Co-Production and Trust in Underserved Communities: Making NHS Community Services Accessible in Practice
Trust is an operational issue. Where communities have experienced discrimination, poor communication, or repeated pathway failure, trust in NHS services can be low. That mistrust then shows up as delayed presentation, reluctance to disclose risk, non-attendance, and disengagement, reinforcing health inequalities. Co-production is one of the few approaches that can change this because it improves how services are designed and delivered, not just how they are described. This article supports Health Inequalities, Access & Inclusion and aligns with NHS Community Service Models and Pathways, because trust is built or lost at pathway touchpoints: referral, first contact, assessment, follow-up and discharge.
What co-production means when it is done properly
Co-production is often reduced to consultation events or feedback surveys. Inclusion-focused co-production is different: it involves people with lived experience influencing pathway rules, communication methods, and service interfaces. It is particularly important where services rely on self-advocacy, written information, or rigid appointment systems—features that often exclude the people with the greatest barriers.
For operational leaders, the key question is whether co-production changes decisions. If co-production outputs do not affect triage criteria, appointment models, communication standards, safeguarding follow-up or discharge practice, it is unlikely to reduce inequalities. Co-production must also be safe: participation should not expose people to harm, stigma or inappropriate disclosure, and the service must manage confidentiality and safeguarding risk.
Operational example 1: Redesigning first contact scripts and information to reduce anxiety and drop-out
Context: A community mental health interface pathway found high drop-out between referral and first appointment, especially among people with past trauma and people from communities reporting negative experiences with statutory services.
Support approach: The service co-produced a “first contact standard” with people who had previously disengaged. The focus was not messaging, but reducing fear and ambiguity at the first touchpoint.
Day-to-day delivery detail: Call handlers and clinicians adopted a short, consistent script: who the service is, what will happen next, what the person can expect, how information is used, and how to request adjustments. An easy-read and translated “what to expect” leaflet was sent by the person’s preferred channel. Staff were trained to offer choices (time, format, venue) and to check understanding using teach-back. If contact attempts failed, the service used a structured follow-up process involving referrers or trusted partners rather than assuming disengagement.
How effectiveness or change is evidenced: The service tracked completion of first appointment by cohort, drop-out rates, and feedback on clarity and reassurance. Improvements were evidenced by reduced pre-assessment drop-out and fewer complaints about communication and feeling “judged” or “dismissed”.
Operational example 2: Co-producing an inclusive appointment model with carers and low-income service users
Context: A community therapy pathway received repeated feedback that appointment times and locations were impractical for carers and people on low incomes, contributing to missed appointments and discharge.
Support approach: The service co-produced an appointment model that reduced practical barriers while maintaining clinical governance.
Day-to-day delivery detail: Co-production sessions identified specific barriers (travel cost, unpredictable caring responsibilities, fear of losing benefits if time off work was needed, difficulty accessing transport with mobility aids). The service introduced evening and weekend options, telephone follow-ups for stable cases, and community venue clinics near public transport. A discretionary transport-support pathway was agreed with commissioners and partners for specific cohorts. Staff were trained to offer flexibility consistently, not only when individuals “complained”.
How effectiveness or change is evidenced: The service monitored DNA rates by cohort, rebooking success, and discharge reasons. It also used short post-appointment feedback prompts to test whether changes reduced barriers. Evidence showed improved attendance and reduced inequitable discharge for missed appointments.
Operational example 3: Co-producing safe outreach pathways with people experiencing homelessness
Context: People experiencing homelessness often accessed care via crisis routes and struggled to engage with standard community services. Previous attempts at outreach failed because they were episodic and poorly linked to core pathways.
Support approach: The service co-produced an outreach pathway with people with lived experience and VCSE partners, focusing on continuity and safeguarding.
Day-to-day delivery detail: Outreach clinics were delivered at trusted venues with consistent staff presence to build relationships. A simple “continuity card” explained how to reconnect with the same team. Clinical records used a minimum dataset that could be completed quickly and later integrated into the main system. Safeguarding processes were built in: staff had clear escalation routes for exploitation, self-neglect and domestic abuse. Information sharing with housing and VCSE partners was governed through agreed protocols and consent processes.
How effectiveness or change is evidenced: The service tracked planned follow-up completion, reconnection rates after missed contacts, safeguarding escalations and outcomes, and urgent care usage. Governance minutes evidenced joint review meetings and action tracking to embed learning.
Commissioner expectation: Co-production must change pathways and produce measurable equity benefits
Commissioner expectation: Commissioners expect co-production to be purposeful and evidenced: who was involved, how participation was supported, what changes were made, and what difference those changes made to access, engagement or outcomes. Tokenistic engagement is increasingly challenged. Commissioners also expect services to show how co-production insight is translated into specifications, training, communication standards and pathway redesign.
Regulator / Inspector expectation: Responsive services that involve people and manage risk safely
Regulator / Inspector expectation (CQC): CQC expects services to involve people in decisions about care and to be responsive to diverse needs. Inspectors will look for evidence that services listen, learn and adapt, especially for people who face barriers to access. Where co-production involves outreach, flexible venues or alternative engagement methods, inspectors will also look for safeguarding assurance, risk management and documentation that demonstrates safe practice rather than informal arrangements.
Governance and assurance: making co-production auditable and defensible
To stand up to scrutiny, co-production needs governance. Credible mechanisms include:
- A defined co-production plan linked to inequality priorities, with clear objectives and measures.
- Documented outputs showing how lived experience changed pathway rules, information materials or appointment models.
- Quality review of whether changes are implemented consistently (record sampling, staff supervision themes, mystery-shopper style access tests).
- Safeguarding and confidentiality protocols for participation, including escalation routes where risk is disclosed.
- Re-measurement of access and engagement outcomes for the targeted cohorts to evidence impact.
When co-production is treated as a quality improvement discipline rather than an engagement exercise, it becomes one of the strongest tools available for reducing inequalities and improving access in NHS community pathways.