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Trust develops a programme to improve outcomes for people using the mental health and learning disability inpatient services, reducing the use of restraint by 37 per cent across all areas


    • Reduce the use of physical restraint and improve outcomes for people suffering from mental health problems and learning disability


    • Introduced the ‘No Force First’ restrictive intervention reduction programme to enhance patient experience 
    • Held engagement sessions to inform staff of the negative impact of restraint on people with mental health issues and learning disability
    • People discussed their lived experience, developing an emotional engagement with staff and inspiring innovation solutions
    • Experts by Experience helped in co-producing and delivering the programme


    • Reduced physical interventions in pilot wards by 60% in the first two years
    • 37% reduction in restraint use across all areas (April 2016 – Aug 2017)
    • 46% reduction in assaults on staff, resulting in financial savings in terms of reduced replacement costs
    • Resulted in 29 NHS Trusts, third sector and external agencies participating in No Force First showcase event

* Please describe the challenges or problems your solution set out to solve.

‘No Force First’ (See attached guide) is Mersey Care NHS Foundation Trust’s restrictive intervention reduction programme that seeks to transform the experience of people who use our mental health and learning disability inpatient services. In response to national care scandals and progressive national guidance we have an audacious goal to completely move away from the historical use of physical restraint. We feel that we are changing the culture of care within our services and transforming the care narrative from ‘containment’ to ‘recovery’. Communicating the need for change was a central facet of this plan.

* Please describe the actions you took to achieve your result.

In terms of a strategy for communicating the need for change, we recognised right from the outset that coproduction of both strategy and process would be critical to developing a ‘No Force First’ culture. Truly authentic co-production occurs when the people who provide and use services work together in a relationship of equals, with no half measures.

All of the interventions and strategies developed through No Force First are co-produced. Experts by Experience are accorded an equal role and status within the process and this is reflected in job title and banding of the Expert by Experience who has a lead role in No Force First.

Harnessing the lived experience of what it feels like to be physically restrained and working together to find innovative and creative solutions has enabled a wider range of people to engage in the programme and support the changes required as a result.

We understood that hard pressed ward teams may have found it difficult to fully engage in yet another new initiative and there could often be a sense that staff were already doing their best in this challenging area, so real improvement could seem unlikely or unattainable. Our solution was to set out a format of introducing the process that developed a sense of urgency through appealing primarily to hearts, rather than minds.

We wanted our clinical teams to gain an insight to the process that left them inspired, but also unsettled by what they had heard. Fundamentally we knew that change was most effectively delivered by a communication strategy that made people ‘want’ to change rather than one which instructed them to do so. Our initial ward ‘engagement sessions’ are delivered by our staff and the people that use services.

They set out, in quite stark terms, the negative impact of restraint on people with mental health and learning disability challenges as a means of developing an emotional engagement with the need for change, and inspiring innovation to improve our services. These narratives relate the huge traumatic impact of physical interventions for people who use our services, relating them directly and honestly to the previous trauma histories that many people who use our services have experienced. The final message, of course, is one of hope and optimism for a different, less coercive future.

* Please list the most significant results

Our pilot wards recorded reductions in the use of physical intervention of around 60% in the first two years. As the process has been implemented across all wards in the Trust we have managed to achieve 37% reductions in restraint use April 2016 – Aug 2017 across all areas. Concurrently, the assaults on staff have decreased significantly by 46%. As fewer staff are involved in physical interventions and are less exposed to assault, there are financial savings in terms of reduced replacement costs. For example, in the secure division of the service in 2016 these savings equated to £249,069 (See attachment).

* Describe how your project has spread to other teams, departments or organisations

We are fortunate to have developed a national and international profile in this area. Healthcare agencies from countries as far afield as Denmark and Japan have visited our services. In this country we have welcomed innumerable mental health and learning disability care providers to the trust to gain an insight into process. We have run our own No Force First showcase event which attracted no less than 29 NHS Trusts, third sector and external agencies. The No Force First process features in good practice case studies for the National Quality Board and the Care Quality Commission.