Risk

“When he took his son to his new school, the principal told him, ‘Don’t worry, our number one priority is your child’s safety.’ Furedi responded, ‘I was hoping it was teaching him to read and write and do maths.’”
—Furedi, 1997

This publication intends to provoke a conversation about the power of embracing risk as a natural part of decision making, and the complexity of sharing risk between professionals and people who access support. We also hope it helps question how well we each understand our own personal and organisational tolerance to risk, and what role our values and emotions play in it.

Why are we concerned with risk?

There’s nothing to suggest that today’s social services are inherently more risky than they have been in the past. In fact, a shift in policy towards self-determination and empowerment – most notably through Self-Directed Support in Scotland – aims, in part, to shift the balance of risk-taking from professionals to individuals. Reassuringly, Carr (2013) suggests that despite efforts to find evidence of increased harm through empowerment, there is none.

However, this does not mean to say that risk-centred culture cannot emerge without an increase in risk itself. Kemshall (2002) highlights that the emergence of risk culture may be a reflection of increasingly limited resources, public and press scrutiny, and the fear of professional scrutiny. Barry (2007) suggests that risk was not a key feature of community care assessment and provision until a series of high profile media cases in the early 1990s led to a public outcry, and a demand for change. Thus, risk is not an issue specific to social services, but is now an issue of the public domain.

Beck (1998) coined the term ‘risk culture’ to describe a shift to make decisions based on a risk ‘we know nothing about’:

“Calculating and managing risks which nobody really knows has become one of our main preoccupations…. we all engage in it, with whatever rusty tools we can lay our hands on – sometimes the calculator, sometimes the astrology column.”
— Beck, 1998

As we move increasingly towards a ‘risk society’ (Beck, 1998), we must acknowledge that the world hasn’t become more hazardous; it is our perception, preoccupation and focus which has changed.

Defining (or not defining) risk

Conceptualisations of risk are so rooted in individual, organisational and cultural values that any definition varies wildly from one person to another. Similarly, there are lots of risk which are identified in social services: personal risk, risk of harm, corporate risk, financial risk and reputational risk. To be able to group these together coherently would be ignoring the complexity of what we mean by risk.

Furthermore, practitioners’ views of risk often differ from the views of people using services, as does the language used to express risk (Carr, 2010). It’s tricky to find a single agreed definition of risk, particularly in a social services context, where different groups of people accessing support and people providing support view and rationalise everyday risk very differently (Baxter et al, 2012). Similarly, many definitions of risk in a social services setting tend to focus on harm rather than the complexities, responsibilities and enjoyment that come with natural risk-taking.

Fundamentally, definitions of risk often distinguish it from its context in human experience, rooted in personal autonomy and choice. It is often seen as ‘outside’ of that process or a variable to be neutralised. We would suggest instead that risk is inextricably linked to all decision making processes in everyone’s lives.

“Risks are not isolated entities that people and societies perceive without considering what to do about them, but are part of human processes, as are rights and responsibilities of choice.”
— Sen, 2009

We suggest that after reading this Iriss On… you may want to discuss your own definition of risk. Exploring assumptions and values around risk is in itself a really useful workforce development exercise. Risk is inherently a person-centred process, and we acknowledge that over-arching systems approaches to risk may not do enough to support practitioners to navigate potential conflicts between their personal and professional approaches to risk. We think there is real value in reflecting on personal practice to learn more about our own approach to risk. Three prompt questions to support this process have been included at the end of this publication.

Risk and power

In an attempt to quantify risk, we shift from person to problem and there is evidence that this managerialism can constrain empowering practice. However, humans are much more complex than systems of risk measurement often allow, not ‘perfect technical instruments’ (Parton, 2006). While systems of risk management have a role in consistency, they rely on the assumption that professionals can be ‘objective’ about risk management. However, in a social services landscape focused on personalisation, should consistency be a priority?

The issue of risk is bound in power relationships between people accessing services and the professionals who plan, assess and deliver them. Evidence suggests that in relationships between practitioners and people who access support, the perceived value and authority of professional opinion can outweigh lived experience and individual determination (Alaszewski and Alaszewski, 2002). Balancing safeguarding and empowerment is inherently difficult and has been a challenge even before the implementation of self-directed support. Alaszewski and Alaszewski reported that very few of the organisations studied were able to achieve this balance, usually giving preference to safety when it came to decision making about risk.

Similarly, learning from the Iriss Pilotlight programme highlights the importance of supported decision-making which is key to ensuring people with impaired capacity can have as much choice and control over their support as possible while keeping safe. The Pilotlight project in the Scottish Borders co-designed tools and examples of how to navigate conversations around risk in assessment, including the Revised Risk Enablement Support Plan. The Pilotlight project also highlighted the importance of advocacy to maximise individuals’ decision making capacity. Ultimately, the project found that a clear understanding and application of the values and principles of self-directed support was needed in order to enable individuals to take greater control of their lives.

Institutional bias also impacts on our understanding of risk and further exacerbates inequality. This suggests that one-size-fits-all approaches to risk assessment and management can exacerbate entrenched inequalities. A study done by Warner (2006) showed that black people accessing mental health services were more likely to be assessed as violent and dangerous (and thus, more ‘risky’) than white people accessing these same services. The study showed a bias in mental health towards ‘archetypical risk figures’ such as young men with diagnoses of schizophrenia or personality disorders. Professional tools to assess and manage risk carry not only individual bias, but institutional bias.

Organisational culture also influences attitudes to risk. There is evidence that if practitioners do not feel supported by their organisation and their line managers, they are more likely to be risk-averse. Borins (2001) argues that the promotion of innovation within organisations will only be successful if staff believe they will be supported from the top, should failure occur. That means that risk is not solely the responsibility of frontline practitioners, but an organisational responsibility that needs permission and support to happen. Britner and Mossler (2002) found different professionals assessed risk based on the organisation in which they worked, rather than based on the ‘characteristics or circumstances of the client.’ This complexity becomes further clouded in the context of the integration of health and social care, where organisational cultures and attitudes may differ (Stewart et al, 2003).

Finlayson (2016) argues that the vehicles, processes and calculations are not designed to support social workers to enhance people’s lives, but ‘Its primary function arguably is to demonstrate professional competence and allow minimisation of professional liability’.

Professionals who work at all levels in social care have legal duties and responsibilities towards the people they work with. These duties and responsibilities are supported and regulated in Scotland through the Scottish Social Services Council and the Care Inspectorate. Evidence suggests that this fear of legal action and misunderstanding of litigation leads to risk-averse behaviour. However, this is perhaps due to a lack of understanding of individual practitioner responsibility, as well as poor support from management. Titterton (2005) suggests that training around the law and good practice can enable practitioners to navigate risk more effectively, balancing individual choice and professional liability. Similarly, a clear line of communication with regulators about responsibility and good practice around risk can help reduce worries about blame.

What’s the harm in being cautious?

Often, a ‘risk culture’ emerges from a fear of failure. In the context of social services, failure goes beyond financial or corporate liability and becomes a matter of life and death. Making serious case reviews public has led to the emergence of a blame culture, which may have further escalated fear of personal consequence. Barry (2007) notes that there is ‘not a culture of learning from mistakes that enables confidential reporting and discussion of near misses; likewise, there is no culture of corporate responsibility.’ We recommend reading the Iriss on… Failure (2014) to understand more about how embracing failure and reflective practice can change organisational culture for the better.

Risk aversion in social services has an impact on organisational development and more seriously, the outcomes for people accessing support. Perhaps the most damaging impact of risk aversion is the depersonalisation and disempowerment experienced by an individual when they are unable to enact choice.

“You cannot underestimate the anxiety that the feeling of being under scrutiny, or having your capacity judged, causes.”
— Providers and Personalisation, 2014

Furthermore, there is a tension between risk aversion and the push for activity and re-enablement. For example, in the case of dementia services.

“Lowering or eliminating the risks of activities or arrangements that are important to people may reduce some risk but at the potential expense of their happiness and fulfilment. They may also affect chances of re-enablement or rehabilitation…”
— Department of Health, 2010

Simply put, the risk of someone falling should not be enough of a reason for limiting their movement; the risk of their health being affected by outdoor activity should not be enough of a reason to confine them to a less fulfilled life.

Taking a risk-averse approach can also stifle human rights based approaches to care and support, by ignoring a person’s right to direct their own life. It is part of an individual’s rights to make ‘bad’ decisions, even if work has been done to explore the evidence and information available. These decisions must be made with this balance in mind, taking into account not only what is needed to abide by the law and promote safety, but ‘what is important to the person’ (Neil et al, 2008).

Scotland’s social services increasingly embrace a human rights based approach across all practice, which permeates all decision-making processes. Prioritising and respecting people’s right to self-determination is a priority detailed in Scotland’s National Action Plan for Human Rights (SNAP). This identifies the implementation of human rights in health and social care as a national priority. The action plan identifies ongoing challenges in practice ‘to uphold autonomy and ensure human rights based decision making’ (SNAP, 2013). It also identifies the integration of Health and Social care as an opportunity to enhance respect, protection and fulfilment of human rights.

Art or science?

Analysing and understanding what can go wrong when making decisions is a key part of care planning, and can ensure that there are measures in place to support people to make the decisions that they feel are best for them.

The evidence thus far suggests that professionally-owned, objective approaches to risk and risk management may not lead to positive outcomes for people. This is not to say that risk is not real, only that it cannot be quantified in scientific terms. Using rating systems for potential risks, such as red, amber, green, can help visualise different perceptions and help people engage in a conversation about risk. Titterton (2005) reviewed a series of these systems, but warned that they should not be used as ‘totting up’ exercises in which the pros and cons are tallied and a decision taken on that basis. Rather, the systems should be used for discussion and compromise. Nick Thorpe (2014) suggests that systems can be used as a safety net rather than a ball of chain, and have the potential to enable practitioners to operate innovatively within a ‘safe’ framework. More simply put, ‘Assessing risk is a mixture of art and science’ (Sargent, 1999).

If we can acknowledge that risk is part of a much more complex picture, and that humans are not ‘perfect technical instruments’ (Parton, 2006), then the next step is to examine the way in which we engage with risk.

Implications for practice: embracing an emotional approach to risk

Illustration depicting heart versus mind conflict

Touched upon throughout this text is the discussion of risk in the context of a full life. However, often scientific or systematic approaches to risk assessment and management are designed to exclude values or emotions. Slovic et al (2004) suggest that there are two dominant systems used to understand risk: the ‘analytic’ system which uses algorithms and formulas to produce a logical response; and the ‘experiential system’ which uses lived experience, emotions and intuition. They suggest that a ‘rational’ decision does not emerge from the analytic approach, but from a blend of both. Roeser and Pesch (2015) blur the divide between logic and emotion in risk decision-making by asserting that ‘risk emotions are not irrational but an important source of insight into what people value’. Thus, emotional responses to decision making can be valuable in rational decision making.

Roeser and Pesch (2015) suggest the following approaches to best engage emotion in discussions of risk:

Talk about values
Talk about emotions
Ask questions
Have a dialogue among all people
Convey respect
Have a clear procedure

However, the authors also warn that these actions require reciprocity so that professionals are not asking people using services to discuss their values and feelings, while professionals discuss scientific fact. Professionals too must examine their own appetite for risk and understand how their personal experience may influence this. This process acknowledges the human variable in risk assessment across all levels.

In another approach, Steven Finlayson (2016) writes about the power of language around risk, and demystifies the conversation by excluding professional jargon. He suggests that some of his simplest conversations about risk have only asked:

What are we worried about?
How worried are we?
What can we do to worry less?

Finlayson argues that the ‘paradigm of risk drives expectations of management and intervention. Talk of human worries drives relationships and discussion’ (2016). A discussion about worries also explores emotion and values.

Finlayson (2016) offers an example of how this approach can have huge impact by telling the story of a young person with a learning disability who wants to go out clubbing until 3am. In this scenario, the young person’s mother is very concerned and the author suggests that a risk assessment approach would view the young person’s wish to stay out late as the risk that needs intervention. However, Finlayson’s approach recognises that it’s really mum’s worries that need to be addressed. In fact, Finlayson suggests that this approach would be ‘much more likely to foster relationships, natural solutions and develop the person’s skills to manage the situation themselves’.

This is just one example of how thinking differently about sharing risk can lead to a radically different outcome. However, we believe that participative, structured conversations about risk could have wider implications on organisational culture, as well as our broader cultural perception of risk and responsibility.

Making decisions in partnership can only be participative when the conversation moves beyond the concept of professional liability and expertise, and becomes a dialogue about values and emotions. This way, decision making can be as much about achieving personal goals as avoiding negative consequence. However, collaborative decision making using these approaches must also be well structured and clear so that each party understands how decisions will be made.

Conclusion

Ultimately, risk is not an experience unique to people who access support, but a universal part of decision-making and human experience. Engaging people who access support and their carers as experts in their own experience and lives not only supports more rational decision making, but also asserts and supports their rights as people. As Stanley (2005) helpfully frames it, discussion of risk should not lose sight of the ‘why’ through the ‘how’ – the mechanisms in place to support decision making and risk taken should broaden and enable choice, not narrow and exclude it.

Reflection questions

What is your personal approach to, and tolerance of, risk? What are the values and assumptions that underpin this?

Is there space within your professional role to incorporate your personal approach to risk? If not, are there opportunities to explore this further?
If you were to use an emotional approach to sharing risk, how could this benefit or detract from your professional practice? How could it benefit or detract from your relationships with the people you support?

References

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Acknowledgments

Illustrations by: Sam Darlow

Reviewed by:

Susan Nevill, Learning and Development Advisor, Scottish Social Services Council
Judith Midgley, Iriss Associate, Pilotlight
Donald Macaskill, Chief Executive, Scottish Care

Special thanks from Rhiann to The National Risk Group who helped to inspire and challenge most of my thinking on the subject.