Regulating the Regulation of the use of Restrictive Practices: Transparency and Innovation vs Repetition and Failure

By CALM Clinical Director, Dr. Brodie Paterson

The past two decades have seen a series of initiatives designed with the ultimate aim of promoting and protecting the human rights of vulnerable children and adults at a national and international level. A key objective of many of those has been to reduce the use of restrictive interventions. Such interventions may include restraint (whether physical or manual), seclusion, a medication used as a restraint and a range of other coercive practices including blanket restrictions.

Such initiatives have taken many and varied forms. Guidance for service providers has been developed. Standards for practice and training have been codified.[1] Good practice has been illustrated, the content of training programmes specified and service providers subjected to inspection, accreditation and increasing levels of external regulation and scrutiny.

Such approaches when complementing whole organisation, public health-based systems and explicit restraint reduction strategies have had some success in some services. Unfortunately, we have also seen many instances in which such approaches to regulation have achieved less than outstanding results. Restraint in some settings has increased.[2] Injuries to staff during restraints have increased.[3] Issuing guidance at a national level has not changed practice. Specifying the content of training does not appear to have had an impact on changing dysfunctional cultures anticipated.[4] Accrediting training providers has not led to the consistent decreases in the use of physical interventions anticipated. In some settings, we have seen not reductions but instead increases in the use of restraint and is seclusion and increases in the restrictiveness of the interventions used. The scandals associated with the misuse of restraint and broader concerns over abuse have not gone away.[5]

We have in the UK perhaps failed to appreciate the maxim that if you keep on doing more of the same, you will get more of the same. Regulation schemes, whether for service providers or training providers, practice standards and inspection programs have repeatedly failed to deliver sustained consistent improvements in practice at the level of the individual service users or prevent abuse from happening. There is little reason to suspect therefore that the ‘new’ standards, accreditation scheme, or regulatory regime will work at least on their own.[6]

The frustrating reality is that there are a number alternative approaches pioneered in Australia[7] that start from the premise that it is the experience of individual service users that needs to be monitored robustly. Only by external monitoring of the experience of every service user who may be subject to restrictive interventions can we ascertain what an organisation is achieving or not. Is there evidence of a comprehensive integrative functional assessment having been undertaken, is there a comprehensive and detailed support plan informed by risk assessment detailing primary, secondary and tertiary prevention plans. Is there evidence of staff training in order to consistently implement the plan, is there evidence the staff who may be involved in the use of a restrictive intervention have access to regular practice supervision and are de-briefed following every use of a restrictive intervention.

The current UK accreditation schemes for service and training providers are both complex and costly. The money, time and effort currently invested in those edifices might better be invested elsewhere. Learning from the Australian experience and developing person-centred approaches to regulating the use of restrictive practices is what we should be doing instead. Such systems may prove more effective in ensuring that best practice is being delivered for every individual who may be subject to their use.

The decision regarding whether to use a restrictive practice outwith an unforeseen emergency should no longer rest with the health, social care or school. It should rest with an expert practitioner not employed by that provider but by government explicitly charged with promoting the best interests of that vulnerable child or adult and ensuring that the principle of least restrictive practice always adhered.

“Quis custodiet ipsos custodes,” a Latin phrase attributed to Juvenal can be translated as, “Who watches the watchers? We should therefore not only welcome new regulations but question them. We should not only produce new guidance but ask tough questions about it’s implementation, its costs and how their impact will be evaluated. We must question whether any and every regulatory scheme creates conflicts of interests. The regulators cannot simultaneously also be providers whether of training or of services.

If we are to achieve the radical transformations in the lives of vulnerable people who may be subject to restrictive interventions we must ultimately ask why we keep repeating the mistakes of the past. In doing so, we should ask whose interests may align with avoiding real innovation and challenge them.  Real innovation demands we question orthodoxy, and that includes what we regulate and how.

 

REFERENCES

[1] https://restraintreductionnetwork.org/know-the-standard/

[2] https://www.bbc.co.uk/news/uk-45652339

[3] https://www.bbc.co.uk/news/health-41514011

[4] Murphy G. Whorlton Hall: a predictable tragedy?BMJ 2019;366:l4705

[5] https://www.independent.co.uk/news/health/whorlton-hall-cqc-whistleblower-learning-disability-abuse-a9297496.html

[6] Murphy G. Whorlton Hall: a predictable tragedy?BMJ 2019;366:l4705

[7]  Department of Health and Human Services  (2019) A national measure of environmental restraint – final report.

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