Hayes et al1 highlight design-based approaches to healthcare improvement as one means of achieving patient-centred care, describing them as involving ‘co-designing care with patients that result in a better fit with patients’ abilities and needs’. They cite Experience-based Co-design (EBCD) as one such approach. They then go on to argue that those leading improvement work in a healthcare organisation or system should adopt similar approaches with their workforce and that, in doing so, they would gain ‘a more explicit understanding of—and goal—to preserve workforce capacity and reduce the workload associated with change.’1

We wonder whether the authors intended what could be read as an apparent separation between, on the one hand, ‘co-designing’ with and for the benefit of patients and, on the other, engaging with staff to ease the perceived burden of improvement work? If so, is such a separation the most useful framing when thinking about ‘smarter’ ways of improving healthcare quality?

The article therefore opens up questions relating to the most fundamental (and radical) tenet of co-design, namely that ‘user and provider can work together to optimise the content, form and delivery of services...[it] entails service development driven by the equally respected voices of users, providers and professionals’.2 …