Positive and Safe:
reducing the need for restrictive
interventions
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Why?
Winterbourne View
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Restraint was not always used only as a last resort
Concerns about the use of anti-psychotic and antidepressant medications
Other restrictive practices common
Subsequent investigations show that these findings are
widespread
Reducing the need for restrictive interventions
Reducing the need for restrictive
interventions
Mind
CountReport
Me In Census
30%
of Trusts
people
with
inpatient
settings
•• 49
Differences
NHS
in the
useLD
ofin
physical
restraint
experienced physical restraint
• 20,000
Over-use
incidents
does occur
of restraint
•
14% of people in MH inpatient settings experienced
• Range
Not
always
3,000
as–last
lessresort
than 50 per Trust
restraint
•• 19,000
AWhat
number
people
of deaths
retrained
have been associated
about
other
settings
with the use of physical restraint
• 1,000 restraint related injuries (60%
•
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Reducing the need for restrictive interventions
response)
Doesn’t include Independent sector
Restrictive interventions:
current UK situation
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Large variation in restrictive practices between hospitals / services
Rates unmonitored or declared
Creeping increases in coercive practices: locking, CTOs, detentions,
expansion of MSUs, opening of seclusion rooms
Evidence of scope for reduction: not just seclusion and manual
restraint, but also rapid tranquillisation, special observation, PRN
No evidence for increasing violence or injuries to staff
Currently 4 reduction strategies:
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Six core strategies – Huckshorn, Duxbury
No Force First – Ashcraft, Recovery Inc., - Trenchard
Positive Behavioural Support –long history in LD and US Schools
Safewards – Bowers
Reducing the need for restrictive interventions
Reducing the need for restrictive
interventions
10 shared commitments
1. Above all - health & care services should be positive, caring and safe
2. Promoting a therapeutic environment, enabling positive, compassionate caring that
promoting physical and emotional wellness
3. Treating all people with dignity; caring and talking to them in a safe and therapeutic way
4. Restrictive practices have no place in a modern, compassionate health and care service
5. Restraining, secluding or excessively medicating people should only ever be used as a
last resort
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Reducing the need for restrictive
interventions
10 shared commitments
6. Promoting positive alternatives, such as positive behaviour support and deescalation techniques, are the most effective means of reducing restrictive
interventions
7. Being open, honest and transparent about the use of restraint and restrictions.
They must be recorded, reported openly and reviewed. Patients and families should
be communicated with
8. Genuine co-production, with experts by experience, of’ policies and training. These
should include alternative, positive measures and means of de-escalation
9. Destructive and dangerous cultures must change. Leaders must stand up publicly
for stopping outdated and damaging restraint and restrictions in health and care
services
10. Assault is assault. The intentional use of pain, restraints or restrictions to punish,
hurt or humiliate is never acceptable and will not be tolerated
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Positive and Proactive Care
Key Principles:
1. Compliance with the relevant rights in the European
Convention on Human Rights
2. Understanding people’s behaviour allows their unique
needs, aspirations, experiences and strengths to be
recognised and their quality of life to be enhanced
3. Involvement and participation of people with care
and support needs, their families, carers and
advocates is essential
4. People must be treated with compassion, dignity
and kindness
5. Services must support people to balance safety from
harm and freedom of choice
6. Positive relationships between the people who
deliver services and the people they support must be
protected and preserved.
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Positive and Proactive Care
Aims
1. Cultural change
2. Therapeutic environments
3. Focus on quality of life
4. Governance models
5. Reducing reliance on restrictive interventions
6. Learning, sharing and promoting practice innovation
7. To ensure that restrictive interventions are used in a transparent, legal and
ethical manner
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Key Actions
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Improving care
• Individualised support planning
• Behaviour Support Planning
• Greater user / carer involvement
Leadership, assurance &
accountability
• Board level responsibility
• Focus on proactive as well as reactive
management
• Reduction plans
• Training
• Reporting to commissioners
• Post incident reviews
Transparency
• Publishing data
Monitoring & oversight
• CQC monitoring and inspection
• Accountability
But this is part of a wider set of actions
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NHS Protect
Mental Health Crisis Care Concordat
NHS England and LGA Core
Principles Commissioning Tool (for
services for people who display
behaviour that challenges)
Skills for Health and Skills for Care
NICE
Mental Health Act Code of Practice
Children’s volume of Positive and
Proactive Care
The Way Forwards
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Government level support
Careful attention to policy and regulation
Service user, family and advocate involvement
Effective leadership
Training and education
New ways of working
Staffing changes
Using data to monitor the use of restrictive intervention
Effective review procedures and debriefing and
Judicious use of medication.
Reducing the need for restrictive interventions
Positive and Safe - goals
1. Creating and sustaining safe, therapeutic and compassionate
environments where the focus is on recovery and avoiding harm, which
covers different conditions and is responsive to people’s individual needs.
2. Wherever the health or social care staff are delivering care, including in
both hospitals and people’s homes and anywhere else it may be required.
3. To significantly reduce the need for the use of restrictive practices.
4. It is very important that we also remember Winterbourne View and ensure we
have the right focus on different groups and their particular needs,
including those with learning disability or autism and behaviour that can
challenge as well as the experiences of other groups, such as those from
minority ethnic communities.
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How we’ll achieve this: five work streams
Commissioning
and . .
Transparency:
monitoring,
and reporting
Standards,
guidance
Workforce,
maintaining
training
andcompliance
development
Communications,
culture &reviewing
leadership
contracts
•• Baseline
review
of• use
of fundamental
PBS and restrictive
practices
acrossworkforce
CQC
• Positive
standards
and proactive
Champions
initiative
NHS and LA funded provision
• Revised NHS Standard
• Positive
Proactive
• HEECare
mandate and
Skills for
• Web based information
and and
practice
Contract
re Care
PBS and
• Revisit
arrangements
for
NRLS
reporting
of
high
impact
programme
exchange
• Updating the MHA Code of Practicepolicies
restrictive interventions
training work
accreditation
• Sharing stories along the journey • Explore issues •reDevelop
on mental
•
Exploring
the
need
for
other
legislative
/
national
policy
• Support self reporting via Quality Accounts
health strategic
clinical
guidance
and / or MH
Joint
• Research and academic
partners • LD professional senate
• NHS England led project on use of medication
for LD and
CB– key
networks
and
Crisis Care
Commissioning
Panel
principles
for
• NICE
guidancee.g.
due 2015
• Standards,
User and carer group
involvement
Transparency:
Concordat
training
Workforce,
Communications,
guidance
monitoring,
Commissioning
MIND,and
mencap etc..
training
and
culture
and
•
Work
with
NHS
Protect
NHS
LD service
maintaining
reporting
and
and
contractsexpert• by
• Develop
experience
guide
to
development
leadership
•compliance
Explore behaviour
change project
reviewing
specification
• Work with HSE training
• BME focused group re afro-carribean users
• to
Work
LGAand ADASS
• Children and Young
• Support
Peopleaccess
Guidance
PBSwith
training
and non discriminatory practice
to develop social care
• Explore eLearning
opportunities
facing
projects
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How we’ll achieve this: reporting and partners
Mental Health
Systems Board
Positive and Safe
Steering Group
Agreed projects,
initiatives and
actions
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Champions
Group
Partners:
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Patients, service users, carers, families and
support and advocacy organisations
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NHS England
•
LGA and ADASS
•
CQC
•
HEE, Skills for Health, Skills for Care
•
NICE, SCIE
•
NHS Protect
•
HSE
•
CCGs and LAs
•
providers, esp provider boards and senior
management teams
•
Royal Colleges, directors of nursing and other
professional leaders, trade unions and networks
•
Learning Disability Professional Senate
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Academics and researchers
•
BILD
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DfE, MoJ, Home Office
•
Etc…
Issues for today?
• How can we work together to identify and agree the actions
required from now to deliver the outcomes and establish and
maintain momentum for this work, including leadership for
particular activities or themes.
• How can we co-ordinate various activities.
• How can we identify and secure relevant resources within our
organisations and recognise when we might be a resource to
others
• How we best communicate the cultural changes that are the
programme’s goal
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