CHAPTER THREE: RISK ASSESSMENT IN COMMUNITY CARE
INTRODUCTION
Risk barely featured in assessments of needs for community care until high profile cases dominated media headlines in the early 1990s. Since then, minimising risk has become a key focus of community care policy. The move towards community care was partly influenced by hospitalisation possibly stifling everyday opportunities amongst in-patients but also by the realisation that many of those living in institutions could, with support, live in the community. This resulted in a strong lobby for the rights of people with learning disabilities in particular to take similar risks to others and to live as normal a life as possible (Alaszewski & Alaszewski, 2002). However, there are concurrent concerns about what is an 'acceptable' risk and minimising risk and empowering users are not necessarily compatible aims. Although the risk to the public from mental health users is minimal overall - sufferers are more likely to kill themselves rather than other people (Munro & Rumgay, 2000) - they are nevertheless defined in terms of risk and dangerousness because of often unpredictable violent incidents and are thus unlikely to be fully involved in decision making.
In the disability and mental health fields in particular, where the social rather than the medical model of disability prevails, risk tends to be defined by service users as exposure to 'unmet need' (Read and Reynolds, 1997), where because they are denied appropriate or timely services, they are at greater risk of vulnerability. Risk management in this respect, however, focuses on risk redistribution at the expense of vulnerability and needs assessment. Again, bifurcation results: those perceived as high risk receive a service whereas those perceived as low risk do not; this is all the more worrying when research suggests that services users often disagree with their supervising social workers about the priorities for intervention (McIvor and Barry, 1998; Neill et al., 1988, cited in Waterson, 1999).
This chapter highlights some of the research on risk in community care as well as exploring the issues for practitioners and policy makers in identifying and assessing risk. The literature demonstrates increasing bifurcation policies (of targeting resources at those assessed as high risk, to the possible neglect of those not assessed as high risk) and argues that the needs and wishes of service users are often marginalised, although arguably much less so in community care than in criminal justice.
LEGISLATION, GUIDANCE AND TOOLS IN COMMUNITY CARE
Recent legislation and policy in Scotland in the community care field aims to ensure faster and better assessments, more integrated professional working, better information sharing across boundaries and opportunities for greater control for individuals. In particular, Community Health Partnerships are not only a response to the need for integration between primary care and secondary care and between primary care and community care, and but also result from a desire to involve the public in the delivery of primary care services. A National Child Health Support Group also joins partners in local authorities and the voluntary sector towards a responsive and evidence-based child health service. Like social work, the National Health Service and Community Health Partnerships aim to 'shift the balance of care' (Scottish Executive, 2005b) through offering a preventive approach, supporting self care, ensuring better targeting of resources to those at greatest risk and developing anticipatory care services for high risk individuals.
'The same as you?', A review of services for people with learning disabilities report (Scottish Executive 2000b) was a key driver in empowering individuals with a learning disability to lead a better quality life, with appropriate supports in place within the wider community. One of the key principles underpinning this review was the need for people to have more say and more control over their lives. The use of direct payments, brokerage and advocacy services was recommended as a way to assist people to have more influence and control over their lives.
There are a range of legal measures to protect the interests of vulnerable adults and their carers in terms of assessment, including the NHS and Community Care Act (1990) which spells out the duty to assess those in need of 'community care services', and the Carers (Recognition and Services) Act 1995 which introduced the right of assessment for carers. In terms of risk taking and user empowerment, both the Adult Support & Protection (Scotland) Act 2007 and the Adults with Incapacity (Scotland) Act 2000 stipulates that interventions must be the least restrictive to achieve the desired benefit, and that the individual should be encouraged to use existing skills and develop new ones. The Mental Health (Care and Treatment) (Scotland) Act 2003 also states that restrictions must be the least necessary to ensure safety and well being. This Act which is regarded as being an exemplar for other countries in the care and treatment of people with mental health problems, also requires attention to the following principles:
- non-discrimination and equality on the grounds of capacity, age, gender, ethnicity, etc.,
- agency commitment to provide safe and appropriate services,
- voluntary rather than compulsory care,
- participation of service users,
- support and respect for carers,
- minimal and least restrictive intervention, and
- positive outcomes/benefits from an intervention.
The Mental Welfare Commission for Scotland stresses that risk to the individual should be the paramount concern, not risk to the organisation caring for that individual. The Commission recently issued guidance on restraint (in 2006) based on the premise that the user should always be involved in decisions and restraint should be avoided wherever possible.
The Mental Health Tribunal for Scotland which was established in the Mental Health Care and Treatment (Scotland) Act 2000 sets out procedures for ensuring that in any decision on compulsory care, the patient and a number of forms of patient representative are actively involved in the hearing to ensure that they influence any decision or assessment of level of risk (to both the community and patient themselves).
The Adult Support and Protection (Scotland) Act 2007, to be commenced in autumn 2008, provides protection for adults at risk of harm, enshrines key principles to be followed by practitioners, and specifies duties on statutory agencies to co-operate in investigating harm, and assessing risk.
Monitoring of client groups within community care, like that of the criminal justice field, now also draws on electronic technology, although the terminology has been softened in relation to other client groups compared with offenders and accused (i.e., 'wandering technology' rather than 'tagging'). Such technology can more readily, and perhaps more cheaply, monitor the safer movements of service users where they are deemed at risk within the community. Risk assessment tools in the field do not readily differentiate between different types of illness and levels of risk and therefore medication and monitoring are often the main methods of risk management:
"… the objective of a standardized, reliable, generalizable set of criteria for dangerous predictions, in law and in mental health, is still an elusive and distant objective." (Menzies et al., 1994, quoted in Munro & Rumgay, 2000).
Alongside the criminal justice and child protection systems, registers of known risk groups in mental health have been developed as a further monitoring mechanism. Supervision registers within the mental health field were implemented in 1994 in England and Wales following the death of someone at the hands of a discharged patient suffering mental health problems (Davies, 1998). These registers classify people as being a significant risk to themselves through self-neglect, being a risk to others or being suicidal. However, numbers of people fitting those categories are generally low and Munro and Rumgay (2000) suggest that low numbers in a given potentially risky population make risk predictions less accurate.
VARIATIONS IN PRACTICE IN COMMUNITY CARE
Within the community care field, in contrast to the criminal justice field but more closely aligned with child protection, the range of agencies involved have differing remits, are accountable to differing stakeholders and thus operate under differing philosophies about risk. Medical staff, for example, may have the concerns of the family or wider public in mind whereas social work staff, carers and user-led organisations may give greater representation to the needs and rights of the service user. Waterson (1999) suggests that professionals and users tend to disagree on levels of risk, not least because risk is subjective and can apply to environments as well as to people. Alaszewski and Manthorpe (1998) equally argue that risk is perceived differently by different professionals and allocating blame is one of the main concerns of public enquiries into failures of community care interventions. If an organisation is secure, it will respond more proactively to risk rather than adopt a blaming approach. Alaszewski and Alaszewski (2002) found that users, families and professionals had differing views about risk and safety. Users and families tended to defer to the wishes of professionals, whilst professionals tended to balance normal risk taking against a 'duty of care'. In these authors' experience, few organisations were able to give equal weight to safety and empowerment, with the effect of tending towards safety at the expense of empowerment.
Various groups have an interest in risk assessment - professionals, service users, carers and advocates - and it is therefore difficult to be completely user-centred when assessing risk. Assessments of people in the community care field are more likely than in other fields to happen at a time of crisis, and are thus generally reactive rather than proactive, and workers in these instances may focus on weaknesses and inabilities rather than strengths and abilities. Professionals thus play safe, minimising risk at the expense of user empowerment. Likewise, performance management has largely replaced trust as a means of auditing such professional practice.
Training in risk assessment and the close recording of decisions are thus seen as crucial in community care work, the former to ensure greater consistency of approach and therefore defensibility, and the latter because of the potential number of professionals who may draw on that assessment for further work with, or management of, the client.
DISCUSSION OF RISK ASSESSMENT IN COMMUNITY CARE
In a study of the role of risk assessment in predicting or preventing homicides by people with mental health problems, Munro & Rumgay (2000) found that 27.5 per cent of their sample of 40 cases could have been predictable and 65 per cent could have been prevented. In 29 of their 40 cases, the authors found that the public inquiry deemed there to be insufficient evidence of imminent risk: in only 8 cases (20%) were patients judged to be high risk at the time of the homicide. In 17 cases, the inquiry concluded that better psychiatric care generally would have been preferable to, and more effective than, better risk assessment:
"… more homicides could be prevented by improving the response to patients who start to relapse, regardless of their assessed potential for violence, than by trying to identify high-risk patients and target resources on them." (ibid: 118).
These authors suggest that patients may vary in their level of risk or vulnerability over time, and indeed a 'ladder of dangerousness' has been devised (Lingham et al, 1996, cited in Munro & Rumgay, 2000) which can help plot a patient's level of risk over time. However, targeting resources on high-risk patients is, to these authors, counterproductive given the high numbers of false positives (non-violent patients being assessed as high risk and having limited resources focused on them unnecessarily). Public perceptions of risk are exaggerated as a result of the current culture of risk assessment and management amongst policy makers as well as sensationalist media reporting. Contrary to common myth, a policy of resettlement from long-stay hospitalisation and integration within communities has not increased the rate of homicides by those with mental health problems: deaths of innocent victims at the hands of drunken or careless drivers far exceed the deaths resulting from mentally ill people being cared for in the community (Munro & Rumgay, 2000).
Risk assessment and public inquiries caused by public pressure are both intrusive of families and draining on limited resources for those most in need. Mental health professionals, according to several authors in the field, should concentrate on diagnosing and treating actual mental health needs rather than assessing, containing and targeting potential risk. However, having said that, there are examples where risk features little in work with community care clients: Langan and Lindow (2004), for example, interviewed 56 professionals in England and found that few undertook systematic risk assessment or developed risk management plans for their clients.
In all aspects of social work, but with the strongest lobby in the community care field, service users' vulnerabilities need to be taken into account when assessing risk and service users should be included in that process. In the field of older people, for example, the literature stresses the need for people to have choice and opportunities to take risks towards maintaining their independence and self-determination: 'risk taking is choosing whether or not to act to achieve beneficial results in an awareness of potential harms' (Lawson, 1996: 55). However, risk assessment in work with older people tends to focus on the worker's interpretation of events and the worker's plans for the future: for example, 'what benefits do you hope to achieve with the user?'. Assessments need to identify what the user wants, why they want it, what their abilities are to fulfil that aspiration and whether there are risks involved within the immediate environment. Risk taking should be carefully planned to enable a good quality of life, developing new skills and trying previously untried experiences. Risk assessment should not be about containing risks or rationing resources/services, which may result in service users being constrained from defining their own risks and needs (Waterson, 1999). Risk assessment in any social work theme should incorporate the views of those whose needs are being addressed by such assessments. What they want, why they want it, what their abilities are and whether there are extraneous risk factors all need to be taken into account, otherwise the service user may not feel committed to or 'own' the resulting intervention. Risk enablement should be carefully planned to promote a good quality of life, to develop new skills and to try previously untried experiences (Tindall, 1997). Although service users are deemed less likely to identify risks than their families or professional workers, they may also feel under pressure to comply with the wishes of others or to fit into existing services. Nevertheless, several authors argue for greater user empowerment, partnership and informed consent in risk assessment and management (Parsloe, 1999; Stalker, 2003; Waterson, 1999).
SUMMARY
The community care field is possibly most akin to criminal justice in terms of media interest in its assessment and management of risk, again because of past dangerousness rather than future risk. In addition, these two fields may sometimes 'share' the same client group. However, unlike criminal justice, the community care field has a better established practice of user participation in decision making and there is also a strong lobby of users (e.g., those with mental health problems and people with disabilities) who actively seek choice and participation in decision making. In community care, the risk-taking model is more in use than the risk minimisation model, although one suspects that if the user movement for greater choice and participation was not so strong, managerialist imperatives would result in a greater use of the risk minimisation model.
Recent community care policies emphasise the importance of ensuring that people have more say and more control over their lives. The use of direct payments, brokerage and advocacy services are strategies which add impetus to this agenda. Legislation in community care protects the aspirations and capacities of users to take risks, within certain safety parameters, and risk assessment tools in this field are less well developed than in the criminal justice system, with workers often resorting to surveillance measures or medication to ensure risk reduction. There is also arguably less time available for risk assessment and wider agency consultation in community care and child protection, since both tend to operate mainly in times of crisis whilst the user is living in the community. There has also been much criticism within the literature about risk assessment and management taking precedence over longer-term patient care and treatment.