COMMUNITIES MATTER Community spaces matter too. Not treatment centres, but everyday places such as libraries, warm hubs, cafes and church halls where people can exist without labels. Many of the staff we spoke to described how small, ordinary interactions – a greeting, a familiar face, a place to sit – can be profoundly protective for someone who spends most of their life alone. People with lived experience also have a crucial role and, when properly paid and supported, bring trust and continuity into the system. They reach those who avoid formal services and often understand the emotional and relational realities of solitary use in ways that others cannot.
Housing policy must also reflect the importance of connection. Rules that
If we want to save lives, we need to redesign our systems around connection, not surveillance, not punishment, not shame.
force people into secrecy increase risk, while safer policies allow visits, check-ins and simple human presence. A place to live isn’ t just shelter – it’ s a container for relationships. Finally, people leaving prison need support that begins before release and continues afterwards. This includes safe accommodation, medication continuity and a named person who maintains contact. The first days after release are among the most dangerous in a person’ s life, so connection during this period can be lifesaving.
The rise in drug deaths linked to solitary use tells us something important. People do not survive because they have the strongest willpower, or the deepest knowledge of risk. They survive because someone is close enough to notice when they need help. Solitary use removes that possibility.
If we want to save lives, we need to redesign our systems around connection, not surveillance, not punishment, not shame. Most of the answers already exist in the everyday practices of harm reduction, lived experience and community work. The task now is to centre them. People aren’ t dying because they use drugs. They’ re dying because they’ re alone. Changing that reality begins with bringing people back into view.
Dr David Patton is associate professor in criminology at the University of Derby
UNDERSTANDING‘ MISSINGNESS’
Many people avoid GPs and healthcare for fear of being judged – some go to great lengths to remain unseen, Prof Andrea Williamson told the RCGP / Addiction Professionals conference. So how can we address this?
As a professor of general practice and inclusion health, Prof Andrea Williamson had studied nearly half a million GP records and more than 9m appointments to build up a picture of people who‘ tend to have a pattern of enduring missingness’.‘ Missingness’, she said, was defined as‘ the repeated tendency not to take up opportunities for care – such that it has a negative impact on the person and their outcomes’.
What the study team found was that‘ patients are not missing appointments because they’ re no longer sick or they don’ t need care. They’ re missing appointments because they’ ve got lots of challenges going on … really complex social circumstances.’ The data also showed an association with higher premature mortality.
The patterns of missingness continued through secondary care – missed outpatient appointments, a likelihood to discharge themselves from hospital, and a continued unwillingness to engage.
The NHS was under enormous pressure – austerity measures had seen a melting away of third sector and voluntary sector organisations and demanded the NHS be more flexible in meeting people’ s needs. But people weren’ t engaging with the NHS when they had the perception that it wasn’ t helpful, and many had negative associations from being mistreated or feeling stigmatised.
We had to flip that into a positive by realising that every contact is important – from the reception staff, to the call handler talking about the next appointment, to the work in clinical care. Accessing care felt difficult when there was gatekeeping in place and a‘ sense of inflexibility’. We also needed to appreciate that people lived with competing demands – the need to prioritise other things above attending health appointments.‘ We tend to make the assumption in the NHS that
Prof Andrea Williamson teaches and trains about the social determinants of health, inclusion health practice and trauma informed care. She leads on research about‘ missingness’ in healthcare and is involved in wider research and policy work to improve care for people experiencing severe and multiple disadvantage. From www. gla. ac. uk
people can just get time off to attend appointments,’ she said.
But looming large was the theme of mistrust and distrust – people experienced stigma, discrimination and being misunderstood.‘ A really important message that came across from our lived experience participants was that the NHS loves easy patients – it literally can’ t cope with people when they’ re more complicated,’ she said.‘ And that’ s not a great thing to hear.’
Trying to understand what drives missingness – including thinking about social determinants, poverty and marginalisation – was the route to a much more person-centred approach, said Williamson. But we needed to go beyond reading the literature on good practice and‘ be really disruptive’, thinking about how we could bring this to the mainstream as a suite of interventions. DDN
Pic: thedoctor. bma. org. uk
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