The use of discharge risk assessment tools in general psychiatric services in the UK

Abstract

Closure of asylums dismantled a system of risk control based on containment, resulting in a rise in homicides and suicides by discharged patients. Remedial action centred on a structured approach to managing multidisciplinary care (the Care Programme Approach) and a system of independent inquiries into homicides. A need for better discharge risk assessment was identified by government and health professions. The literature points to inherent limitations in the predictive power of actuarially based tools, restricting them to augmenting clinical judgement. This paper addresses the development and effective use of tools to predict risk to patients and public following discharge into the community. Methods used were: (i) a questionnaire to NHS Trusts in the UK; (ii) an analysis of documentation on tools in use; and (iii) interviews of hospital and community mental health teams at eight NHS Trusts. Findings point to: (i) a sporadic development of risk assessment tools at Trust level; (ii) that this has been stimulated by clinical governance but is unguided by any coherent national strategy; and (iii) that information technology for risk data collection is not well used in the UK, where there is reliance on use of paper records and informal communication. The implications for management and health professions are discussed.

Investigating the Evidence for the Effectiveness of Risk Assessment in Mental Health Care

“…Importantly, actuarial tools developed from predictor variables do not necessarily reflect the experiences of the individual (Crowe & Carlyle, 2003) and are therefore the province of research rather than everyday clinical practice (Undrill, 2007). Stein's (2002) review of actuarialbased tools used to aid the process of discharge risk assessment in the UK surmised that there are inherent limitations in the predictive power of these types of tools. This review expressed reservations as to the ability of risk assessment tools to account for the complexity and diversity of human behaviour.…”

“…For example, different tools may be required for males and females as the predictor variables for one gender may differ from the other. The transferability of actuarial tools from one setting to another or one country to another also is doubtful (Stein, 2002).…”

Exploring the human resource implications of clinical governance

“…But from the literature, it emerges that the human resource implications of health policies in general and clinical governance in particular remains largely unexplored. Most clinical governance discussion in the literature has focused on its definition [3][4][5], organisational strategies [6,7], leadership [8][9][10][11], professional development [12], clinical audit [13], role of chief executives [14], managerial and clinical approaches to quality [15], clinical guidelines [16], organisational culture [17], risk management [18,19], staff development needs [20], education [21] and information management [22,23]. Few of these publications pay attention to the human resource implications of clinical governance.…”

Assessment and Management of Suicide Risk in Primary Care

“…The rapid improvement of information technology may facilitate both the collection and communication of risk information. 20 Systems could flag up patients at risk, indicate who is responsible for follow up care and may be updated regularly, including for patients who do not attend appointments. Further research to investigate and understand the variation in risk assessment among health professionals may also help to improve practice.…”