Dave Atkinson Lead on Department of Health’s Positive and Safe Guidance Independent Consultant Nurse working who led on Department of Health's ' 'Positive and Proactive Care'

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

2. 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. 3
Reducing the need for restrictive
interventions
Reducing the need for restrictive interventions
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
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
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

4. 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

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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 de-
escalation 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

7. 7
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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8. 8
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

9. 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. 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. 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. 12
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.

13. 13
How we’ll achieve this: five work streams
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
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

14. 14
How we’ll achieve this: reporting and
partnersPartners:
•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
Agreed projects,
initiatives and
actions
Champions
Group

15. 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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