There is a phrase that has accompanied social care for decades – person-centred. It has been spoken in training rooms, written into legislation, embedded in strategies, inscribed into inspection frameworks. It has become, in many ways, the lingua franca of good care.
And yet, I increasingly find myself uneasy with it.
Not because it is wrong – far from it – but because it is no longer enough. Words which once challenged the system have, in time, been absorbed by it. They have become familiar, comfortable, sometimes even performative. And in that familiarity, the edge of their radicalism has dulled.
So perhaps the question is not whether we believe in person-centred care. Most of us do. The deeper question is this: what are we really trying to protect, enable and honour when we use that phrase?
The moral impulse: why personhood matters
When I think of care at its best, I do not think of policies or frameworks. I think of belonging.
I think of someone saying, quietly but with fierce clarity: “I want to stay myself.”
That simple desire – to remain recognisable to oneself – is the thread that runs through everything we do.
No older person sits at their breakfast table measuring their life by compliance with standards or sub-sections of regulation. They measure it by whether they still feel known, whether they still feel connected, whether their story still matters.
This is why the motivation for what we have called person-centred care has always been moral rather than managerial. It is rooted in the conviction that social care is not about the maintenance of bodies but the enabling of lives. It is about enabling people “to flourish and thrive, to be independent, to have voice, choice and agency.”
At its deepest level, it is about freedom, not abstract freedom, but lived, relational freedom. The kind that enables someone not simply to exist safely, but to be.
Autonomy: the engine beneath care
If there is a single concept that lies beneath all of this, it is autonomy.
Not autonomy in the crude sense of being left alone. But autonomy as the experience of being an agent in one’s own life, being the author, rather than the subject, of one’s story.
I have described autonomy before as “the psychological engine of flourishing.” Without it, identity fragments. With it, people retain resilience, dignity, coherence.
And yet so much of our system, often unintentionally, erodes that very autonomy. We manage, we organise, we protect, we assess. We wrap systems around individuals in the name of safety and consistency. But the uncomfortable truth is this: a system can be well organised and still diminish the person within it.
From person-centred to person-led
It is for that reason that, in recent years, I have found myself drawn more and more to the language of person-led care and support.
In truth, I suspect this is less a rejection of person-centredness than an attempt to reclaim its original intent. Because there is a subtle but critical difference between placing someone at the centre and enabling them to lead.
To be at the centre is still, in some ways, to be surrounded – by professionals, by plans, by systems. To lead is to move, to direct, to shape, to decide, with support, if necessary, accompaniment and care, but nonetheless with agency intact.
Person-led care asks harder questions of us. Not “how do we design around the person? But “how do we enable the person to design the moment?”
That shift is not semantic. It is structural, cultural, and deeply ethical.
The daily tension: autonomy and protection
Nowhere is this more evident than in safeguarding and adult protection. We often talk as if autonomy and safety sit on opposite sides of a scale; that to increase one is to reduce the other. But in practice, that framing is false. Safety achieved at the expense of voice is not safety. It is containment. Autonomy exercised without awareness of harm is not freedom. It is abandonment. The real work of care and support lies in the difficult space between. It is the work of accompaniment, of walking with someone, neither seizing control nor stepping away, but holding a steady presence. It is the discipline of asking, repeatedly: “Is there a less restrictive way?”
This is not theoretical work. It is moral labour, undertaken daily by practitioners who must tolerate uncertainty, who must sometimes carry decisions which never feel entirely comfortable.
And in that labour, what is being protected is not simply safety, but agency.
What gets in the way
If we are honest, the barriers to person-led, agency-driven care are rarely about individual intent. They are systemic.
Urgency is one of the greatest enemies. When time is short and risk feels acute, the temptation is to act quickly, to do something, even if that something narrows a life more than is truly necessary.
Risk aversion follows close behind. Systems, understandably fearful of harm, can become more concerned with avoiding blame than enabling life.
Technology, too, carries risk. Not because of its presence, but because of how it is used. It can drift into surveillance, into prediction, into control; systems that “infantilise rather than empower” and erode autonomy in subtle ways.
And perhaps most insidious of all is language itself. When terms like “person-centred” are used without discipline, without measurement, without reflection, they can mask a reality which is altogether less person-led.
What helps: anchoring care in rights and practice
If agency is to be more than aspiration, it must be operationalised. That is where human rights frameworks matter. Not as abstract philosophy, but as daily discipline.
Approaches such as PANEL – participation, accountability, non-discrimination, empowerment and legality – force us to ask hard questions about who is involved, who decides, who benefits, and how rights are protected in practice.
Similarly, structured approaches to decision-making: asking what is necessary, what is proportionate, what is least restrictive – ground care in accountability rather than assumption.
These are not bureaucratic tools. They are, at their best, mechanisms for protecting agency when pressure is high and instinct leans toward control.
Agency in the age of AI
All of this becomes even more urgent as we enter an era of advanced technology, nanotechnology and artificial intelligence.
AI has the capacity to transform care and support; to coordinate, to anticipate, to support. But it also carries the risk of deepening existing patterns of control if we are not vigilant. The test remains simple: Does this innovation strengthen autonomy? Does it widen possibility? Does it deepen relationship?
If it does, it belongs. If it narrows choice or fragments connection, it does not.
The future we are building is not one of machines replacing care, but of systems either amplifying or diminishing agency. And that choice is ours.
Towards an agent-centred future
There is a growing conversation, which is philosophical, practical and international, about shifting from person-centred to agent-centred care.
For me, that shift holds considerable promise.
Because it names explicitly what has always been implicit in the best of social care and support: that individuals are not merely recipients of services, but active agents with capacities, histories, relationships and rights.
But we must tread carefully. Agency is not individualism stripped of relationship. It is not independence at all costs. True agency is relational. It is supported. It is held within community, within belonging, within continuity of connection. It is the capacity to say, in whatever way is possible: “This is my life.” And to be heard.
A final reflection
Some time ago, I sat with an older woman who, despite significant frailty, held a quiet authority over her life. She did not use the language of rights, or autonomy, or person-centred care.
She simply said: “I want things done with me, not to me.” That, perhaps, is the essence of everything. Not centre. Not system. Not even service. But relationship, agency, and the fragile, beautiful act of enabling someone to remain themselves.
And if that is the task, then our challenge is clear:
To move beyond language, to reclaim intent, and to build a future where care and support does not merely place the person at the centre, but walks with them as they lead.
Donald Macaskill
Photo by Truong Tuyet Ly on Unsplash
