There is a recent myth we have heard about: “a Choice appointment does not include a risk assessment”.  This is such an important issue that we decided to clarify risk assessment in Choice appointments and CAPA generally.

So is it true? No.

Where does this myth come from? We think there is a significant misunderstanding about what goes on in a Choice appointment. A simplistic view of a Choice appointment is that it is a cosy chat with a young person and family, focussed on finding out what they want, without comment or opinion, and agreeing to it. This is not what should happen in a Choice appointment.

Choice involves an active conversation between the young person and their family 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.

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 risks will  be central to the current situation and thus a key focus in Choice.

The stance in CAPA is collaborative, open and transparent. Talking about risk in Choice will be conversational in style but in such detail as needed to agree a safety plan. A relaxed, conversational style will gather more accurate information and engage the young person and 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 its particularly important that there it is clear who is the key worker, especially for those families who see someone different in Partnership. Ensure rapid completion of written communication and Care Plans, copied to the user and network. We aim for this paperwork to be sent out within 48 hours.

Skills in risk assessment and management are included in the concept of assessment as an extended skill CAPA- the A of the  Alphabet skills.

The Department of Health guidance” Best Practice in Managing Risk Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services” (National Mental Health Risk Management Programme June 2007) notes two key best practice points:

1. 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

2. 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 Royal College of Psychiatrists document “Rethinking risk to others in mental health service” (College Report 150) noted several key concerns:

1. 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

2. Risk cannot be eliminated

3. 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”.

This guidance all fits seamless into CAPA and Choice.