Health risk escalators and the rehabilitation of offenders with learning disabilities

This paper presents a study of risk management in a hospital within the UK. National Health Service which attempts to rehabilitate offenders with learning disabilities. Analysis is based on the metaphor of a ‘risk escalator’. Health and social care systems can be characterised as risk escalators if they possess three attributes. Firstly, risk managers should agree the rough ordering of the severity of a set of related risks. Secondly, a repertoire of responses which provide different trade-offs between autonomy and safety, and which can be calibrated against risk severity, should be available. Thirdly, the potential for positive and/or negative feedback, which give risk escalators their dynamic character, should be identified. Risk escalators may be deliberately designed, or may, like the hospital regime discussed in this paper, coalesce from pre-existing sub-systems offering different autonomy/safety balances. They may carry service users upwards towards greater safety if needed, as in health screening systems, or downward towards greater autonomy if justified, for instance in rehabilitation systems. Their therapeutic status is contestable. Upward risk escalators can be accused of generating positive feedback, with iatrogenic effect. Downward risk escalators may be criticised for pushing service users too strongly towards less intense interventions, causing neglect. The present case study brings out emergent properties of a downward risk escalator, including: organisational disruption to system functioning; preferencing of safety over autonomy; active and reflexive system management by clients; multiple, organisational risk rationalities; and the reification of riskiness as a generic attribute of individuals.