Blogpost – What do the statistics tell us about what’s happening to people with learning disabilities and autistic people in inpatient units during COVID-19? Part 3: Restrictive interventions

Summary

The statistics on ‘restrictive interventions’ (restraints) seriously underestimate the true picture, because many independent sector inpatient services do not report into the MHSDS dataset where restraints are recorded.

From January to March 2020, the percentage of people with learning disabilities and/or autistic people in inpatient units who were subject to restraint increased as the overall number of people in inpatient units decreased. In January 2020, 11.3% of people in inpatient units were subject to some form of restraint, rising to 13.5% of people in March 2020.

Those people who did experience some form of restraint experienced restraint on average 9.6 times in January 2020 (almost once every 3 days), reducing to 7.8 restraints per person in March 2020.

People in NHS units and younger people were more likely to experience restraint. 

Physical restraints, particularly supine restraint, standing restraint and seated restraint, were the most commonly used types of restraint, with seclusion and rapid tranquilising injections also common. Around 100 people each month were subject to prone restraint.

As COVID-19 really hit in April 2020, with all the extra restrictions placed on people in inpatient units and no visitors allowed, it will be important to track what happens to people in terms of being restrained – especially as the percentage of people in inpatient units being restrained seems to be increasing.

 

 

 

This blogpost updates and adds more detail to a previous blogpost asking whether regular statistics could tell us anything useful about what was happening to people with learning disabilities and/or autistic people as the first wave of COVID-19 hit from March 2020 onwards. This is the third of three linked blogposts. Part 1 focused on what the statistics show about the number of people in inpatient units as the first peak of the COVID-19 pandemic hit. Part 2 focused on how many people were admitted to these units, how many people left these units, and how many people in these units died. Part 3 (this post) focuses on what the statistics say about restrictive interventions used on people in inpatient units leading up to the start of the pandemic.

In this blogpost, we only have information from NHS Digital from one database, the Mental Health Services Dataset (MHSDS), which is reported monthly from mental health service providers – this records all people flagged across all mental health inpatient services as a person with learning disabilities or an autistic person. This database takes longer to analyse, so information using the MHSDS is only available up until the end of March 2020.

As we have seen from the other two blogposts, the number of people in inpatient units, particularly young people not sectioned under the Mental Health Act typically admitted for short periods of time, had substantially decreased from January to March 2020. This was mainly happening in the wider range of NHS inpatient units rather than in ‘specialist’ independent sector inpatient services, where numbers seemed to be more stable. This decrease in numbers, by the end of March 2020, happened because of fewer people being admitted to inpatient units and more people being discharged from inpatient units. By March, the number of people dying in inpatient units had not increased to the point where the published statistics recognised them.

The question I want to ask in this blogpost is as follows: As the first peak of the COVID-19 pandemic started to hit in March 2020, how often were various types of ‘restrictive intervention’ (restraint)  reported, how many autistic people and/or people with learning disabilities were subject to them, and did any of this change over time?

Before going through yet more graphs, I first want to say that all the numbers I go through will severely underestimate the number of people with learning disabilities and/or autistic people subject to these restraints, and the number of restraints that people are subjected to. As I discuss in the 1^st blogpost in this trio, the MHSDS reports vastly higher numbers of autistic people and/or people with learning disabilities in inpatient units than the Assuring Transformation data preferred by NHS England/Improvement. However, many independent sector organisations recorded by Assuring Transformation as having people in inpatient units do not appear in the MHSDS dataset at all. The table below firstly lists independent sector organisations which recorded a total of 345 people in inpatient units in the Assuring Transformation dataset but no-one in the MHSDS (remember, only the MHSDS records restraints) at the end of March 2020. This includes two organisations (Partnerships in Care and the Priory Group) which were recording people in the MHSDS up until the end of January 2020 but then mysteriously stopped.

[I’ve also included in this table three big organisations (Cygnet, Elysium and St Andrew’s) who recorded 450 people with learning disabilities and/or autistic people in inpatient units in Assuring Transformation at the end of March 2020, but recorded 1,115 people in inpatient units in the MHSDS, just to show how severely Assuring Transformation under-records the number of autistic people and people with learning disabilities in inpatient units].

Number of people recorded as being in inpatient units at the end of March 2020	Assuring Transformation	MHSDS
Independent sector providers recording people in Assuring Transformation but not in the MHSDS
Bramley Health	10
CAS Behavioural Health Ltd	35
Cheswold Park Hospital	5
Lighthouse Healthcare Ltd	15
MHC (Health) Ltd	5
Partnerships in Care Ltd	95	[until January 2020, MHSDS recorded 200 people in Partnerships in Care inpatient units]
Priory Group Ltd	155	[until January 2020, MHSDS recorded 15 people in Priory Group inpatient units]
Raphael Healthcare Ltd	5
St George Healthcare Group	15
The Breightmet Centre for Autism	5
Independent sector providers recoding much larger numbers of people in the MHSDS than in Assuring Transformation
Cygnet Health Care Ltd	175	300
Elysium Healthcare	135	470
St Andrew’s Healthcare	140	245

The MHSDS has been reporting information on people with learning disabilities and/or autistic people in inpatient units for two years now – this should have been more than enough time to enforce reporting into it by all inpatient services, including those in the independent sector (why is reporting into the MHSDS not a condition written into contracts or CQC registration?).

Bearing this large gap in mind, what do the MHSDS statistics tell us about restrictive interventions in inpatient services from January to March 2020? The first graph shows the total number of restrictive interventions recorded in each month and the number of people in inpatient services subjected to these restrictive interventions, broken down by type of service.

The light red line shows that NHS inpatient services used restrictive interventions with autistic people and/or people with learning disabilities 2,935 times in January 2020, decreasing to 2,415 times in March 2020. In January 2020 (the dark red line), 260 people in NHS inpatient services experienced a restrictive intervention at least once, compared to 280 people in March 2020. Independent sector inpatient services (the purple lines) used restrictive interventions 945 times on 145 people in January 2020, compared to using them 840 times on 140 people in March 2020.

 

 

To find out a bit more what these numbers mean, we need to take into account that the number of people in inpatient units from January to March 2020 dropped quite a lot. The graph below shows two things. First, the solid lines show what percentage of autistic people and/or people with learning disabilities were subject to at least one restrictive intervention in each month (the solid light red line is for people in NHS inpatient units; the solid light purple line is for people in independent sector inpatient units). In January 2020, 11.7% of people in NHS inpatient units and 10.5% of people in independent sector inpatient units were subject to at least one restrictive intervention. By March 2020 this had increased to 14.4% of people in NHS units and 12% of people in independent sector units. There could be several reasons for this, including more restraints being used as lockdown restrictions began to tighten, or fewer people coming into inpatient units who wouldn’t typically be subject to restrictive interventions.

In the same graph, the broken lines show, for those subject to restrictive interventions, the average number of restrictive interventions that people were subject to. In NHS inpatient services (the dark red line), people were subject to an average 11.3 restrictive interventions per person in the month of January 2020 (just over 1 every 3 days), which reduced to 8.3 per person in March 2020. In independent sector inpatient units (the dark purple line), people were subject to an average 6.5 restrictive interventions per person in January (just over 1 every 5 days), which reduced to 6.0 per person in March.

 

  

Because young people in inpatient units have been more likely to be subject to more restrictive interventions in previous statistics, I also looked at restrictive interventions for the age bands under 18, 18-24, 25-34 and 35+ for January to March 2020. The first graph below shows the percentage of people in inpatient units subject to at least one restrictive intervention in each month January to March 2020. [The light orange line for people aged under 18 is invisible because it is almost identical to the line for people aged 25-34 years]. This shows that people aged 18-24 years were most likely to experience at least one restrictive intervention in each month, and that for all younger age groups (except people aged 35+) the percentage of people experiencing restrictive interventions increased from February to March 2020.

 

 

The next graph shows the average number of restrictive interventions that people were subject to, by age band. Overall, people aged under 18 and 18-24 were subject to more restrictive interventions than older age groups, with a general trend towards people experiencing fewer restrictive interventions from January to March 2020.

 

Finally, I looked at the specific types of restrictive intervention that people with learning disabilities and/or autistic people in inpatient units are subject to (or more correctly, are recorded by inpatient services as being subject to). The graph below shows the number of episodes of different types of physical restraint that people were subject to each month. The MHSDS reports a proliferating range of different types of physical restraint, which I find very depressing. The most commonly used form of physical restraint was ‘supine’ restraint (being restrained lying down but face up rather than face down as in prone restraint), which was used 1,110 times in January 2020, dropping to 850 times in March 2020. Prone restraint, which has been acknowledged to be particularly dangerous, was used 275 times in January, increasing to 290 times in March. Standing and seated restraint were also common. Restrictive escort was less common (but still used around 170 times per month), and side and kneeling restraint were relatively rare. Large numbers of physical restraints (525 in January through to 365 in March) were classified by services as ‘other’, which is a place my imagination does not want to go to.

 

 

The next graph below shows the number of autistic people and/or people with learning disabilities who were subject to these types of physical restraint in each month. Large numbers of people were subject to supine (165 people in January, 150 people in March), standing (160 people in January, 155 people in March), and ‘other’ physical restraint (150 people in January, 125 people in March). Substantial numbers of people were subject to seated (105 people in January, 95 people in March), prone (100 people in January, 90 people in March), and restricted escort (70 people in January and March) physical restraint.

 

 

In the MHSDS, inpatient services also record various types of chemical restraint, mechanical restraint, seclusion and segregation. As the graph below shows, these were generally used less frequently than physical restraint. The most common of these forms of restraint was seclusion (time-limited solitary confinement), which was used 290 times in January and 260 times in March. Injection with a rapid tranquiliser was recorded as being used 180 times in January and 130 times in March. Oral medication as a form of chemical restraint was used 100 times in January and 80 times in March, and mechanical restraint was used 70 times in January and 85 times in March. Seclusion (longer-term solitary confinement) was recorded as being used 20 times in January and 10 times in March.

 

The final graph below shows the number of people subject to these types of restrictive intervention. In January 2020, 135 people were subject to seclusion, compared to 130 people in March 2020; 75 people were subject to rapid tranquilising injection in January (70 people in March), 45 people subject to oral medication as a form of chemical restraint in January (50 people in March), and 35 people were subject to mechanical restraint in January (25 people in March).

 

 

Overall, because many independent sector independent sector services inexplicably don’t report to the MHSDS, these statistics seriously under-estimate the number of restrictive interventions that people with learning disabilities and/or autistic people in inpatient units experience. Published figures also do not report physical assaults and self-harm experienced by people in inpatient units. As inpatient units started to prepare for/adjust to COVID-19, the percentage of people in inpatient units subject to restraint increased as the overall number of people in inpatient units decreased. In January 2020, 11.3% of people in inpatient units were subject to some form of restraint, rising to 13.5% of people in March 2020. People in NHS units and younger people were more likely to experience restraint. However, those people experiencing restraints experienced a decreasing number of restraints from January to March 2020.

Physical restraints, particularly supine restraint, standing restraint and seated restraint, were the most commonly used types of restraint, with seclusion and rapid tranquilising injections also common. Around 100 people each month were subject to prone restraint.

As COVID-19 really hit in April 2020, with all the extra restrictions placed on people in inpatient units and no visitors allowed, it will be important to track what happens to people in terms of being restrained – especially as the percentage of people in inpatient units being restrained seems to be increasing.