Co-design: Do we need to (co-)change our (co-)thinking?

Abstract

The origin of co-design is first traced back to the ‘northern’ and ‘southern’ traditions of participatory research. The ‘northern’ tradition of Kurt Lewin (1948) promoted empowerment and social equity through action cycles as means of work that was ‘with’ or ‘by’ marginalised groups rather than ‘to’, ‘on’, or ‘for’. The ‘southern’ tradition from Freire (1970) had origins in emancipatory theory and posited that people should be active in determining their own needs and solutions, as full participants in any form of inquiry. At the core was the philosophy of inclusivity and agency of the group of focus in the process of inquiry and not as the focus of the inquiry. The participatory co-operative design tradition of Scandinavia emerged from this background in technology and information system projects during the 1970–1980s. The projects incorporated a politically based desire to increase democracy within the workplace and promote inclusion of the workforce in the design processes of the computer systems utilised by their organisations (Bødker et al., 2000; Gregory, 2003). This work from Scandinavia is regularly cited as the origin of the term ‘co-design’ and the evolution of experience-based co-design (EBCD). Initially developed and piloted as evidence-based design within a UK health service design project, EBCD has become the participatory design method of choice for healthcare quality improvement.

EBCD was devised to promote participatory action research, user-centred design, learning theory, and narrative-based approaches to change (Donetto et al., 2015). However, recently, it has been highlighted that the co-design aspect may at times be lost in translation (Donetto et al., 2015). We agree and propose that the toolkits developed for EBCD have led to the process becoming the focal point, while the skills, principles, and approaches necessary to authentically power share and privilege the voices of the individuals and collectives has been lost. Or as recently highlighted by Dancis et al. (2023), EBCD has become a ‘watered down, de-politicised, checklist approach’, which is at risk of not honouring the power-sharing, user-driven intent of the Scandinavian tradition of participatory research. Increasingly this issue appears to extend beyond EBCD and to any project claiming to utilise co-design.

Collaboration, capability building empowerment, and positive societal impact are principles that should be at the core of co-design (Greenhalgh et al., 2016). This requires careful attention to iterative and flexible approaches that support power sharing, shared decision making, and sustained consumer and community engagement (Butler et al., 2022). The widespread adoption of co-design appears to have been accompanied by inconsistent attention to these fundamental principles and approaches. Service development activities within healthcare contexts are often tagged as co-design despite being better described as a service-led consultation. Research projects labelled as co-design may not incorporate the required power-sharing and user (consumer) driven intent throughout all stages of the project. Within a design context, there has been a notable evolution from prioritising aesthetic appeal and function towards a more human-centred approach, with an emphasis on co-design to fulfil the needs of people. Yet, within the design field the delivery of co-design continues to often rely heavily on the designer's interpretation. In practical and educational settings, this can often look more like a user observational design approach, with the user not the focus of the processes rather they are invited to provide feedback of design features in the form of a consultation.

We are at a significant crossroads in the evolution of participatory approaches, which we should not ignore. Lived experience experts (consumers) tell us that they often feel unheard during co-design processes and as a result, outcomes are not fit-for-purpose. They feel that co-design should be an experience of collaboration and contribution rather than participation and co-operation. This is a semantic distinction that carries profound implications for consumers. They believe that inadequate opportunities to collaborate and contribute has compromised the outcomes and quality of previous co-designed processes and solutions. A focus on the steps and limited attention to the principles and approaches essential for authentic collaboration have led to lost opportunities to elevate outcomes from ‘okay’ to ‘great’.

There is a need to critically review when and how the term co-design is used to describe our design and research activities. It appears that co-design has become widely used to describe processes that fail to include the foundational principles and approaches supportive of participatory, user-centred methods. We are concerned that the widespread overuse may mean that accountability for the correct application of the term may no longer be possible. Perhaps it is time for the evolution of the next iteration of consumer-driven participatory approaches within disability and healthcare settings. If so, in the spirit of collaboration and contribution, we would strongly recommend that we look to our consumers and communities to learn from each other and shape this participatory future together.

The authors have no conflict to declare.