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The Framework for Mental Health Services in Scotland2 was launched in September 1997 to assist in the process of mental health service development by setting out the key issues to be addressed by the care agencies in achieving transition to local comprehensive mental health services, provided by a broad local partnership. The Framework continues to provide a relevant template against which that wider partnership, which includes Health Boards, Primary Care Trusts, Local Authorities, voluntary agencies, users of services and those who care for them and staff at all levels, to agree priorities for action related to outcomes and to quality of process. The service elements section of the Framework draws attention to the importance of managing risk in service settings among many other issues.
The Mental Health Reference Group (MHRG) was set up in 1996 to assist the (then) Scottish Office working party developing the first draft of the Framework. Chaired originally by my predecessor, Dr Angus MacKay OBE, the Reference Group had members from all the professions involved in mental health care, representatives of Health Boards and Trusts, Local Authorities and voluntary agencies and user and carer organisations' representation. Members were from across Scotland and included Scottish Office officials. The wide acceptability of the Framework during the consultation period and after its launch, was greatly assisted by the ongoing advice and input of the MHRG.
After publication, it was clear that the MHRG had a continuing contribution to make. In this respect, 4 sub-groups were established, one of which was charged with developing guidance for all in mental health services on the management of risk. (The other groups are examining the interface between primary care, secondary care and social work; needs assessment; and outcome indicators.)
I am pleased to have been involved since the start of this report. The outcome document represents a real effort in the best spirit of joint working by pooling the diverse experience of many individuals in a complex area of practice. At this time, when Primary Care Trusts and their various partner agencies are setting out on new ways of working and clinical governance is being implemented, I believe that this document will make a useful contribution to that work. If it enables people in all parts of a mental health service to deliver timely, appropriate and effective care to service users and their carers, in partnership, then it will have been a successful outcome. Risk cannot be avoided, it has to be recognised, assessed, reduced as far as possible and well managed. Management of risk is the key to safety for staff, the patient and the public. This document endorses a collective, responsible, progressive and open approach to the whole issue. I commend its contents to you.
Since this report was commissioned the Mental Health Reference Group has evolved into the Mental Health and Well Being Support Group.
Ian Pullen
Chairman
Taking risks is part of everyday life. Those with mental health problems and those who care for them can be more vulnerable to a variety of risks than others. It is recognised that to remove risks completely may result in unwanted outcomes, not least the removal of personal dignity and human rights.
Good communication, record keeping and the sharing of relevant information are vital components in the management of risk. For this to be effective however those involved must be clear not only about their own roles and responsibilities, but also of the confidentiality policies of other agencies and the human rights dimension.
I would ask that all agencies involved in caring for, or who have regular contact with, people who have mental health problems consider the contents of this report and measure how the practices followed compare with best practice in risk management. If your organisation has a risk management group this report will be of direct relevance to their ongoing task. If not, then consider the risks you, your colleagues and your organisation are running in not having a risk management group!
I take this opportunity of thanking all the members of the Risk Management Sub-Group for their enthusiasm and hard work. In particular, I would like to thank those members of the editorial team and also Dr John Loudon and Ewen Cameron for their support and guidance.
(The sub-group membership is set out at Appendix A.)
Tony Wells
Sub-Group Chairman
Concern about how best to reduce the risk to the individual, those who care for them, and the public is not new in the discussion of mental health services. Asylums were originally established in part to reduce risk. Since the more enlightened development of community care the need to minimise risk and awareness of how difficult it is to predict has been a continuing concern. During the 1990s, especially in England, a series of incidents such as the Christopher Clunis episode1 heightened public awareness. For some this was taken to an exaggerated extent in considering the risk to the community arising from those with mental health problems who live within it.
Subsequent inquiries found that services had in part been at fault owing to communication breakdown and poor co-ordination of services. In Scotland less negative publicity for mental health services has arisen, in part due to a cautious considered approach to discharge and the link to after care services.
A central part of the philosophy of the Framework for Mental Health Services in Scotland (1997)2 was that no patient should be discharged from hospital unless services and accommodation were in place and available. However, undue delays in the discharge process can constitute an infringement of the right to liberty. Mindful of the experience elsewhere it was clear that Scottish mental health services needed a good practice model to both help minimise risk and realise individual ambitions within the discharge arrangements. A system was required which linked all involved in a way which was; appropriate to need, safe, fair, and sustainable.
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