On the road to value co-creation in health care: the role of consumers in defining the destination, planning the journey and sharing the drive

Internationally, there has been a growing focus on the governance and performance of health systems and health professionals, and a redefining of the role of the health consumer. Crises relating to increasing aged populations, the increasing burden of chronic and complex disease, the continuing challenges of quality and safety, and escalating health care costs have resulted in pressure to achieve a more productive and sustainable health system that is responsive to the needs and cognisant of the rights of health consumers.1

In Australia, the focus on partnership approaches between researchers, health professionals and the community has been seen as a central part of this transformational change.2 This partnership must extend the role of the consumer beyond engagement and participations and enable a more substantial contribution in all aspects of health system and health service activity — as co-participants and co-creators of health services and health system sustainability.1,3 It is this form of consumer value co-creation that is critical to improving health services, enhancing the quality of care, increasing patient and health care provider satisfaction, and contributing to primary health care reform in Australia.

Consumer involvement in value co-creation

The inclusion of consumers in health care has been variously described as patient participation, patient-centredness, shared decision making and patient engagement.4,5 While consumers continue to be involved as active participants in managing their own health,6 the focus is now moving forward to include the potential for consumers to be involved in innovation and value co-creation in health care.4,6

Consumer value co-creation is not a new concept and has been described in business management literature and practice since the 1970s.1 Payne and Frow7 described two dimensions of co-creation, namely co-production and co-creation relating to value-in-use. Co-production is defined as the engagement of consumers in a specific product development; examples of this in health care encompass the development of health care services such as proposed models for chronic care.4,7 In comparison, value co-creation is defined as collaborative activities that enhance customer lifetime value.7 In this definition, value is co-created if and when a consumer is able to personalise his or her experience in using an organisation’s services or products and in undertaking tasks the organisation gives them.8 Thus, consumers determine value based on their individual experiences as end users of health care, and have control over value co-creation in health care. The health care team participates in this process as co-creators.9

There is growing literature on health value co-creation and the benefits of consumer value co-creation in the health care sector.10-13 These include increased efficiencies in health services,14 improved health outcomes,15 increased trust in the health care team, reduced health care costs to the patient and the health system, increased value and use of medical research, and increased patient satisfaction and compliance with treatment regimens.12,16,17 Value can be co-created for the individual, clinical practices, health care organisations and providers, and government.12

Engagement opportunities for value co-creation

There are many co-creation opportunities where the health consumer can engage with the health system, health professionals and other stakeholders to co-create value. Engagement platforms vary in type (such as cognitive, emotional and behavioural engagement); in level (from non-engaged to highly engaged individuals); and in duration (one-off, recurring and continuous engagement).18 It is through purposefully designed co-creative interactions — such as face-to-face discussions, online information sharing, collaborative product development, physical spaces for knowledge exchange and problem solving, site visits, open forums or joint ventures19 — that health consumers share their resources and experiences, build relationships and so co-create value.20 The building blocks of interaction for value co-creation include dialogue, access, risks–benefits and transparency.20 For active dialogue to occur, health care organisations or health care providers and consumers must become equal partners, focused on the issues of interest to both.

A framework for consumer value co-creation in primary health care

The use of value co-creation in health care involves embedding this approach across entire health systems — from the microsystem level (individual practices) to the mesosystem (health care organisations) and the entire macrosystem (overall health system and government policy).1 The system thus needs to allow for the consumers to inject their views, experiences and expectations through ongoing dialogue on varying aspects of treatment options, health services delivery, health policy and the overall health system.1

In relation to health care, numerous models and approaches to value co-creation have been proposed. Drawing on both the theory and practice of value co-creation, Nambisan and Nambisan6 describe four models of value co-creation in relation to consumer and health care organisations. These are:

• a partnership model for consumer co-creation in health care (ie, explicit knowledge acquired from consumers, such as innovative ideas, are combined with existing knowledge to develop new solutions or to improve existing services);

• an open-source model of consumer value co-creation in health care (consumer and community led activities with a focus on new knowledge co-creation);

• the support group model of consumer value co-creation in health care (consumer and community led forums for sharing specific knowledge and experiences related to disease and treatment); and

• the diffusion model of consumer value co-creation (knowledge-sharing activities initiated and led by health care organisations, focusing on those services or products offered by the organisation).6

In the following section, we provide examples of how these models have been used or are expected to be adopted across the health system.

Use of consumer value co-creation across different levels of the health system

Health care in Australia has only just begun to regard consumers as integral to value co-creation. Frameworks such as the maturity matrix developed by KPMG Global Healthcare21 reinforce the need for comprehensive and transformative approaches to realise the benefits of patient involvement in health care improvement. In addition, they encourage health care organisations and providers and government to move beyond simply involving consumers on boards and committees towards ongoing genuine consumer involvement across the journey from the inception and development phases to the implementation and evaluation phases of health care.

There is, however, an emerging trend of co-creation models taking place at the micro-, meso- and macrosystem levels in the Australian context. This demonstrates a growing recognition that working with consumers to establish what matters most to people about the health care they receive can powerfully shape health status and outcomes through improved service and system development.

The support group and diffusion models of co-creation have been applied at the microsystem level in hospital settings. In 2013, the Patient Based Care Challenge of the New South Wales Clinical Excellence Commission was implemented to spur system-wide change to promote patient-centred care. Designed in collaboration with a patient advisory committee, it has been implemented in 13 local health districts. Each district had tailored partnerships with patients, families and carers to address the health service priorities of their local community, which included involving them in the design of processes, new facilities and staff interview panels. Patient experience surveys and patient complaints data will inform an assessment of the impact that this initiative has had on hospital culture, systems and practices.22

At the mesosystem level, we can expect to see the partnership model of co-creation systemically applied. Guidelines require Primary Health Networks (PHNs) to involve consumer experience intrinsically in their core strategic and operational practices.23 It will be critical that PHNs appreciate the various models of consumer value co-creation and that steps are taken to support them to systematically adopt and embed good practice in consumer participation in all phases of primary care commissioning. A standards-driven approach to commissioning that is person-centred and outcomes-focused has enormous potential to exercise a lasting impact on the triple aims of health care: better population health, better experiences of care and more cost-effective health care delivery.

In education and research settings, we see the application of partnership and open-source models to initiatives that enable consumer input in generating ideas for local service and system improvements and provide suggestions for direction in health and medical research. For example, the University of South Australia’s International Centre for Allied Health Evidence offers a Professional Certificate in Health Consumer Engagement co-designed with the Health Consumers Alliance of South Australia. Health professionals and consumers worked together to inform the objectives, curriculum, delivery and assessment. Course participants are health consumer representatives and professionals who learn together, and plan and conduct a joint workplace improvement-oriented intervention.

At the macro level, broadly reflecting the partnership model, national policy mandates consumer representation and engagement as an important factor in policy development and governance of national agencies. Consumer representation is evident at the highest level in key federal reviews including the Primary Health Care Advisory Group,24 which examined new ways to coordinate and fund care for people with complex and chronic conditions, the Expert Panel for the Review of Pharmacy Remuneration and Regulation,25 and the Medicare Benefits Schedule Review Taskforce.26 Consumer involvement in the implementation of government responses to these reviews will be important to the integrity of policy translation and to upholding policy intent. A peak consumer body, the Consumers Health Forum of Australia, is a key part of the health architecture and facilitates consumer input into policy and decision making and builds the capacity of the consumer sector overall in public participation.

Conclusion

Existing and emerging practice demonstrates the role and value of consumers in shaping health care in Australia. Such practice is starting to become better accepted and embedded at various levels across the system and is no longer a peripheral issue in policy, research, program and service development, and care delivery. However, shifting from the paternalistic caregiver–care receiver dynamic continues to be challenging.27 Embracing the way we conceive of patients and thinking of them less as “users and choosers” and more as “makers and shapers” of services offers a way of achieving a more collaborative dynamic.28 In the Australian context, this requires further investment in consumer leadership, in building the capacity of consumers and all relevant stakeholders as co-creators, and in the active promotion of patient–clinician alliances. Only then can consumers define the destination, plan the journey and share the drive.