a collaboration with Ninewells Hospital in the city of Dundee, UK, Duncan of Jordanstone College of Art and Design (DJCAD) at the University of Dundee, Halley Stevensons Ltd. (a local textile manufacturer) and local citizens. We then go on to describe the methodological approach of reflexive thematic analysis (RTA) before presenting the findings and discussion around four themes that emerged from this analysis, which include emotional motivators, flattened hierarchies, agile fast-moving collaborations and locality, open-door policy and digital communication.

Collective co-production

Citizen-sourcing is a useful mechanism for organizations and governments to engage with citizens (8) and has been used in public consultations, policymaking, and open innovation (9). With roots in Crowdsourcing, a widely recognized online approach of outsourcing a task to an “undefined network of people” (10), citizen-sourcing employs similar techniques that have the potential to transform the design and delivery of new products and services in local communities. By creating environments that empower people at all levels, it democratizes knowledge and harnesses mass collaboration in pursuit of collective decision making for improved outcomes. It can also help to increase transparency throughout the process, enabling citizens to experience first-hand how decisions are made and to have a stake in the provision of public goods or services. A prerequisite for success is a clear process and the use of tools that enable citizens to engage in an equal, collaborative, and meaningful way in real time. Two conceptual frameworks can be used to examine and evaluate citizen sourcing projects (8). The “Dimensions of citizen-sourcing” framework provides the key dimensions to view a project such as the purpose of the initiative; the type of wisdom collected to solve the problem; and the different strategies for government bodies to adopt to harness the collective intelligence from the crowd (8). “The framework for assessing citizen-sourcing” outlines the importance of evaluating how citizen-sourcing works, helping to generate insights and build comparisons between multiple projects. To align with the operations of central government, the framework carefully outlines the core criteria of evaluation drawing on three perspectives, namely, design, process, and outcome.

In line with notions of social and cultural innovation (11), citizen-sourcing and its evaluation criteria, such as inclusiveness, diversity, partnership, and deliberation play a significant role in the process and can determine the success or failure of projects. These criteria can also be found in the application of other collaborative and participatory processes, such as co-design, co-creation, and co-production. Co-production as a form of procurement in the context of citizen-sourcing might have something to offer in the design and evaluation of new initiatives.

Research has shown that in the early stages of a crisis, self-organized citizen groups can often respond more effectively than governments and organizations in mobilising and delivering resources in response to local needs (12). Citizen contribution and engagement with tasks in projects varies depending on their capabilities, expertise and which part of the process or cycle they are involved in, ranging from data acquisition to the design of solutions. Co-production refers to the collaborative process of involving a group of participants and stakeholders in the production of new goods and services (13). Nabatchi et al. (14) categorise co-production as follows: (I) individual co-production, where individual citizens act as co-producers for their own consumption and benefit; (II) group co-production, where a group of citizens interact with service providers to enhance the products or services they access; and (III) collective co-production where “… public organizations and citizens [collaborate] with the aim to produce services that are beneficial to society at large … rather than personal benefits” (15). Citizens are usually driven by a variety of motivators like self-interest, altruism or beliefs in specific social causes (16). Pestoff (17) points out that “Collective action and, even more, collective interaction have the ability to transform the pursuit of self-interest into something more than the sum of individual self-interest”, leading to “the development of social capital, mutualism and reciprocity” (p.30). The benefits include a sense of shared ownership, identity and purpose, enhanced creativity, diverse expertise (15) and can lead to new forms of learning among participants (18). Co-production can be between companies, public or private sector, however, when citizens and public sector organizations come together to jointly produce products or services it is citizen-sourced co-production.

Clearly, there is a strong rationale for organizations to adopt collective co-production in the pursuit of improved project outcomes, which can range from better public products and services to positive behavioural change and improved public governance. However, challenges and barriers for implementation, such as, bureaucratic structures and poor decision-making processes, the lack of coordination and communication, poor control, accountability, and standards, need to be mitigated. Gheduzzi et al. (19) have usefully summarized “antecedent barriers”, “process barriers” and “negative effects” of a co-production process (p.3). For instance, negative effects on citizens can include “fatigue to participate” (20), “low satisfaction toward results” (21) and the time investment creating an “additional burden on citizens” (20), while on the other hand, downsides for co-production initiators could generate “additional costs & effort” (21), yield “unreliable and unsatisfied results” (21) and require management of a “complex network” (22).

In the context of the pandemic, citizen-sourcing was applied by various governments to engage citizens in counteracting the shortage of scrubs, mobilising citizen groups to produce garments for their local health centres or hospitals (23). In this report, we examine how Ninewells Hospital in the city of Dundee, UK, collaborated with DJCAD at the University of Dundee, Halley Stevensons Ltd. (a local textile manufacturer) and local citizens to bridge scrubs shortages during the pandemic through citizen-sourced collective co-production.

RTA

To understand the role and value of citizen-sourced collective co-production as a form of procurement for Ninewells Hospital (part of NHS Tayside in Dundee), this report examines and reflects on the DJCAD Scrub Hub initiative, a community intervention around sewing to provide scrubs for healthcare workers during the first UK national lockdown. It identifies the critical success factors that allowed Ninewells Hospital to pivot and overcome disrupted international supply chains and unprecedented shortages.

A purposive sampling approach was taken selecting four interviewees who were central to the creation and delivery of the DJCAD Scrub Hub initiative as well as two other interviewees who managed the Hub. The interviewees included an ear, nose throat (ENT) surgeon at Ninewells Hospital, a textile designer and educator at the university, an NHS Tayside Programme Director for Mental Health and Wellbeing Strategy and the Managing Director of Halley Stevensons Ltd. The two interviewees who managed the hub were textile design educators at the university. The interviews were conducted over Microsoft Teams in June 2021 with approximately 6 hours worth of audio data. The interviews were semi-structured, consisting of questions arranged around the themes of motivation, roles, organization, relationships, decision making process, project approach and communication, challenges and barriers, outcomes and impact, and type of participation that occurred in the project.

The transcripts of the interviews were analysed using an adapted 6-step process of RTA as outlined by Naeem et al. (24): “(I) transcription; (II) selection of keywords; (III) coding of the data; (IV) development of themes; (V) conceptualization through interpretation of keywords, codes, and themes; (VI) development of a conceptual model” (p.15). RTA was selected for its organic, iterative, and interrogating properties (25), where themes are actively and deliberately created by the researcher (26), applying an inductive coding approach of real data (27). RTA can be a flexible existentialist or realist method which reports experiences and the reality of participants and does not require detailed theoretical knowledge of the approach (21). Each interview was transcribed manually to generate an orthographic verbatim account, providing both a transcribed data set and a unique first-person voice of interviewed DJCAD Scrub Hub contributors (27). Collating the data codes, in this case extracted portions of text, enabled manual random ‘shuffling’ of extracts to create unexpected combinations and groupings of initial codes to inform and generate data codes and subsequently four main themes.

Findings and discussions

Ninewells Hospital staff identified the need for 5,000 sets of scrubs in addition to the 6,500 sets that were already in circulation in the linen services. They contacted an educator in the field of textiles at the university, which led to the idea of involving a community of approximately 600 sewing volunteers, consisting of citizens aged between 16–92 years. Halley Stevensons Ltd. for the procurement of fabric and J&D Wilkie Ltd. for the provision of the pre-cut pattern. Staff and volunteers from the University of Dundee organized a ‘DJCAD Scrub-Hub’ to assemble and deliver ‘scrub packages’ to be sewn by citizens in their homes. All partners involved in the DJCAD Scrub Hub initiative donated their time and resources without remuneration. Completed pieces were then collected via the hub and delivered to the hospital. An estimated 1,000 pairs of scrubs were produced by citizens. The following findings reveal some of the “critical success factors” that enabled citizen-sourced collective co-production when usual procurement channels were disrupted. The RTA produced initial codes that were collapsed or collated to form an over-arching theme namely ‘Mutual benefit between the NHS and the public is generated, when the public has opportunity to serve public services.’ This overarching theme was underpinned by four sub themes, namely:

Emotional motivators engender community and public service collaboration

When the UK Government imposed unprecedented restrictions on physical liberty through social distancing, emotional motivators such as fear, terror, and helplessness were some of the driving factors mentioned by the interviewees. Other motivators identified included guilt and a sense of uselessness, especially in terms of not being at the front line. Interviewees stated that the opportunity to contribute had a positive effect on mental health and wellbeing. Furthermore, an actual “need to create stuff’, became a coping mechanism, as the public felt they were “able to contribute in a really difficult social, health and wellbeing moment”. Interviewees identified that they were “motivated to try and keep the medical staff at the front line as safe as possible and demonstrate our care and support”. It was an opportunity to actively contribute in a very practical way and the driver of emotional pain and a sense of threat created urgency and incited focus that expedited solutions. Emotional motivators such as threat, fear, and guilt, generated an instinctual desire and need for personal security through investment and active contribution. Similarly, fear and threat may be considered as powerful motivators for change. For the public to physically demonstrate their support removes a sense of helplessness, aiding mental wellbeing.

Flattened hierarchies aid autonomy and visibility

The catalyst for change and key person who identified need and urgency was neither in a senior nor mid-management position in the NHS. It was a member of staff in the laundry department who had oversight of the day-to-day practicalities and requirements of quality and quantity of scrubs and was therefore able to identify shortages. Interviewees identified that events had occurred “on [the] ground level [that] changed perceptions of those further up [the chain of command]”. They related this to a new flattened or circular hierarchy, where individual roles moulding into whatever was necessary and “people within that collaboration having some kind of input into it.” Interviewees also identified that it was possible to “collegiately solve problems”, further noting that “it’s the expertise or knowledge of individuals” that shaped the collaborative. In terms of personal disposition, several coded extracts related to the necessity of a positive mindset and naturally motivated outlook. The flattened hierarchy was identified as a “creative way of problem-solving and thinking about how to turn things on their head and not go down the normal route”. This circular collaborative way of working empowered people to make decisions independently and focus on the delivery. Interestingly, the uniform visual appearance of all staff now wearing scrubs, served as an equalizer, further fostering a sense of a circular hierarchy. Although scrubs may provide a level playing field in terms of appearance, an appreciation that the scrubs had been made by members of the public during the pandemic was identified in the analysis. The flattened hierarchy presented a mutually beneficial exchange. Another key collaborator identified his personal experiences of crossing hierarchical boundaries, breaking down barriers of interpersonal communication and going above and beyond traditional roles and responsibilities within the organization. Other key features that facilitated this flattened hierarchy and expedition of delivery were informal leadership roles, geographical size and proximity of the project partners (see section Locality). The triangular relationship, between the hospital, university and manufacturer was summarized by an interviewee, articulating that “… at that collaborative table, you always need to create a rotational leadership structure to support that approach.” As flattened circular hierarchies emerged, the NHS became an accessible institution permitting help from people it usually serves, thus enabling mutual benefit that was able to overcome unprecedented challenges.

Traditional procurement protocols and processes prevent agile, fast-moving collaborations

Procurement protocols and standardized processes, such as application forms for participants, were too complex and eventually made redundant during the pandemic due to its unprecedented nature. The coding identified the irony that traditional financial and health and safety protocols that usually apply to the procurement process for good reason hindered the procurement of scrubs during the pandemic. A new supply chain for scrubs needed to be implemented quickly and new processes developed, such as, sourcing the materials, onboarding of makers, planning material delivery routes and drop off and pick up points. Both the NHS and the university entered negotiations about where barriers could be removed, and trade-offs achieved to support the co-production process. It is therefore apparent that adapting certain processes and established structures, in this particular context, enabled open-minded collaboration to support fast-moving and agile collaborations.

Locality, open-door policy, and digital communication

Locality

Local proximity increased a sense of belonging among the project contributors, with one interviewee noting the project was an “interesting example (…) community action and how people are invested in a core value and shared purpose”. The inclusive nature of this project enabled a feeling of ‘belonging’ for a broad demographic. Reverence was given to the skill set and lived experience of a retired, local population. Contributors and makers in their 80s and 90s, adept at engaging networks and the practicalities of sewing, engendered enthusiasm. Several retirees cycled from rural areas to deliver scrubs at the drop off points. Even the tailoring division inside HM Perth Prison contributed to this initiative. Evidence suggests the scale of Dundee, as a small city with a large hospital, university and local industry within 2.5 miles of each other, presented an ideal geographical proximity that enabled an agile collaboration between project partners, enabling quick and efficient distribution of tangible goods, despite restrictions on face-to-face interactions.

Open-door policy

New communication structures emerged from the pandemic and allowed for an open-door policy between key contributors. The catalyst for change was the key worker in laundry who was able to approach another key collaborator at a surgical level. This enabled communication channels that had not existed before between the two areas. A positive attitude and personal disposition of being naturally motivated were identified as key personal skills for collaborators. It was noted that “in any big organization [poor] communication and culture are the two things, that to my mind, sit right up there the whole time as being barriers to great stuff happening.” An open-door coupled with an open-minded attitude reduced communication barriers and aided quick decision making throughout the project.

Digital communication

After the initial face-to-face, open door policy interaction, the informal networks grew exponentially. In this time sensitive, urgent situation, usual protocols were adapted and processes expedited. Face-to-face conversations turned into telephone calls, forming a collaborative group, which then met weekly and virtually. Unrestricted by agendas, committees and protocol, the urgency of the situation could only be met through quick digital channels. In addition, social media platforms were used to attract more volunteers. Facebook enabled a wide local community to be accessed immediately, generating an overnight response of 500 people offering to help. However, the NHS communication to the public on this platform needed to be handled in a careful manner so as not to incite more fear.

In sum, it appears that the adeptness of this project to respond the pandemic relied heavily upon good communication skills and an open-door policy. This open-door policy created an opportunity to start a small network of collaborators in local proximity, which even grew into a vast social media network which fostered a sense of belonging and community.

Limitations of the study

The authors acknowledge limitations of the study, such as the sample size prohibiting the generalization of the findings. A larger sample size would have further enhanced the data set increasing robustness and credibility of the results. Furthermore, the research setting is conducted in a unique context, involving a specific hospital and city, which might not reflect other healthcare structures within the UK or internationally.

Conclusions

This report sought to highlight some of the key drivers of the citizen-sourced co-production process that enabled the NHS to pivot and overcome disrupted supply chains and unprecedented shortages in the sourcing of scrubs during the first national lockdown in the UK. It is apparent that deeply rooted cultural commonalties and shared knowledge bases act as critical success factors for creating new, citizen-sourced co-produced initiatives. Engaging citizens in a way that creates meaningful exchange and fosters a sense of purpose in their contribution is paramount—their own “Citizen Story” (6), thus providing opportunity for engagement based on self-interest, altruism or beliefs in specific social causes (15). The urgency of the pandemic arguably mobilized mass participation, which will be difficult to replicate in other projects, hence the importance of a strong rationale for any temporary collaboration on citizen-sourced co-production initiatives. This study has shown how flattened circular hierarchies enabled the public to be involved and serve as producers of scrubs thereby showing support in a very practical way. Under these unprecedented circumstances, the NHS presented itself as an accessible institution and, opened itself up to be helped by the people it normally serves, enabling mutual benefit and reciprocity (17). When established protocols are removed, opportunities can arise, and much can be achieved. Citizen involvement is facilitated by allowing autonomous ways of working that encourages relevance, usefulness, and liberty in the experience. The adeptness of this initiative to respond to the crisis, also relied heavily upon geographical proximity, good communication skills, flow and an open-door policy. This open-door policy triggered the start of an informal network, growing into a vast social media network at the end. Use of digital communication also enhanced the communication flow further and mobilized a “crowd” of makers, which emphasized the advantage of the local proximity and fostered a sense of community and belonging. We would suggest that the benefits presented and outlined above using collective co-production would not have materialized without the emergence of the pandemic. However, since the pandemic, the NHS has invested and put measures in place to improve a crisis response and increase supply chain resilience. The experience of the pandemic has also highlighted the strategic role of local administrations, in all areas of service, in directing and coordinating actions to contain the pandemic. Today, local administrators must equip themselves with the management of infrastructures, which was unimaginable before COVID-19. The DJCAD Scrub Hub initiative demonstrates how local communities were able to overcome this state of unpreparedness and work with private businesses and public services to create positive outcomes for their own products, services and wellbeing, leveraging existing digital tools to facilitate new ways of communication and collaboration. As Wheatley and Frieze (28) usefully point out: ‘As networks grow and transform into active, working communities of practice (…), suddenly and surprisingly a new system emerges at a greater level of scale. (…) It isn’t that they were hidden; they simply don’t exist until the system emerges’ (p.1).

Acknowledgments

The authors gratefully acknowledge the support of all the interviewees in the completion of this work.

Funding: None.

Footnote

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-46/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-46/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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