Risk Management in Practice The NHS Perspective Morag Slesser, State Hospital Claire Hamill, NHS Fife Levels of Security • • • • • Maximum Security (The State Hospital) Medium Security Low Security Community – direct responsibility Consultation – indirect responsibility Risk Processes – Tiered Approach • Guided by SPJ Framework • Tiers detailed in FRAME documentation – Scan – Examine – Scrutinise • Sole vs. Team Based Assessment SPJ Framework • • • • • • Gather information Evaluate presence and relevance of risk factors Evaluate presence of protective factors Offence analysis/formulation Scenario planning Risk management planning – Link with CPA process, traffic light plans Training • Basic information to all staff • Risk awareness training – OPBs • • • • Training in SPJ paradigm Training in specific SPJ tools Training in personality assessments Supervision The Challenges • • • • • • • Working within the mental health act Patients with on-going impairments Dual role of care and managing risk Government policy and direction Theory into practice Organisational strategy and clinical leadership Implementing governance systems Theory into Practice • Generally too much focus on the SPJ “tool” rather than on the other parts of the risk management process • Teams vs. individual emphasis • Not everyone has equal training/competences in formulation of offending behaviour, scenario planning, writing risk management plans • Risk management as part of the CPA process. How to make sure it doesn’t get lost. Organisational Strategy • Are senior management supportive? • Is it part of the organisation’s strategy? Are their associated targets set? • Is there a structure that everyone can follow? Keep it simple! • Is there funding for training of staff? • Is there a system for overseeing implementation? • Is there a “change leader?” Governance • Audits (big and small/process vs. quality) • Targets – Does everyone know what they are? Are they being achieved? • Training – is it working? • Supervision • Consequences – what happens when targets are not achieved? Audits Audit Year Scenario plans No of care and treatment plans audited No of HCR-20s completed 1 (04/07 – 03/0808) 84 35 (42%) 24 (29%) 61 35 (73%) (42%) 27 (32%) 2 (11/08 – 01/09) 30 19 (63%) 18 (60%) 18 (60%) 25 (83%) 3 (12/09 – 02/10) 21 19 (90.5%) 16 (76%) 19 (90.5%) 19 (90.5%) 4 (12/10 – 02/11) 27 26 (96%) 26 (96%) 24 (88%) Formulation of offending behaviour 25 (92%) Hospita l Warning Signs other HCR-20 risk factors HISTORICAL FACTORS Risk Factor Identified (definite or partial evidence) On problem list Objective set for risk management History of violence 27 22 17 Relationship problems 25 5 2 Employment problems 26 0 9 Substance misuse 24 20 11 History of major mental illness 27 27 20 Psychopathy 8 1 4 Early maladjustment 24 5 1 Personality disorder 20 8 3 Prior supervision failure 26 7 3 Table 15: Management Strategies by each Objective Heading (53 patients) Objectives I S M V Not known 1 Improve Mental Health 96 7 55 0 3 2 Improve physical Health and address health promotion 104 0 66 0 1 3 Address any cultural spiritual or diversity issues (including disability if relevant) 17 0 3 1 17 Provide appropriate treatment and management strategies to reduce risk of violence 78 3 19 2 3 5 Tailor security levels and rehabilitation plan to level of risk 22 27 40 (22 preset) 0 5 6 Address any family or relationship issues 69 4 5 3 6 7 Address any financial incapacity or other social welfare issues. 11 2 1 0 16 8 Provide appropriate structured activity 71 0 2 0 4 9 Address daily living functions 50 3 6 0 6 10 Develop /review future plans 22 52 2 0 9 4 Example: Results for Schedule 1 offenders - TSH • 4/14 CSO did not have sexual violence risk assessment • 5/18 had full description of main offence against a child in the CPA paperwork • 9/18 had objectives that explicitly targeted offending against children • VSP in relation to children in only 1 case • 9/18 had objectives that explicitly targeted offending against children • 10/18 scenario plans relating to children within TSH; 12/18 outwith TSH Questions? morag.slesser@nhs.net claire.hamill@nhs.net