Best Practice in Managing Risk in Mental Health Services

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Best Practice in Managing Risk in Mental Health
Services

• Dr. Richard Whittington
• University of Liverpool Mersey Care NHS Trust
• CPAA Conference
• Leicester, 28/11/07

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Project team and advisors

• Dr. Richard Whittington
• Dr. Caroline Logan
• Dr. Wally Barr
• Mr. Andrew Brown
• Dr. Maria Leitner
• Dr. Rajan Nathan
• Ms. Janet Davies
• CSIP Expert Advisory Group

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Aims

• Overall, to
• draw together current evidence and good practice
• set out a practical framework of clinical risk
  assessment and management tools and methods for
  mental health trusts
• Specifically, to
• be helpful to services and support them in
  assessing and managing the clinical risks with
  service users with a range of presentations and
  needs
• draw on current research and make clear the
  strength of evidence bases
• cover the full range of risk from self-harm and
  neglect to forensic and risk to others

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More aims

• Specifically, to
• be mindful of existing requirements trusts have
  to meet on risk management
• highlight the importance of user and carer/family
  involvement in assessing and managing risk
• consider race and gender issues and be
  appropriately culturally sensitive
• draw attention to any specific issues around dual
  diagnosis
• present an ethos of positive risk management and
  service-user focused practice.

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When things go wrong

• 35 year old male
• Psychotic symptoms, substance misuse
• Stranger killing
• Occasional contact with various services
• No structured / systematic assessment
• Poor formulation of risks
• Poor communication between agencies
• Poor communication with family
• Missed early warning signs and intervention
  opportunities

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Violence and mental health

• Violence and mental health
• In-patient burden on services
• Work-related trauma/injury
• Discharge blocker
• Anti-therapeutic environment
• Community public concern
• Median inpatient incidence 29
• 18 violent one year post-discharge
• Rate doubles with substance misuse

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Homicide and mental health

• 249 homicides by recent or current inpatients
  1999-2003
• 9 of all homicides
• Stable trend over time
• 29 seen in week prior to homicide
• ECPA
• 95 care coordinator allocated
• 42 missed last appointment
• 43 attempts to engage

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Suicide and mental health

• High national policy priority
• gt6,000 suicides by recent or current patients
  2000-2004
• 27 of all suicides
• 49 in contact with services in preceding week
• gt800 involved recent or current inpatients
• 31 occurred on the ward
• 20 under non-routine observation at the time

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English policy and legal context

• National MH Risk Management Programme
• Transition from old to new MHA
• CPA
• NPSA, adverse events
• NICE
• Carers
• Diversity
• National Suicide Prevention Strategy
• Workforce
• Supported decision making
• MH Policy Implementation Guides

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National standards for and against

• Help staff know what is required and stay within
  the law
• Enable assessment of the quality of decisions
• Make decisions transparent and easier to
  communicate
• Encourage a systematic and comprehensive approach
  BUT
• Create illusions of certainty
• Freeze the state-of-the-art and are hard to
  change
• May stifle creativity
• May create unnecessary work
• Can never reflect all views

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Process

• July 2006 June 2007
• Systematic review of violence risk assessment
  tools
• Other systematic reviews
• Policy review
• Consultation with
• Expert advisory group
• Practitioners
• Service users
• Carers
• International experts

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Overview

• Framework of best practice principles
• Directory of tools
• Philosophy
• balancing care and risk needs
• positive risk management
• collaboration
• building on strengths
• the organisations role
• Expectations
• Benchmark and change practice
• Consider incorporating one or more of the tools

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16 Best Practice Points

• Introduction
• Fundamentals
• Basic concepts
• Working with service users and carers
• Individual practice and team working

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16 Best Practice Points Fundamentals

• e.g.
• 3. Risk management should be conducted in a
  spirit of collaboration and based on a
  relationship between the service user and their
  carers that is as trusting as possible.

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16 Best Practice Points Fundamentals

• e.g.
• 5 Risk management requires an organisational
  strategy as well as efforts by the individual
  practitioner.

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16 Best Practice Points Working with Service
Users and Carers

• e.g.
• 12. All staff involved in risk management must be
  capable of demonstrating sensitivity and
  competence in relation to diversity in race,
  faith, age, gender, disability and sexual
  orientation.

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16 Best Practice Points Working with Service
Users and Carers

• e.g.
• 13. Risk management must always be based on
  awareness of the capacity for the service users
  risk level to change over time, and a recognition
  that each service user requires a consistent and
  individualised approach.

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16 Best Practice Points Individual Practice and
Team Working

• e.g.
• 14. Risk management plans should be developed by
  multidisciplinary and multi-agency teams
  operating an open, democratic and transparent
  culture that embraces reflective practice.

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16 Best Practice Points Individual practice and
team working

• e.g.
• 16. A risk management plan is only as good as the
  time and effort put into communicating its
  findings to others.

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Issues in identifying tools

• Actuarial and structured judgement approaches
• Predictive validity
• Clinical utility
• Deployment in a UK context

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Identified tools

• Risk of violence, sexual violence, antisocial or
  offending behaviour
• E.g. HCR-20, PCLR
• Risk of self harm or suicide
• E.g. BHS, SSI, STORM
• Multiple risks
• E.g. FACE, GRiST, RAMAS, START

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Tool analysis

• Description, manual
• Depth
• Setting, practitioners, origin, format
• Guidance on risk management
• Cost
• Evidence

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Clarifying concepts positive risk management

• working with the service user to identify what is
  likely to work
• paying attention to the views of carers and
  others around the service user when deciding a
  plan of action
• weighing up the potential benefits and harms of
  choosing one action over another
• being willing to take a decision that involves an
  element of risk because the potential positive
  benefits outweigh the risk
• being clear to all involved about the potential
  benefits and the potential risks
• ensuring that the service user, carer and others
  who might be affected are fully informed of the
  decision, the reasons for it and the associated
  plans

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Clarifying concepts high risk

• High risk risk of committing an act that is
  either planned or spontaneous, which is very
  likely to cause serious harm.
• few if any protective factors to mitigate or
  reduce that risk
• requires long-term risk management, including
  planned supervision and close monitoring and
  organised treatment

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Clarifying concepts low risk

• Low risk may have caused, attempted or
  threatened serious harm in the past but a repeat
  of such behaviour is not thought likely between
  now and the next scheduled risk assessment.
• likely to cooperate well and contribute helpfully
  to risk management planning and s/he may respond
  to treatment.
• a sufficient number of protective factors (e.g.
  rule adherence, good response to treatment,
  trusting relationships with staff) to support
  ongoing desistance from harmful behaviour can be
  identified

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Clarifying processes collaborative and
defensive risk management
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Clarifying processes tools as one part of the
overall assessment
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Phase 2 national implementation project

• Toolkit
• Website, including discussion forum
• Other
• Northern conference Liverpool, 14/12/07
• National evaluation survey
• Pilot implementation in 8 trusts
• Revision of guidance
• Project lead Dr. Caroline Logan
• caroline.logan_at_merseycare.nhs.uk

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16 Best Practice Points Introduction

• 1. Best practice is a decision based on knowledge
  of the research evidence, knowledge of the
  individual service user and their social context,
  the service users own experience, and clinical
  judgement.

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Implementation toolkit BPP1

• This Trust has a library service that provides
  updates on government guidelines and new
  publications relevant to clinical risk assessment
  and management. There are methods available to
  disseminate that information across the Trust
  (e.g., bulletins).
• Links exist between the Trust and local
  universities or colleges and clinical risk
  assessment and management is one of the subjects
  on which advanced learning is available.
• The Trust has one or more practitioners who
  specialise in promoting best practice in clinical
  risk assessment and management across the
  locality.

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Implementation toolkit BPP1

• The Trust has a dedicated risk manager who
  coordinates policies and procedures and leads the
  clinical and non-clinical risk agendas.
• The Trust has policies and procedures on the
  assessment and management of clinical risk that
  are up-to-date and accessible.
• Clinical risk assessment practice is reviewed or
  formally audited within the Trust or there are
  well advanced plans to undertake such a process.
• A central facility (such as the intranet) ensures
  that all practitioners are kept informed of new
  guidelines that affect practice in clinical risk
  assessment and management.

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Implementation toolkit rating scale

• 2 All of the areas listed above are fully and
  competently addressed within this Trust.
  Evidence is available for each area indicating
  that this is so. This Best Practice principle is
  being fully addressed in this Trust.
• 1 50 or more of the points above are being fully
  and competently addressed in this Trust. Work is
  underway to develop the remaining areas.
  Evidence is available for each area indicating
  that this is so. This Best Practice principle is
  being partially addressed in this Trust.
• 0 Work in most of the areas listed above is only
  partial or development is incomplete. This Best
  Practice principle is not being fully addressed
  in this Trust.

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Website

• http//www.managingclinicalrisk.nhs.uk