Risk Assessments in Choice

Choice involves an active conversation between the person, their family/network and us. We are interested in what they want and we use our expertise to facilitate the formation of a joint understanding. And consideration of risk is a part of that. Sometimes we hear that people think that a Choice appointment does not include a risk assessment. So is it true? No!

We think this myth comes from a significant misunderstanding about the Choice appointment. A simplistic view is that it is a cosy chat with a client and their family, focused on finding out what they want, without comment or opinion, and agreeing to it. This is not what should happen!

The key reason for including risk in a Choice appointment is that the goal is to reach a joint understanding. If risk is present then it has to be openly talked about and included in the Choice Care Plan. Any risk will be central to the current situation and thus a key focus in Choice.

Best Practice

Guidance in England ‘Best Practice in Managing Risk Principles ’ (National Mental Health Risk Management Programme June 2007a) notes two key best practice points:

  • 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
  • Risk management must be built on recognition of the service user’s strengths and should emphasise recovery. The document emphasises the differences between defensive risk management which has a poor user experience, poor user engagement and increasing risk with collaborative risk management which has a good user experience, strong user engagement and lower risk. There are dangers in completing tick box assessments.

The Risks of Risk

The Royal College of Psychiatrists’ document ‘Re- thinking risk to others in mental health services’ (2008) noted several key concerns:

  • Being preoccupied with risk instead of stimulating better and safer practice, appears to have had a negative impact on mental health professionals, professional practice, service users and the public
  • Risk cannot be eliminated
  • The limitations and value of risk assessment instruments must be understood.

The document notes that structured clinical judgement is important, stratifying risk into low, medium or high and the detail of the assessment must be relevant to the degree of risk. Any tools used must be valid for the population the user comes from.

They also note that ‘Cooperation with patients and carers in assessing and managing risk should be fostered through care planning’. An excellent practical guide to risk assessment and management that follows these principles can be found in Flewett (2010).

Risk in CAPA

Choice appointments and CAPA generally, incorporates these principles. The stance in CAPA is collaborative, open and transparent. A relaxed, conversational style will gather more accurate information and engage the person and their family better than asking a list of questions that does not follow their processes. This does mean that the clinician needs to be confident and experienced in basic risk assessment and have a structured approach in their head to apply.

Following the Choice appointment we continue to be aware of risk throughout Partnership. It is important that it is clear who is the key worker. Ensure rapid completion of written communication and Care Plans, copied to the user and network.

Skills in risk assessment and management are included in the concept of assessment as an extended skill in CAPA – the A of the Alphabet skills (see Core and Specific section of website).