50. A survey undertaken in 1998/99 of Trusts in the UK identified as treating adult mentally ill patients gives an indication of current practice.17 There was a 33% response rate. The main findings were:
Over half of respondents use a discharge protocol and over a quarter say they have one under development. One in 7 neither use one nor have one under development;
Nearly two-thirds use a discharge checklist;
Nearly a third use a discharge rating scale;
In many Trusts work is underway on risk assessment scales and measures;
The Care Programme Approach29 and the associated statutory obligations appear to be the basis for many instruments, particularly checklists;
The multi-disciplinary team bringing shared information to the decision making process is a large, shifting number of professionals. The influence of different line managers, training, professional loyalties and traditions is evident;
Psychiatrists remain the key presence in the decision making process;
Each patient may generate several different sets of records kept in a variety of formats, locations and under different codes;
A common record shared by the widest possible multi-disciplinary team is not yet in widespread use. There remains the danger that bits of information, essential to making up the overall picture, are held in different places, rarely being brought together;
Electronically stored and shared records are in use by only a very small number of Trusts, but have great potential for widely communicating and sharing information about risk;
Practice differs in Trusts, and even within components of a single Trust - "seamless" care is often far from being a reality;
There is evidence of joint working between health and social services, but the role of voluntary organisations is unclear, risking their exclusion;
There is some evidence of a clear stance being taken against the use of scales - suggesting that in some cases they have been tried but discontinued. Also some staff feel uncomfortable about their use;
Some Trusts have a well developed "suite" of instruments. Each one may be excellent in itself, but in combination with the others there is a potentially bewildering array of paperwork;
In care plans the role of the key worker is well defined, but not the role of others;
In many instruments there is much "pinning down" of responsibility in the form of names, signatures and dates, raising fears for some about their position in the event of an incident;
The distinction between assessment and management/control of risk appears well understood;
Most instruments concern themselves with a full range of risks;
The perception of the need for a continuous cycle of assessments is evident.
51. The use of instruments can help to make the decision making process more transparent. For staff this can be a protection. For service users this can mean the process is less arbitrary. Less robust instruments including checklists may promise less but actually deliver a more practicable, widely acceptable and cost efficient aid to risk management. The dangers are that different instruments of unproven validity will give a false sense of security and will make staff less flexible in working with individuals.
52. It has been important for the development of evidence based knowledge about mental health problems that tested and standardised psychiatric assessment scales have been developed and widely used. They result in reliable diagnoses of psychiatric syndromes for clinical purposes and assessments of aspects of social function. However, reliable scientific assessment of risk is still far from being achieved. Research in this area has to continue as a matter of priority. For most practitioners there is more to be gained at present from a combination of gut feeling together with the implementation of simple risk management procedures and controls, than from the pursuit of complex instruments of unproven validity and reliability. Scales may have promise but as yet do not convince that they can deliver.
53. Those whose task it is to implement risk assessment procedures within a service should bear in mind the 13 factors identified by Potts (1995)31 which health professionals do not take into account sufficiently in practice, thus risking a weakening of the process. These are:
Minimisation of historical events
Over-reliance on recent progress
Sudden change of view in the care team
Extraneous factors, not openly recognised
Infrequency and/or discontinuity of assessment
Non-verification of statements by patient and/or others
Not taking account of evidence contrary to patients assertions
Not recognising patient manipulation and consequent staff discord
Lack of thorough investigation and assessment of assertions of "insight" and "remorse"
Lack of openness between those involved in the patient's care and treatment
Discounting information if not supportive of hoped for outcome
Self expectations of being decisive and successful
Avoiding confrontation with the patient
These touch on complex matters of personal and collective attitude and behaviour. How best to allow wisdom and experience to develop?