The Guardian Newspaper, in its article entitled ‘Alarm over restraint of NHS mental health patients’, revealed that:
# There were 80,000 restraints of patients on mental health units in the UK last year (2016-17).
# This included 10,000 who were held face-down or given injections to subdue them.
# Girls and young women under the age of 20 were the most likely to be restrained, each one being physically restrained an average of 30 times a year.
# Black people were three times more likely to be restrained than white people.
# Patients were controlled by “non-prone” physical restraint 43,000 times and that chemical restraint was used on another 8,600 occasions.
The figures were published by the NHS Digital Statistical Agency.
The Guardian Newspaper also reported that “In its annual report in July, the Care Quality Commission, which regulates NHS care in England, said its inspectors had found unwarranted and wide-ranging variation between units in terms of how often staff used restraint. Wards with low rates had staff who had been trained to handle difficult behaviour and de-escalate challenging situations”.
The Department of Health, who issued guidance in 2014, said that restraint should only be used as a “last resort” and only if other means of dealing with difficult situations were unlikely to succeed, and a spokeswoman for the Department of Health said that “physical restraint should only be used as a last report and anything less is unacceptable.”
So, my question is – despite all of the guidance to the contrary, why are so many restraints taking place, and why are techniques such as face-down and prone still being used to the degree that they are?
And I’d like to make one thing clear right from the start. The vast majority of staff working in mental health units that I meet, genuinely care for their service users very much.
They are absolutely committed to keeping them safe, and I know of a number of people who chose to work in mental health for personal reasons. Some because they lost a close friend or relative to mental illness, others because they have a family member or friend who suffers with a mental health issue.
Therefore, I’d like you to be mindful when we read statistics like this in that we don’t take these published figures and make the mistaken presumption that staff who work in mental health get some form of perverse enjoyment in restraining people who are mentally ill.
Let me explain.
In a recent conversation with a very experienced mental health professional who is also a very well respected and experienced restraint trainer.
During our conversation, he highlighted the fact that in his service there are now a lot more younger people being admitted into mental health units than before. He also went onto say that because of the increase in retirement age the nursing staff expected to care and at times control these young people are now much older than the young people in their care and do find it difficult to control these younger and stronger patients.
However, this is also combined by other factors too that I am going to highlight now.
1. There is a lot of well-meaning guidance produced by very well-meaning people, but it is at times contradictory and some of the advice it gives is legally flawed, yet some CQC inspectors will expect management to follow the guidance to the letter and many managers will simply follow the guidance simply to placate a CQC inspector, even to the detriment of patient care and staff safety.
2. In a clarification document issued by the now redundant NHS Protect in March 2015, it states: “The Positive and Proactive Care guidance provides information and good practice; it is not statutory guidance or legally binding”.
3. Some training companies are also still teaching out-dated and old types of restraint systems that still use techniques that have been advised not to be used, such as prone and face-down restraint, where other alternatives exist, simply because they have produced systems that are ‘set in stone’ and which haven’t evolved over time, which I believe is possibly down to a cognitive bias known as the ‘IKEA Effect’ – I made it so it must be right!
4. And these training companies promote their system in many cases as ‘accredited’ or ‘approved’ when it is only self-accredited or accredited by another organisation who runs its own self-accreditation system. Oh, and for clarity, the Department of Health (and indeed no other Government Agency or Department), actually approves or accredits any system of restraint – despite some agencies trying to promote their system on that basis.
5. Many NHS management systems will also not look at equipment which could provide alternatives to prone or face down restraint, such as the new fit for purpose SafetyPod or the Soft Restraint system, both of which have been industry tested and medically reviewed as being fit for purpose and which can reduce prone and face-down restraint.
6. There is also a high dependency on agency staff who may either be not trained in physical restraint or trained in a completely different system of restraint to what the employed staff are, resulting in an uncoordinated approach to a restraint which can and does result in a situation going to the floor.
7. Conflict resolution/management and de-escalation training is simply either not being delivered or is being ‘squeezed’ into an already limited time-period used for physical restraint training, primarily because of staffing problems resulting in management either not wanting to release staff for additional training resulting in them being away from already poorly staffed wards. This gives rise to a ‘tick-box’ training culture when it comes to physical restraint and conflict management.
8. And here’s my biggest gripe. Some of these so-called ‘expert panels’ who produce a lot of this well-meaning guidance are made up in the main of people who have never had to actually restrain a violent person so have no realistic and competent understanding of how difficult it is.
So, what is the point that I’m making?
Well the point I’m making is that any restraint system must be fit for purpose for the environment that it is being used in, and that means to comply with the various laws and guidance:
1. It must provide the least restrictive range of intervention options available;
2. It must be consistent with promoting a ‘reducing restrictive practices approach’, which means it must review any interventions and then plan to avoid/reduce or eliminate the need to intervene again.
3. It must be designed and developed in line with the needs of the patient/service user in mind from the best interest criteria;
4. Whilst also considering the health, safety and welfare of staff.
This means that systems of restraint must continually evolve and develop in line with an organisation’s changing patient, staff and environmental landscape.
Restraint systems must also be underpinned by current research and evidence, and not just simply be based on an individual or a committee’s ‘opinion’ as that opinion could be flawed amounting to a ‘rule-based’ or ‘knowledge-based’ mistake which would simply leave the organisation liable.
Then, where an organisation needed to detract from the Department of Health Guidance to keep patients and staff safe, it would be able to show that it had ‘cogent’ reasons for doing so which would provide a legal defence against any challenge by an inspector or in court.
In short, the days of off implementing training simply by commissioning and ‘off-the-shelf’ package are gone, as was highlighted Lady Nuala O’Loan (who was commissioned by a previous Government to investigate complaints of mistreatment of deportees post the death of Jimmy Mubenga).
When interviewed by the Guardian newspaper on the death of Jimmy Mubegna, Lady Nuala O’Loan stated that “the training[this was the training that the staff had received] was textbook training but…..it was one size fits all: it made no difference whether they were dealing with a five foot girl or a 20 stone man”.
Therefore, it isn’t about what ‘system’ of restraint you use per se or which training provider you choose to commission to deliver the training for your organisation.
What it is about is ensuring that whatever you start with has the adaptability and flexibility to change over time to meet the needs of the organisation, the organisational environments, it’s patients/service users and staff.
That means it needs to flexible enough to be adapted on an individual case by case basis if need be, and not be a one-size-al fits package.
If it is structured properly then staff feedback can be used to help with the ongoing continual development of your programme, and I use the words, “your programme” deliberately, as the programme should be wholly owned by the organisation with the training provider working in true partnership with you.
So, the ultimate point I’m making is this.
Stop looking for the holy grail of restraint in terms of just which training provider you commission with regards to what techniques they may or may not teach or what accreditation they may or may not have.
Find a training provider who can work with you to deliver a system of restraint that is fit for purpose for your organisation and manage it properly and allow it to develop through a systematic and structured process of positive and reactive feedback on an ongoing basis.
That is the only true accreditation you need.
And if you need any help doing that, please feel free to get in touch.
We have reduced one agency’s use of prone / face-down restraint to almost zero, by working with our agency partner very closely, implementing the right equipment where necessary and using staff and management reported feedback proactively.
Best Regards
Mark Dawes