Health Care Analysis

, Volume 20, Issue 3, pp 268–280 | Cite as

Conflict in Medical Co-Production: Can a Stratified Conception of Health Help?

Original Article


This paper considers proposals for developing ‘co-productive’ medical partnerships, within the UK National Health Service (NHS), concentrating in particular on the potential problem involved in combining professional and lay conceptions of health. Much of the literature that advocates the introduction of co-productive healthcare partnerships assumes that medical professionals and patients share, or can easily come to share, a common set of beliefs about what is valuable with regard to health interventions and outcomes. However, a substantial literature documents the contestability of the concept of health, particular across professional and lay divides. We suggest that this potential disagreement ought to be taken seriously, and suggest that the prospect of a co-productive NHS in which patients and professionals act in partnership is threatened by the existence of unresolved epistemic differences. We suggest that part of the solution may lie in re-framing this potential disagreement in the terms provided by Engel’s bio-psycho-social account of health, and demonstrate how support for this account can be grounded upon a critical realist foundation. What we call a ‘stratified conception of health’ reveals the potential complementarity between health beliefs which may have at first seemed to be essentially contradictory. We consider some of the practical implications this idea has for conceiving and creating co-productive medical partnerships.


Bio-psycho-social Co-production Critical realism Medical partnership NHS Patient choice Personalisation Shared decision making 


  1. 1.
    Bhaskar, R. (1998). The possibility of naturalism. London: Routledge.Google Scholar
  2. 2.
    Bhaskar, R. (2008). A realist theory of science. Abingdon: Routledge.Google Scholar
  3. 3.
    Bhaskar, R. (2009). Scientific realism and human emancipation. Abingdon: Routledge.Google Scholar
  4. 4.
    Bhaskar, R., & Danermark, B. (2006). Metatheory, interdisciplinarity and disability research: A critical realist perspective. Scandinavian Journal of Disability Research, 8, 278–297.CrossRefGoogle Scholar
  5. 5.
    Boorse, C. (1977). Health as a theoretical concept. Philosophy of Science, 44, 542–573.CrossRefGoogle Scholar
  6. 6.
    Bury, M. (1998). Postmodernity and health. In G. Scambler & P. Higgs (Eds.), Modernity, medicine, and health: Medical sociology towards 2000 (pp. 1–29). London: Routledge.Google Scholar
  7. 7.
    Canguilhem, G. (1991). The normal and the pathological. New York: Zone Books.Google Scholar
  8. 8.
    Danermark, B. (2002). Interdisciplinary research and critical realism: The example of disability research. Alethia, 5, 56–64.Google Scholar
  9. 9.
    Daniels, N. (1985). Just health care. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  10. 10.
    Daniels, N. (2008). Just health: Meeting health needs fairly. Cambridge: Cambridge University Press.Google Scholar
  11. 11.
    Department of Health. (2004). Better information, better choices, better health. London: DH Publications.Google Scholar
  12. 12.
    Department of Health. (2008). High quality care for all: NHS next stage review final report. London.Google Scholar
  13. 13.
    Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136.PubMedCrossRefGoogle Scholar
  14. 14.
    Groopman, J. E. (2007). How doctors think. New York: Houghton Mifflin Harcourt.Google Scholar
  15. 15.
    Heath, I. (2003). A wolf in sheep’s clothing: A critical look at the ethics of drug taking. British Medical Journal (Clinical Research Edition), 327, 856–858.CrossRefGoogle Scholar
  16. 16.
    Jennings, D. (1986). The confusion between disease and illness in clinical medicine. Canadian Medical Association Journal, 135, 865–870.PubMedGoogle Scholar
  17. 17.
    Loewy, E. (2005). In defense of paternalism. Theoretical Medicine and Bioethics, 26, 445–468.PubMedCrossRefGoogle Scholar
  18. 18.
    Marinker, M. (1997). Personal paper: Writing prescriptions is easy. British Medical Journal, 314, 747.PubMedCrossRefGoogle Scholar
  19. 19.
    Marmot, M. (2005). Social determinants of health inequalities. The Lancet, 365, 1099–1104.Google Scholar
  20. 20.
    Marmot, M., et al. (2010). Fair society, health lives: Strategic review of health inequalities in England post 2010. London: University College London.Google Scholar
  21. 21.
    Mol, A. (2008). The logic of care: Health and the problem of patient choice. London: Routledge.Google Scholar
  22. 22.
    National Prescribing Centre. (2007). Introduction to medicines concordance & adherence to treatment. Available online at
  23. 23.
    Nordenfelt, L. (1995). On the nature of health: An action-theoretic approach. London: Kluwer.Google Scholar
  24. 24.
    Royal Pharmaceutical Society of Great Britain. (1997). From compliance to concordance achieving shared goals in medicine taking. London: Royal Pharmaceutical Society.Google Scholar
  25. 25.
    Sandman, L., & Munthe, C. (2009). Shared decision-making and patient autonomy. Theoretical Medicine and Bioethics, 30(4), 289–310.PubMedCrossRefGoogle Scholar
  26. 26.
    Seedhouse, D. (2001). Health: The foundations for achievement (2nd ed.). Chicester: Wiley Blackwell.Google Scholar
  27. 27.
    Segal, J. Z. (2007). “Compliance” to “concordance”: A critical view. The Journal of Medical Humanities, 28(2), 81–89.PubMedCrossRefGoogle Scholar
  28. 28.
    Shorter, E. (1991). Doctors and their patients: A social history. Piscataway: Transaction Publishers.Google Scholar
  29. 29.
    Stilgoe, J., & Farook, F. (2008). The talking cure. London: Demos.Google Scholar
  30. 30.
    Tannen, D. (1998). The argument culture: Moving from debate to dialogue. New York: Random House.Google Scholar
  31. 31.
    Walker, R. (2008). Medical ethics needs a new view of autonomy. Journal of Medicine and Philosophy, 33(6), 594–608.PubMedCrossRefGoogle Scholar
  32. 32.
    Wirtz, V., Cribb, A., & Barber, N. (2007). The use of informed consent for medication treatment in hospital: A qualitative study of the views of doctors and nurses. Clinical Ethics, 2, 36–41.CrossRefGoogle Scholar
  33. 33.
    World Health Organization. (1946). WHO definition of health. Available online at:
  34. 34.
    World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Centre for Public Policy ResearchKing’s College LondonLondonUK

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