‘No Force First’ 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 as a means of supporting people who become distressed.
We feel that our main achievement is changing the culture of care within our services and transforming the care narrative from ‘containment’ to ‘recovery’. Our Inpatient units have embraced six key interventions that we feel combine to transform the experience of people using our services and guide the culture of care towards one that will, ultimately, make physical intervention in response to challenging behaviour as outdated a mode of intervention as the chains, shackles and straight jackets of the old Victorian asylums. We believe that progress is inevitable – the challenge for our service is to accelerate the momentum to that point. The key to this is our dedicated care teams and collaboration with the people who use our services, their joint expertise and unique insights eclipsing the impact of any management directive.
Any change process of this scale and ambition will have its challenges. Perhaps, looking back, we may have needed to be more robust in initially setting out that, whilst a restraint free future is an absolute ambition, we were not saying to staff right at the outset that we were stopping them from using interventions that may help people to feel safe. Our organisational commitment to a ‘just and learning culture’ – not based on blame, has been invaluable.
We cannot blame staff for doing what they have been taught to do in the past and the recognition that systems and cultures, rather than people, can often let us down, should provide a sense of psychological safety among our teams, that will continue to free them up to deliver interventions based on positive risk-taking, flexibility and individualised risk assessment, which are at the core of No Force First. Delivering the reductions in physical intervention use as we have scaled the programme up from its initial pilot wards has been a challenge that we are happy to acknowledge and determined to overcome. Many of our wards are making fantastic progress while others are requiring more support.
Primarily we have seen significant reductions in the use of physical intervention. Since the establishment of the programme across all of our inpatient units, within an expanding organisation, in April 2016, we have seen a reduction of 30% in the use of physical intervention. Within this more peaceful, collaborative culture we have also seen an incredibly encouraging reductions in harmful assaults on staff.
We do feel that any cynicism that may have existed about the process, as being indirectly critical of staff and their interventions, has been successfully replaced by the positive and celebratory nature of our supportive role of the team delivering No Force First. A ward experiencing challenges is ‘a ward to be supported’, not criticised, and a ward delivering positive practice is a ward to be lauded and thanked extensively throughout the organisation.
Our Experts by Experience will identify restrictive issues that impact negatively on their care but will be sensitive to the challenges staff may face and how so much of what we deliver in terms of care is constantly improving, and how that changes their lives positively. We are all sensitive to the need to carry people with us.
At a local level we believe that our comprehensive guide to reducing restrictive practices, coupled with the designated support of our team in the Centre for Perfect Care at clinical level, has facilitated the spread of the process from the initial pilot wards to over 50 wards where the process is currently established.
We are also 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 29 NHS Trusts, third sector and external agencies.
The Care Quality Commission highlighted our work as a good practice exemplar in its December 2017 report - ‘A focus on restrictive intervention reduction programmes in mental health inpatient services’. We are also incredibly proud to be key contributors to the new World Health Organisation initiative - ‘QualityRights capacity building materials on mental health, human rights and recovery’, which involves the team here providing training materials and speakers at international events.
We believe strongly that moving away from the routine use of restrictive interventions such as physical restraint can provide significant value to an organisation in terms of its status as a compassionate, progressive and person centred body. The customer-focused message of No Force First and the crucial role of people who use services in its delivery has helped the trust develop a national reputation for innovation, recognition for culture change and working in full collaboration with the people that use services.
Inevitably, 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 work related sickness absence. For example, in the secure division of the service in 2017 these savings equated to £249,069.
The experience of people who have been subject to restrictive interventions such as physical restraint remains at the centre of the No Force First process. As well as using first-person narratives to make an emotional case to staff for change, our experts by experience have been at the absolute centre of planning and producing of materials related to the No Force First process.
We are currently in the process of recruiting more people with lived experience to share their insights into inpatient experiences in relation to restrictive interventions in the hope that they can support us to continue to deliver co-produced No Force First Engagement Sessions to newer staff.
We now understand that a process dominated by professionals simply fails to recognise the unique perspectives and talents of the people we serve and we are determined to pursue a consumer-driven path forward.
While ward teams have adopted the interventions from our guide we have fantastic examples of teams generating their own improvements and innovation. For example, one of our clinical teams stepped back while a service user took the lead in successfully de-escalating a person in distress.