CURRENTLY, there seems to be no let-up of bad news stories about mental health. However, despite the challenging environment nationally, the improvements made in Mersey Care NHS Foundation Trust with regard to how they manage conflict has led to a cultural shift on the wards, along with international recognition and awards.

These developments are focused on the reduction of forceful restraint in a strategy called No Force First, which has the potential to be transferred and adopted in other settings such as prisons and police cells.

Within Mersey Care, Dr Jennifer Kilcoyne explained that there was the growing realisation within the clinical teams that the amount of physical intervention being used in the trust, although not increasing, wasn’t particularly coming down either.

“There was organisational discontent about this, which was galvanised by stories from our service-users talking about how forceful restraint could be re-traumatising for them. Our chief executive, Joe Rafferty, considers hearing these accounts to be the pivotal event in his personal commitment to make No Force First one of our absolute priorities. Deep down, we knew our clinical teams had the expertise and ability to do things differently if we gave them the freedom to do so.”

The Department of Health guidance, Positive and Safe, was issued, a year after No Force First was introduced. “This reinforced everything we were trying to achieve,” Kilcoyne said. “Once a national momentum was added to our own,  we knew were on the right track.

What is exciting is that the principles in the No Force First model can be adopted into other settings, such as secure hospitals, prisons and potentially police cells

“No Force First  focuses on prevention of conflict and ensuring ward environments are therapeutic, safe, calm and recovery-focused places. In order to deliver a restraint-free future for our services, we have a comprehensive guide that all our ward teams have, which outline a range of interventions in areas such as individualised activity planning, reducing frustrating ward rules and more frequent community meetings.

“We have redesigned our personal safety training to integrate the message of No Force First as a central foundation of the curriculum while continually looking to replace physical interventions with preventative strategies.”

No Force First redefines the relationship between staff member and patient. To do this Mersey Care had to look at all areas of their practice, including the planning and delivery of care. Kilcoyne said:

“We aspire to no less than a rebalancing of power within the organisation between those who use and deliver services. For too long the professional view has held precedence over what the person using our services, and their families, wanted. This means that in terms of treatment the voice of the person using our services must be heard.

“However, at a strategic level it also means that the planning and delivery of care is co-produced with people who use our services. We have more to do of course, but we are excited to see our ‘Experts by Experience’ (individuals who have used services and with these experiences, help inform policy) having a real impact on decision making and our direction of travel.

“One example of the new approach in action — where staff felt able to collaborate more with the people using services — happened recently on our Psychiatric Intensive Care Unit. One of the service-users on the unit became highly distressed. He tried to leave the ward and attempted to assault staff who were talking to him.

“Resolution of the incident was hampered due to a language barrier. In the past, this man might have been restrained, but instead the ward manager decided to ask another service user who was fluent in his language to come into the room and offer some words of reassurance and explanation to him.

“This had such a positive impact that the incident was fully resolved soon after.

“This sort of approach completely disrupts the traditional template for supporting people in times of crisis, in which all other service users, irrespective of their relationship with the person in distress, are usually ushered away under the premise of ‘maintaining safety.’

“What happened here was that the service user led the process of de-escalation and provided translation. Not everyone would be instinctively comfortable with this, but this is a highly innovative example of positive risk taking.

“It indicates a future where the traditional lines separating roles are far more blurred. Where recovery happens in an environment of mutual support, with fewer power differentials between ‘them and us.’ It challenges us to consider whether healthcare professionals are always best equipped to support people in distress.

“If there are other people using services at that time who are able to talk to that person more successfully, then this should be tried, with staff ensuring the safety and wellbeing of everyone involved.”

As the policy of No Force First requires not simply a reduction in the use of forceful restraint, but a change in culture on the wards, Kilcoyne said that teams are celebrated when they have positive results. When results are less positive, support for staff members is increased. Kilcoyne acknowledges that a culture of criticism would be completely counterproductive, given the innovation they are trying to encourage.

She added: “Board level support is a distinctive feature of the process we’ve really valued. Having an organisational conversation that keeps our priorities at the forefront of people’s thoughts is really invaluable. Initiatives like this can often come and go, but five years in, we still have that momentum behind us.”

As this has been a new policy, the impact has been monitored closely. Compared against the baseline from the monthly average of April 2015-2016, the position in July 2018 represents a 23 per cent reduction in the use of physical restraint by staff. Assaults against staff across the whole Trust have reduced by 21 per cent, with a 31 per cent reduction in assaults causing harm to staff. This demonstrates the effectiveness of the approach, improving the safety for service-users and staff.

“What is exciting is that the principles in the No Force First model can be adopted into other settings, such as secure hospitals, prisons and potentially police cells. Mersey Care have already been using these principles within the High Secure wards and subsequently within the High Secure Prison estate through the HOPE(S) model.

“The HOPE(S) model of care aims to reduce the need for restraint and segregation by identifying preventative and protective factors and increasing the coping skills of staff and service users. The goal is to introduce a positive and structured environment in an enabling environment.

“Within our High Secure Services at Ashworth Hospital, people have historically been deemed so difficult to support, they have been nursed in long-term segregation.

“Ward staff are supported by specialist practitioners, who help them  move away from restrictive solutions, as well as role-modelling the person-centred approaches required as people integrate successfully back into the ward community — sometimes after years of hugely traumatic isolation.

“The success of the HOPE(S) approach is critical in emphasising to our workforce, in both hospital and prison settings, that there’s no person that cannot be supported by these compassionate principles and that recovery is wholly attainable. We don’t believe anyone who uses our services should be ‘left behind’ as we progress forward.”

The implementation of  the No Force First policy has led to Mersey Care winning awards and gaining international recognition. Mersey Care has also worked with over 40 external health providers both nationally and internationally giving it the opportunity not only to share its practices but also learn from these providers, further developing its own approaches.

“Award recognition has been wonderful and and a huge boost for the organisation,” Kilcoyne acknowledged. “But it’s really about the success of our fantastic clinical teams, and service-users, who’ve tried new things, taken positive risks and encouraged learning,  all in the pursuit of a greater goal.”

Dr Jennifer Kilcoyne is Clinical Director at Mersey Care NHS Foundation Trust  
Ruth F Hunt is a freelance journalist and author.