Why person-centred care?

In many countries in the second half of the 20th century we saw a shift in the practice of medicine, not only in the technical delivery of care and treatment but also in the voice of the patient, moving from a predominantly acquiescent subject to a participatory agent. This has been accompanied by broader concerns that routine healthcare has become commodified and impersonal, with a focus on profits. Medical advances towards a more targeted ‘precision-medicine’ approach can only happen with a more personalised (and human) approach to care.

Internationally, these scientific advances and improvements in quality are inequitably distributed. The provision of healthcare varies dramatically, with over one billion people remaining without any access to healthcare. The rise in the prevalence of long-term and mental health conditions, accompanied by a significant strain on human and financial resources, has highlighted the need for integrated people-centred health services.³

So, why is this important for psychiatry?

After all, psychiatry adopts a biopsychosocial approach and is inherently person centred. Despite this, the history of psychiatric practice has varied between the humane and the oppressive. Psychiatry has a long history of being criticised for its focus on categories and classes of disorder that are seen as dehumanising people and labelling them as deviant while ignoring key aspects of subjective experiences of culture, ethnicity, political oppression and trauma. And even today, in many parts of the world (including many higher-income countries) people with mental health conditions are marginalised and mental health services are poorly resourced compared with physical health services.

Independent care quality reports in the UK highlight the power differential that continues to exist between professionals and patients, with only 60% of patients reporting definitely being involved in decisions pertaining to their own care.^{Reference Fisher, O'Dowd, Dorning, Keeble and Kossarova4} In psychiatry, with a significant number of patients detained against their will, issues such as personal capacity and the conflicts between personal and public good pose additional challenges in implementing person-centred care. However, clinicians’ attitudes seem to be the key barrier to a successful implementation of person-centred care in routine psychiatric practice. Psychiatrists tend to overestimate their person-centredness.^{Reference Goossensen, Zijlstra and Koopmanschap5} Observational studies of psychiatrists’ interview style show that psychiatrists vary significantly in their ability to work collaboratively with patients,^{Reference McCabe, John, Dooley, Healey, Cushing and Kingdon6} raising questions about standardisation of training and professional practice. Clinicians may falsely believe that person-centred care is more time-consuming and costly. Moreover, they are often ignorant of human rights legislation and other primary legislation that underpins person-centred practice.^{Reference Berwick7} Learning outcomes that might help embed person-centred care are often not stated explicitly in training curricula,⁸ posing yet another challenge to implementation.

From patient- to person-centred care

A further obstacle to widespread implementation has been the gamut of definitions and the shift from patient-centred to person-centred care. But what runs through the various definitions are several constant themes: the provision of holistic, biopsychosocial or integrative care that is responsive to people's needs and values, that treats people with dignity, respect and compassion, and that empowers them and offers choice, involvement and a partnership approach. The single overarching theme that links these definitions is ethical: the idea that patients should be ‘treated as persons’.^{Reference Entwistle and Watt9}

This move of focus from patient to person is important as it embraces the central principle of ‘personhood’ – put simply, that ‘people with severe mental illness are people’.^{Reference Anthony10} This description then applies to all people, of all ages, with mental health conditions and with intellectual disabilities. By embracing this principle, personhood then becomes the superordinate principle from which other principles arise and offers the lens through which the individual's experience of illness and its challenges are viewed. In a subtle but significant shift, person-centred care focuses on the patient's history, strengths, values, beliefs, etc. not merely to inform decisions about diagnosis and treatment but to help them live the life they wish to lead.

Given the central importance of personal identity, a person-centred approach requires consideration of the person's social and community connections and of the cultural milieu that helps define their identity. This focus on the sociocultural dimension is important not only to understand the individual in their social and cultural context, but to appreciate how these reflect on care interventions and the choice of clinical interventions. This achieves particular relevance in today's globalised and diverse world, where migration is commonplace and adds another layer of complexity to personal identity.^{Reference Bhugra and Becker11} Digitalisation has led to more and more people having a social media presence, which also has an impact on personal identity and, by extension, on person-centred care.^{Reference Kirmayer, Raikhel and Rahimi12} Equally important is the spiritual dimension, which, although commonly associated with particular religious traditions, is applicable to many faiths and cultures.^{Reference Cox, Campbell and Fulford13}

Embracing a person-centred approach in medicine can have a powerful effect, bringing together not only medical professionals but other clinical and non-clinical groups working in health and social care. The focus on the person points to a change in the way the therapeutic alliance is viewed, with co-production becoming a central tenet of clinician–patient collaboration. This focus on justice and fairness is not only relevant clinically but also has wider policy implications, given the current context of global health inequality.

Key facets of person-centred approaches

There are many aspects to person-centred approaches, but five important global considerations are: rights; relationship to practice and service organisation; importance for clinicians; values and evidence; and training.