Health and Social Care in the Community 6(1), 1–3

Providing effective health and social care in the com-munity essentially rests on decisions made aboutrisk. Decision-makers include those who are profes-sionally concerned, those who are managerially orfinancially responsible and, above all, those practi-tioners who provide care or treatment in communitysettings. Our understanding of the meanings associ-ated with the word or image of community is nowbound up with the concept of risk. Aspects of com-munity care have been perceived as uncertain,unwelcome and unclear. In particular there isambivalence about provision for people with mentalhealth problems, children accommodated by localauthorities or services for drug or alcohol misusers.Public perception is often that community facilitiesplace ordinary citizens at risk. Professionals areaccused of being unable to manage risks and as hold-ing unrealistic views about the dangers associatedwith certain categories of people.

As the literature on risk proliferates, professionalsin the field of health and social care may appreciatean up-dating on current thinking. This special issueof Health and Social Care in the Community offers suchan opportunity. Its aim is to inform readers aboutrecent research in the burgeoning area of risk studiesand to point to the complexity of, and lessons from,work in this arena. In doing so we hope that otherresearchers and academics will be stimulated toaddress issues of risks in their own field of study;while practitioners and educators will be betterinformed and more able to contribute to practice andpolicy developments about risk issues. Two inter-related aspects of professional practice haveassumed particular attention. The requirement forrelevant information and its application to the deci-sion in question and the ability to carry out an effec-tive risk assessment are linked to professionals’ abili-ties to sift great amounts of information for detailswhich are significant, and to recognize what is signif-icant by reference to research or current professionalwisdom. An effective risk assessment is also a matterof communication, especially in community settings,where there is likely to be a range of professionalsand support staff involved in the care of individualservice users. An emphasis on clarity is part of the

communication process particularly in identifyingthe precise nature of the risk and ensuring that otherprofessionals understand or share the meanings ofprofessional language.

Risk assessment and the skills to determine the levelof risk appropriate to individuals have been seen ascentral to professional training and recently commis-sioned Department of Health work (Alberg et al. 1996)has provided a framework for this in relation to mentalhealth. Much risk assessment however, is conductedby non-professionals, such as care assistants, familymembers and informal carers and one new directionfor research and professional practice is to acquire anunderstanding of how such assessments are carriedout by people who have great practical and perhapsemotional involvement with the individual in ques-tion. Just as significant will be work in establishing ser-vice users’ own perceptions of risk and why they viewsome risks as positive matters which are exciting andenjoyable. Such understanding is vital to health careand public health: offering perspectives about why weall, at times, might take the risk of smoking, drinkingalcohol, or crossing a road less than carefully.

The second dimension of professional activity inthis arena is that of risk management, the business ofreducing the likelihood of negative events occurring,coupled with attempts to minimize the danger, ormaximizing positive factors. Again community-basedhealth and social care has to take account of uncertainenvironments at times and also the increasing range ofservice providers who may hold different accountabil-ities. Both risk assessment and risk management areskills expected of competent professionals and theiremploying agencies in relation to vulnerable peoplebut also, to some extent, in relation to the general pub-lic which expects that professionals will provide themwith details of environmental dangers such as newlyidentified diseases or the presence of dangerous indi-viduals in their communities. In many ways risk is cen-trally concerned with communication: between profes-sionals and the public, between professionals, andbetween professionals and their patients or serviceusers. Such communication, however, is importantboth regarding the content of what is communicatedand the process of imparting, listening to and respond-

© 1998 Blackwell Science Ltd 1

Special issue on risk: editorial

Jill Manthorpe and Andy AlaszewskiSchool of Community and Health Studies, University of Hull, Hull HU6 7RX, UK

Editorial

ing to others’ views. For many professionals and thoseinvolved in training or education this confirmationthat communication skills are important may help bal-ance worries that they are not equipped for the techni-calities of risk assessment and management.

This issue contains a number of pieces of originalresearch, two of which, Alaszewski and Manthorpeand Kelley, Hood and Mayall, arise from the initiativefunded by the UK Economic and Social ResearchCouncil. This initiative, under the Direction ofProfessor Graham Loomes1 has been an importantstimulus in developing research from a wide disci-plinary base. A second phase of the initiative hasrecently been funded, which will further debate anddiscussion.

This special issue is thus part of a larger corpus ofwork and we would argue that it is important on sev-eral levels. Kelley, Hood and Mayall’s paper, for exam-ple, presents a rare opportunity to develop our under-standing of the meaning of risk in everyday life. It isalso valuable methodologically since the voice of chil-dren is curiously under-reported in discussion of theirdaily lives. Professional views, however, are generallymore accessible and the other papers here which focuson professional matters explore the ways in whichtheir activity is increasingly managed and driven byexternal forces.

In mental health, Davies and Woolgrove explorethe working of supervision registers of patientsdeemed to be at risk in the community. Here profes-sionals make, often within the context of a therapeu-tic relationship, an assessment of people’s likelihoodto neglect themselves or to place themselves or othersin danger. To manage this risk, when custodial orinstitutional care is not thought justified, the UK gov-ernment has granted legal powers to professionals.These powers of supervised discharge can be used tocontrol individuals’ activities or their physical loca-tion, thus confirming a ‘prioritization of rights’(Kemshall & Pritchard 1997, p. 10) where certain risksare classified as too serious to be left to the possiblyimpaired judgements of people with mental illness.

The flowering of risk policies within agenciesinvolved in health and social care continues.Alaszewski and Manthorpe’s paper explores the orga-nizational aspect of risk and its impact on professionaldiscretion and activity. Whether risk policies affectprofessional practice is another matter and this paperexamines the extent to which policies are interpreted

and assimilated at local level. Reich et al. focus moreprecisely on the level of practice when they discussprofessional views of risk and whether increased pro-fessional experience impacts on decision-making.Here the examples used are from the ‘classic’ problem-atic interface of discharge from hospital of older peo-ple. The paper draws attention to the potential of inter-professional work in this area: since occupationaltherapists often play a key role in providing evidencefor other professionals’ risk assessments or are part ofmulti-disciplinary teams bringing fresh perspectivesto the traditional medical – nursing – social work tri-umvirate. As most of the papers here confirm, ourunderstanding of risk in professional practice isenmeshed with analysis of decision-making processesand structures. What is relevant to such processestoday is the extent to which tight hierarchical modelshave been flattened by the contributions of other pro-fessionals and support workers and by the expressionsand choices of users themselves.

No overview of risk issues would be completewithout a discussion of risk factors. Whilst there hasoften been heated discussion about the precision andutility of risk factors and their possible misuses inrelation to certain groups, it is clear that risk factorsare commonly accepted as important clues to futurebehaviour or developments. The general enthusiasmfor evidence based practice in both health and socialwork embraces the notion that risk factors are impor-tant in both risk assessment and risk management.Downs and Harrison’s paper provides a detailedoverview of the risk factor of childhood abuseapplied to common later mental disorders, includingalcohol and drug related problems. While such a rela-tionship might appear entirely possible to profession-als and lay observers alike, their argument is that weneed clarity about casual links and if these exist whatshould be done, with whom and to what effect. Workwith children who have been abused and work withadults who have drug or alcohol problems is increas-ingly bifurcated within the UK (as children’s andadult’s services have been organizationally divided),yet those practising in community settings oftenencounter needs or problems that cross such barriers.Research establishing such risk factors may well helpmaintain professional connections and communica-tion by providing evidence, rather than professionalwhim or fashion, which points to the importance of alife-course perspective.

Finally we hope that readers whose interest in riskhas been stimulated will turn to the review section.The wide variety of books reviewed illustrates theimportance of the issue at many levels of professionalactivity. Applying a risk lens to material often helps

2 © 1998 Blackwell Science Ltd, Health and Social Care in the Community 6(1), 1–3

1Professor Graeme Loomes is the Director, ESRC Risk andhuman behaviour Programme, University of Newcastle,Newcastle-upon-Tyne, NE1 7RU. email:risk@newcastle.ac.uk

Editorial

to identify what harm or benefit is being predicted orconceptualised and the extent to which dangers andrisk affect vulnerable individuals and others involvedin their care. Working in health and social care meansgrappling with issues of risk, at a time when commu-nities are not always keen to run the risk of trustingprofessionals.

References

Kemshall H. & Pritchard J (Eds) (1977) Introduction. In GoodPractice in Risk Assessment and Risk Management 2. JessicaKingsley, London.

Alberg C., Hatfield B. & Huxley P. (1996) Learning Materialson Mental Health: Risk Assessment. The University ofManchester, Manchester.

© 1998 Blackwell Science Ltd, Health and Social Care in the Community 6(1), 1–3 3