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A Human Rights Based Approach To Risk

Dr. Beth Greenhill (Mersey Care NHS Trust/University of Liverpool )

Human Rights and Risk Assessment

Faculty of LD RCPsych & BPS Meeting, 30/03/2012

Human Rights & People with Learning Disabilities

• More likely to experience rights violations (Sobsey, 1994; Mazzucchelli, 2001;

Davies, et al., 2000)

• May not fully understand their rights (Mazzucchelli, 2001; Flowers, 1998)

• Violations may be rooted in ableism & paternalism (Tarulli et. al., 2004)

Faculty of LD RCPsych & BPS Meeting,

30/03/2012

• healthcare and treatment (DH, 2001; Mencap, 2007; 2012; Lunsky et al.,

2009; Wullink et al., 2009)

• service responses to behaviour which

‘challenges’ (Emerson, 2000, 2002; McGill et al.,

2009; Webber et al, 2011)

• sexuality (Abbott & Howarth, 2005;

Joint Committee of Human Rights, 2008;

Richards et al., 2009)

Common Human Rights Issues


• ‘Risks to’ and ‘risks from’ people with learning disabilities

• Instead of thinking about human pain

anger, & attraction, we do

“risk assessment and management”

• Clinical risk as a distiller of

practitioner’s and service’s values

Rights are often understood as risks


Positive Risk Management

• Widely seen as necessary; few practical initiatives (Whittington & Logan, 2011)

• CPA’s ‘tick-box’ approach problematic • Strong impetus for service users to become involved in all

aspects of their own care (Department of Health, 2010)

• Government ‘think tanks’ advocating for more equal distribution of power for service users (Boyle & Harris, 2009)

• Move away from medical, predictive models; towards a social model of risk.

• Requires structures and tools within the MDT to support culture change.


Service User Inclusion in Risk Assessment • Service user’s voices often excluded (Langan & Lindow,

2004; Bates & Silberman, 2007; Sheldon, 2011)

• Services focus on managing threats to organisations whilst marginalising SU’s human rights (Langan & Lindow, 2004)

• Services fail to explore possibilities of consensus between SU’s and staff (Langan & Lindow,

2004; Hall & Duperouzel, 2010)

• Mental health policy increasingly

emphasises both SU’s human rights

and inclusive practice (Roberts et. al., 2012) Faculty of LD RCPsych & BPS Meeting,

30/03/2012

Person Centred Approaches to Risk • Alternative to actuarial ‘technocratic’ assessment (Alaszewski

& Alaszewski, 2005; Neill et. al. 2008).

• Absence of a legal basis for much of the good practice proposed (Mansell & Beadle-Brown, 2006).

• Calls made for a rights based approach to risk assessment (Sheldon, 2011)

• May allow less “them and us” constructions.

• Pilot work suggests a human rights based approach (HRBA) shows promise as a possible model for positive risk management for people with learning disabilities


Defensive Risk Management

Defensive approach to risk

Negative experience for the service user

Disengagement from services

No strategy in place to manage risk

positively

‘Negative Events’

Increasingly defensive

approach: Escalating

risk

(Whittington & Logan, 2011)


Collaborative Risk Management

Collaborative approach to risk

Positive experience for the service user

More engagement

with the process

Greater collaboration with services

Lower risk as strategies

for management are designed

and acted upon

Open approach: engaging with the

user in planning

risk

(Whittington & Logan, 2011)


Tug of War

‘Duty of Care’ (Sellars, 2002)

Paralysis, Getting Stuck

‘Dignity of Risk’ (Perske, 1972 )


Service User Inclusion and Person Centred Practice (QIPP Agenda)

Relationships and relational context: Collaboration, formulation & dialogue

Recovery Model Legal Rights and Frameworks

(HRA, MCA, MHA)

Positive Risk Management & Least Restrictive Practice Human

Rights Based Approach to

Risk

Human Rights: A Unifying Framework

(Bailey, Ridley and Greenhill, 2010; Whitehead, Carney and Greenhill, 2011; Greenhill and Whitehead, 2012)


Our solution….


The Human Rights & Risk Project

1. Risk Assessment

2. JRAMP

(Joint Risk Assessment and Management Plan)

3. The Human Rights Benchmarking Tool.

Developing service user’s human

rights

abilities and capacity

Developing staff’s abilities and

capacity in human rights


Key Concepts in HRBA to Risk: Balanced Decision Making

We need to balance the rights associated with:

• the risk posed (for the person or other people)

• and the strategy employed (for the person or the other people)

In practice you may be trying to balance :

• the Service User’s different rights

• Service User, staff and community rights


Key Concepts in HRBA to Risk: Proportionality

• ‘Not using a sledgehammer to crack a nut’

• A strategy should

– Be appropriate and not excessive to the risk

– Ensure that any restriction of rights is kept to a minimum

• Always use the least restrictive strategy

Level of perceived risk Le

vel o

f st

rate

gy e

mp

loye

d


Practical Human Rights & Risk Tools

•Developed with

•Practical tools to guide clinical judgement

•Supported by staff training & Service User human rights workshops

•Available on Equality and Human Rights Commission’s website


‘Keeping Me Safe and Well’ Risk Assessment


‘Keeping Me Safe and Well’ Risk Assessment • Looks at risk through a ‘human rights’ lens • Identifies equality and diversity issues • Maximises participation and empowerment • Includes guidelines to individualise the screen • Includes good practice examples


Section 1: Risks to Self

Transport (public and private) Mobility

Safety at home Hurting myself Not looking after myself

Medication


Section 2: Risk to Others Religion Sexuality Dependents

Truthfulness Fire starting Physical Violence (weapons)


Section 3: Risk from Others Sexuality Physical abuse by others Skin colour/ and or culture

Looking out for my family Financial abuse by others

Emotional abuse by others


Section 4: Risk Relating to Property Damage to my property Damage to other people’s property

Fire starting


Relational Risk • Possibilities of this opened up by formulation based, collaborative

approach • Clinical risk implicitly constructs risk as residing in the person • Risks are “inextricably connected to interpersonal relationships:

They do not just ‘exist’; they are taken, run or imposed” (Hansson, 2000)

• Increasing interest in interpersonal approaches (Wood & Blumenthal, 2011) • and ‘Relational Security’ (Allen, 2010; Kennedy, 2002; Kinsley, 1998) • Also ‘Value Congruence Theory’ (Casali & Day, 2010)


(Ipsos MORI, 2010; Greenhill, under review; Roberts et. al., in preparation; Owen et al., 2009)

“organisational culture as key to rights protection and promotion”


What is Organisational Culture?

beliefs, values, attitudes, behavioural norms,

established routines and traditions of its

workforce

(Davies, Nutley & Mannion, 2000)


Influences on Paid Carers

(adapted with permission from Richard Hastings)

Formal Context – Service & Policy

What staff do

Informal Organisational Culture

Emotional responses to

risk

Knowledge Beliefs & Attitudes


Threats to Culture Change: ‘Risk’ and Fear

Of change (Psychological reactance)

Organisational Insecurity

Of Organisational

blame

Of Professional

failure

Of Learning Disability

Of Mental Health

Fear


An Organisational and Personal Moral Compass


KMSAW Validation Steering Group….

Blackpool

Salford

Cheshire and Wirral

Lancashire Care

Calderstones

Five Boroughs

Keeping Me Safe and Well


http://www.salford.gov.uk/index.htm

http://www.salford.gov.uk/index.htm

Why it matters…


Conclusion • To integrate rights into risk assessment we need to:

– Move away from ‘them and us’ ways of working

– See risk as part of relationships – not just as an attribute of someone else

– Use rights to understand those relationships

– Have clear practical decision making tools within services to support culture change

– Make ‘choices guided by values’ (Casali & Day, 2010)

– Talk about risk and plan how to tackle it together

– Provide emotional support for staff so they can keep on ‘being people’ in the jobs they do

– Think about how power is used within organisations (for staff and service users)


Acknowledgements

Georgia Fair (Occupational Therapist)

Ged Carney (Community Nurse)

Damian Howard (Community Nurse)

Amy Lee (Assistant Psychologist)

Mel Grannel (Assistant Psychologist)

Jim Williams (Clinical Psychologist)

Alex Cookson (Clinical Psychologist)

Frank Chapman (Clinical Psychologist)

Emma Ward (Assistant Psychologist)

Amanda Roberts (Assistant Psychologist)

Kulivindar Kaur (Assistant Psychologist)

Lucy Mathews (BIHR)

Hanna Clayton (BIHR)

Lyndsey Dyer (Director, Service Users & Carers)

Meryl Cuzak (Equality and Human Rights Lead, Mersey Care)

Michelle Redman (Assistant Psychologist)

Jenna Vyas (Assistant Psychologist)

Irene Byrne Watts (Service Director, Rebuild CBU)

Liz Rushbrooke (Trainee Clinical Psychologist)

Shameem Butt (Trainee Clinical Psychologist)

Bill Hiley (Clinical Specialist)

Reuben Furlong (Residential Services Manager)

Debbie Bannister (Assistant Psychologist)

Learning Disability Team REBUILD

Annie Talbot (Trainee Clinical Psychologist)

Richard Whitehead (Clinical Psychologist)

Claire Punshon (Clinical Psychologist)

Laura Nicholson (Assistant Psychologist)

Ellie Taylor (Assistant Psychologist)

Anna Sharp (Speech and Language Therapist)

Jennifer Eaton (Community Nurse)

Zesh Khawaja (Trainee Clinical Psychologist)

Lauren McEwen (Trainee Clinical Psychologist)

Lesley Taylor (Trainee Clinical Psychologist)

Gavin Evans (Trainee Clinical Psychologist)

Carol Legge (Service User)

Yvonne Rooke (Service User)

Clare Sharrock (Service User)

Tony Peacock (Service User)

Ann-Marie Occomore (Service User)

Tina O’Connor (Service User)

British Institute of Human Rights

Department of Health

Innovate Now

Jenny Morris (Clinical Psychologist)

Sam Townsend (Clinical Psychologist)


References

• Allen, E. (2010). Your Guide to Relational Security: See, Think, Act. • Bates, P., & Silberman, W. (2007). Modelling Risk Management in Inclusive Settings [online] London: National

Development Team. Available from: http://www.ndt.org.uk/docsN/ET_SIrisk.pdf • Boyle, D. & Harris, M. (2009). The Challenge of Co-Production. How Equal Partnerships between

Professionals and the Public are Crucial to Improving Public Services. Discussion Paper. London: New Economics Foundation & NESTA Available from: http://www.nesta.org.uk/library/documents/Co-production- report.pdf

• Casali, G.L., & Day, G.E. (2010). Treating an Unhealthy Organisational Culture: the Implications of the Bundberg Hospital Inquiry for managerial ethical decision making. Australian Health Review, 34, 73-79.

• Davies, H.T.O. (2002). Understanding organisational culture in reforming the National Health Service. Journal of the Royal Society of Medicine.95, 140-142.

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