Authors: the South-West Community Mental Health Knowledge Mobilisation Network. Collated by Jennie Hayes and approved by network members.
Previous blogs:
Part 1: roles needed to implement the Framework
Part 2: working together across different sectors
Part 3: The use of language when working together to support people with mental health problems
The Community Mental Health Knowledge Mobilization Network is an open-invite group who share knowledge and experiences about implementing the Community Mental Health Framework For Adults And Older Adults 2019 (CMHF). This blog series shares the network’s reflections about implementing the Framework. Our fourth blog discusses the concept and impact of ‘risk’ when implementing the Framework.
Holding risk
We discussed two different areas: the likelihood of risk and the impact of risk. There was an awareness that healthcare practitioners feel responsible for ‘holding’ the risk, but sometimes we can’t change the nature of the risk. Through safety planning we can support service users to take responsibility for managing risk. This shared endeavour can help us understand the risks better. The reality is that most practitioners have experienced an adverse event so understand the impact for the service user, for themselves and for the service.
Risk assessment and risk aversion
We discussed how, over many years and based on previous events, the system itself has developed to be risk averse, and with a focus on risk assessments. It was suggested that risk formulation was a more effective approach than risk assessment. Attempting to hold on to risk too tightly can be harmful to service users. Instead, a systemic approach is needed to manage people at risk that involves everyone, including service users. It can be refreshing for service users to say they take responsibility: management and shared responsibility, rather than assessment, is key.
We reflected that it is important to acknowledge the difficult reality that those who are depressed can have suicidal ideation, harm themselves or others, and sometimes people die. We have to be brave and honest and appreciate that this is not only the responsibility of practitioners, but individuals and their friends and family who also manage these risks every day. We need to have these difficult conversations and empower our own staff to have them. The system itself does not give enough support to practitioners to take decisions that might be risky, even if best for the service user. Practitioners can end up feeling anxious, worried about their job and feeling entirely responsible for someone’s wellbeing.
Learning from the service user
One network member gave a powerful example of learning from the service users they work with. Even without systemic support, they were really able to listen and respond to the service user’s feedback that being hospitalised made no long-term changes to their health, and were able to support them to stay at home. Although this felt risky and was a new approach for this established practitioner, listening and learning from the service user ended with a good decision. This can depend on the service user being able to articulate what they need, which is not always the case, and is about being experienced enough to make the judgement despite systemic pressures. If a practitioner has experienced an adverse event recently, or doesn’t have management support, these kinds of shared decisions can be challenging.
Collaborative decision making
Importantly, responsibility should not be held by one person; caseloads should be managed within a group. We should have a presumption of competence rather than a culture of risk assessment and individual responsibility. However, we need to be aware of the potential for groups making worse decisions than individuals, respect experience and find ways to diversify the workforce whilst maintaining a safe system.
Caseload and resources
Managing the volume of service users is important – when there are large caseloads, managing risk can be more challenging, especially when there is a risk to others. People can have the same mental health profile, but it may not be clear which ones may be at risk of harm to themselves or others. Caseloads need to be resourced with the opportunity to access appropriate interventions. There are gaps and unmet needs. Large caseloads prevent creative thinking and do not allow people time to imagine something different. Innovative approaches to both risk management and caseload management are therefore useful. One network member described contributing to organising a community event for people on waiting lists which helped people find different ways to support their mental health.
Overall, we felt we need more time, more money, more resources, and more experience. Sometimes we cannot meet the needs of service users, and this is not our failing. Service users can think that the ‘right’ care is being withheld, whereas in some cases it’s simply not possible to meet their needs. Although it is difficult to accept as a practitioner, sometimes adverse events happen. At times expectations of what is possible are too high. Practitioners can work well with people who might have complex needs, but they need time and space to do it well and to ensure the response is appropriate, whether it be structured time, limited interventions, trauma related support, or social support, etc. Supporting people well involves us working differently. Overall, we need time to think and smaller caseloads to enable us to manage risk in a way that empowers people.
Interested in joining the South-West Community Mental Health Knowledge Mobilisation Network? Please email charley.hobson-merrett@plymouth.ac.uk
This blog post is supported by the Peninsula Clinical Trials Unit (PenCTU) and the NIHR ARC South West Peninsula (PenARC)