Micro-regulation is not the most effective way to manage risks and improve services. The best guarantee of high standards is ethics-based risk control, underpinned by rules-based codes.
Formal risk management systems can encourage a box-ticking mentality, threaten internal and external relationships, and — in the literal sense of the word — demoralize people. The dangers are likely to be greatest where stakeholders have a strong emotional investment in self-regulation and ethics-based risk management.
Formal risk management systems now provide the dominant logic for governing an uncertain world and are prevalent in public services as well as private firms. What happens when these systems interact with indigenous risk practices and ethics-based risk controls?
Existing literature suggests that hybridization is likely — that rules-based and ethics-orientated models complement each other and that tensions between them can be managed. A longitudinal case study challenges this view.
The study was based on four years’ fieldwork at a democratic therapeutic community (DTC) — a residential unit for people with serious personality disorders. (Such ‘extreme’ settings can be useful for studying dynamics that are more difficult to observe in other environments.)
The DTC model, introduced by the British National Health Service in the early 2000s, uses an ethics-based approach to risk management. Residents are expected to take responsibility for their own and others’ treatment as ‘co-therapists’ and to participate in community decision-making and community tasks. Staff members, who include psychiatrists, nurses, social workers and administrative staff, are all expected to participate in the day-to-day running of the community. Clinical risk is managed interpersonally.
Residents live in the unit for 12 months and agree to abstain from alcohol and drugs while there.
The unit studied had been described as the ‘jewel in the crown’ by its local NHS Trust and held to exemplify the Trust’s stated principles of service user engagement. It adapted outside influences such as the NHS Care Programme Approach for the mentally ill to strengthen in-house practices.
During the fieldwork period, however, its future was threatened by a critical incident involving two former residents, Mark and John. The two men had started a relationship while at the DTC and, unknown to staff, began living together after leaving the unit. Shortly afterwards, Mark stabbed John to death during a drunken row.
Officially, the homicide was not the DTC’s responsibility. Faced with strong external pressure, however, the Trust’s board imposed its standard risk management procedures, enforcing strict controls through weekly risk reports from the DTC and official inspections. This eroded the culture of the DTC — with disastrous results. The NHS commissioners and the local Trust eventually decided to close the unit — and to discharge all residents.
What contributed to the dramatic decline of the unit? There were four main stages:
Anarchy ensued. Instead of upholding the DTC’s rules, residents protected each other from staff scrutiny as they devised drug deals and established a new norm of sexual relations between residents. A once self-regulating therapeutic community operating within a broader rules-based framework (the Care Programme Approach) had become a dysfunctional unit riven by conflict.
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