Borrowing From Software: Agile Co-Design Takes Root in Public Mental Health Reform

When Australia’s Royal Commission into Victoria’s Mental Health System delivered its final report in 2021, it issued a mandate that has echoed through the country’s health bureaucracies ever since: mental health services must be redesigned with, not merely for, the people who use them. Authentic co-design and lived experience leadership were no longer aspirational language but formal requirements of a sweeping system reform. Yet a persistent practical problem has haunted that ambition. Co-design, as it is usually practiced, arrives as a discrete project with a beginning, a middle and an end, after which the workshop posters come down and the service returns to business as usual. A new paper published in the Community Mental Health Journal argues that this episodic habit is precisely what has limited co-design’s transformative potential, and it proposes an unlikely remedy borrowed from the world of software engineering: Agile project management.

The paper, authored by Jonathan Tyler and James Wilson of Barwon Health’s Mental Health, Drugs and Alcohol Service in Geelong, alongside Stephanie L. Bennetts of Deakin University’s Institute for Health Transformation and Rachel M. Tindall of Deakin University and Orygen, presents an integrated Agile co-design model illustrated through reflective analysis of its implementation within a public mental health service in Victoria. The authors’ central claim is architectural rather than cosmetic. Rather than treating co-design as a phase within a conventional improvement project, they argue it should be embedded as an ongoing governance capability, a permanent structural feature of how a service listens, decides and adapts. Agile methods, with their iterative cycles, built-in reflection and tolerance for changing requirements, provide the scaffolding that makes such continuous collaboration operationally feasible.

To understand why this matters, it helps to consider the technical mismatch between traditional project management and the realities of public mental health. Waterfall-style approaches, in which requirements are fixed upfront and delivered in sequential stages, assume that the problem is well understood at the outset and that the operating environment will remain stable. Neither assumption holds in mental health services, where demand fluctuates, workforce pressures shift, and the needs of consumers and carers evolve as reform unfolds. Crucially, service change in this sector must occur alongside ongoing service delivery; clinicians cannot pause care while the system is rebuilt. Agile project management, developed originally for software teams facing exactly this kind of uncertainty, replaces fixed plans with short iterative cycles, frequent review and continuous reprioritisation. Frameworks such as Scrum formalise this into regular ceremonies: planning sessions, stand-up check-ins, reviews and retrospectives that force teams to inspect and adapt their own process.

The evidence base for importing these methods into healthcare is still maturing but increasingly encouraging. A 2024 report in BMJ Open Quality described a multisite home hospital accelerator that used Agile implementation to improve delivery pace and cross-functional collaboration, and a 2022 synthetic scoping review in Applied Sciences documented growing adoption of Agile software development across health systems. Quality improvement science offers a parallel lineage: the plan-do-study-act cycle, long a staple of healthcare improvement, shares Agile’s iterative DNA, and a systematic review in BMJ Quality & Safety found broad evidence that such cyclical methods can drive measurable quality gains. What the Victorian team adds is the fusion of this iterative machinery with co-design’s participatory ethos, so that each cycle is not merely a technical adjustment but a fresh opportunity for consumers, carers and clinicians to shape the direction of change.

That fusion is grounded in a substantial body of research on what co-design actually achieves. A 2024 systematic review and meta-analysis in the Journal of Affective Disorders found that co-designed, in-person mental health interventions were effective in reducing anxiety and depression symptoms, giving participatory methods an empirical footing beyond principle. Broader reviews of co-production and co-creation in health services, including a 2022 systematic review in BMC Health Services Research, indicate that involving patients and communities mobilises knowledge in ways that top-down redesign cannot, strengthening service relevance, acceptability and trust. Experience-based co-design, pioneered in the United Kingdom and now supported by toolkits from organisations such as the Point of Care Foundation, has demonstrated how systematically gathering patient and staff experience narratives can anchor improvement work in lived reality rather than managerial assumption.

Yet the co-design literature is equally candid about its failures. A 2024 systematic review and thematic synthesis in Health Expectations examined what is known about sharing power in mental health co-production and surfaced persistent concerns about tokenism, with lived experience contributors invited into rooms where the real decisions had already been made. Scholars such as Diana Rose and Jacqui Kalathil have gone further, arguing in Frontiers in Sociology that co-production’s promise of equal partnership is often untenable within institutions that retain control over resources, knowledge and legitimacy. A 2025 systematic review in the Journal of Public Health catalogued a bewildering proliferation of co-design concepts, processes, models and frameworks, highlighting how inconsistent definitions complicate both evaluation and replication. Against this backdrop, the Victorian authors position their Agile model not as a replacement for existing co-design frameworks but as a complement, a delivery mechanism that keeps participatory input flowing through continuous system reform rather than being confined to one-off project phases.

The practical context for the model is the reform agenda that followed the Royal Commission, which demanded that lived experience leadership become structural rather than symbolic. The authors’ implementation took place within Barwon Health, a regional service in Geelong whose earlier co-design work, described in papers in the International Journal of Mental Health Nursing in 2021 and 2025, documented both the opportunities and the strains of doing this work in a live service environment. The acknowledgements of the new paper credit the members of the Lived Experience and Community Collective, including carer, Aboriginal and Torres Strait Islander and community members, alongside the workforce of the service’s local area, whose contributions shaped the model of care and the improvement work described. That detail matters: the model was not developed in a simulation but in a working public service under real operational pressure.

Technically, the integrated model can be understood through a systems lens. Drawing on the kind of systems thinking popularised by Donella Meadows, the authors treat the service as a set of interlocking feedback loops rather than a machine to be reengineered. Co-design supplies the information channels through which consumer and clinician experience enters the system; Agile supplies the cadence through which that information is converted into decisions, tested, and re-evaluated. Each iteration becomes a feedback loop with a defined rhythm, and the retrospective, the structured reflection at the end of each cycle, becomes the mechanism by which the collaboration itself is improved, not just the service. This is where the model departs most sharply from episodic co-design: the participatory process is itself subject to continuous iteration, so that power-sharing arrangements can be adjusted when they are found to be failing, rather than defended because they were agreed at a project’s launch.

The model also speaks to a stubborn gap in Australian mental health provision, often described in the literature as the missing middle: people whose needs are too complex for primary care but who do not qualify for acute services. A 2025 consensus definition published in the Australian and New Zealand Journal of Psychiatry formalised what clinicians have long observed, and Orygen’s policy work has documented the scale of the gap. Services serving this population cannot afford long design cycles during which people fall through the cracks; they need improvement processes that deliver usable change quickly while remaining responsive to feedback. Agile’s emphasis on delivering small increments of working change, rather than waiting for a complete redesign, aligns with that operational reality. Hybrid approaches, blending Agile iteration within broader governance structures, have already found advocates in healthcare leadership circles, suggesting the Victorian model is part of a wider convergence.

None of this resolves the deeper tensions that co-design scholars have identified, and the authors are careful not to overclaim. Their paper is a reflective analysis and a proposed model, not a controlled evaluation, and the authors note that no datasets were generated or analysed in the study. Whether Agile co-design produces measurably better outcomes than other participatory approaches will require the kind of rigorous implementation research that The Lancet Psychiatry Commission on transforming mental health implementation research called for in 2024. But the conceptual contribution is significant at a moment when health systems worldwide, from the NHS’s co-production agenda to New Zealand’s lived experience workforce initiatives, are grappling with how to make participation permanent rather than performative. If the Victorian team is right, the future of co-design may look less like a workshop and more like a heartbeat: a regular, structured pulse of collaboration running through the service indefinitely, turning lived experience from an input at the start of a project into the operating rhythm of the system itself.

Subject of Research: An Agile co-design model for continuous improvement in public mental health services

Article Title: Agile Co-design in Public Mental Health: An Integrated Model for Continuous Service Improvement

Article References: Agile Co-design in Public Mental Health: An Integrated Model for Continuous Service Improvement. (n.d.). https://doi.org/10.1007/s10597-026-01733-3

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01733-3

Keywords: co-design, Agile project management, mental health reform, lived experience, participatory design, implementation science, public mental health, service improvement, Victoria Australia, Royal Commission, co-production, healthcare quality