by Uisce Cooney-Newton, REALITIES Early-Career Researcher

As public services grapple with complex, interconnected, and cross-sectoral societal challenges, co-production has become an increasingly prominent ambition in policy and practice.y By bringing lived experience perspectives into how problems are understood and responses are developed, it promises to make public services more responsive to the complexities and contexts of people and communities. In Scotland, this ambition is reflected in fifteen years of commitments to community empowerment and prevention (The Scottish Government 2011, 2025a, 2025b). However, inclusion does not guarantee systems change. We should be cautious about assuming that co-production alone has the capacity to transform the systems within which it operates, especially when its insights challenge rigid systems and call for upstream action.

Co-production is an organising principle for many creative, community-based, and nature-based health projects. Rather than just including lived experience perspectives, they are guided by lived experience practice: building relationships and trust precedes data collection, approaches are iterative to allow for collaboration, and activities are often open-door and ongoing rather than bounded trials. Such principles can sit uneasily alongside conventional health economic evaluation, which relies on baseline data, standardised quantitative questionnaires, defined participant groups and intervention periods. While these approaches offer consistency and comparability, they struggle to capture context, fluctuating outcomes, and the qualities of experience that cannot easily be expressed on a scale of one to five.

Emerging work in Creative Health Economics has made important progress in translating evidence of creative health’s benefits into forms valued by public institutions. Guidelines on Economic Evaluation in Creative Health (Fujiwara et al. 2026) and Creative Health Economics: building the foundations for a commission-ready sector (McNeill et al. 2026) offer practical approaches to ensuring that creative health is recognised within healthcare commissioning and public health investment decisions. Yet the dominance of economic paradigms, and the methodologies through which they define credible evidence, raises a question: to what extent can co-production transform knowledge structures that govern investment decisions, rather than simply creating minor reforms within an existing framework?

This is an epistemological as well as a methodological problem: neoclassical economics has a profound influence on what we understand as ‘value’. Polanyi ([1944] 2024) describes how the logic of economic markets infiltrates non-market domains, creating a ‘market society’ that requires the ‘fictitious commodification’ of intrinsic value. This is evidenced in public health initiatives’ need to translate intangible, relational, and subjective benefits into economic returns to be recognised as legitimate investments. Marx’s ([1867] 1990) distinction between use-value and exchange-value furthers this understanding: something can be profoundly useful in meeting personal and communal needs without necessarily generating a high financial return on investment. This narrow understanding of value as ‘value for money’ requires those intangible, relational, and subjective benefits to be quantified and monetised, privileging economic representations of value at the expense of other ways of experiencing, understanding, and expressing what matters to people and communities.

These assumptions have political consequences. Economic evaluations can inform decisions about resource allocation, but their market-orientation risks privileging what is measurable over what matters, and immediate downstream wins over long-term upstream ones. The result is a tension between public health’s preventative ambitions and investment approaches that are determined by reactive crisis management and short-termism. An investment framework which disincentivises meaningful action on the social determinants of health is myopic, and the urgency of this tension in Scotland is stark: despite ostensibly progressive policies, life expectancy differs by 13.6 years for women and 16.3 years for men between the most and least deprived areas (Marmot et al. 2026).

This is all the more critical because access to cultural and social participation that can support health is itself shaped by inequality. In 2019, 62% of adults in Scotland’s most deprived areas participated in cultural activities, compared with 85% in the least deprived areas (The Scottish Government 2020). Evidence shows that education, socioeconomic status, and parental socioeconomic status predict arts participation and cultural engagement (Mak et al. 2020). Given the role of the arts in health prevention, promotion, management, and treatment (Fancourt and Finn 2019), this creates a double disadvantage: those facing the greatest structural disadvantages are more likely to experience poorer health, while also having fewer opportunities and resources to access activities that support health and wellbeing. As Marmot et al.’s (2026) recent report highlights, it is inequalities in income, wealth, and social conditions, rather than just healthcare design, which drive health inequalities in Scotland. The efficacy of public health policies cannot be separated from the material conditions in which people live, including low real wages, austerity, and regressive social policies.

Health economic evaluations risk limiting systems change in two ways: by privileging quantified and monetised representations of value, they can overlook the intrinsic and relational value of health and wellbeing; and by focusing on discrete interventions and measurable returns, they can favour downstream treatment over preventative action. To meaningfully engage with lived experience here means to incorporate the complexities and interdependencies that conventional approaches struggle to capture; if co-production is to make public services more responsive to people’s lives, its insights must do more than inform the design of individual interventions. Small methodological reforms may help creative and community-based approaches gain recognition within existing investment frameworks, but they do not, in themselves, challenge the assumptions about value that underpin those frameworks or address the structural determinants of health. Realising the transformative potential of co-production therefore requires a more fundamental shift, not just in how we economically evaluate creative and community approaches to health, but how we understand, value, and invest in health.

References

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Fujiwara, Daniel, Paul Dolan, Alberto Muelas, et al. 2026. Guidelines on Economic Evaluation in Creative Health. University College London.

Mak, Hei Wan, Rory Coulter, and Daisy Fancourt. 2020. ‘Patterns of Social Inequality in Arts and Cultural Participation: Findings from a Nationally Representative Sample of Adults Living in the United Kingdom of Great Britain and Northern Ireland’. Public Health Panorama: Journal of the WHO Regional Office for Europe 6 (1).

Marmot, Michael, Jessica Allen, Peter Goldblatt, and Benjamin Viles. 2026. ‘A Fairer, Healthier Scotland: The Collaboration for Health Equity’. UCL Institute of Health Equity.

Marx, Karl. (1867) 1990. Capital: A Critique of Political Economy. Translated by Ben Fowkes. Vol. 1. Penguin Classics.

McNeill, Elaine, Uisce Newton, Marisa de Andrade, et al. 2026. Creative Health Economics: Building the Foundations for a Commission-ready Sector. University College London.

Polanyi, Karl. (1944) 2024. The Great Transformation: The Political and Economic Origins of Our Time. Penguin Classics.

Ray, Rashawn, Paula Lantz, and David Williams. 2023. ‘Upstream Policy Changes to Improve Population Health and Health Equity: A Priority Agenda’. The Milbank Quarterly 101 (S1): 20–35. https://doi.org/10.1111/1468-0009.12640.

The Scottish Government. 2011. Christie Commission on the Future Delivery of Public Services. The Scottish Government.

The Scottish Government. 2020. Scottish Household Survey 2019: Culture and Heritage. The Scottish Government.

The Scottish Government. 2025a. Scotland’s Population Health Framework. The Scottish Government.

The Scottish Government. 2025b. Scotland’s Public Service Reform Strategy: Delivering for Scotland. The Scottish Government.