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mental health practice
S t o c k b y t e / R e x F e a t u r e s
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 profile
Our 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 profile
The 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:
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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.