The centrality of users is undergoing drastic changes when it comes to designing (or redesigning) public services(Nasi & Choi, 2023). Over the last couple of decades, the active involvement of users in the design of public services was promoted to support providers in capturing latent users’ needs and preferences, enhancing services’ effectiveness and inclusiveness (Bovaird, 2007; Brandsen et al., 2018; Nabatchi et al., 2017). More recently, Osborne (2018) introduced the public service logic arguing that users’ involvement is not an add-on to the traditional service delivery practices, but rather is an intrinsic and unique source of value (Osborne, 2018). According to this logic, public service organizations cannot create value without users. Therefore, the involvement of users is not only a way to increase the service’s effects but also the sole modality for public organizations to (co-)create value (Grönroos, 2019).
This new logic obliges public service providers to shift their focus from within to outside the boundaries of their organizations, looking at what constitutes value for users. Instead of focusing solely on optimizing internal efficiency, public providers should rethink their service delivery processes to improve users’ experience before, during, and after the service’s usage. While internal efficiency might be a good approach for cutting organizations’ costs, it does not guarantee a great service experience (Trischler & Scott, 2016) and, thus, value creation.
Understanding and adopting this new view is still challenging for several public service organizations (Rose et al., 2018). Being used to adopting their own perspective, providers struggle to gather the point of view of users and understand how to reorganize resources to maximize users’ service experience (Hurley et al., 2018; Pinho et al., 2014). Co-design can help public service organizations in this direction as it allows users to be involved in decision-making processes and reorganize services according to their preferences (Sanders & Stappers, 2008). This approach uses design tools (e.g. games, images, stories) that facilitate users to understand the contextual scenario, express their latent needs, and imagine potential service solutions (Trischler et al., 2019). Using these tools makes users, even those not experts in processes’ optimization or innovation, able to provide a relevant contribution in identifying users’ needs and prototyping possible solutions (Dietrich et al., 2017).
Service co-design has been applied to different sectors, services and users (Pirinen, 2016). This wide interest can be explained by co-designing long-lasting benefits on: services by raising their effectiveness in addressing user needs, users by enhancing consumers’ satisfaction, and organizations by improving cooperation between users and professionals (Steen, 2011). The private sector has taken advantage of co-design benefits for increasing service consumption and improving labour relations. Similarly, the public sector has widely used co-design to promote service innovation by activating a “collaborative design thinking process” in which citizens and providers share, compare and combine opinions and co-produce knowledge (Selloni, 2017). Differently from the private sector, the public one has to deal with users that do not always have the competencies (e.g. elders with dementia), the interest (e.g. prisoners), and the resources (e.g. non-native speaker users) to be involved (Loeffler & Bovaird, 2016). The involvement of these groups of users is fundamental for guaranteeing the inclusiveness and accessibility of public services to all typologies of potential users (Grubb & Frederiksen, 2022; Osborne & Strokosch, 2013), which is the aim of public services. Despite the relevance of involving these vulnerable groups of users, public service organizations often give up due to the complexity of designing an inclusive and easily accessible participatory approach (Dietrich et al., 2017). To overcome this challenge, public service organizations often involve volunteers who may have experienced this vulnerability in the past (e.g. expert patients)( Van Dijck & Steen, 2024) or have helped some of these vulnerable groups (e.g. caregivers of fragile citizens)(Flemig & Osborne, 2019), or users representatives that belong to the same vulnerable group of users but have the competencies and expertise to be involved (Eriksson, 2019). In all cases, the outcome of co-design might be less effective than involving vulnerable users directly (Parveen et al., 2018; Condon et al., 2019). Indeed, volunteers and user representatives might have sporadic relationships with vulnerable users with negative consequences on their effective understanding of vulnerable users’ needs or they might report their personal needs instead of the ones of vulnerable users (Grubb & Frederiksen, 2022).
For these reasons, scholars have started to rethink the traditional co-design approaches for ensuring the inclusivity of vulnerable groups of users. Pirinen (2016) highlighted the importance of integrating a co-design approach to an organization’s activities to ensure its endurance over time. In doing so, public service organizations should opt for flexible methods that can be easily adopted by the service organization according to its aims and resources (Pirinen, 2016). Flexibility is confirmed by Trischler et al. 2019 who highlighted the necessity to foresee potential iterations and adjustments when both at the beginning (i.e. planning and recruiting users) and at the end (i.e. reflecting and building for change) of the co-design process (Trischler et al., 2019). These and similar pioneering studies (e.g. (Mulvale et al., 2021; Mulvale & Robert, 2021)) provided general guidelines and principles for supporting public service providers in involving vulnerable users, confirming the complexity and unpredictability of co-design with vulnerable users. Despite their relevance, examples and experiences of service co-design with vulnerable users remain sporadic and episodic. One explanation for this limited adoption of co-design practices relies on the public service organizations’ scepticism about involving vulnerable users. The high unpredictability, time-consuming and complexity of co-design approaches with these groups of actors make public service organizations reluctant to adopt them.
In this paper, we argue that practical and detailed guidance on how to adopt co-design with vulnerable users can reduce service providers’ prejudices in its adoption. Accordingly, this paper aims to unfold the adoption of a co-design approach when involving vulnerable citizens and to identify guidelines for its adoption. To do so, we conducted a mixed-method analysis(McKim, 2017) addressing the following research questions: how does the service co-design with vulnerable citizens occur, and how it can be structured and guided?
To investigate this research question, we carried out a co-design process in a neurology department of an Italian hospital by involving both professionals, and analyzed its success in adopting both participants' and external actors’ perspectives. In doing so, we first adopted qualitative analysis grounded on experience-based co-design approach through 17 semi-structured interviews and one co-design workshop. Then, we collected patients' and professionals’ experiences with the co-design approach using an anonymous survey. Finally, we discussed the effectiveness of the co-design approach by interviewing a group of 12 experts about participatory approaches. Triangulating patients, professionals and experts’ feedback about the co-design approach helped us to provide reliable, generalizable, and practical guidelines for co-design adoption when involving vulnerable users. Overall, these findings suggest that co-design approaches can be systematized and replicated by breaking the overall process complexity into a step-by-step guiding framework.
Ethics approval
This study was approved by the Territorial n. 5 Ethical Committee of Lombardy Region (Italy) (Decree XII/281).
