Department of Health publish new guidance on reducing the need for restrictive interventions

A handout photo, issued by the BBC, of a screen grab from the Panorama investigation into abuse at Winterbourne View. Photograph: BBC/PA

In Scandal, Social Work and Social Welfare (Policy Press 2005), Butler and Drakeford examine the ways, in which, social welfare policy is often formulated in a response to scandals or inquiries. These scandals highlight areas of abuse or neglect but also can act as an engine for change.

This is true across all areas of social work and social care including areas such as child protection and mental health services. If we take the example of mental health services, a series of inquiries in long-stay hospitals including Rampton Special Hospital played a significant role in the moves to community care. In his influential work Hospitals in Trouble (1985), Martin outlined the institutional features that enabled a culture of abuse to develop. These included:

A lack of privacy/autonomy
Large staff
Patient ratios
Poor training

As Martin noted, the isolation of these institutions from mainstream services meant that they became essentially closed environments.

One of the fundamental aims of community care was to tackle the abusive nature of the institutional environment. However, recent media reports and inquiries have emphasized that the most vulnerable members of our society are still being subjected to abuse in environments which are meant to be caring and supportive. In April, the Department of Health published new guidance:

Positive and Proactive Care: reducing the need for restrictive interventions

As the DH outlines, there is a very important need for such issues to be given much greater consideration. The scandal of Winterbourne View and MIND’s Mental Health Crisis in Care: physical restraint in crisis (2013) highlighted the fact that restrictive interventions were not being used as a last resort. As Winterbourne VIew and the recent Panorama documentary have demonstrated, restraint has been used, “ to inflict pain, humiliate or punish”. There surely can be no greater condemnation of an organisational culture than that it allows restraint to be used as a form of punishment. As the Winterbourne View case highlights, these interventions take place in residential care homes or similar settings that are far removed from the public gaze.

A handout photo, issued by the BBC, of a screen grab from the Panorama investigation into abuse at Winterbourne View. Photograph: BBC/PA

The aim of this new guidance is to create a framework that will support a new service culture. The guidance covers a wide range of service providers working with people with mental health conditions, learning disabilities, dementia and a number of other conditions, who may present with what in the current jargon is usually termed “challenging behaviour”.

Physical interventions should be used as a last resort

The underlying philosophy of this guidance is that physical interventions should be used as a last resort. There is a recognition that restrictive interventions will have to be used in some circumstances but their use must be “transparent, legal and ethical”. It is a sad indictment of the current systems that such guidance has to be issued or that such a clear statement of basic decency is seen as necessary. However, it is welcome that the Minister for Care and Support, Norman Lamb, has made a personal commitment to tackling this area. When this is taken alongside the recent Mental Health Crisis Care Concordat, moves to tackle some of the most long-standing issues in mental health services appear to be gathering pace. Caution is required here as the huge pressure on public service budgets has two inter-related effects. It creates a great demand for services at a time when they are having to restrict eligibility for services.

Restrictive interventions are defined as follows:

Deliberate acts on the part of other person(s) that restrict an individual’s movement, liberty and/or freedom to act independently.

Such actions are needed to take control of a dangerous situation or to reduce the danger to others. It is important that such actions and the limiting of a person’s freedom should only be in place for as long as is necessary. If such restrictions are not imposed without there being a clear ethical framework and proper safeguards, then as the guidance makes clear such acts may be unlawful.

The guidance is clear that if a restrictive intervention has to be used, it must always represent the least restrictive option to meet the immediate need

Recovery model

This guidance is influenced by a very clear values-based approach that should be the basis for the development of services. In far too many cases, the development of services has started from organisational and structural considerations rather than from the more fundamental questions of what values should underpin services. The guidance is written from a Recovery-based approach. The recovery model requires:

The promotion of human rights based approaches, enhancing personal independence, promoting and honouring choices and increasing social inclusion.

The Recovery model is founded on the basic principle that recovery is possible for everyone. Recovery is very personalised and is defined within individual and personal goals.

This guidance has the clear aim of reducing the use of restrictive interventions. It quotes a review conducted by the Irish Mental Health Commission (2012) that examined ways, in which, services can reduce the use of these interventions. The review emphasized that there needs to be a strong policy lead at both a national and organizational level if progress is to be made. Effective leadership is one factor alongside the involvement of people who use services, their families and advocates. When restrictive interventions are used there needs to be proper recording and data collection alongside appropriate post-incident reviews and staff training. All these features were completely absent at Winterbourne View. The net result was that a culture of fear, intimidation and abuse was allowed to develop.

The guidance recommends that individualised support plans should be implemented for all people who use services who are known to be at risk of being exposed to restrictive interventions

The values-based approach of this guidance is to be welcomed. It shows a clear commitment to reducing the use of restrictive interventions and doing away with the use of blanket bans. The real test of such guidance is not in the reception that it receives now, but in how its implementation is monitored. Unfortunately, scandals such as Winterbourne View soon fade from the media spotlight. The underlying conditions that gave rise to them take much longer to tackle effectively. They require a shift in the values of service provision but also greater investment in the services themselves. This new DH guidance needs to be seen as the start of this process.