Title: Risk Management Paradigms in Health and Social Services for Professional Decision Making on the Long-Term Care of Older People
Author: Brian Taylor
Institution: University of Ulster
Title: Standing Secure Amidst a Falling World? Practitioner Understandings of Old Age in Responses to a Case Vignette
Authors: Sally Richards, Sheila Donovan, Christina Victor and Fiona Ross
Institution: The authors hold positions at the University of Reading and St George’s Hospital Medical School, University of London
Social care is experiencing a reappraisal of the balance between risk and protection, with a much greater emphasis on encouraging service users to take informed risks. This has major implications for professionals, but the ways in which social care professionals currently conceptualise risk and reach judgements about the right level of care remains far from clear. These studies explore such conceptualisations in relation to work with older people and reveal that professional practice is varied and changing.
The focus of Taylor’s study is on the frameworks (or “paradigms”) used by health and social services staff to conceptualise risk about the long-term care of older people in Northern Ireland. His sample is drawn from four community health and social services trusts and involved focus group activity and semi-structured individual interviews with 99 staff across social work, community nursing, GPs and others. Richards et al used a more unusual research technique that draws upon secondary analysis of 30 interviews with health and social care practitioners in a London locality that focus upon a single case vignette – that of a vulnerable older person, “Mrs Groves”, who is suffering from falls in the home but is reluctant to seek help. This created the opportunity to investigate how different practitioners make sense of an identical scenario. Both studies, therefore, try to understand how front-line practitioners arrive at decisions about individuals considered to be “at risk”.
Taylor found that participants relied heavily upon their work experience and informal learning from colleagues to guide their professional judgements – wider evidence or theory were little apparent. It was not possible, however, to identify a homogeneous approach rather professionals responded to uncertain situations by drawing upon distinct “paradigms” each with its own assumptions. Taylor identifies six such paradigms:
● Identifying and meeting needs: people come with needs, and the professional task is to assess these in relation to circumstances and meet them where possible.
● Minimising situational hazards: helping service users and staff (particularly home care workers) to avoid domestic hazards, with an emphasis upon avoiding risk rather than taking risk.
● Protecting this individual and others: in situations where individuals may harm others or themselves, their wishes may have to be challenged and a decision imposed without consent.
● Balancing benefits and harms: risk-taking (as opposed to only risk avoidance) is seen as an intrinsic part of the job and sometimes necessary to encourage rehabilitation.
● Accounting for resources and priorities: resource shortage results in the establishment of “panels” to ensure justifiable resource allocation that is prioritised by conceptually labelling levels of risk that relate to the urgency of the response required.
● Wariness of lurking conflicts: staff concerns of being at risk themselves, such as concern at being sued or becoming the focus of unwanted media attention – a “sixth sense” of professional danger.
In examining professional responses to the Mrs Groves’ scenario, Richards and colleagues similarly conclude that the most prominent professional understanding of old age is based on experience (rather than theory or evidence) and is largely derived from working with older people in difficulty. The authors suggest that this leads to a negative perception of old age as a problematic life stage that is at odds with the policy emphasis on active ageing and prevention. Although knowledge based on experience is acknowledged to be an essential competence in practice, Richards et al argue that theoretical and research-based knowledge can support and develop experiential knowledge in a way that promotes sensitive and reflective practice with older people.
Taylor concludes that “no single model for doing risk emerged” – rather there are distinct conceptual frameworks that are used as required, with professionals moving between the six paradigms he identifies. The underpinning rationale was more about what was defensible rather than what was right – fear of taking risks led to the avoidance of more positive approaches to promoting health and wellbeing.
This is all in line with the conclusions of Richards et al, and results in a call for more standardised guidance and tools to support practitioners in decision-taking about risk. The social care green paper, Independence, Wellbeing and Choice encouraged a debate about risk and consulted on the right balance between protecting individuals and enabling them to make decisions about their lives, including risk. Subsequently the white paper, Our Health, Our Care, Our Say gave a commitment to develop a national approach to risk management in social care, and this promise has been fulfilled with the publication of new guidelines from the Department of Health on “best practice in supported decision making”.
In his foreword to the new guidance, care services minister Ivan Lewis (as if in answer to the research findings) states that the avoidance of risk is inconsistent with the current emphasis on choice. He concedes that decision-making “can be a complicated job, especially if people have a different understanding or perception of risk”. The publication is therefore intended “to encourage practitioners and their organisations to adopt the common approach set out in this guidance as the basis for working practice”.
The “governing principle” behind the guidance is said to be that “people have the right to live their lives to the full as long as that doesn’t stop others from doing the same”. To put this principle into practice, it is said that those supporting users of services have to:
● Help people to have choice and control over their lives.
● Recognise that making a choice can involve some risk.
● Respect people’s rights and those of their family carers.
● Help people understand their responsibilities and the implications of their choices, including any risks.
● Acknowledge that there will always be some risk.
The guidance, along with the research reported here, offers up a classic scenario about top-down decision making. The government has every right to develop a new approach to policy and practice in relation to choice, risk and responsibility, and a more standardised approach will be essential to the success of individual budgets and the personalisation of welfare. However, changing the deep-rooted outlook and behaviour of professionals is no simple task. Taylor seems to put his faith in precisely such guidance, Richards et al in the power of theory and evidence both may underestimate the complexity of the task, and neither piece of research takes a serious look at the implementation issues that would be involved.
Developing concepts of risk
This may appear to be a somewhat technical aspect of specialised professional practice but in fact it has very wide implications for policy and practice.
The development of personal based care
Choice and control are critical elements in moving towards more personalisation in health and social care, and these require a more open approach to risk-taking.
Regulation and inspection
Approaches have typically focused upon health and safety issues rather than the outcomes people want to achieve and the appropriate management of risks a new model of risk management is needed.
CSCI and the Department of Health are consulting on the detailed development of an outcomes-driven framework for performance assessment the management of risk is central to this approach.
Implementation of fair access to care
The key question posed by Fair Access to Care Services guidance is “what is the risk to loss of independence or greater loss of independence if nothing is done?” The implication of the research reported here is that FACS will be applied inappropriately and inconsistently.
Bob Hudson is visiting professor of partnership studies at the school of applied social sciences, University of Durham
● The paper by Taylor can be found in the British Journal of Social Work, 36, pp1411-1429 (2006).
● The paper by Richards et al is in the Journal of Interprofessional Care, 21(3), pp 335-349 (2007).
● The new guidance on risk from the Department of Health, Independence, Choice and Risk: a Guide to Best Practice in Supported Decision-making
● CSCI has produced a useful report on risk – Making Choices Taking Risks
● A review of literature about different perceptions of risk from the Social Policy Research Unit, University of York
● The Economic and Social Research Council (ESRC) has funded a very big research programme on a wide variety of aspects of risk under the SCARR (Social Contexts and Responses to Risk) programme.