Collaborative risk assessment and management across the forensic mental health pathway in England: a realist review and mixed methods evaluation

RESEARCH QUESTION What works for patients, carers and practitioners in collaborative risk assessment and management planning in the adult forensic mental health pathway in England? BACKGROUND Forensic psychiatric services are complex and resource-intensive. Risk, such as to others or oneself, is integral to admission, discharge, and stepwise progress through the pathway.

Optimising patient-centred care, by making assessment of risk and linked management decisions collaborative, is of utmost importance.

There are challenges to achieving this however, and the level and effectiveness of such collaboration in the secure pathway is not known. This is an important gap, because there is potential to improve outcomes, and because experiences are likely to vary.

AIMS AND OBJECTIVES The work will 1) identify what approaches to collaborative risk assessment and management planning are available in the adult forensic mental health pathway in England, and assess evidence for their outcomes, 2) examine current practice in terms of what approaches are implemented, what the barriers/facilitators are to their integration, and pathways to impact, and 3) make recommendations for best practice.

METHODS Our plan is for a realist synthesis, an approach that explains what works for whom, in what circumstances, in what respects, and how.

It is suited to the complex health intervention question by accounting for contextual factors and interacting mechanisms and outcomes. Our work comprises three main components: Realist review of available approaches.

In collaboration with patient and public involvement (PPI) and steering groups, we will develop an initial programme theory (PT), which explains how and why collaborative risk assessment is expected to work. Iterative literature searches will populate and refine this theoretically based framework with evidence.

Mixed methods study.

A sequential pilot survey, individual interviews and a national survey will map provision of collaborative risk assessment/management, barriers/facilitators to implementation, and outcomes of interest, and further refine the PT. Best practice recommendations from the overall realist synthesis.

The combined learning, in the form of the PT refined through each phase, will help formulate recommendations for best practice.

PPI Lived experience is embedded at each stage of our research cycle, with a public co-applicant and designated PPI leads. The application has been informed by a pre-submission PPI meeting. PPI leads will support and train two PPI members to feed into the main project steering group.

PPI groups will co-develop the equality, diversity and inclusion strategy, input into PT development, and co-design the survey, interview schedules and outputs.

IMPACT AND DISSEMINATION Policymakers and commissioners will be a primary target, who may use learning to refine commissioning or monitoring of quality.

Recommendations for improvements in clinical practice may utilise best practice cases, or measurable recommendations for how e.g. care plans may reflect learning. Dissemination will harness national networks. Work will be published in peer-reviewed journals in psychiatry and justice. Findings will be presented at conferences including the Royal College of Psychiatrists Forensic Faculty conference.

Patient- and carer-facing summaries will be tailored for diverse populations, such as with easy read formats, lay summaries, blogs and other accessible approaches.