How can we design weight management services with under-represented groups?

Project aims

We wanted to know:

• How adult weight management services were co-designed
• Barriers and facilitators to co-design
• What this means for commissioning services in the future

What we did

We selected four adult weight management services in the West of England that incorporate co-design. These case studies represented a range of populations and settings.

We gave our case study services the following pseudonyms:

• Healthy Choices – originally planned to target racially-minoritised communities
• FitnFun – working with adults with mild learning disabilities
• Active People – targeting areas of high deprivation and racially-minoritised communities
• The Men’s Project – working with men

We spoke to seven commissioners, eight providers and three community members involved in co-designing the services.

The case studies used a range of co-design activities from light-touch to more in-depth approaches.

What we found and what this means

Participants across all four services saw the potential benefits of co-designing weight management services with community members.

They felt co-design could:

• Create more suitable services
• Reach populations traditionally excluded from mainstream services
• Increase engagement

However, they also saw co-design as challenging and needing significant time and effort.

Building relationships

Building strong relationships was seen as critical to co-design.

It took time and effort to build the trust and credibility needed for successful co-design. This was done in different ways:

• Partnering with a well-respected local voluntary organisation (Men’s Project)
• Commissioning a private company (Active People)
• Using in-house local authority resources (Healthy Choices, FitnFun)

You can’t just go in and “do” co-production… It takes groundwork. You have to build all these relationships to do it well.

Funding for co-design

Funding for co-design was often short-term and unpredictable. Two services were unable to implement all their co-design plans because the timeframe was too short or government funding was pulled at the last minute.

Participants noted this unpredictability could damage relationships with communities.

Communities have been hit by the “hit-and-run”, people saying we’re going to do this… then a month later they’re gone.

Evidence, effectiveness and evaluation

Some commissioners were concerned with the lack of an evidence base for co-design. In the context of tight budgets, they wondered if public money would be better spent on well-evidenced national programmes. Other commissioners felt their current approach was not working and they needed to try something new.

Are we better spending a huge amount on one [co-designed] group and we don’t know how effective it is, compared to less on a wider group where we know the results are reasonable?

Evaluating co-designed services and building the evidence base was challenging. Short-term funding made it hard to build in rigorous evaluation.

But a wider issue related to what outcomes should be assessed. For example, the Men’s Project was funded as a weight management project but, being fully “co-created”, the men chose its focus.

Their priorities were more about loneliness, mental health and building community, than weight loss. The commissioner of this project felt it created “the context that enables people to make choices around their weight at a later date” but recognised it posed challenges for evaluation.

Would I say it was a success? Yes, but that’s taking new perspective on what success is. If I presented this to a board of clinicians or NHS England, would they say it was successful? I don’t know!

Commissioning for ‘true’ co-design

Some participants felt current commissioning practices – which focused on “Key Performance Indicators, bums on seats, people through the door” – did not fit easily with the flexibility needed for co-design.

Some participants felt commissioning for co-design required “a change in mindset and culture”, as well as “courage” and a willingness to embrace uncertainty. Finding the right partners to work with – those who shared your ethos and values around co-design – was seen as critical.

As a commissioner you think you know what you want to come out of it, and it might not be that. If you’re truly going to do co-creation… it demands flexibility and openness… which is not a traditional commissioner role, allowing for that uncertainty and emergence.

What next?

Drawing on our analysis, we identified key considerations (PDF) for those wanting to co-design health services:

Build relationships

• Connect with communities
  Consider partnering with local voluntary organisations, commissioning private companies or using in-house resources
• Develop shared values
  Discuss your values, what you hope to achieve and how you will build a shared vision for co-design with partners
• Strengthen relationships
  Establish trust, rapport and credibility with communities – an essential part of co-design. It will take time and can’t be rushed

Create supportive organisational cultures

• Get comfortable with uncertainty
  Co-design involves uncertainty. Stakeholders may see issues in different ways. Co-design should focus on the most important outcomes to community members
• Reflect on commissioning practices
  Consider how you might commission to produce longer-term ‘value’ rather than focusing on short-term, pre-specified outcomes
• Think about the long game
  Short-term or unreliable funding hinders meaningful co-design and can damage relationships with communities

Develop the evidence base

• Share the successes and the failures
  Use evaluation approaches that capture the subtle, long-term and upstream impacts of co-design