BACKGROUND: Innovations in coproduction are shaping public service reform in diverse contexts around the world. Although many innovations are local, others have expanded and evolved over time. We know very little, however, about the process of implementation and evolution of coproduction. The purpose of this study was to explore the adoption, implementation and assimilation of three approaches to the coproduction of public services with structurally vulnerable groups.

METHODS: We conducted a 4 year longitudinal multiple case study (2019-2023) of three coproduced public service innovations involving vulnerable populations: ESTHER in Jönköping Region, Sweden involving people with multiple complex needs (Case 1); Making Recovery Real in Dundee, Scotland with people who have serious mental illness (Case 2); and Learning Centres in Manitoba, Canada (Case 3), also involving people with serious mental illness. Data sources included 14 interviews with strategic decision-makers and a document analysis to understand the history and contextual factors relating to each case. Three frameworks informed the case study protocol, semi-structured interview guides, data extraction, deductive coding and analysis: the Consolidated Framework for Implementation Research, the Diffusion of Innovation model and Lozeau's Compatibility Gaps to understand assimilation.

RESULTS: The adoption of coproduction involving structurally vulnerable populations was a notable evolution of existing improvement efforts in Cases 1 and 3, while impetus by an external change agency, existing collaborative efforts among community organizations, and the opportunity to inform a new municipal mental health policy sparked adoption in Case 2. In all cases, coproduced innovation centred around a central philosophy that valued lived experience on an equal basis with professional knowledge in coproduction processes. This philosophical orientation offered flexibility and adaptability to local contexts, thereby facilitating implementation when compared with more defined programming. According to the informants, efforts to avoid co-optation risks were successful, resulting in the assimilation of new mindsets and coproduction processes, with examples of how this had led to transformative change.

CONCLUSIONS: In exploring innovations in coproduction with structurally vulnerable groups, our findings suggest several additional considerations when applying existing theoretical frameworks. These include the philosophical nature of the innovation, the need to study the evolution of the innovation itself as it emerges over time, greater attention to partnered processes as disruptors to existing power structures and an emphasis on driving transformational change in organizational cultures.

BACKGROUND: Recent years have seen a dramatic growth in interest in the nature and extent of co-production in the health and social care sectors. Due to the intense proliferation of work on co-production, there is intense variation in practice in how co-production is defined, understood and used in practice.

METHODS: We conducted a narrative review to explore, and provide an overview of, which models of health and social care co-production have been developed, applied and critiqued over the last few decades.

RESULTS: Seventy-three peer reviewed articles met our inclusion criteria. In this set of articles, we identified three broad types of models: conceptual/theoretical; practice-oriented; and presenting a typology. We found that practice-oriented models, predominantly from the Health Services Research and Quality Improvement literature, had largely not drawn on conceptual/theoretical models from the disciplinary fields of Public Administration & Management and Sociology. In particular, they have largely neglected theoretical perspectives on relationships and power and agency in co-production work, as well as the concepts of Service-Dominant Logic and Public Service-Dominant Logic as ways to think about the joint, collaborative process of producing new value, particularly in the context of the use of a service.

CONCLUSION: Our review has identified distinct literatures which have contributed a variety of models of health and social care co-production. Our findings highlight under-explored dimensions of co-production that merit greater attention in the health and social care contexts. The overview of models of co-production we provide aims to offer a useful platform for the integration of different perspectives on co-production in future research and practice in health and social care.

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Objectives: Analyse reported processes of co-design and co-production in the context of health and social care to explore the underlying mechanisms that enable inclusive and reciprocal engagement.

Search strategy: Peer review research was obtained from a prior scoping review searching eight databases consisting of all methodologies relevant to co-design or co-production in the context of health and social care services and involving service-users.

Methods of selection: Articles were included for synthesis if they reported a process of dialogue, with mutuality, insight and clarification in their engagement process. Ninety-three peer-review articles informed our programme theory development.

Analysis: Data relating to co-design and co-production processes were extracted and analysed through inductive, abductive, and deductive analysis leading to the development of an initial programme theory.

Main results: This realist synthesis finds that co-design and co-production can occur at different times, in part or all of the research and participatory process. There is an over reliance on the term ‘co-design’ or ‘co-production’ to convey complex engagement or participatory processes. We identified six mechanisms (intention, assets, dialogue, documentation, interpretation and understanding). Interaction between these six identified mechanisms in context, even if only brief, is important for supporting meaningful engagement, alignment and agreement within a co-design or co-production process.

Implications for practice: The initial programme theory presented in this article provides clarity by identifying essential mechanisms which can guide the design and implementation of a range of participatory approaches. Rather than relying on a single label to convey complex participatory methods or processes, the values and principles of co-design or co-production, in combination with this programme theory, could be applied to guide implementation and reporting of specific activities within a range of research or participatory methods.

Patient and public contribution: The initial programme theory was presented and piloted in a series of collaborative workshops between May 2023 and March 2024 with patient and public contributors, health professionals and researchers. This engagement process is currently underway to refine the programme theory and it is anticipated that this next phase will be completed in September 2024.

This paper explores leadership as a dynamic phenomenon, characterized by dialogical and negotiation processes. The study focuses on a company that differentiates itself with a non-hierarchical business structure promoting collective responsibility and self-leadership. Operating as a complex network without formally appointed managers, except for the legally mandated CEO, the organization embodies principles of agility, teamwork, and continuous reinvention. Taking departure in the results of our recent case study in the present organization (Bergmo-Prvulovic et al., forthcoming), this paper aims to understand how Holacracy (Robertson, 2007) as an analytical framework addresses the balance between autonomy and control, the distribution of power and of responsibilities, expectations on engagement, and different leader roles. What can the insights and lessons from Holacracy offer for managing the paradoxes in today's complex organizational environments?

Bergmo-Prvulovic and colleagues (forthcoming) employed a social representations theory approach to reveal and address the implicit values, ideas, and practices that shape leadership development among employees in the present company. Social representations are defined as: “a system of values, ideas and practices” (Moscovici 1973, xiii), with a dual function: establishing an order which enables individuals to orientate themselves and enabling communication among members of a community. Representations are socially, culturally, and contextually shaped through individuals’ communicative actions and daily practice (Jovchelovitch 2019; Marková 2003; Moscovici 2001). The study revealed a web of social representations of leadership and leadership development that shape the company’s values, ideas, and practices, forming a contextually characterized leadership development system. Furthermore, showing that the representations were both stable and dynamic, reflecting ongoing negotiations and conflicts in understanding. The results clearly show how the shared responsibilities distributed along with both various leadership roles and self-leadership causes confusions and conflicts. In contrast, leadership research typically emphasizes a functional perspective, focusing on individual leaders and their performance improvement (Fraher and Grint, 2018), which possible overlook the social, cultural, and contextual shaping of leadership and leadership development (Alvesson and Spicer 2012; Carroll 2019; Mabey 2013; Uhl-Bien and Ospina 2012). The results of the study demonstrated that uncovering hidden values, ideas, and perspectives can support organizational learning and cultivate a deliberate and purposeful approach to leadership development.

To explore how leadership can be both understood, practiced and developed in a flat business structure, this study applies the practice concept and management philosophy of Holocracy (Robertson, 2007) on the results of our recent study (Bergmo-Prvulovic et al., forthcoming). Holacracy redistributes authority and decision-making across an organization, promoting self-organization and autonomy (Robertson, 2007). By structuring teams around specific tasks and granting individuals the freedom to make decisions within their roles, Holacracy aims to foster innovation, enhance employee engagement, and drive organizational growth. The approach offers several benefits, including increased autonomy, improved agility, clarity in roles, and enhanced collaboration. Academic researchers have begun to examine sociocratic and holacratic organisations (Salovaara et al., 2024) and theorize new organizational forms that offers alternatives to hierarchy (Puranam et al., 2014). While practically employed in organizations, holacracy have been found to be technical and quite 'managerial,' often pushing pre-given solutions rather than supporting local approaches to self-organizing (ibid.) Challenges such as role ambiguity, decentralized decision-making, potential cultural shifts, and increased workloads can arise, as noted by Bergmo-Prvulovic and colleagues (forthcoming). Contrary to popular belief, voices have been raised that Holacracy is not non-hierarchical. Instead, it features a rigid hierarchy of self-governing circles, each subordinate to a higher circle that dictates its purpose and can modify or dissolve it if it fails to meet expectations.

Thus, since a holacratic system emphasizes democratic procedures within each circle, its structure is inherently hierarchical and inward-looking, focusing on internal governance rather than customer feedback or external outcomes. This critique underscores the complexity and potential limitations of adopting Holacracy as an organizational strategy. The results of the uncovered leadership representations in the specific business environment explored here reveal tensions regarding responsibilities and commitments, as well as between leadership as an individual or a collective act. Additionally, fostering a self-leadership culture presents both difficulties and possibilities, challenging traditional divisions of labor, roles, and responsibilities. Koistinen and Vuori (2024) underscores this, exploring five organizations that experimented with more self-managing practices. When authority relations between 'leaders' and 'followers' were weakened, it created asymmetries of responsibility, pushing the authoring of organizational arrangements to include both shared and hierarchical forms of control.

Our study illustrates the changing nature of leadership and how the meaning of leadership needs to be continuously renegotiated and recaptured in practice, especially in times of growth. The circular structure is in constant movement, and when new employees enter the circle of structure, they bring their own meanings ascribed to leadership as a phenomenon, not always compatible with the meanings of leadership that Holocracy aims at. 

BackgroundAs coproduction in public services increases, understanding the role of leadership in this context is essential to the tasks of establishing relational partnerships and addressing power differentials among groups. The aims of this review are to explore models of coproduction leadership and the processes involved in leading coproduction as well as, based on that exploration, to develop a guiding framework for coproduction practices.MethodsA systematic review that synthesizes the evidence reported by 73 papers related to coproduction of health and welfare.ResultsDespite the fact that models of coleadership and collective leadership exhibit a better fit with the relational character of coproduction, the majority of the articles included in this review employed a leader-centric underlying theory. The practice of coproduction leadership is a complex activity pertaining to interactions among people, encompassing nine essential practices: initiating, power-sharing, training, supporting, establishing trust, communicating, networking, orchestration, and implementation.ConclusionsThis paper proposes a novel framework for coproduction leadership practices based on a systematic review of the literature and a set of reflective questions. This framework aims to help coproduction leaders and participants understand the complexity, diversity, and flexibility of coproduction leadership and to challenge and enhance their capacity to collaborate effectively.

Leadership development (LD) plays a significant role in achieving high-quality performance and business results, but there is little research on how leadership development itself evolves as the organization develops. This study explores how a leadership development system evolved over 30 years, during a time when the organization became increasingly high performing. Through reflexive thematic analysis of organizational documents and interviews with top managers and practitioners, the study provides a rich longitudinal description of the evolvement. The results revealed three pervasive changes of the leadership development system: 1) from a system for business-specific learning to one for system-wide learning; 2) from a system for personal development to one for customer-oriented quality development; and 3) from a leadership development system consisting of leadership development programs to one that is integrated into regular meetings and uses simple rules. These changes supported the gradual transformation of the leadership development from being independent to becoming integrated in the wider system, supporting the business system. The findings offer a unique insight into how an organization transitioned from individual leader development towards promoting collective aspects of leadership development. The study provides two main theoretical contributions that support the perspective of viewing leadership development as integrated within organizational development. Firstly, we present a more multifaceted way of understanding leadership development, wherein managers and employees, customer outcomes, and business advancement are seen as mutually developing. Secondly, we introduce two new critical points that complement previous descriptions of an advanced leadership development system: It is system wide (not only business specific) and customer oriented (not only leader/participant oriented).

Organizations, communities and societies are faced with ever more complex challenges such as public health problems. Attempts to address such challenges require involvement of various actors ranging from state and regional authorities to non-governmental organizations and individuals. Additionally, many of those that are delivering social care services are with different professional backgrounds and belong to different departments. Such partnerships create ground for complex relationships between the actors involved in each project. As a result, such actors find themselves in complex and volatile contexts where the questions of who, when and where to take the lead are, often, ambiguous. Leadership is an integral part of any organization’s practices (Schedlitzki et al.,2023). However, theories of leadership have primarily focused on boosting individual leaders’ successes within systems, thus curtaining the relational aspects of leadership. Like Uhl-Bien(2021a), we understand leadership as a co-creation. Yet, the knowledge on the necessary competence to manage such projects and what enables cooperation and adaptability is limited. Thus, our overall aim is to further the understanding of how co-creative leadership can enable interconnectivity and adaptability in complex systems.

The context for this presentation is a new project on competency supply in social care services. A general shortage of different kinds of professionals has urged the municipality in a medium sized town in Sweden to create cross departmental projects which seek to explore new ways of managing staff shortage issues. Through follow-up research in the form of process evaluations, our focus is on how the project affects the larger system in which it is part of. Our research will be exploratory, and informed by complex system perspectives, such as complexity leadership theory (Uhl-Bien etal., 2007; Uhl-Bien, 2021b), generative emergence (Lichtenstein, 2014; 2021) and complex systems perspective (McGill, 2021), on the one hand, and co-creative leadership perspectives (Denis et al., 2012; Kjellström et al., 2020), on the other.

Our ambition is to address the following research questions:

1. How a cross department project evolves over time and how what happens can be illustrated and explained based on theories of complexity?
2. If and how a co-creative leadership is used, and why and how certain approaches to leadership allow adaptive responses, while others hinder them?
3. How continuous improvement is integrated in the management of the project?
4. How is leadership developed in daily practice throughout the project?

We will utilize a mixed methods approach, and, as a first step, use shadowing of project meetings (Czarniawska, 2007). Through shadowing, we aim to “be there” when the practices occur, and to see first-hand what, and how it, happens. This would allow us to notice things that our study objects do not necessarily think of sharing during a regular interview. The shadowing process will start in September 2023, and we plan to have a learning seminar with all parties involved in November 2023, where our initial observations are shared with researchers and municipality professionals. Our goal for the conference is to present our early findings and discuss future avenues of this project which is under way.