When speaking with anyone working mental health services, one of the challenges that will be surfaced quickly is how to effectively manage risk.
Tameside & Glossop based GP Vinny Khunger and Occupational Therapist in the High Peak Living Well Prototype in Derbyshire Megan Shenfield explore how when considering risk, there is a tension between managing the risk of a specific action for the person and the service, with taking in account the risk within the bigger context of the person’s life.
‘We need to consider risk for each person in the bigger picture of their life”
‘We need to assess risk for both the person and the service for each action we take’
This episode does include themes of suicide. If you are affected by any of the themes raised in this episode you can contact the Samaritans at samaritans.org
Megan: The best way of managing risk isn’t just filling in a risk assessment or doing a safety plan or a wellbeing plan it’s helping the person to deal with the things that are going on in their life, that are making their life difficult and them getting a better quality of life - that’s the ultimate isn’t it.
Jo [Narrator]: Welcome to the Living Well Dialogues a series of podcasts of intimate conversations between people striving to understand how our mental health system is shaped and seeking to find new possibilities to continue to grow their Living Well Systems in places across the UK.
Whose risk is it anyway? The risks in mental health are very real. Last year in England and Scotland over 100 people were reported to have died from suicide every week and almost a quarter of those were known to mental health services. Importantly in recent decades there has been increasing public education and awareness for the prevalence and the complex challenges of suicide. With this comes significant increases in media coverage and public scrutiny on the related role and importance of our mental health services and with this we have seen more rigorous investigations from Coroner’s Courts and more public calls for better learning and necessary improvements. One result of this means that there is increasing pressure on people working in mental health services to prevent and reduce risk.
Today, risk is the issue that dominates the minds of those delivering mental health services. So often it is raised as the primary reason for why mental health services struggle to integrate different forms of support, collaborate and share information and work in more creative and collaborative ways. All of these impacts means that shared risk management is challenging to achieve, that many people delivering services feel that the systems and processes and even cultures lead to a focus on risk avoidance rather than risk management. In short risk is a contested issue for our mental health services and it is full of powerful tensions that can feel difficult to navigate, because like all powerful tensions they often call on us to manage two or more seemingly competing truths. To help us to navigate these tensions in this dialogue is Megan and Vinny.
Megan Shenfield is an Occupational Therapist by training with a background largely working with Community Mental Health Teams (CMHT). Megan currently works in the High Peak Living Well prototype team in Derbyshire.
Vinny Khunger is a GP Principle in Tameside and Glossop and the Clinical Commission Group Governing Body Lead for Mental Health. He is also a clinical lead for projects across the Greater Manchester area. Vinny has been involved with the Living Well Programme in the area since its start, 4 years ago.
So, Megan and Vinny what shapes our perception and understanding of risk when working with people with mental health challenges?
Megan: I don’t know whether it is worth me saying at this point Vinny, I’ve had lots of experiences over the years around risk, but I think one of the things I was thinking about … where the fear comes from in terms of staff and how that influences how staff deal with risk with people and how that impacts on people’s experience of services. I have had the experience of someone sadly ending their life when I have been working with them and finding that person.
So, I have been through that process of having to have the Trust review what’s happened … the internal process and going to Coroners Court, having all the notes trawled through and being interviewed and all of that kind of stuff. The impact of that cannot be underestimated in terms of how staff work. It doesn’t really get talked about in Community Mental Health Services, but I think there are a lot of staff who have had that experience and it is incredibly difficult and it is an incredibly protracted process as well and, you’ll know this, but average Joe public doesn’t know this, it can take years to get through that process.
It’s almost retraumatizing for staff. If you haven’t had that experience, you know someone who has. We’re expected in mental health services to save everybody and keep everybody safe and that sounds like a good thing in theory doesn’t it, it sounds like a positive thing, but actually the reality is some of the things we are expected to do to keep people safe isn’t always in the person’s best interest, so I think it is an interesting tension to explore.
Vinny: I completely agree, and there are so many factors that affect our own personal attitude to risk. There’s ourselves, so it’s our mental state as well as to how we are feeling at that particular time during the day. So, I know for example on a Monday morning I am much more ready for the challenge and up for the fight than I would be on a Friday afternoon when I had worked 40 or 50 hours that week already, and things seem a little bit too much at that stage.
If we think about negative experiences, for example the suicide that you talk about and subsequent involvement of the coroner, and if we just go back to the reason we came into these jobs. I quite firmly, passionately believe that pretty much all of us came into what we are doing because we wanted to do good things, we wanted to help people. We wanted to create goodness in the world effectively. We have this view we are trying to do our best - we’re trying to do everything, and I think it can hit you like a ton of bricks when something as negative as that happens.
I’ve been involved in one or two suicides, distantly, not people I was directly involved in or had seen toward the end of their life. Massively, massively shakes your confidence, massively questions your belief and understanding as to why you are doing this - and that in itself will also play on further down the line in terms of future decisions you will make around risk, where you perceive that there is some threat and there is some risk. How are you actually going to then go on and manage that? Quite often the answer is, well, there are lots of other services out there, lets share this risk - rather than trying to embrace it.
Megan: I think you’re right there. We all come into the job wanting to help people get a better quality of life ultimately, that’s what were here for, we want people live a good life - but that gets derailed sometimes by systems we work in and our best intentions for people, being able to make their own choices, and live lives that are meaningful for them, get side tracked by perhaps not being able to offer to them what would be ideally helpful to them or maybe being worried about the implications of choices. If I take a more risk positive approach is something going to happen and am I going to have my notes scrutinised or what would Joe Public think if something happened as a consequence of this decision, it’s tricky.
Vinny: There’s another thing that interests me - as we become more experienced both as an organisation or the Living Well structure, but also as individuals - something I often wonder, do you think our ability to accept and manage risk gets better or gets worse because I think sometimes, we can actually play on both positive and negative experiences. But I always feel, certainly from my point of view - if I’m seeing a patient, with a particular condition I won’t remember the 1000 things that went well, the thing that sticks in your head is the one that went wrong, so you’re trying to avoid that. Does our ability to accept and manage risk get better or worse the more experienced we are?
Megan: I think it can go both ways. I don’t know about you, both are true, because as you get more experienced you get better at knowing where the real risk is, better at making a judgement from what you know about a person. Do I need to be really concerned? Or is this something actually that I can manage? I think that just comes with experience, in that sense you get a little bit less reactive. I think also, when you are first starting out there is more of a temptation to go by the book - this person saying they want to kill themselves therefore I am going to refer them to crisis team - rather than thinking more flexibly and into the grey areas. Being a bit more creative and thinking around it and perhaps trying to manage things in different ways. But then at the same time, as you say, if you’ve had some bad experiences those do tend to stick, and I am very mindful myself of that potential in me to be risk averse because I’ve had that bad experience. I work really hard not to do that - you need to be very self-aware.
Vinny: To me when I am thinking about risk there is always that question - what if, what if this happens? Sometimes I catastrophise and totally over blow things and totally go over the top and actually there wasn’t that much risk there. I’m talking about both physical and mental health when I say that. … I’ve totally catastrophised that in my head and convinced myself that if I let this patient go something terrible is going to happen to them - that’s the end of my career and my kids are going to starve because I can’t work, and all kinds of crazy things can go through your head when you’re thinking about risk.
Jo: The impact of how we relate to risk is very real for both Megan and Vinny. They help us recognise that how we understand and manage risk can be very personal to each of us. Our knowledge, experiences and even state of mind might well shape the ways in which we both perceive and respond to risks. Being self-aware then becomes important to helping us navigate what is shaping our understanding and driving our actions. The conditions and relationships around us also have a significant impact on how we manage risk. Most importantly perhaps is the quality of the relationship that we have with the person whose risks we are concerned about. What other kinds of practices in relationships with those that we work with, and support, help us be aware of how we are managing risk, and perhaps do it differently?
Vinny: It’s something that interests me a lot as a GP. Because I think in reality the job as a GP is around managing risk and uncertainty. We don’t work in a big Hospital setting where we have access to lots of different facilities lots of different X rays and blood tests that we can get quickly. So, we are quite used to managing risk in the wider context. Because I suppose from our point of view, all day long we are making decisions around weighing up probability and weighing up risk and I think one of the frustrating things that most GP’s would probably say about risk is that people aren’t willing to adequately embrace it and accept that not everything is cut and dry. As a result of that ultimately the people that suffer probably are patients and to some extent also the workforce because they [patients] are just being passed around the system because people aren’t really willing to accept and embrace that risk.
Megan: … I totally agree with you. The services that already exist to help manage risk I think aren’t always right. They aren’t right for the people we serve. So, one of the reasons why I was really interested in Living Well is because if we are thinking about people with a trauma history and emotional unstable personality disorder, which I guess is the group of people who tend to stereotypically present the biggest risk in terms of the people we work with.
I guess NICE guidelines says those people aren’t best helped in a hospital setting. A hospital setting can actually make the risk worse. You can imagine - someone struggles with relationships, trust and need a lot of consistency the hospital is the absolutely worse place for you to be when there’s lots of people also struggling with their safety, there’s a lot of chaos about, frequent staff changes.
It’s not really a brilliant therapeutic place for you to be and that’s kind-of our default position if somebody is a significant suicide risk is to put them in hospital. I think the model of managing risk for the riskiest group of the people we work with doesn’t work, it’s not helpful for them. So, we find ourselves, for the staff that work in the community, in this almost impossible position - trying our best to help people stay safe in a way that feels right for them, but the options we have available just aren’t working for them, and we are left holding the risk with nowhere to take it, which is quite tricky, I think.
Vinny: … this is actually one thing that general practice in itself … does that very poorly. General practice is still very much a single person in a room - so if you are seeing someone with suicidal ideation, you’re individually making that risk. Whereas outside in the community and in secondary care risk is shared much better and people are potentially more comfortable with it.
Megan: It must be very difficult in GP setting where you are seeing people back-to-back for very short periods of time. Your relationship with people is based on those short sessions and you don’t have time to perhaps share that. I guess we are privileged in Community Mental Health Services in so much as we have time to get to know people. In terms of what kind of practice helps us to judge risk, that is the fundamental thing, is the relationship with the person, your understanding of their context.
If you really get a good relationship with someone where they trust you, you understand them, they know that you understand them. Then that allows people to be honest with you, it allows you to work in a collaborative way with them to form risk assessments and plans that you do together - that is the most important thing is that ability to get good therapeutic relationship.
It’s very hard assessing and managing risk jointly with someone when you don’t really know them that well, that’s the truth. That whole sharing risk thing is an interesting one. Although in Community Mental Health Teams there is more opportunity for sharing the risk and holding it together. In the past it hasn’t felt like that. Quite often as a clinician you spend most of your week running around out in the community - jumping between visits - on your own - you feel like you personally hold that risk as an individual, and if something happens you are personally responsible. Working in Living Well has felt different, largely because of the meeting structure believe it or not! Not that I am one to normally advocate going to meetings! We have a get together every single day in the Huddle and that’s our chance to share anything we are concerned about and also this kind of flattened hierarchy idea, where everybody’s voice is important.
That allows staff to be open and honest with each other about things that are going on or you’re worried about and you’ve always got a touching point with colleagues to kind-of say “Oh, I saw this person yesterday and these are the things that we talked about and I’m really concerned about that, and what do you think we should do”, and that feels really a weight has been lifted off your shoulders - you don’t feel like you are holding it on your own. You’re making decisions together, and you’re documenting that you have discussed it and shared it. I suppose that gives a kind of support to then make trickier decisions to do more positive risk taking.
Vinny: That to me is massively important, that ability to share. … At the end of the day you can’t also underestimated the psychological impact that it has on us as individuals. If we’re talking to people whose lives are that bad, that terrible, … that they are actually considering such a drastic step of ending their own life or significantly harming themselves in some way. That in itself is going to have a psychological toil eventually on people. So having that ability to share - having that almost, it’s a professional outlet obviously, also helps the individual come to terms with what they are doing and the significance of the decisions they are being asked to make - as well as medically, legally and from a Coroner’s point of view it does help share that risk. And I think that’s something again that from a GP point of view I think we do that very poorly, although we might have a practice full of nurse practitioners and GP’s and whoever else … actually it is something we do quite poorly. Has Living Well helped your ability to share that risk a bit better?
Megan: Yes - I think it has. It’s a bit of a funny one - on one level, the way we assess and manage risk is quite different from in the Community Mental Health Team in that we don’t have same degree of documentation that you’d have in a Community Mental Health Team. The risk assessment we used to use was incredibly detailed and thorough whereas the one we use in Living Well is simplified. The focus in the past was about asking all the things, ticking all the boxes because that was what the organisation needed.
They wanted all that information to be on the file just in case something happened. But for the person some of those questions would feel quite unhelpful and intrusive. And the format is not something they would keep in a drawer and get out when they were in a crisis - it was something very much for us not for them. … Living Well has helped me in feeling like a process that is helpful for the person - which is so much nicer as a member of staff because you don’t want to go in with this hideous form with lots of tick boxes and questions that they are going to hate.
You want it to be something that feels helpful for them too. But also, it’s just that whole thing of being held by the team. …I feel like if I have a problem, if there is someone I am concerned about, I can take that to the team, easily, that day or the next day, and I know that they will be really supportive, that there is a space for me to talk about it, that people will offer to help as opposed to before when it could be another week before I could catch anybody to discuss it. Everybody tended to be a little bit avoidant of helping out because everyone was so pushed and overwhelmed with work - so yeah, I do feel that it has helped - definitely.
Jo: Megan raises how existing services for those that we believe are most risky don’t necessarily support us to truly reduce their risk in the long term. This can leave individual teams feeling that they need to hold the risk for the person. Vinny underlines how a failure to share risk is something that general practice struggles to do also. Sharing risk might start with the relationship with the person seeking support. Key to this is taking the time to build the relationships that enable us to hold the risk with the person. However, Megan raises that existing structures and processes can limit the possibility to create this kind of relationship because each individual practitioner can feel very isolated trying to hold the risk of many different people.
Importantly Vinny brings that back to the importance of the psychological toll on practitioners. This is where Living Well has offered some promise for Megan. Where processes like team meetings, different forms of recording risk and assessment and a more flattened hierarchy hold the team in relationships that enable more collective holding of risk and support different ways of managing risk. So, Vinny and Megan what have we learnt about the wider system conditions that might better enable or impede these kinds of ways of working and managing risk?
Vinny: … with my catastrophising hat on - there’s quite a stark difference between the medical/legal set up for primary care and that for Community and secondary care. For example, I work in a practice … nobody can actually sue the practice if something goes wrong. You can only sue individuals. Whereas … in a secondary care Trust you can’t sue the individual. And that to me is part of the reason why probably why primary care manages risk slightly differently. And why we haven’t embraced that ability to share the risk across our own organisation, across primary care better. Ultimately there is going to be a decision maker - and that person is pretty much going to have to live or die by the decision that they make. … And that’s why we often end up taking the more risk averse options. … I think things can be done better on both sides. Primary care has to stop being as protective as we are. We are protective of own organisations. We are protective of the fact that we are the data controller, the record keeper for patients - and one quite simple way would be if everybody just had access to our records. Again, I think we need to step out of our own silos, step out of own organisations. We certainly need to look at patients from a much more holistic point of view. I think sometimes with mental health services there’s a very narrow focus - particularly around embracing complexity. So, somebody has mental health issues, but on top of that driving it is actually their poor housing, their difficult financial circumstances, their ropey relationships and in addition to that there may be drug and alcohol seeking behaviour. I think mental health services sometimes struggle to accept that. Coming together to embrace that more holistic view would probably make our lives easier and would definitely help patients a lot more as well.
Megan: That’s a really good point about holistic care. I think you are right. Sometimes mental health services in the past can be narrow focused - again that’s something about Living Well that is different. If somebody has got needs that are more social care, but someone has also got some health needs maybe around … emotional regulation, or someone needs an occupational change and also the drug and alcohol side of things as well - we’re not quite there yet I don’t think, well we aren’t, but we are moving towards a point where people can get most of those needs met in one place rather than … sometimes in the past it was like passing the baton and hoping that the other person did grab it. And sometimes they might drop that baton, but we might not even know that because we didn’t check. Instead, we’re kind of running alongside them for a little bit, we are trying to make sure that we have that warm handover - that the person has got to where they need to get to. And you’re right that is really instrumental in managing risk. Because risk isn’t just about whether you want to end your life or not, it is in the context of a person’s whole life and what’s going on for them. So ultimately the best way of managing risk isn’t just filling in a risk assessment or doing a safety plan or a wellbeing plan it’s helping the person to deal with the things that are going on in their life, that are making their life difficult. And getting a better quality of life - that’s the ultimate isn’t it.
Vinny: Absolutely … I completely agree - it is. And I just think that if we are able to embrace that much more holistic view and not have to pass people around - if we are able to engrain that sort of more holistic view of people and their lives, I think it potentially might make a difference. Then again, it might just start to help us embrace risk a bit more. But again, that is quite a big cultural change because ultimately it will require people stepping out of their own silos and their own organisations … and I completely understand how that is uncomfortable. If you told me tomorrow even to go and work in a different practice half a mile down the road, I would find that difficult, I would find that hard to do. The culture of the organisation is set from high up and I think unless people start - the leaders in the organisation are willing to discuss the concept of risk and embrace it themselves, then that does tend to trickle across the organisation, and you can end up with this culture of shifting people around in order to avoid accepting and embracing risk.
Jo: Legal and structural differences like data sharing often lead us to having significantly different ways of dealing with risk and the ability to take a more holistic approach. Both Megan and Vinny agree that a more holistic view and the ability to connect care and support around an individual’s complex needs might be the best way of managing risk. Vinny describes how this is a significant cultural shift that will require significant adaptation in people, stepping out of safe silos into uncomfortable places and Vinny advocates for this cultural change requiring strong leadership that models a different form of holistic engagement of risk. But does this cultural shift go deeper, what wider shifts might we need to see in how we collectively see risk as a whole system?
Megan: I think it’s interesting how risk is held in the community as well. Traditionally we have seen managing risk and protecting people as being our business - certainly as Mental Health staff or in the Mental Health Trust - it’s like ‘that’s our job’ and we kind-of take ownership of that. And I think it is interesting to think of that in a different way. It’s the person’s risk not our risk for us to help them to manage and kind of empower them to manage and also how we in a more planned and - in an organisational sense - how we help the wider community to manage risk. Because ultimately people do better when they feel connected to their community, connected to other people. And I think there is so much that the wider community can offer people; making sure that places in the community are trained about mental health, about suicide. If you are struggling and you go into your corner shop, or the hairdressers … they might have a certain sticker in the window - and you might know, there is somebody there who I can have a little chat with and they wouldn’t be expected to manage someone’s risk but they might know what to do with that … so I think it is really good to think about how we can create more opportunities for people to feel held and safe and to connect with people in the wider community rather than it just being about a clinical offer …
Vinny: I completely agree, and I think this is one of the big issues probably of the 21st Century, in that we have moved away now from a societal model … recognise that they are heading toward a crisis situation that they may potentially go to speak to somebody close - that kind of social human contact is going unfortunately. I think that ultimately does have a big impact across society and does decrease people’s resilience and potentially increases their risk if they are in a bad place …. One of the things I was really interested in was when you said, “is risk actually our business?” I think that is a really interesting way of looking at it. I suppose intrinsically we are taught “yes, it is - that’s our job” - it’s our job to stop this happening - If I ask myself that question, my answer is, “yeah, I’m a doctor, of course it is, I have to stop bad things happening to good people - that’s what I’m here for.” But actually, am I going to do that all the time?
Megan: I totally agree with that … I think the attitude of Joe Public is that it is our job as NHS staff to prevent risk, to prevent people harming themselves or harming other people. And if ever there is an incident, we have somehow failed. And obviously I think it is important that things that have happened, that have gone wrong, that that is looked at and evaluated and we learn the lessons from the that. For me risk is definitely our business, of course. We have a duty of care, we come into this job to help people. I think it is the moving away from us owning the risk to facilitating the person we are working with feeling enabled to manage their risk with support and help from us to find the right resources, to learn the right skills. It’s where the power sits. Staff tend to feel like the power sits with us - we’re protecting that - and that isn’t in a good way for either us or the person. And I think to do that requires a massive mental shift for the public, for Commissioners, for Coroners, for Trust Boards and staff within it. … Until we have moved to accept - as you said very rightly - we accept that we can’t save everybody we can only help people to have the best resources they can to live and live a good quality of life and sometimes that will mean taking risks and sometimes the right outcome won’t happen. We need to be allowed to accept that things won’t be perfect. As soon as we get into this idea that we’ve got to rescue and save everybody that’s when we start making choices and decisions for the person rather than them being empowered to make choices and it means that people have things happen to them that isn’t actually really in their best interests that keeps them safe but doesn’t necessarily make them well.
Vinny: You’ve summed that up really, really well, to have the attitude that we need to have towards risk, about having that more holistic view toward the individual and seeing them as a person, not just the acute risk there and then, but as a more holistic individual and how we should be managing ourselves to help patients manage themselves. And it’s going to be difficult. These next few years are going to be really difficult. We are going to see a lot of risky patients … the world is in a very difficult position at the moment with cost of living … we’ve definitely got some tough times ahead, so I think we will be managing more of this risk as we go forward.
Jo: The nature of the challenges we face during the 21st Century might mean there is an ever-growing urgency for a deep change in how we understand and hold risk. The desire in people delivering public services to prevent risk and harm runs deep. It is core to a duty of care, a moral and virtuous belief that for many was at the heart of their calling for a life of care and public service. But perhaps this desire has led to a culture that seeks to rescue and protect and as Megan says, that makes decisions about the safety, care and well being for people not with them. Instead, we might seek to hold people in relationships that enable them to make decisions and where necessary to take risks in search of leading a bigger, better life. This change to how we see risk may well run beyond the boundaries of our mental health services and require a wider societal shift, but perhaps we can find hope in people like Megan and Vinny to lead the way.
The Living Well Dialogues is brought to you by the Living Well UK Programme, funded by The National Lottery and delivered by the Innovation Unit. For more information visit livingwellsystems.uk.