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risk assessment

major theme throughout all recent mental health pol-icy documents has been the high priority that mentalhealth services need to give to issues relating to clini-

cal risk assessment and risk management. The Care Pro-gramme Approach (CPA) (Department of Health 1999a) wasintroduced to ensure the effective coordination and deliveryof mental health care. Risk assessment and risk managementare said to be ‘at the heart of effective mental health prac-tice’ within the CPA. The National Service Framework for men-tal health (NSF) (DoH 1999b) for adults sets out seven nationalstandards for mental health (these standardsalso apply to older adults when not alreadycovered by the older adult NSF) coveringmental health promotion; primary care andaccess to services; effective services for peo-ple with severe mental illness; carers; andachieving the targets set to reduce nationallevels of suicide. Standard four (effectiveservices for people with severe mental ill-ness) specifies that all mental health serviceusers on the care programme approachshould ‘receive care which optimises engage-ment, anticipates or prevents a crisis, andreduces risk’. Standard seven (preventingsuicide) highlights how the other NSF stan-dards, especially risk issues, can be used tocontribute to reducing suicide. The series ofMental Health Policy Implementation Guides(DoH 2001) stresses the primacy of ‘safe,sound, and supportive’ services which placethe individual patient at the centre of careprovision.

The NSF and CPA documents suggest thatrisk assessment of an individual should includethe risk to the individual and to others, andthat an individual’s social, family, and envi-ronmental circumstance, as well as the needfor positive risk taking, should be consid-ered as part of the risk assessment process.The assessment should be fully integratedwith the CPA, including the written careplan provided to the patient.

Services that already have an effective riskassessment and risk management strategywill be able to integrate this strategy intothe CPA. Services that do not have an effec-tive risk strategy will need to develop one.The need to develop effective strategies

places substantial demands and challenges on trusts, not leastin ensuring that staff have access to the substantial and spe-cific training on risk suggested by both the Safer Services pub-lication (DoH 1999c) and the National Suicide PreventionStrategy for England (DoH 2002), in order to ensure that staffare adequately prepared to fulfil the requirements of thesepolicy documents.

This paper describes the implementation of such a trust-wide strategy for clinical risk assessment and risk manage-ment by the Leeds Mental Health Services Teaching NHS Trust.

Implementing a trust-widestrategy for clinical riskassessment in mental healthWith the spotlight being turned on the management and assessment of riskin recent government policy documents, one trust in Leeds has responded byattempting to standardise the way staff communicate on these issues.Graham Paley and Peter McGinnis report on the findings of a pilot study

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‘decisions made aboutrisk assessment and riskmanagement should,wherever possible, bedone in collaboration

with patients andcompleted in a sensitive way’

september 2003 vol 7 no 1 mental health practice 15

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risk assessment

In November 2001 a steering group was formed to over-see this process. Membership included three trust directors(director of mental health, director of nursing and workforceplanning, and the trust medical director) to ensure that thecommittee had the authority to make and implement deci-sions. Clinical, managerial, research, educational, and serv-ice user perspectives were seen as essential in the committee.The committee’s main aim was to ensure that any risk strat-egy would be fully integrated within other trust-wide initia-tives, particularly the roll-out of a networked trust intra-net,and also the CPA process.

Informal consultation about the practice of risk assessmentswas carried out both within our own trust and across neigh-bouring trusts in our region. This consultation showed thata minority of people felt comfortable about managing riskand that they had the skills and good quality tools in placefor assessing risk. There was a second, smaller group of peo-ple who felt very uncomfortable about risk and were oftenliterally doing nothing in relation to assessing and managingrisk in a formal way. In the middle were the majority of peo-ple with varying degrees of perceived expertise about deal-ing with risk.

This seems to be a similar distribution found across manyaspects of mental health practice. Our consultation alsoshowed that there was a range of risk assessment tools inuse, many of poor quality.

Choosing the FACE risk profileOur trust decided to use the risk profile section of the Func-tional Assessment of the Care Environment (FACE) assess-ment and outcomes system (Clifford 1999) to form the basisof our integrated approach to assessing and documentingclinical risk across the trust. We decided to use the FACE riskprofile for a number of reasons:1. The risk profile is only ‘one slice’ of the wider FACE sys-

tem ‘pie’. In addition to the risk profile, the full FACE pack-age contains a series of increasingly comprehensive andintegrated assessments, namely: triage; core assessment;health and social assessment; and two assessments forservice-users to complete on their wellbeing and experi-ences of treatment and care. The FACE system (see www.face-code.com) comprises three elements. First, an approachto working with information about people. Second, a suiteof information recording and measurement tools. Third,a suite of computer-based personal profiles that providereports and outcomes data on the information collected.All FACE assessments follow the same multi-dimensionalframework for thinking about people and collect infor-mation on the dimensions of – psychological, physical,

activities of daily living, interpersonal relationships, familyand informal carers, and risk.

2. A key advantage of the FACE system is that it providesoutcome data that enables an individual patient’s, or group’s(e.g. a key worker’s total caseload or a whole team’s case-load), progress to be followed and also compared withother individuals or groups. The provision of outcomesdata should offer services robust evidence on patient out-comes as well as data to inform decisions about resourceallocation within services e.g. a team currently carrying acaseload of patients with a high level of risk may needextra resources.

3. The FACE system is available electronically. This offers ussome degree of ‘future proofing’ in keeping with otherintended trust agendas including roll-out of a trust intra-net to all clinical areas; full integration of electronic FACErisk profiles into our impending 24-hour seven day accessCPA database; and eventually, the implementation of multi-disciplinary electronic patient records.

4. FACE was devised by Paul Clifford, a clinical psychologistby training with a background in mathematical logic, cod-ing and classification. He is a leading national and inter-national figure in mental health measurement in the UK,is a former director of the British Psychological Society’sNational Centre for Outcomes, Research and Effective-ness, and has been running national R & D programmesin health care since 1987. FACE has a good evidence baseand has been developed and researched over a numberof years in various settings. A comprehensive bibliographyon the research undertaken is available on the FACE web-site (www.facecode.com). However, it is important to stressthat the FACE risk profile is a generic risk assessment tooland is not intended to be a predictive tool.

5. Our trust is also currently involved in a Department ofHealth study which is looking at outcome measures anda number of trust services are piloting the whole FACEsystem as part of this study.

6. Not least, during our consultation process we visited twoother trusts that had already implemented the FACE riskprofile in a trust-wide approach, demonstrating what canbe done when planned well. It also confirmed that organ-isation-wide approaches to clinical practice challenges canoccur, contrary to some beliefs.

A description of the FACE risk profileThe FACE risk profile comprises four A4-sized sheets. Thefirst page acts as a ‘front sheet’ that summarises a patient’sdemographic and service contact details. This sheet alsosummarises ratings of risk, on a five-point scale ranging from‘0’ – ‘no apparent risk’ through to ‘4’ – ‘serious and appar-ent risk’ (see Box 1 for the definitions of all five risk ratings)on various types of risk. On the working age adult versionof the risk profile these are: 1. risk of violence or harm toothers; 2. risk of suicide; 3. risk of deliberate self-harm; 4.risk of severe self-neglect; risk to child; and 5. risk of elderabuse.

The second sheet is a checklist of historical and current indi-cators of risk grouped into categories e.g. ‘clinical symptomsindicative of risk’ and ‘treatment-related indicators of risk’.The working age adult version contains a total of 39 indica-tors. The third sheet comprises free text boxes where a descrip-tion of the specific risk factors, both current warning signsand risk history, can be fully described and individualised forthe patient. The fourth sheet comprises relapse and risk man-agement plan, including ‘buffers against risk’, can be spec-ified and tailored for an individual patient. Therefore, theFACE risk profile offers a:

15 mental health practice september 2003 vol 7 no 1

Box 1. Definitions of the FACE risk profile rating points

0 = no apparent risk. No history or warning signs indicative of risk.

1 = low apparent risk. No current behaviour indicative of risk but patient’s historyand/or warning signs indicate the possible presence of risk. necessary level ofscreening/vigilance covered by standard care plan, i.e. no special risk prevention meas-ures or plan are required.

2 = significant risk. Patient’s history and condition indicate the presence of risk and thisis considered to be a significant issue at present, i.e. risk management plan is to bedrawn up as part of the patient’s care plan.

3 = serious apparent risk. Circumstances are such that a risk management plan shouldbe/has been drawn up and implemented.

4 = serious and imminent risk. Patient’s history and condition indicate the presence ofrisk and this is considered imminent (e.g. evidence of preparatory acts). highest priority tobe given to risk prevention.

16 mental health practice september 2003 vol 7 no 1

risk assessment

■■ convenient and structured way of summarising and collating key risk information

■■ single place where risk information is collated■■ structured method that reminds professionals of areas to

cover when screening for risk■■ method of storing and communicating information on risk

to other professionals■■ means of recording that basic screening for risk has been

carried out■■ means of recording risk management plans.

How our trust has adapted the FACE risk profileFACE suggest that all four sheets of the risk profile should becompleted to form a generic risk profile. However, the LeedsMental Health Trust decided to use the profile slightly differ-ently by separating off the ‘front sheet’ into what we term a‘level one’, or screening, risk assessment. The remaining threesheets are then used, if further assessment is judged neces-sary, into what we term a ‘level two’, or comprehensive, riskassessment. This adaptation was undertaken for two reasons.First, we want to be as least prescriptive as possible aboutclinical practice and not to prescribe or proscribe the meth-ods that staff used to assess risk. Second, we want to avoidburdening both staff and patients with unnecessary ques-tions and paperwork about risk. However, we also wanted astandardised method of documenting that a risk assessmenthas been completed and to use a tool that is sensitive enoughto trigger further assessment when this may be needed.

The model of risk assessment and risk management under-taken in our trust and outlined in the flow chart in figure 1 isintended to highlight that risk assessment is a dynamic process,rather than a static task, and that risk management is of equalimportance as risk assessment. Figure 1 describes our threelevels of assessment: level one (screening), level two (com-prehensive), and level three (intensive). Patients will enter thisprocess at different levels according to their clinical historyand presentation, but may follow level one through to leveltwo.

Level one – initial screening Level one comprises one sheet of A4 paper which forms theFACE risk profile ‘front sheet’. As described, this summarisespotential risks to self and others on a five-point scale with 0= ‘no apparent risk’ and 4 = ‘serious and imminent risk’. Level1 assessment is intended to be flexible enough to excludepatients who do not need a comprehensive assessment andsensitive enough to act as a trigger for patients who do needa further comprehensive assessment. If the rating of any his-torical or current risk is rated at ‘2’ or above then a level tworisk assessment should be completed. The rationale for choos-ing this cut off is twofold. First, evidence of significant cur-rent risk obviously warrants further assessment. Second,research shows that a history of significant risk is one of themost robust predictors of future risk and therefore a signifi-cant risk history in itself is a sufficient trigger for further assess-ment of current risk. If there is no evidence of a significantcurrent or historical risk then a completed ‘level one’ assess-ment on its own is sufficient to formally document that a riskassessment has been completed.

Level two – comprehensive risk assessmentLevel 2 comprises the remaining three A4 sheets of the FACErisk profile. First, a ‘check-list’ section to identify clinical riskfactors (both historical and current). Second, a free text descrip-tive account section to note the risks faced by that individual.This is a very important section as it allows the risks faced byan individual patient to be clearly individualised and to state

the specific potential risks faced by this individual and underwhat specific circumstances those potential risks are likely tobecome actual risks. Third, a relapse and risk managementplan which summarises the specific plans developed to man-age the specific risks faced by the patient. Level two risk assess-ments in our trust are expected to be completed on amultidisciplinary basis. Information from level two assessmentis expected to be incorporated into, and to inform, multidis-ciplinary care plans; CPA requirements; and observation levelrequirements. Level two assessment should be seen as a con-tinuous assessment, hence being used at different times dur-ing a patient’s care.

Level three – specialist/intensive assessmentWork is still in progress in fully defining level three assess-ments. These are expected to be either service, discipline orclient specific to allow flexibility across differing clinical areas.However, these assessments must be evidence based andprovide more information than can be obtained using any

Fig. 1. Flow chart of standardised approach to clinical risk assessment

Standardised Approach to Risk Assessment and Management

Patient referred to any trust service

Patient has known history of significant risk behaviours

Yes

Yes

Yes No

No

Complete level 2assessment

Is further detailed riskassessment needed?

1. Complete careplan including riskmanagement plan

2. Reassess as perthe care plan

Known to the service. Posed significant risk previously. Showssimilar signs now.

1. Complete careplan including riskmanagement plan

2. Reassess as perthe care plan

Complete level 3risk assessment

1. Complete careplan

2. Reassess as perthe care plan

Any significant previous or currentrisk behaviour identified, i.e. level 2

Complete level 1risk assessment

No

september 2003 vol 7 no 1 mental health practice 17

risk assessment

level two assessment. The trust has currently funded the foren-sic service to use the more intensive and forensically-orien-tated Risk Assessment Management and Audit System (RAMAS)tool (O’Rourke et al 1997), given that most of their work couldbe expected to be at level three. We are currently liaising withother specialists and groups of staff to identify appropriateassessments at this level.

We hope to identify a ‘basket’ of evidence-based tools thatcould be used as intensive assessment at level 3 and to ensurethat staff can draw on appropriately-qualified colleagues toadminister these intensive assessments.

Our main aim is to help our staff to structure the way theythink about risk, record and document risk, and especiallyhow they communicate about risk. We want our staff to usea common language when communicating about risk toensure that our patients receive a consistent service, no mat-ter which of our trust services they may be accessing at anyone time. We see the FACE risk profile, both level 1 and level2 assessments, forming the ‘trunk’ of the model. It is expectedthat this ‘trunk’ can be, and in many cases will need to be,supplemented by ‘branches’ formed from information-gath-ering tools already in use by clinicians. The FACE profile isintended to help staff organise and structure the way theycollect and record risk information and to promote discus-sion among teams about decisions made to manage iden-tified risk.

Carrying out a pilot studyAlthough the trust steering committee felt that the FACE riskprofile would be acceptable, it was felt important to involveand collaborate with staff and patients in any decision regard-ing trust-wide implementation. As part of this collaborationwe embarked on a pilot study of the profile.

We organised a three-month pilot study of the FACE riskprofile on 11 wards/departments which included working ageand older adult trust services. We also included services runby colleagues from social services and the voluntary sector.

The pilot study revealed evidence to support the imple-mentation process. Audit of 140 sets of case notes from thepilot study areas showed high compliance with the FACE riskprofile. Of the 140, 94 per cent (n=132) of notes had evi-dence that risk had been assessed during the episode of careand 84 per cent (n=111) of notes showed that the FACE toolhad been used to assess risk, with no evidence of the use ofother formal risk assessment tools.

Responses from 52 staff who participated in the pilot studyshowed that: 88 per cent (n=41) supported a tiered approachto risk assessment (as outlined in figure 1). The majority foundboth the level 1 (92 per cent, n=49) and level two (87 percent, n=41) risk assessments easy to understand and helpfulin assessing risk (96 per cent, n=43). The majority supportedthe trust-wide introduction of both the level 1 (79 per cent,n=41) and level 2 (86 per cent, n=42) assessments.

Involving the patientThe Mental Health Implementation Guide (DoH 2001) isexplicit that the individual patient should be the central focusof his or her care. Involving patients is obviously a key issuewhen considering issues around risk. We have taken steps totry to address this issue. We ensured that patient represen-

tatives were members of the steering committee. We wereespecially fortunate that one of our representatives had pre-vious experience of being involved in training courses for theFACE risk profile in another trust.

Our patient representatives felt that it was important thatpatients were accurately assessed for risk using a credible risktool and that using a standardised approach could help tominimise variation in the quality of risk assessments carriedout across our various trust services that a patient may accessduring his or her episode of care. We also gave presentationsto service-user groups so that they could comment on ourproposal. We have also tried to stress the desirability of col-laboration and transparency over risk assessment whereverpossible with patients during our staff training. For example,stressing the explicit statement in the guidance notes pro-vided by FACE that the risk profile is not intended to be usedas an interview schedule. However, we have also made itequally explicit that the FACE risk profile is, ultimately, a methodof recording and documenting the professional opinion ofthe clinician and that there may be times when staff andpatient disagree about the assessment of the level of risk.Trewin (2002) offers very clear suggestions on involving patientsin risk assessment using the FACE risk profile and covers issuesaround copying the document, sharing information, and deal-ing with conflict and disagreement.

An additional key finding from the pilot study was that moststaff felt that they need more training on risk assessment andrisk management. We are currently undertaking a trainingprocess involving groups of clinical staff to try and familiarisestaff with the FACE documentation and offer them time todiscuss with each other the implications of introducing theFACE risk profile into their team and clinical area.

Conclusions■■ risk assessment at different levels is supported by front-line

staff■■ a single assessment process, such as FACE, offers clinicians

a systematic approach to risk management■■ communication of risk is paramount where teams are man-

aging risk. A tool like the FACE Risk Profile offers a consis-tent method with which to communicate

■■ any change needs to be underpinned by training and support■■ risk assessment is an essential ingredient in supporting care

planning, CPA implementation and observation of patientsin wards

■■ decisions made about risk assessment and risk manage-ment should, wherever possible, be done in collaborationwith patients and completed in a sensitive way. However,there may be occasions where staff and patient perspec-tives on risk may differ, and where this occurs staff are stillresponsible for documenting their own opinions about thelevels of risk for individual patients ■

Graham Paley RMN, PhD, Nurse Research Fellowand Psychotherapist, Leeds Mental HealthTeaching NHS Trust, The Psychological TherapiesResearch Centre, Leeds; Peter McGinnis MA,BSc(Hons), Dip Nurse (London), RMN, Director ofNursing and Workforce Planning, Leeds MentalHealth Teaching NHS Trust

‘We want our staff to use a common language when communicating aboutrisk to ensure that our patients receive a consistent service, no matter which

of our trust services they may be accessing at any one time’

Referencesd

Clifford P (1999) The FACErecording andmeasurement system: ascientific approach toperson-basedinformation. Bulletin ofthe Meninger Clinic.63, 3, 305-331.

Department of Health(1999a) The NationalService Framework forMental Health: modernstandards and servicemodels. London, HMSO.

Department of Health(1999b) Effective CareCo-ordination inMental Health Services:modernising the careprogramme approach.London, HMSO.

Department of Health(1999c) Safer Services:National confidentialinquiry into suicide andhomicide by peoplewith mental illness.London, HMSO.

Department of Health(2001) The MentalHealth PolicyImplementation Guide.London, HMSO.

Department of Health(2002) National SuicidePrevention Strategy forEngland. London,HMSO.

O’Rourke MM et al (1997)Risk assessment andrisk management: theway forward.Psychiatric Care. 4, 3,104-106.

Trewin M (2002) Guidanceon the use of the FACErisk profile and theassessment of risk.www.facecode.com/Home_B30.htm