Positive and Safe: reducing the need for restrictive interventions

Why? Winterbourne View Restraint was not always used only as a last resort Concerns about the use of anti-psychotic and anti- depressant 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 Count Me In Census 30% of people with LD in inpatient settings experienced physical restraint 14% of people in MH inpatient settings experienced restraint What about other settings Mind Report 49 NHS Trusts 20,000 incidents of restraint Range 3,000 – less than 50 per Trust 19,000 people retrained 1,000 restraint related injuries (60% response) Doesn’t include Independent sector Mind Report Differences in the use of physical restraint Over-use does occur Not always as last resort A number of deaths have been associated with the use of physical restraint Reducing the need for restrictive interventions

Restrictive interventions: current UK situation 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: 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 Above all - health & care services should be positive, caring and safe Promoting a therapeutic environment, enabling positive, compassionate caring that promoting physical and emotional wellness Treating all people with dignity; caring and talking to them in a safe and therapeutic way Restrictive practices have no place in a modern, compassionate health and care service Restraining, secluding or excessively medicating people should only ever be used as a last resort Enter the presentation's title using the menu option View > Header and Footer

Reducing the need for restrictive interventions 10 shared commitments Promoting positive alternatives, such as positive behaviour support and de- escalation techniques, are the most effective means of reducing restrictive interventions 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 Genuine co-production, with experts by experience, of’ policies and training. These should include alternative, positive measures and means of de-escalation Destructive and dangerous cultures must change. Leaders must stand up publicly for stopping outdated and damaging restraint and restrictions in health and care services Assault is assault. The intentional use of pain, restraints or restrictions to punish, hurt or humiliate is never acceptable and will not be tolerated Enter the presentation's title using the menu option View > Header and Footer

Positive and Proactive Care Key Principles: Compliance with the relevant rights in the European Convention on Human Rights Understanding people’s behaviour allows their unique needs, aspirations, experiences and strengths to be recognised and their quality of life to be enhanced Involvement and participation of people with care and support needs, their families, carers and advocates is essential People must be treated with compassion, dignity and kindness Services must support people to balance safety from harm and freedom of choice Positive relationships between the people who deliver services and the people they support must be protected and preserved. Enter the presentation's title using the menu option View > Header and Footer

Positive and Proactive Care Aims Cultural change Therapeutic environments Focus on quality of life Governance models Reducing reliance on restrictive interventions Learning, sharing and promoting practice innovation To ensure that restrictive interventions are used in a transparent, legal and ethical manner

Key Actions 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 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 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 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. 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. To significantly reduce the need for the use of restrictive practices. 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. The goals of the Positive and Safe programme overall will be to: To contribute to transformation of quality in health and care services with an emphasis on 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. This should be the standard 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. Ultimately we want to significantly reduce the need for the use of restrictive practices, including seeing an eventual end to deliberate face down/prone restraint, such that restrictive practices are only ever used as a last resort for the shortest possible time necessary to prevent serious injury or harm, and never to humiliate, punish or inflict pain -It is very important for me also that we 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.

How we’ll achieve this: five work streams Standards, guidance and maintaining compliance Workforce, training and development Commissioning and contracts Communications, culture and leadership Transparency: monitoring, reporting and reviewing Communications, culture & leadership Champions initiative Web based information and practice exchange Sharing stories along the journey Research and academic partners User and carer group involvement e.g. MIND, mencap etc.. Explore behaviour change project BME focused group re afro-carribean users and non discriminatory practice Transparency: monitoring, reviewing and reporting Baseline review of use of PBS and restrictive practices across NHS and LA funded provision Revisit arrangements for NRLS reporting of high impact restrictive interventions Support self reporting via Quality Accounts NHS England led project on use of medication for LD and CB Standards, guidance and maintaining compliance. CQC fundamental standards Positive and Proactive Care Updating the MHA Code of Practice Exploring the need for other legislative / national policy guidance NICE guidance due 2015 Work with NHS Protect Work with HSE Children and Young People Guidance Workforce, training and development. Positive and proactive workforce HEE mandate and Skills for Care programme Explore issues re training accreditation LD professional senate and / or MH Joint Commissioning Panel – key principles for training Develop expert by experience guide to training Support access to PBS training Explore eLearning opportunities Commissioning and contracts Revised NHS Standard Contract re PBS and policies Develop work on mental health strategic clinical networks and Crisis Care Concordat NHS LD service specification Work with LGAand ADASS to develop social care facing projects

How we’ll achieve this: reporting and partners Patients, service users, carers, families and support and advocacy organisations 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 Academics and researchers BILD DfE, MoJ, Home Office Etc… Mental Health Systems Board Positive and Safe Steering Group Champions Group Agreed projects, initiatives and actions

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 Enter the presentation's title using the menu option View > Header and Footer