Rosemary Smyth Mental Health Commission 17/09/2013

Regulation of Seclusion and Restraint in Ireland The Mental Health Act 2001 provides for the use of seclusion and mechanical restraint for the purposes of treatment or to prevent the patient from injuring himself or herself or others. In line with Section 69(2) of the 2001 Act, the Mental Health Commission published Rules Governing the Use of Seclusion and Mechanical Means of Bodily Restraint (MHC, 2009d) which regulate the use of seclusion and mechanical restraint in approved centres. The Commission also published a Code of Practice on the Use of Physical Restraint in Approved Centres (MHC, 2009a) which contains best practice guidance on the use of physical restraint for persons working in approved centres.

Rules and Code of Practice The provisions of the Rules and Code of Practice make clear the Commission’s belief that these are not standard interventions but emergency measures which should be used “in rare and exceptional circumstances and only in the best interests of the patient when he or she poses an immediate threat of serious harm to self or others”. Provisions within both documents also encourage approved centres to focus on preventative measures that eliminate or minimise the use of restrictive interventions.

Definition of Seclusion Seclusion is defined as “the placing or leaving of a person in any room alone, at any time, day or night, with the exit door locked or fastened or held in such a way as to prevent the person from leaving.”

Definition of Mechanical Means of Bodily Restraint Mechanical means of bodily restraint is defined as “the use of devices or bodily garments for the purpose of preventing or limiting the free movement of a patient’s body”.

Definition of Physical Restraint Physical restraint is defined as “the use of physical force (by one or more persons) for the purpose of preventing the free movement of a resident’s body when he or she poses an immediate threat of serious harm to self or others”.

Seclusion & Physical Restraint Reduction Strategy Mental Health Commission Seclusion and Physical Restraint Reduction Strategy is being developed having regard to the Commission’s mandate to: “promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centres” (Mental Health Act 2001, Section 33(1)).

Rationale for Strategy The MHC plays a lead role in the regulation of seclusion and restraint and encourages services to try and reduce the use of these interventions The Commission has published data on seclusion and restraint from 2008 to 2011 and continues to monitor data on seclusion and restraint Concerns have emerged internationally over the safety and effectiveness of restrictive interventions and of their impact on patients Seclusion and restraint reduction initiatives have taken place successfully in other countries One of the strategic priorities outlined in the Commission’s Strategic Plan commits to Safeguarding Human Rights and incorporating these principles in all our work.

Mental Health Policy Ireland’s national mental health policy document, A Vision for Change (Department of Health & Children, 2006), stresses that the range of interventions offered in Irish mental health services should be comprehensive and should reflect best practice for addressing any given mental health problem. It also states that a “recovery” approach should inform every level of service provision. International literature on seclusion and restraint reduction suggests that the recovery approach demands a reduction in the use of restrictive interventions carried out against a patient’s wishes (Smith et al., 2005; Huckshorn, 2004).

National Standards for Mental Health Services Ireland’s national standards for mental health services, the Quality Framework for Mental Health Services in Ireland (MHC, 2007) provide clear guidance to service users, their families/chosen advocates, service providers and the public as to what to expect from a mental health service and compliment the recommendations outlined in A Vision for Change. A number of the standards in the Quality Framework should clearly inform any consideration of and actual use of these interventions. Standard 4.1 states that “Service users receive care and treatment in settings that that are safe, and that respect the person’s right to privacy and dignity”.

Data Collection Data collected during 2011 show that 4,739 restrictive interventions were used in all approved centres in that year. Overall use of restrictive practices in 2011 was down by almost 12% (5,370 episodes in 2010). In the period the use of seclusion and mechanical means of bodily restraint has steadily declined however there has been a year on year increase in the use of physical restraint. Substantial variation in the use of seclusion and restraint between approved centres and between different regions in Ireland. The variation that is evident in Ireland is in line with findings from other countries.

Purpose of the Strategy Achieve significant reductions in the use of seclusion and physical restraint while also ensuring patient and staff safety. Reductions in the use of seclusion and restraint refer to decreases in the number of seclusion and restraint episodes and decreases in the duration of these episodes.

Keys Steps in Development 1 1. Knowledge Review The implications of the literature and the context for applying evidence based interventions in Ireland were considered. 2. Following consideration of these issues, the Commission prepared a Draft Seclusion and Physical Restraint Reduction Strategy that consisted of 18 actions in seven different intervention categories. (i) policy and regulation changes, (ii) leadership, (iii) staffing, (iv) training and education, (v) patient, family and advocate involvement, (vi) review procedures/debriefing and (vii) using data to monitor seclusion and restraint episodes

Keys Steps in Development 2 3. A written consultation exercise sought stakeholder views on the draft strategy and took place from June 2012 to September A consultation report has been completed which summarises stakeholder views on the draft strategy. 5. A revised Seclusion & Restraint Reduction Strategy prepared for International Peer Review.

Key Changes following consultation The strategy now aims to reduce the use of and duration of four restrictive interventions. Mechanical restraint and rapid tranquilisation are now also identified as interventions that we aim to reduce alongside seclusion and physical restraint. The strategy now consists of eight intervention categories. We have added- the physical environment. In order to successfully implement a reduction strategy, we consider that approved centres must implement actions in all eight of these categories. Each intervention category now identifies a number of key actions that can be used to implement each of the intervention categories. Most of the 18 actions that had been identified in the draft strategy are now included in the final version, plus a number of additional actions which have been sourced from best practice literature. We are clear, however, that the appropriate actions chosen will vary depending on the nature of the service such that some actions will not be appropriate to implement in some centres.

Intervention Categories S & R Reduction Leadership Staffing Training & Education Service user/carer Involvement Using Data Policy & Regulation Debriefing & Review Environment

Proposed Implementation A phased implementation process. The strategy will initially be piloted in a small number of approved centres before national roll out. Implementation literature suggests that innovations will be more easily adopted and implemented if they can be adapted to suit local needs and are feasible and practical in multiple locations. Based on the consultation feedback, we considered that it was not feasible to implement all actions in the draft strategy in all approved centres immediately. A successful pilot should lead to a comprehensive strategy being more easily adopted at a later stage.

Next Steps International Peer Review Training – development of curriculum Select Pilot sites Agree with pilot sites Details of actions to be implemented A training plan A communications plan Details of monitoring & audit Sequencing of training & implementation actions Clarification of roles and responsibilities of all staff Commence Pilot

Thank you for your attention!