The healthcare system’s current participation and co-production practice with diverse and marginalised communities remains, at best, extremely variable. At its worst, it can be actively harmful in its exclusion of some of the most marginalised voices in society.
All too often, we see piecemeal, extractive activity, which communities are expected to shoulder with little agency or sustainable funding. This prevents effective action to tackle ethnic health inequalities, exacerbates mistrust, and fuels disengagement with healthcare services.
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Central to the government’s 10-Year Health Plan, neighbourhood health services will bring NHS care closer to home and provide better support for people, including those with complex conditions, keeping them well and avoiding unnecessary hospital trips. At the heart of this ambition will be the approach to embed impactful community participation and co-production practice across all levels of the healthcare system – from strategic planning and commissioning to the design, delivery and evaluation of care.
Communities with the greatest need and those for whom healthy life expectancy is lowest are the focus of attention first – and rightly so. As we know, a focus on deprived areas alone is insufficient in tackling some of the deep-seated and long-standing challenges, including those related to ethnic and racial inequalities in health. After all, deprivation can tell you where the inequality may exist, but not why it exists.
The evidence is clear: repeated exposure to racism leads to an accumulation of disadvantage and poorer health over the life course. We know racism affects health in three interrelated ways. Firstly, experiencing racism directly damages physical and mental health. Secondly, racism damages health through the inequitable operation of the healthcare system and other services. Thirdly, and critically, racism can be a cause of socioeconomic disadvantage and lead to adverse exposure to the social determinants of health, which undermine health.
The effects of racism contribute to avoidable inequalities in health between ethnic groups – a particularly unacceptable form of health inequity. There is, therefore, a level of urgency for us, as a society and as a healthcare system, to focus on tackling the damage to health and wellbeing as a result of racism. The NHS has an important role to play – genuine engagement and meaningful co-production, with all communities, will be critical to success.
Core principles of effective co-production, participation and engagement:
- Involve communities at the earliest opportunity and throughout the process
- Understand your communities
- Build trust and mutually beneficial relationships
- Facilitate power-sharing
- Be flexible and adaptable
- Embed monitoring, evaluation, and co-learning
True inclusion means actively partnering with those typically excluded from healthcare decisions – ensuring their voices shape priorities, design, implementation and outcomes. It goes beyond simple consultation to the point of genuinely sharing power with communities. By embedding this principle into planning and delivery, healthcare systems can begin dismantling long-standing power imbalances that contribute to racial injustice. Involvement must not be “symbolic”, but system-wide, intentional, and ongoing to ensure equity is ingrained at every level – driving lasting transformation towards a more just and inclusive healthcare system.
The NHS Race and Health Observatory is working to co-produce a practical living resource that supports national, regional, and local healthcare bodies to reinforce community participation and co-production at the heart of their work, working closely with the National Neighbourhood Health Implementation Programme (NNHIP). The resource will be designed for use by integrated care boards, local government, providers, and other organisations supporting health and care. It will enable meaningful partnership with diverse and marginalised communities, patients, and healthcare workers, as well as with voluntary, community and social enterprise organisations that champion them.
The fundamental principles of meaningful engagement and co-production with diverse communities include building trust and partnerships, fostering two-way communication and collaboration, ensuring inclusivity, showing respect for community expertise, and creating mechanisms for accountability and feedback. These principles, alongside the persistent drive to tackle racism, need to be central if we are to shift healthcare closer to where people live. Only with this approach can we build a healthcare service that will truly be fit for everyone.
