Epistemic injustice and co-production in healthcare
Service User Involvement, Co-Production and Healthcare Quality Improvement: Addressing the Case of Epistemic (In)justice
During the January MCHP seminar, we had Arbaz Kapadi, Research Associate at the MCHP, give an insightful talk on service user involvement, co-production and healthcare quality improvement. Arbaz discussed how there has been renewed impetus for the involvement of service users in the design and delivery of healthcare services over the last decade, yet several barriers, many indicative of power asymmetries, continue to be observed in practice. In particular, Arbaz argued how the concept of epistemic (in)justice (Fricker, 2007) – an individual’s capacity and right to develop, hold and share knowledge – might be useful to understand how service user knowledge is mobilised in participatory spaces.
Towards the Co-production of Quality Improvement (QI)
Participatory ‘co-’ approaches (co-design, co-production, co-creation) are propositioned on transforming service relationships through merging of different values, knowledge and sharing of power. Justifications for involving service users in QI are premised on the value of their lived experience knowledge (a technocratic rationale) and their right to influence decisions that may impact on their health status or the health services they receive (a democratic rationale) (Williams et al., 2020).
Whose Knowledge? What Knowledge? The Case of Epistemic (In)justice
Drawing upon results of an empirical study, the presentation discussed how the space of knowledge exchange in QI is tightly controlled by professionals, leaving little room for service user participation. This occurs for a number of reasons that include credibility judgements of service users and the knowledge they provide e.g. ‘knowledge is too subjective’, ‘service users can be unpredictable’, ‘service users fail to be representative’. Subsequently, Arbaz argued how current mechanisms in the organisation and practice of QI lead to service users encountering potential epistemic injustices. That is, the knowledge of service users is unfairly excluded from the very spaces that call for it.
Arbaz emphasised the importance of critical reflective practice – ‘epistemic humility’ – to counter assumptions and prejudices held about service users. He also spoke about the need to pay attention to the relational dynamics of the service user-professional relationship and structural mechanisms that inhibit service users from getting involved in QI (Batalden, 2018). Importantly, concentrating on making QI practices epistemically just may entail greater integration of service users, leader to closer alignment with the vision of ‘co-produced QI’.
Batalden, P. B. (2018). Getting more health from healthcare: Quality improvement must acknowledge patient coproduction – An essay by Paul Batalden. BMJ, 362, 4-7.
Fricker, M. (2007). Epistemic Injustice: Power and the ethics of knowing. New York: Oxford University Press.
Williams, O., Robert, G., Martin, G. P., Hanna, E. and O’Hara, J. (2020). Is Co-Production Just Really Good PPI? Making Sense of Patient and Public Involvement and Co-Production Networks. In M. Bevir and J. Waring (Eds.), Decentring Health and Care Networks, Organizational Behaviour in Healthcare. (pp. 213-237). Palgrave Macmillan.