Covid recovery: learning from person-centred approaches

Annex 1: Case Study – The Promise

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

This case study, the report of the Independent Care Review ^[1], contains several themes which are highly relevant to the concept of a person-centred approach. The title of the document, The Promise, is itself significant in that, unlike previous care reviews, it promises to effect into practice its recommendations. This strong assertion establishes a relationship between policy makers and people at the centre of the care system; other aspects of person-centredness stem from this basis.

Consistently throughout The Promise ^[1], the voices of people with care experience are represented, including the use of case studies. The large number of participants consulted for the review, over 5000, represents significant engagement with the policy making process, and these narratives are effective in maintaining the focus on persons; their direct influence on the recommendations is manifest. The policy's receptiveness to bearing witness to these perspectives facilitates an in depth and open account of what is important to persons at the centre.

Building on GIRFEC ^[38], this is an impactful and influential document which seeks to reframe not only how the workforce views and interacts with persons with whom they engage, but also how communities and wider society in Scotland share in this responsibility.

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

Although not defining the term, several aspects of The Promise offer insight into the concept of person-centredness. The principles of intensive family support stated in the document although relating to a specific approach, set out some interesting themes which may offer insight into what is meant by person-centred (page 58).

• Community based
• Responsive and timely
• Work with family assets
• Empowerment and agency
• Flexible
• Holistic and relational
• Therapeutic
• Non-stigmatising
• Patient and persistent
• Underpinned by children's rights

These principles can also be identified, in varying forms, in the other case studies and may be useful in constructing a definition of person-centred approaches.

The significant focus on relationships at the core of The Promise reflects what is of importance to the children, young people, their families and carers who shared their stories. The deeply relational nature of what is valued by the participants merits exploring in a project involving person-centredness. This strong emphasis, particularly on the family, is consistent, again indicating a direct link between narratives and the recommendations made.

The Promise, in actively listening to children, young people, their families and carers, seeks to recognise the strengths within persons and those with whom they have significant relationships. This case study moves beyond the individual at the centre to persons within the context of their social networks.

Additionally, this case study also explores how services engage with children, young people, families and their carers. From the perspective of the person or persons at the centre, an interesting insight into these interactions reveals practices, organisational and structural factors which may act as barriers to a person-centred approach.

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

Although The Promise predates the Covid-19 pandemic, it nonetheless provides many interesting themes to examine around person-centredness, and evaluations and reflections on the provision of related services during restrictions may be viewed through the lens of this policy.

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

The large number of participants consulted for The Promise affords credibility to an assertion that person's voices and experiences are at the centre of the making of this policy. The depth and breadth of its findings, the willingness to represent the voices of participants and for policy to be influenced by this, provide a strong basis for person-centredness.

In actively listening to what is important to children, young people and families with experience of the care system, this policy demonstrates willingness to engage with concepts not easily defined, such as love; it is possible that this could provide an antidote to the over-professionalisation described below.

The policy's openness around some of the barriers to person-centredness is very useful; without this discussion, there is a risk that the approach could remain or become an abstract and idealistic phrase. As such The Promise offers dialogue for moving person-centredness into reality.

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

Significantly, in The Promise, persons, and those important to them, are viewed as having strengths to be utilised. Additionally, and crucially, this has the potential to shift the balance of power from the workforce to persons, identifying and addressing some of the limitations below. Consequently, person-centredness may challenge and overcome experiences of stigma and marginalisation related by participants experienced in their contact with the care system. While some of these negative impacts may have come from communities, they may also have been created or exacerbated by workforce practices, as described below.

Further, by recognising the value placed on informal and social networks, supporting and sustaining these reduces over-reliance on services. This document acknowledges the impact of limited resources on the realisation of previous policies around the review of care.

Due to the centrality of the relationship, person-centred approaches maximise the personal qualities of the workforce which can be drawn on as resources. By engaging with a strongly relational approach, it is possible that the workforce, in services which purport to value personal qualities, may feel a greater sense of satisfaction. Where persons are viewed and engaged with on a strengths basis, and where the workforce are enabled to use their "whole selves", this may create an environment to support positive relationships. The insight provided by participants into what is important to them, may provide a mutual understanding and shared value base for meaningful, person-centred, partnership working.

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

Limited resources, in terms of workforce, may place pressure on the amount of time, depth and length of relationships; this is a significant challenge to the provision of longer-term support which this policy recommends may, at times, be required. Additionally, the limitations of the built environment, around accessibility and comfort may impact on the realisation of person-centred approaches.

It is, however, possibly organisational structures and workforce culture that have a more significant influence on limiting person-centredness. The narratives of children, young people and their families provide some insight into factors which may act as barriers to how this approach is used and received.

The Promise identifies the over-professionalisation of the workforce as, not only impeding the strengths identified above, but also creating and maintaining stigma and marginalisation. Examples of this, found in workforce practice, include the use of professionalised terms not in everyday use, and the wearing of lanyards and badges, all of which can create distance between persons and the workforce, setting them apart.

Multiple and complex issues may require a multiple and complex service provision; however, again the perspective of persons at the centre should be understood. Increasing specialisation results in not only confusion around roles, but also persons having to repeatedly tell their story, which can often be retraumatising.

A risk averse work culture within services may be a very real barrier to the collaborative approach in person-centredness. In identifying the notion of risk aversion, and recognising that this requires to be addressed, The Promise sets out a significant concern of the workforce and acknowledges that this should not only be addressed, but also reframed around the definition and assessment of risk, taking into account the perspective of the person or persons at the centre.

This policy recognises that the workforce itself requires nurturing and it may be useful to explore whether some of the aspects of person-centred approaches identified above, if effected, bring about a shift in attitudes and a closing of this gap. It would be interesting to explore why such practices persist, and what purpose or meaning the workforce attach to them.

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

• The necessity of actively seeking the views of persons at the centre and openly engaging with this from policy making to front-line practice.
• The centrality of the relationship, both the relationship between the person and the workforce, and between the person and those who are important to them.
• The value of understanding persons and those important to them, not only around the challenges they face, but also in the context of their strengths.
• Acknowledgement of workforce and organisational culture and practices which may act as barriers to person-centred approaches.