Positive and Proactive Care – Reducing the Need for Restrictive Intervention
Trust Board - February 2015
1.
INTRODUCTION
This briefing sets out the key elements of the Positive and Proactive Guidance and the
work that has been taken forward nationally with regard to its implementation and
monitoring. It clarifies the current workstreams within the Trust in advance of a formal
plan being brought to the board.
2. POSITIVE AND PROACTIVE CARE GUIDANCE
Positive and Proactive Care: reducing the need for restrictive interventions was
launched by the department of Health in April 2014. The guidance is aimed at
promoting the development of therapeutic environments and minimising all forms of
restrictive practices so they are only used as a last resort. It is part of a wider 2 year
initiative – the Positive and Safe programme – to deliver this transformation across all
health and social care. Accompanying guidance in relation to children, young people is
being developed and was due to be published in Spring 2015.
The guidance sets out mechanisms to ensure accountability to reduce the use of
restrictive practices, including effective governance, transparent reporting and
monitoring. It applies to all health and social care settings including health and social
care staff working in non-health settings such as police cells, immigration removal
centres and prisons.
Recovery-based approaches are seen as fundamental and the principles of positive
behavioural support are to be embedded across the wider health system. Positive
behavioural support is an approach rooted in learning disability services, which
promotes understanding the context and meaning of behaviour to inform the
development of supportive environments and skills that can enhance a person’s quality
of life.
Key points of the guidance to note are:
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All forms of restrictive practice should be reduced over 2 years
Restrictive practices should only be used as a last resort in emergency situations
There is an objective to end prone (face-down) restraint
Board members should be fully informed of their trust’s position on restrictive
practices and the management plan to reduce their use
• The board should identify an executive director to lead on recovery approaches
and reducing restrictive practices
• Providers should publish an annual report on the use of restrictive interventions
• The CQC will monitor and inspect against compliance with the guideline
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• There is an assumption of linking to existing programmes such as Safewards and
No Force First
The Positive and Safe programme has 5 workstreams addressing standards, guidance
and maintaining compliance; workforce training and development; contracts and
commissioning; communications, culture and leadership; and transparency, monitoring,
recording and reporting. Within the implementation of the programme there will be:
• The launch of a National Champions Network for local and national leaders for
change
• A new process for reporting and recording restraint via the National Reporting
Learning System to NHS England
• Encouragement to report using the national Mental Health Minimum Data Set
• Products focusing on quality issues, for example, excessive use of physical
intervention for individuals of Afro-Caribbean descent
• New fundamental standards underpinning regulation and inspection, to be
introduced by March 2015
• A one and two-year review of progress
Expectations on Trust implementation are set out in the diagram below which was
published by the MH network in collaboration with the CQC.
The revised MHA Code of Practice published in February 2015 incorporates the
guidance within its changes.
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3. CURRENT TRUST WORKSTREAMS
Executive leadership for the work going forward will sit with Julie Hankin as medical
director. There are clear overlaps with Simon Smith’s lead on recovery and Julie Hall’s
on violence and aggression which offer opportunities for joint working and synergy.
Sharon Rosenfeld, as Head of Compliance and Robert Mooken, as Head of Risk, will
be supporting the governance aspects of the work which will be monitored through the
patient safety and effectiveness group. In addition Rachel Wingfield, Senior
Organisational Development Lead with EMLA will be supporting the programme 1 day a
week and working with the divisional leads.
A data review group has been set up, accountable to patient safety and effectiveness,
including informatics and IT. This group will met quarterly to scrutinise both data quality
and emerging trends. This group has representation from all divisions and will ensure
consistency in definition and measurement across the workstreams.
An initial conference for staff is being held on the 25th February and athough not up to
now brought together within a single framework a great deal of work is already being
taken forward within the divisions to address these issues.
Forensic Services
Collaborative work is being undertaken across the three High Secure Hospitals to agree
a joint training programme for physical restraint.
Work is underway through Louise Bussell, Associate Director of Nursing, Quality and
Patient Experience to conduct a blanket restrictive practice review. Research is
underway to measure current activity and what changes can be made, taking into
consideration risk management, flexibility in options and current regulation. The first
group meeting to review blanket restriction is planned for February 24th.
Proposals are also being considered with David Jones, Nurse Consultant and Violence
Reduction Lead at Rampton to potentially conduct a pilot of the ‘No Force First’
approach on Adwick Ward. The intention would be to pilot an approach that
incorporates the actions recommended from the review of all blanket restrictions
alongside the implementation of the ‘No Force First’ methodology, supported by
research to capture current baseline activity and future outcomes and impact of the
pilot.
Local Services
Work on the LPR agenda is being led by Sandra Crawford and Mick O’Discoll in Local
Services. A steering group has recently been established and has now met twice. The
steering group will focus on key actions going forward to ensure actions are identified
and reported on and that tangible activity is captured effectively. A new activity template
will be designed for use in the projects already underway and teams will be encouraged
to present new ideas to reduce restrictive practice in their services for consideration by
the steering group, thus generating a bottom up approach to change.
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Gareth Foote, Clinical Psychologist in Local Services has submitted a request for funds
to support a band 7 post for the implementation of a No Force First project. The
intention is for a similar pilot to the one planned for Forensic services will then be
established in a local services AMH setting yet to be agreed. Julie Repper has agreed
to support the research element of this project and will conduct all baseline measures
and subsequent evaluation once a pilot site is agreed.
Other projects being taken forward in local services include developing videos for use in
training that are created by patients, reviews of observation procedure, section 17 and
ground leave procedure and perfect ward round.
Health Partnerships
Work is commencing with Michelle Bateman, Associate Director (nursing, quality and
patient experience) to scope the applicability of the guidance within health partnerships.
4. KEY ISSUES FOR THE BOARD TO NOTE
Despite ongoing representations from clinical groups and organisations the government
continues to hold to the position the prone restraint is to end completely. This poses a
number of significant issues for trusts as there is a lack of accredited alternatives to the
current training on restraint and no established evidence base for safer alternatives.
The divisional groups are currently reviewing the potential implications for clinical
practice to inform the formal reducing restrictive interventions plan. We are continuing
to liaise closely with the department of health regarding this and Dr Hankin has now
been invited to join the National Champions network.
From this month the trust has now been able to record prone restraint via Ulysses
which wasn’t previously possible. This has meant that our data returns have previously
been inaccurate in reporting that prone restraint has not been used. Training is ongoing
regarding reporting of both seclusion and restraint with staff and it is expected that the
numbers reported will actually increase over the next six months in order to get to a true
baseline position which can then be monitored. Work is ongoing with the
communications department to ensure that reporting of this position is clear and
accurate to all stakeholders.
5. RECOMMENDATIONS
The Board is requested to note the report.
Dr Julie Hankin
Executive Medical Director
19th February 2015
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