1. Positive and Safe: reducing the need for restrictive interventions

2. 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

3. 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

4. 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

5. 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
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6. 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
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7. 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.
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8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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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