Covid recovery: learning from person-centred approaches

Annex 3: Case Study – Drug Deaths Taskforce Response

1. Why was this case study ^[16] selected as an interesting example of a person-centred approach?

This case study offers an opportunity to answer the question: what is the person at the centre of? Substance use is an interesting area of policy to examine as the person at the centre may be at the intersection of health, social care and justice systems. Conversely, the person may be on the margins of society and excluded from participating in the community.

In seeking to respond to the high number of drug deaths in Scotland, the report in this case study situates problematic substance use within a health framework, moving the issue away from the justice system. ^[16] Although the person is at the centre of justice processes, their experience may be at odds with the concept of person-centredness; when the focus is on the person's behaviour, and who has been harmed by it, a punitive and stigmatising message is communicated by the justice system. While this shift is significant, some legislative barriers remain and the interaction of different ecologies and systems on the person at the centre is an important aspect to explore.

Interestingly, the move towards a health focus avoids situating the person within a purely medical framework; instead, in placing the person in their social context, they can be understood with reference to circles of informal networks, from family, peers and to the wider community.

The term person-centred support appears in the document as a core value. Although it is not itself defined, the paragraph it heads contains some themes which appear to be connected to the concept and are not only expanded on in the document but are also present in the other case studies. This case study therefore provides an opportunity to seek commonalities with other policies and to identify where there is divergence of meaning around person-centred approaches.

"Every person with a substance use issue is entitled to holistic, person-centred, co-designed care and support that is focused on their needs and is respectful and responsive to them." ^[16]

2. What elements of this policy are of particular interest in relation to learning about person-centred approaches?

This strategy provides an example of the complex and multiple issues experienced by the person at the centre and how policy seeks to address these through service provision, in particular drawing on themes such as "no wrong door". In recognising the need to move away from "service-centric" approaches ^[16] there is some interesting discussion around interagency and interprofessional dynamics, and the acknowledgement that these require to be addressed if person-centredness is to be meaningfully experienced.

Further, the policy moves beyond the professional and identifies assets within a person's informal supports and the community, and seeks to actively engage with a strength-based approach. In order to understand the importance of the social context, and the relationships within this, it may be useful to explore the concept of persons at the centre, as a unit, as opposed to solely the individual.

3. Does this case study relate to the period during which Covid restrictions were in place? If so, how?

Yes, this policy was published in 2022. However, there is only limited reference to the pandemic, examples being the rise in remand prisoners during that time and the increase in digital technologies. Nonetheless, evaluations from the period of Covid restrictions, particularly around the role of the third sector, may be drawn on to explore some of the themes in this case study.

4. What were the enabling factors that supported a person-centred approach?

In identifying the need to draw on ethical principles the policy recognises the normative base required to effect change.

"Respect, choice and dignity are central to supporting people who may feel they have lost all three because of multiple complex health and social issues" ^[16]

Additionally, the case study asserts that these positive values are also shared by wider society, stating that the public are largely sympathetic in relation to reducing drug deaths. By moving substance use into the field of public health, this strategy seeks to address the negative impact of stigma which may prevent people from seeking help. The willingness to shift away from a justice system approach, where the person may be viewed as in conflict with society, may support a more inclusive and person-centred approach.

An openness around the needs of the workforce and families in supporting the individual with problematic substance use can provide a more realistic and effective practice of person-centredness. By using peer support from people with lived experience this may facilitate the articulation and understanding of the person's perspective. This move beyond the professional as the expert may further support the placing of the person at the centre.

5. How does this case study help us to understand the strengths of person-centred approaches?

Where person-centredness involves viewing an individual holistically, that is recognising and validating their strengths as well as the multiple and complex challenges they experience, this approach can provide not only hope but also empowerment.

Understanding the different roles a person has, such as parent, son, daughter, or friend can provide insight into what and who is important to the person. In this way, person-centredness acknowledges the relational aspect of the approach, and support may be offered to relevant individuals in order to maintain this informal network.

Policies, such as The Promise ^[1] and The Whole Family Approach ^[38] which recognise the importance of relationships between children, young people, parents, carers and the extended family, compliment this case study and further strengthen person-centredness.

In working within a normative framework which seeks to promote respect, dignity and choice, person-centredness enables individuals and their support networks to openly express their circumstances. Facilitating honesty and insight enables organisations and persons to work with a mutual understanding of what is realistic at that time; an example of shared expectations is Housing First not requiring a person to be abstinent from drug use as a condition of tenancy. ^[33]

Further, an ethical foundation of respect and dignity can draw on strengths within the person, utilising their stories of lived experience to communicate a positive message of hope to the community. Such stories can bring persons into the centre of communities, overcome stigma and marginalisation, and effect a shift of power away from "service-centric" approaches.

6. What does this case study suggest might be some of the limitations of a person-centred approach?

The case study highlights some of the structural barriers which potentially inhibit person-centredness. Although approaches such as no wrong door have the capacity to provide holistic services for persons with multiple and complex issues, the dynamics between agencies may present barriers to person-centredness.

The strategy understands the challenges faced by people seeking support and acknowledges the difficulties experienced when not eligible for a service. The case study highlights the hierarchy of service provision which exists between statutory and third sector organisations and the lack of joined up working which may result from a lack of cooperation between agencies. Practical issues such as the pressure of short-term funding can significantly impact on the aspiration that person-centredness be holistic. Without positive and enabling relationships between agencies, the coordination of services will not provide comprehensive support for the person.

Stigma and a culture of failing to understand the trauma experienced by the person at the centre can give rise to individuals not seeking appropriate help and support; stigma may be exacerbated by service providers. Additionally, the stigma which may be experienced by service providers working with person with substance use issues is acknowledged. Further, the report understands that the workforce, in dealing with the trauma of the person, may themselves experience trauma and this requires to be addressed.

The report recognises wider societal factors and the role the media have in significantly influencing how substance use is portrayed and how this impacts on public opinion and, in turn, on the experience of the person at the centre.

Although policy can support positive change towards person-centredness, the case study acknowledges the limits of working within a legislative framework which militates against the desire to take substance use out of the justice system and into the field of health. This current position is illustrated by the exclusion of addiction from the definition of "disability" in the Equalities Act 2010 and the criminalisation of possession of the substances included under the Misuse of Drugs Act 1971. Restrictions around the relevant legislation being UK rather than Scottish statute would suggest systemic limitations to the person-centredness being facilitated by this policy.

However, within these limitations, it is possible to work around this challenge; suggestions in the document include making more use of diversion from prosecution and arrest referral schemes which would steer person towards health and social care services.

7. What is the key learning from this case study relating to person-centred approaches?

• The importance of understanding the systems and networks impacting, influencing and supporting the person at the centre.
• The value of a strength-based approach in engaging the community in reducing stigma and marginalisation.
• The necessity of a relational, value-based foundation in person-centred approaches.