Use of HCR–20 in routine psychiatric practice

I read with interest the recent editorial by Maden (Psychiatric Bulletin, April 2005, 29, 121-122) and the paper by Dowsett (Psychiatric Bulletin, January 2005, 29, 9-12), which supported the use of the HCR-20 in routine psychiatric practice. I would like to suggest that the HCR-20 may be of particular value in clarifying the interface between generic and forensic services and in directing the allocation of resources.

In an audit of our local service, we used the HCR-20 to compare the level of risk of the community forensic service case-load with forensic in-patients in a low security facility and in-patients managed in the same locked ward environment by general psychiatry services. Despite sizeable differences in the demographic profile compared with Dowsett’s study, the size of the potential risk as measured by the historical sub-scale was similar for our forensic groups (mean=12.0 (s.d.=3.0) for community forensic patients and 12.3 (s.d.=2.2) for forensic in-patients). This compared with an H-scale mean of 7.2 (s.d.=2.2) for general psychiatry patients who were in the same locked ward environment. There is often a discussion as to whether particular patients in this unit should be admitted under forensic or general services. Similarly the combined clinical and risk management scores showed statistically significant and clinically relevant differences between community patients and the in-patient groups.

I would therefore support the call to incorporate the HCR-20 into standard risk assessment procedures. There are obvious advantages in using a tool based on empirically derived information. At the service level the HCR-20 may be useful in stratifying services according to the level of risk they should manage, such that an H-scale score could provide an initial indicator of the suitability for supervision by a community forensic team or a generic team. Stable low clinical and risk management scores for forensic patients could highlight their suitability for transfer to generic services. A full clinical assessment could then be instigated. The HCR-20 may also be useful in demonstrating to those who fund forensic services that expensive services such as assertive outreach or intensive case management are being directed to an appropriately ‘forensic’ and high-risk client group.