Alarm Over Restraint of NHS Mental Health Patients As Reported in The Guardian Newspaper 10.12.17


Hey everybody Mark Dawes here and in this short
video I want to address an article that appeared in The Guardian newspaper on
the 10th of December 2017, and the article is entitled ‘Alar over restraint of
NHS mental health patients’, and this article revealed that that there were
80,000 restraints of patients on mental health unit in the UK last year (that’s
between 2016 and 2017). This included 10,000 who were held
facedown 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. And back people were three times more likely
to be restrained than white people. Patients who were controlled by a
non-prone physical restraint had that done to them 43,000 times, and that
chemical restraint was used on another 8600 occasions. And 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 it’s inspectors had found an unwarranted and
wide-ranging variation between units in terms of how often staff use
restraint. Wards with low rates had staff who had been trained to have a
difficult behaviour and de-escalate challenging situations” and I’ll come on to that in a
minute when we well I give you my opinion about conflict management training. “The
Department of Health, who issued guidance in 2014, said that restraints
should only be used as a “last resort” and if other means of dealing with difficult situations were unlikely to succeed, and
a spokeswoman the Department of Health said that “physical restraint should only be
used as a last resort” and let anything else is unacceptable”. So my question is
despite all the guidance to the contrary, why are so many restraints
taking place, and why are techniques such as facedown and prone, still being
used to the degree that they are? And I’d like to make one other thing clear, right
from the start. The vast majority of staff that I meet who work in mental
health units genuinely, genuinely care for the
patients that they look after. They are absolutely committed to keeping their
patients safe – and I know of a number of people
who chose to work in mental health for personal reasons. Some because
they had a close relative or a friend die due to a mental health illness, and
others because they have a close relative or friend suffering from a
mental health illness. therefore I’d like you to be mindful that when we read
statistics like this we don’t jump to the presumption that staff who work in
mental health units get some sort of perverse pleasure out of restraining
people who are mentally ill, in the vast majority of cases that is far from the
truth. These staff genuinely and passionately care for the people that
they look after. Now let me explain this a little bit further for you. In a recent
conversation I had with a very, very experienced mental health professional,
who’s also a restraint trainer or as they call them in some areas of the NHS a
PMVA trainer. We had a discussion about staffing levels and the issues
that he’s experiencing on his wards, and he said the problem they have right now is
that there are a lot of staff who were working up to a later retirement age,
because obviously the retirement age now has gone up for people working in the
NHS. But there’s also the issue of a lot more younger people coming in who are
suffering with mental health issues. Therefore, you have staff who are older,
not as fit, who may be suffering injuries, trying to physically care for and in
some cases control younger and much fitter and stronger patients who are exhibiting
challenging and violent aggressive behavior, and they’re finding it
difficult. But this is also compounded by other issues, and let me just explain
them to you one by one, and it’s not an exhaustive list by the way. it’s
just some things that I picked up on it having been doing this for a long time.
Okay guidance. Well there’s a lot of well-meaning guidance out there and it’s
produced by very well-meaning people and I get what they try to do. They’re trying
to stop the overuse of restraint particularly some techniques and positions of the
may increase the risk of death, and I get that, and I absolutely get it. However, a lot of
this advice and guidance published, is contradictory, one piece of
legislation or one piece of guidance contradicts the other, and in fact in one
piece of guidance it actually contradicts itself.
Now the problem managers have with this in the NHS, is when the CQC inspectors come along to actually you know check against
the guidance, the managers don’t know what they should and shouldn’t be doing,
so they will just go with the CQC inspectors recommendations for fear of
being sanctioned, so they don’t want to upset CQC inspector. So whether they
think the CQC inspectors right or wrong never becomes the issue. The fact is they
disagree with it because they don’t want to be sanctioned. That in many cases
compromises patient safety and care as well as staff safety as well. Now a lot
of people follow this guidance, this Department of Health guidance, and I’m referring
to the positive proactive care guidance issued on the 1st of April 2014 by the
way, and I’ll leave a link by the video to it. But because they’ve actually been
told or they believe that the actual guidance is legally enforceable. Well
it’s not! The actual document is not statutory guidance, and in fact the the
‘NHS Protect’, which is now obviously a defunct organisation but NHS Protect
back in March 2015 issued a document – a clarification
document – and in that document it states this, and it says “The positive and
proactive care guidance provides information and good practice; it is not
statutory guidance or legally binding”. So that means we can depart from the
guidance if we need to provided we have ‘cogent reasons’ and I’ll come to that
in a little bit later on. Now there’s another aspect to this too,
and that is that some training organisations out there are still
teaching outdated and old types of systems, and are still using techniques
which were advise, even by coroner’s, not to be used; such as face down restraint, prone restraint and other techniques that increase of risk of harm and death, and
they do this despite the fact that alternatives – indeed safer
alternatives – exist. Now one of the reasons they do this is because when they
developed their systems they fundamentally set in stone, that means they can’t
change and that they don’t evolve with time, so they never seem to move on, and I
think this is primarily down to a cognitive bias, and their cognitive bias
I’m referring to specifically is what’s referred to as the ‘IKEA effect’ now
Daniel Kahneman won the Nobel Prize for research on to this, and in terms of
the IKEA effect what that means is, is ‘I made it so it must be right’. So in other
words there’s an ownership and there’s a protectiveness to something that we
produce, and even if we produce it wrong we still defend it as though is right,
despite evidence to the fact that it’s wrong, and that’s a very, very strong
point and something that people need to consider when they’re looking at
commissioning training programs. And a lot of these training companies promote
their services as though they’re accredited and approved, when actually
in many cases their only ‘self-accredited’ and they’re only ‘self-approved’, or
they’re accredited by an agency that only has a ‘self-accreditation’ basis,
without any basis in relation to a National Vocational Qualification or an
independent audit or an independent review. Oh and for clarity by the way, the
Department of Health, and indeed no other Government department or agency, actually
approves or accredits anything. They will not do it, they do not approve it or
accredit any system of restraint despite the fact that some agencies actually try
and promote this system on that basis. Now you may see for example that a
Government document, a Department Health document, may say “an example
accreditation will be…”, well we challenged the Government on this because we said
you cannot promote one system over another,
we’ve got letters from the Minister of Health etc., on this one, and what they
says is we’re not trying to promote one over the other
we’re not favoring one, we are merely signposting people. But here’s the thing, and I’ll be absolutely straight with you, they signposting people towards organisations
that provide a ‘self-accredited’ system of accreditation not a formal one
recognised by a National Professional Standard or a regulated awarding
organisation which is it again regulated by Ofqual, so that makes it interesting
aswell. Now many NHS management systems and
managers out there will not actually look at equipment which could provide
alternatives to prone and face-down restraint and there’s good equipment out there. The
Safetypod, the Soft Restraint Belt or Soft Restraint Kit, these are
brilliant pieces of equipment and they could reduce or eliminate the need to
restrain people in a prone or face-down position. They’ve been
medically reviewed, they’ve been industry tested and they’ve absolutely fit for
purpose, but again managers are reluctant to actually buy this equipment for
various reasons, and the one I hear time and time again is ‘we have no budget’ and
the other one I hear, which is quite common is ‘what we don’t want to be using
equipment to restrain people it’s not ethical’. Actually not using the equipment to
restrain someone isn’t ethical if the equipment is the least intrusive option
and I’ll come on to that probably in a later video. Now in many organisations
there’s also a high dependency now on agency staff, so part time staff that are
recruited from agencies to supplement the employed staff on wards and units.
And the problem we have here is a two-tier approach to actually managing
the use of force in an organisation. So employed staff will be trained within
the system that that organisation wishes them to use, then agency staff
will come along who may be trained in that system, they may be trained another
system or they may not be trained in any system whatsoever. And this causes an
immense about confusion, is terribly difficult to manage and increases risk.
Well you heard me mention just now about conflict management and de-escalation
training and you heard me mention the fact that CQC quite keen on it because
they allegedly have evidence to support the where conflict management and
de-escalation is being implemented there are lesser incidents of restraint. Well I
can tell you now that in many many areas conflict management training is not
being implemented or, and this is primarily because the organisation
cannot allocate the additional time to allow staff to be released from the
wards for conflict management training because they needed on the wards, because
of staffing issues. And here’s my biggest gripe. Some of these so-called panels
that are set up by Government departments to actually look at
developing and designing these guidances that they bring out are made up in the
main by people who never actually physically had to control someone in
reality, or have done it that long ago they can’t even remember what it’s like, or they’re being bludgeoned on the head by a Government directive that says ‘make this
happen this way’ and therefore take no notice of any specific expert that they
may have on that panel, and that’s my biggest gripe, and we’ve had this with a
Government panel and we challenged it, and when we challenged it – a particular comment
by the Chair of that panel we had it proved by an independent
lawyer that the comment made by the Chair of the panel, that she was trying to bully
basically, and steamroll through, was legally flawed. It had no basis in law
and her number two on that panel who had the OBE as well by the way, also was
giving out legally flawed advice. But that’s the problem. We have these panels
that look at actually placating Government and producing guidance, but it has no basis
in law, and then this gets pushed through. Okay so I’ve had a bit of a rant, but
what’s the actual point aren’t making? Well the point I’m making is this any
restraint system must be fit for purpose. I mean I think that goes without saying
that’s pretty obvious. But it must be fit for purpose for the environment it’s
going to be used in and for the makeup of the staff and service user or patient
demographic. And it must actually have a basis in the law. It can’t just have a basis
in opinion. Restraint systems must also be underpinned by current evidence and
research in this area into what works and what doesn’t, and not just be down to
an individual’s or a committee’s opinion as to what they think they should and
shouldn’t do, because that actually leads to another problem which is classified
in a system called HSG48 as a rule based or a knowledge based mistake.
And it’s been evidenced time and time again that where these opinions are
allowed to override fact and evidence, mainly because of the IKEA effect, a
cognitive bias, we have an increased margin for human error and the problem
is the system fails because it wasn’t fit for purpose, the members of staff is ‘hung out to to dry’, but the system was designed with failure built-in, because
it’s not been allowed to continually develop and evolve in line with current
evidence and research, and of course feedback from operational incidence in
the place of work. And what this means then is that if an organisation needs to
detract from the Department of Health guidance, the positive and proactive care guidance,
which actually is not statutory guidance anyway, if it’s done all the work and it
has all the evidence and it has everything to support it, it can do so because it can
justify that it has what’s now termed as ‘cogent reasons’ for doing so, and that is
defencible against any challenge by an inspector,
and is certainly defensible or good defensive evidence if you are
challenged in Court. In short, the days of implementing training simply by
commissioning an off-the-shelf training package are gone,
and this was highlighted by Lady Nuala O’Loan, who was commissioned by a previous
Government to investigate complaints of the mistreatment of deportees post the
death of Jimmy Mubenga who died on a flight being restrained on a flight out of Heathrow in 2010. And when interviewed by the Guardian newspaper on the death of Jimmy
Mubenga Lady Nuala O’Loan stated that “The training [and this was the
training the staff had received] was textbook training …. but it was
one-size-fits-all: it made no difference whether they were dealing with a 5-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 for you to deliver the
training for your organisation, what it is about is ensuring that whatever you start has
the capability to be able to adapt and change and has the flexibility to evolve
over time to meet the needs of the organisation, the staff and the service
user ever changing demographic these days, and that is true accreditation. That
will stand the test of time. That will give you a legally defensible
training system. So the point I’m making to you is this, if you are a
commissioning agency, an NHS Trust, a hospital, stop looking for the holy grail
of restraint training in a training provider. It doesn’t exist okay.
The holy grail, the panacea or the way forward with this is to accept that what
you start with must change over time and you need to work in partnership with
your training provider. You need to make sure that your training provider is
up-to-date on current knowledge and expertise and not just accept it because
they say we have a badge or we’re accredited by – and that includes us by
the way – you know check everyone out fully. And that’s the only true accreditation
you need. Now if you’d like to to know more about this or how we can help you
or indeed how we help one organisation reduce the need to restrain people in a
prone or face-down position, then get in touch and we’d be delighted to help you too.
In the meantime please feel free to share this video, please leave a comment
I’ll be interested on your thoughts on this one, there’s probably comments box
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for watching and I’ll speak to you soon.

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