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The opening two decades of the 21st century can arguably be characterised as a period of continued technocratic consensus about the need for a better articulation between evidence and public services, alongside rising contestation about how that relationship should be realised. This has been accompanied by an increase in the range of data that are amenable to analysis, synthesis and use (see Chapter Ten) and a broadening of notions of evidence that are seen as legitimate (see Chapter Eleven). At the same time, however, there has been some disillusionment – itself informed by a growing body of knowledge – about the feasibility of a straightforward path from evidence generation, through policy formation (the challenges of which are articulated in Chapter Two) and into implementation in service delivery (the focus of this chapter).

We explore these developments with a particular emphasis on evidence-informed service delivery. First, we describe traditional ‘top-down’ approaches to the dissemination and implementation of evidence. Despite rhetoric to the contrary, these approaches remain important in many public services, backed by sometimes rigid and powerful regimes of audit, inspection and rating. However, their limitations are increasingly acknowledged, and the second section outlines critiques of such approaches and describes ‘bottom-up’ alternatives that rely on more localised evidence generation and utilisation, often with a view to incorporating wider forms of knowledge. In the third and fourth sections we consider approaches to the sharing of knowledge and evidence within and across public service organisations, and the challenges in so doing, and then highlight a number of cross-cutting challenges to the use of evidence in service delivery.

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Volume 1: The Challenges and Necessity of Co-production

EPDF and EPUB available Open Access under CC-BY-NC-ND licence. Groups most severely affected by COVID-19 have tended to be those marginalised before the pandemic and are now largely being ignored in developing responses to it.

This two-volume set of Rapid Responses explores the urgent need to put co-production and participatory approaches at the heart of responses to the pandemic and demonstrates how policymakers, health and social care practitioners, patients, service users, carers and public contributors can make this happen.

The first volume investigates how, at the outset of the pandemic, the limits of existing structures severely undermined the potential of co-production. It also gives voice to a diversity of marginalised communities to illustrate how they have been affected and to demonstrate why co-produced responses are so important both now during this pandemic and in the future.

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The COVID-19 pandemic has drastically altered people’s lives. While pandemics have of course occurred before, for modern times COVID-19 has been unusually destructive and inhibitory in scale. However, what this pandemic shares with previous ones is having a disproportionately detrimental impact on people who were already disadvantaged by structural inequalities before the pandemic began (Bambra et al, 2020; Marmot et al, 2020). The virus has been particularly pervasive and destructive in its impact on Black, Asian, and minoritised ethnic groups; people of lower socioeconomic status; people in undervalued employment; people living in deprived areas, poor housing, and/or overcrowded accommodation; older people; disabled people; people with learning difficulties; people with psycho-social disabilities; and people with long term conditions – especially those who rely on social care. This has caused us to reflect on the relative strengths and weaknesses of approaches typically taken in modern politics and public policy in general, and health and social care specifically, as well as to consider alternatives that could better serve us in the future. For us, key among these alternative approaches is co-production.

Predictably, those most severely affected by COVID-19 are the people and groups who are now largely being ignored in developing responses to the pandemic and consequently are further detrimentally impacted by it – in many cases fatally. Co-production offers an alternative. It is consistent with efforts to challenge the exclusionary nature of much ideology underpinning health and social care policy and practice and to move to more inclusive and participatory approaches (Beresford, 2021).

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The COVID-19 pandemic has drastically altered people’s lives. While pandemics have of course occurred before, for modern times COVID-19 has been unusually destructive and inhibitory in scale. However, what this pandemic shares with previous ones is having a disproportionately detrimental impact on people who were already disadvantaged by structural inequalities before the pandemic began (; ). The virus has been particularly pervasive and destructive in its impact on Black, Asian, and minoritised ethnic groups; people of lower socioeconomic status; people in undervalued employment; people living in deprived areas, poor housing, and/or overcrowded accommodation; older people; disabled people; people with learning difficulties; people with psycho-social disabilities; and people with long term conditions – especially those who rely on social care. This has caused us to reflect on the relative strengths and weaknesses of approaches typically taken in modern politics and public policy in general, and health and social care specifically, as well as to consider alternatives that could better serve us in the future. For us, key among these alternative approaches is co-production.

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Our title quotes what British Prime Minister Boris Johnson reportedly said when comparing his COVID-19 experience (which required intensive care) with cabinet members who had mild symptoms. It is suggested that Johnson’s brush with mortality profoundly impacted him – it was followed by public declarations to lose weight and policy shifts he previously would have likely dismissed as nanny statism. While it is politically convenient for Johnson to link the severity of his illness (and by inference the impact of the virus more generally) with factors popularly promoted as within individual control (for example, bodyweight), he is not alone in exploiting this pandemic to promote simplistic and stigmatising ideas about bodyweight and health.

Although not popularly known or accepted, in recent decades research, advocacy, and activism has made significant progress in demonstrating the complexity of relationships between bodyweight and health, the multifaceted and interrelated biological, psychological, and social causes of ‘obesity’, and how common (mis)conceptions and prejudice ultimately promote discrimination of people who variously identify as (among others) Fat, higher weight, and living with obesity. Responses to the COVID-19 and Body Mass Index (BMI) link have largely ignored this. The urgency of a pandemic, and opportunism of those with vested interests in over-emphasising personal control and responsibility, create a perfect storm for harming people across the weight spectrum – particularly those above and below what is considered ‘healthy’. We consider evidence that has been ignored and ways this pandemic is disproportionately harming those who transgress medically and/or popularly ‘acceptable’ bodyweight and eating norms – drawing on personal experiences of transgressing these norms, providing healthcare to those with eating disorders, and academic expertise (including that imbued with related ‘lived experience’).

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In the introduction to this volume, we outlined how the COVID-19 pandemic has highlighted the need to better understand and utilize co-produced responses to improve public policy, political responses, and health and social care research and practice. However, there are extensive constraining social structures that inhibit working in this way. The experiences of the most exposed, marginalised, and discriminated – in short, those who are systematically excluded in our societies – rarely directly influence the policies and practice that are ostensibly created for their protection. Crucially, given the disparities in the risk and outcomes of COVID-19, why are these people and communities not considered best placed to create and implement sought-after solutions for effective management, improvement, and research of pandemic responses?

Through this book, we wanted to:

  • explore how so many people are ignored, disempowered, and discriminated against in health and social care research, policy, and practice;

  • address how and why more collaborative, diverse, and inclusive responses could lessen the toll of this pandemic and future health emergencies, as well as more generally improve health and social care research, policy, and practice;

  • illustrate how and why collaborative ways of working can help to address the social wrongs and power imbalances that we need to right.

In particular, this volume set out to explore: (1) the impact of existing structures on ambitions and efforts to work in more participatory and collaborative ways in health and social care research, policy, and practice, and (2) how the pandemic has highlighted and exacerbated existing inequities and marginalisation both in practice and research. The collection has demonstrated through a diverse range of examples the impact of the pandemic on people’s lives and ways of working.

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Open access