Moving towards Individualised Risk Management: The NICE clinical guidance on self-harm, updated in 2022, brought a significant shift in approach to risk assessment and management.
Once considered essential for predicting suicide or self-harm repetition, risk assessment tools, scales, and levels are now discouraged, and guidance recommends against their use for:
a) predicting suicide or self-harm repetition, and
b) making decisions about treatment or discharge.
This change aligns with the Suicide Prevention Strategy for England 2023-28, published in 2023. All services have been urged to reassess their use of these tools and scales, and to transition towards an individualised approach to risk assessment and management.
To support you and your team in meeting the updated NICE clinical guidance (NG225), we’ve developed a resource titled, ‘Moving Towards Individualised Risk Management’.
In this blog;
In this blog, we’ll explore how the NICE guidance and National Strategy combined have spurred services into action. Some of this action has involved both our Director Keith Waters, and our CEO Bianca Romanyk. They have both recently been invited (separately) to present on this topic.
Keith’s presentation came first, and his approach to the task was clear: he wanted to understand and explain the development of risk assessment tools and scales, with a focus on where they had come from, why they were used, and – most importantly – what had changed.
What did we learn from the literature review?
At Storm Skills Training, we want everything we produce to be linked to evidence, best practice, and lived experience, as these are core elements of our values.
A comprehensive literature review was my first step, to lay the foundation for Keith’s presentation and develop our understanding of the topic.
Historically, approaches to risk assessment across a range of human behaviours (including self-harm and suicide) have been primarily focused on prediction.
Knowing which service users would go on to repeat self-harm or take their own life allows professionals to intervene.
However, traditional approaches to self-harm and suicide risk assessment involve making decisions about risk based on professional judgment.
This approach drew criticism for its subjectivity, since decisions about treatment and care were effectively driven by opinion, intuition, or “gut feeling”.
There was also increasing evidence to suggest that professionals’ predictions about risk of future self-harm or suicide were largely inaccurate.
All of these factors combined paved the way for risk assessment tools and scales to emerge as a solution, since they seemingly removed subjectivity from the assessment process and used available evidence to improve practice. These tools offered some tangible benefits, such as providing a structured framework for the assessment process and offering an “aide memoire” for clinicians, especially those with less experience.
Despite our best efforts and intentions, however, evidence has consistently revealed the inherent limitations of trying to predicting suicide, either with or without tools. Put simply, we can’t predict who will end their life. This is because suicide is both complex and relatively rare, and risk of suicide is dynamic. The 2024 annual report from the National Confidential Inquiry into Suicide Safety in Mental Health (NCISH) strikingly revealed that 82% of patients who were in contact with services before their death by suicide were judged to be “low” or “no risk”.
This underscores the need for an alternative approach. Until recently, however, the alternative has not always been obvious.
There’s a lot of information and evidence out there, but sifting through it takes time and not all of it is accessible or practically oriented. Along with the support of the Storm Skills Training team, I’ve taken the time to do the work for you - view the resource here.
Keith's presentation and the resource received a positive response from a group of specialist mental health professionals, they found understanding the history and changes over time helped to understand the reasons and need for the guidelines, and it sparked conversations about its benefits for other team members in different departments and roles.
If you’re interested in learning more, our CEO Bianca presented at the National Suicide Prevention Alliance (NSPA) members’ webinar titled "Best Practice in Assessment of Suicide Risk" on May 28, 2024. This event focused on exploring effective practices in using risk assessments to support individuals experiencing suicidality. The webinar also featured Philip Pirie, a bereaved father advocating for suicide risk assessment reform, and NSPA Lived Experience Influencer Andy Willis. View the resource: Moving Towards Individualised Risk Management.
Reflections
Recognising the limits of traditional predictive approaches has been sobering, but the shift towards a more individualised and compassionate model signals a positive change that is long overdue. This shift isn’t just about changing processes; it’s about fostering a culture of empathy – one which focuses less on predicting risk and more on promoting safety and meeting individual needs.
Moving forward, we’re committed to providing more evidence-based resources for the self-harm and suicide prevention community. Your input is really valuable in helping us to tailor this content and provide resources that are practical and relevant. Whether it’s risk management, therapeutic intervention, or a topic that you feel needs more attention, please do get in touch with us at enquiries@stormskillstraining.com to share your ideas and suggestions.
