A case for co-production

Every year, more people receive the opportunity to attend university and experience 'university culture'. It feels like a rite of passage for many – moving away from home to become independent, socialising with like-minded students and often balancing part-time jobs whilst cramming for exams. As we know from our own recent experiences, there's no doubt that this ever-shifting student life can take a toll on our mental health – especially during a pandemic. This has led to students dropping out of university, moving back home, or becoming heavily reliant on crisis centres.

University mental health services have ramped up their provisions to educate students on mental wellbeing, to help people articulate their feelings and experiences and to provide support strategies. Despite these efforts, students with pre-existing mental health problems or those whose mental health problems emerge during university have voiced the need for more support and interventions, especially from services which have a student-centred approach. On top of this, higher education institutes (HEIs) and mental health services were aware that existing support structures were at their breaking point, overstretched and overburdened, which made it harder to meet the growing demand for student focused mental health care.

The Greater Manchester Universities Student Mental Health Service (GMUSMHS) was created in efforts to help students with complex needs improve their mental health, making their personal and academic lives more manageable by offering mental health assessments, support and interventions. Partnering with the NHS and the five Greater Manchester HEIs (The Universities of Bolton, Manchester and Salford, Manchester Metropolitan University and the Royal Northern College of Music), the GMUSMHS is a trailblazing commitment to ensure students get the support they need to do just that.

Students are referred to the GMUSMHS by their HEI's counselling and wellbeing service, making this a university-NHS partnership. It aims to smooth referral pathways and to ensure students are supported in a manner that reflects the timescales and complexities of student life. It is a sector-wide first and has been running as a pilot since October 2019.

Excitingly, the innovation didn't stop there. The University of Manchester along with paid student employees (which we call student partners) from each of the five Greater Manchester Universities were commissioned to complete a co-produced evaluation of the GMUSMHS. The service was created for students with complex mental health needs, but it also wanted to move towards being influenced by these students. Here, we explain how we achieved this, through co-production. We hope it inspires other organisations to take a similar stance.

Our Team

Co-production is a community approach to systems, where those involved in the system (for example, providers, funders, and users) contribute towards decisions about its direction and development. People and professionals work together to create systems that meet the needs of that community (Involve, 2018). Our community was the GMUSMHS, the HEI counselling and wellbeing services, and the student body – particularly the student union officers and, of course, the students using the services.

Funded by the Office for Students as part of the Student Mental Health Partnership Project, we were tasked with carrying out a co-produced evaluation of the GMUSMHS. Our team consisted of 11 Student Partners from the five Greater Manchester HEIs and a Project Coordinator with post-doctoral research and facilitation experience who worked with the Head of Campus Life at the University of Manchester.

To centre the student voice from the start, our Project Coordinator worked with Student Union Officers from the HEIs to recruit us, the Student Partners. Together, they developed the job description, application form and recruitment process and encouraged students from all fields with a passion for student mental health to apply. Two Student Union Officers then conducted interviews to offer a strong student perspective in candidate selection.

Learning about co-production

When we started working as Student Partners, we didn't know what co-production was or how to do it, which is why we are so excited to shed some light on this topic. We initially learnt about co-production by reading peer-reviewed published literature and key resources like the Student Minds' co-production guide and the Mind Influence and Participation toolkit. We found aspects of co-production that were important to us. For example, co-production can facilitate open lines of honest communication and reduce unequal power dynamics which empowers people to voice their opinions with dignity and respect. It also helps others understand users' experiences at a deeper level by uncovering nuances within every interaction (Faulkner et al., 2019).

Our Project Coordinator offered training on data protection and confidentiality, workshop building and communication, and often facilitated ideation sessions to support us in developing and following our own ideas. We received external training about the power of personal storytelling, project planning, understanding our skill sets, partnerships and influence, and, from Student Minds, co-production and student mental health. In the spirit of co-production, we also learnt skills from each other. Student partners delivered training on group facilitation, structuring podcasts, and generating I-poems (Edwards & Wellor, 2012). We shared knowledge from our university degrees, for example doing thematic analysis (Braun & Clarke, 2006).

Listening to the service users' stories

We recognised that the GMUSMHS users were the experts because they had received care from this service, they were intimately familiar with the experience of going through the care pathway, interacting with staff, and, in navigating the larger web of mental health services. If anyone is going to know how the service is really working, it's them!

Our Project Coordinator ran interviews with the leads of the HEI counselling and wellbeing services, and a workshop with student union officers to get a better understanding of what they thought was important to explore. We then condensed the list of questions gathered into three key themes to help guide our evaluation.

The first phase of our evaluation lasted three months. We developed our workshop and interview schedules, ran two trial workshops with GMUSMHS users and received feedback from them. We generated themes from the experiences that the GMUSMHS service users shared with us and fed back our findings to the GMUSMHS.

The second phase lasted a year, where we revised our workshop and interview schedules from the feedback received in the first phase. We stepped into the shoes of the service users by piloting these workshops with each other – giving us a sense of what it felt like to be a participant - and we reflected on our practice and got input from the team and Project Coordinator. We then tested our methods with students from HEI counselling and wellbeing services and finally held two workshops and six 1:1 interviews to evaluate GMUSMHS.

In workshops and interviews, we would start by going over some ground rules to let the participants know we wanted to create a safe enough, non-judgemental space, where we could fully understand their experiences. For example, we let participants know that they could drop out at any time without needing to give a reason, encouraged them to skip topics they didn't feel comfortable discussing and to share and respect differing views. These ground rules helped participants feel comfortable with each other too, not just with us, student partners. We then asked the service users to walk us through their journey with the service – their referral process, views about their care, choices they had, inclusivity, the pros and cons of the service, discharge processes, and the impact the GMUSMHS had on their lives including their university courses.

We naturally built rapport with the service users by finding common ground – talking about common student experiences and using phrases and references familiar to students today. In a way, it was easy because we, like them, had navigated mental health services ourselves, were figuring out how to be an 'adult' for the first time, we were trying to complete our education during a global pandemic and had concerns about our collective future. As we were also students in Greater Manchester, we wanted to help services focus on supporting students who face a unique set of challenges to 'survive' university, like meeting deadlines, trying to get a good degree, and managing the emotional and financial consequences of issues such as resits and interruptions.

What resulted from this ethos was reciprocity. The service users showed up as themselves and shared detailed stories about their experiences of navigating the GMUSMHS and the role it played in their life outside care. They were honest about what did and didn't work for them. For example, service users praised parts of the care pathway where they felt comfortable and heard, and we felt this was authentic because there was no pressure to please us as there might be with service staff. They also felt safe enough to tell us what was difficult for them. We knew this feedback would be hard to give directly to members of staff who were highly qualified and experienced, and service users might also be concerned that it would affect any future care with the service, but co-production helped us lower the barriers by being honest and, in a sense, vulnerable. Our approach allowed us to bridge the gap between the service users and staff by protecting the service users' identities which enabled them to speak on their own terms and articulate their stories authentically.

After the workshops, we debriefed with our Project Coordinator. This gave us an opportunity to talk through the experience of facilitating and to share any concerns for ourselves or our participants. We also had a distress protocol in place with our Project Coordinator who was available during workshops if we needed immediate support.

Seeing staff as community members too

Although our focus was on the students, co-production is a community approach, and the students were only one part of that community. Having spoken to service users, we started looking at our data and realised we were missing something. We had only explored the students' experiences of the service and the care pathways. To gain a wider understanding, we also needed to hear the views and experiences of the GMUSMHS staff and to understand the higher-level factors that may have impacted on the care they provided.

The GMUSMHS staff had helped us to understand the service structure, and to reach service users during the recruitment process. We attended GMUSMHS Operational Group meetings to link in with service staff and understand the context and development of this new service, and how they partnered with the referring HEI counselling and wellbeing services. Then, to understand how staff felt working in the GMUSMHS, we spoke to four members of staff with different roles using an interview schedule guided by the themes that emerged from talking with the service users.

Influencing change

After collecting the experiences of staff alongside the moving personal stories from service users, it was time to treat them like data. We thematically analysed each workshop and interview transcript, while highlighting powerful messages that stuck out (Braun & Clarke, 2006). We elevated the service users' voices and showcased their emotional impact by presenting our findings using their own words. We did this by creating I-poems, where each line of the stanza started with 'I' or were phrases which expressed a personal experience or opinion (Edwards & Weller, 2012). These resonated deeply with GMUSMHS staff, board members, and with partners in our Student Mental Health Partnerships funding group as it uncovered how much this service meant to students. Without co-production, staff said it would have been difficult to get such intricate and rich stories. The feedback we received helped us realise the plethora of benefits to co-production and inspired us to encourage its use in future work.

We also hosted a Sense-making Session with the GMUSMHS staff, which is a commonly used collaborative technique to improve shared understanding of research findings (Faulkner et al., 2019). Co-production was put into action as we worked together as a community to dig into the experiences of the service users, express which areas were of importance to us and respond with curiosity to the views of others. The session was developed by our Project Coordinator in conjunction with us and an external consultant with expertise in facilitating workplace change.

Firstly, we celebrated the work we had all achieved in the face of the pandemic and then explored service user quotes exemplifying key themes that emerged from our qualitative analysis. We drew out ways in which the service and care pathways had created a supportive space for service users and discussed the challenges highlighted in the service users' journeys. As the staff who attended had a range of roles and levels of experience, we used breakout rooms and time limited slots to ensure all voices were heard. At the end, we all fed back something that had been important to us during our discussions.

This approach allowed us to represent the voice of the service users, engage the staff in service users' journeys and bring the service and clinical expertise of the staff into the process of growing the service to further meet the service users' needs. We shared a summary of the session to remind staff of areas they wished to explore and develop, as well as giving them the full report of all our findings as these couldn't all be covered in the Sense-making Session.

In addition, we presented our work to the GMUSMHS board. We shared the personal journeys of the students through our key themes and I-poems, and how staff perspectives often overlapped with those of the students. As all of us realised that students' voices are critical to develop student-specific mental health services, we encouraged the GMUSMHS to make co-production an ongoing part of service development by appointing a co-production champion on the board. We raised the profile of what co-production is and why it's important.

Final thoughts

Through co-production, we have shown that students want to use their lived experiences to get involved and can make meaningful changes to their systems. Our team included students from a wide range of disciplines from music through social policy to psychology and medicine, as well as different personal backgrounds. This demonstrated that a diverse pool of thoughts and experiences paves the way for innovation – highlighting a key principle of co-production. We found we could empower ourselves and our communities to affect change and be part of the solution.

One of our biggest takeaways from this project has been that the possible ways in which co-production could be used are endless! Co-production is not an end goal, but a process and ethos of working. It elevates under-represented voices and ensures our systems and services are actively meeting the needs of the people they serve. Co-production is in no way trying to take over systems or jobs. It's about each person or group bringing their experiences and ideas to the table and then collectively making decisions.

We have a few tips for anyone who wants to incorporate co-production. Firstly, be ready to listen. Sometimes the truth about others' experiences can be wonderful and affirming, yet at times, it can be difficult to hear. Both are important to sit with! Secondly, aim to build an alliance between yourself and your community members. The whole point of co-production is system improvement and development, which means that the enemy is the way the system works – or doesn't, not your fellow community members. Of course, you will have differences of opinion, but also aim to recognise what you have in common, find shared goals and be ready to put yourself in others' shoes. Lastly, consider bringing in an intermediary. Try to pick those who are not direct current service users but still belong to the same community, such as our role as Student Partners for the GMUSMHS evaluation. Sometimes when topics are emotionally charged, it can be hard to have calm community-oriented discussions. Having trained empathetic mediators can help everyone feel heard and help bring those perspectives together.

We hope that this article has helped you better understand (and maybe even encouraged you to try) co-production. If you would like to hear more about this in action, check us out on our: 'Trust Me, I'm a Student' podcast, SPEQS Toolkit, Office For Students Mental Health Challenge Competition. You can also find a summary of our project on the UWE led Student Mental Health Partnerships project.

This article was written by two of the Student Partners, Anvita Vikram and Madeleine Siniscalchi, with the support of our Project Coordinator, Anita Banerji. However, all the Student Partners (Oluwatobi Adegboye, Caitlin Blackburn, Lili Chowdhury, Alice Flannery, Eleanor Gammon, Shaheen Hajira, Joseph Marshall, Sigourney Porter and Kiye Simister) contributed fully to creating a co-production team ethos and the goals of the project.

We would like to express our deepest thanks to Singhashri Gazmuri, Kathryn Entwistle, Student Minds, and Company of Mind who trained us to build our research and co-production skills.

We would like to thank Sarah Littlejohn (Head of Campus Life, The University of Manchester) who was instrumental in supporting this project; Simon Postlethwaite (Operational Manager, GMUSMHS), all GMUSMHS staff, and the staff of the five Greater Manchester HEI Counselling and Wellbeing Services for their support on this project, and Jamie Darwen (EDI Projects Lead, University of West of England) and our other partners in the Office for Students funded Student Mental Health Partnerships project for their encouragement and collaboration.

References

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101.

Broglia, E., Nisbet, K., Chow, H., Bone, C., Simmonds-Buckley, M., & Knowles, L. et al. (2022). Supporting Partnerships Between Higher Education And NHS Mental Health Services. Smarten.org.uk. 

Edwards, R., & Weller, S. (2012). Shifting analytic ontology: using I-poems in qualitative longitudinal research. Qualitative Research, 12(2), 202-217. 

Faulkner, A., Carr, S., Gould, D., Khisa, C., Hafford‐Letchfield, T., & Cohen, R. et al. (2019). 'Dignity and respect': An example of service user leadership and co‐production in mental health research. Health Expectations, 24(S1), 10-19. 

Greater Manchester Universities Student Mental Health Service. Greater Manchester Mental Health NHS Foundation Trust. (2019). 

Home - Office for Students. (2022). 

Piper R., & Emmanuel, T. (2022). Student Minds. Co-producing mental health strategies with students: A Guide for the Higher Education Sector. Student Minds, 2-99.

The Influence and Participation Toolkit. Mind. (2022). 

Student Mental Health Partnerships Project - Mental health and wellbeing | UWE Bristol. Uwe.ac.uk. (2022).

Student Partners, The University of Manchester. (2021). Trust me, I'm a Student [Podcast].