The Department of Health often launches snazzy initiatives – bestrewn with ‘champions’ and ‘guardians’- in response to failings being exposed. But when the cameras move on, little improves because root causes are not tackled. Excessive use of restraint by highly stressed mental health services is one of a long line of issues that has had the DH treatment, complete with champions . However, cuts to mental health services have continued and recorded incidents of restraint in mental health trusts have in fact increased from over 39,883 incidents in 2011/12 to over 66,681 incidents in 2015/16. The NHS has contended that this is due to better recording, but there are still gaps in the data provided by trusts via FOI and when trusts’ records are inspected. The increase in recorded episodes of restraint has been revealed by FOI data and not by the CQC, which has again not been fully accountable to the public. CQC’s reports do not give a full picture. Evidence about this has been submitted to parliament as follows:
To Health Committee 31 October 2016
Dear Dr Wollaston and colleagues,
Inconsistency in CQC’s regulation of the use of restraint in mental health services
I write to submit additional evidence for the forthcoming CQC accountability hearing of what I perceive to be arbitrariness by the CQC. The recent rating of Northumberland Tyne and Wear NHS Foundation Trust (NTW) as ‘Outstanding’ is an example of CQC ratings not following the evidence. In my view, the CQC contributes to Department of Health’s denial about NHS under-funding and crisis.
NTW has for years had by far the highest number of violent incidents out of all English NHS trusts. This raises serious questions about quality of de-escalation practice and whether there are preventative, positive therapeutic interventions to avoid and manage conflict. High rates of violence can reflect strain on services and on staff, and the increasing acuity and over occupancy of psychiatric beds.
NTW has the highest numbers of physical restraints and specifically, prone (face down) restraints. According to FOI data obtained by Norman Lamb’s office  NTW had 7855 episodes of restraint in 2014/15. In 2908 of these episodes, the patient was in the prone position, which is recognised as posing a high risk to patients. The average numbers of restraints and prone restraints in English mental health trusts during 2014/15 from the same FOI data, were 1374 and 320 respectively. In the same period, eighteen other mental health trusts had fewer than 100 episodes of prone restraint. Trusts with a higher number of bed days than NTW had fewer episodes of restraint and prone restraint. Nottinghamshire Healthcare NHS Foundation Trust, a similarly large trust with many Forensic beds – including high secure beds at Rampton – and a higher number of bed days, reported no episodes of prone restraint at all. Even allowing for possible under-recording by other trusts and differences in trust profile and specialism, NTW’s outlier status on this important parameter of both safety and governance seems clear.
NTW’s use of prone restraint was cause of much concern when MIND released its 2013 report on variable use of restraint amongst mental health trusts in 2011/12.  NTW’s use of restraint has increased since then and since the Department of Health’s 2014 launch of policy to drive down the use of restrictive interventions and dangerous prone restraint.  Based on a six month sample preceding the last CQC NTW inspection, NTW’s episodes of prone restraint have more than tripled since 2011/12. There are also other reasons to question CQC’s rating of ‘Outstanding’. I have summarised the issues here:
The ‘Outstanding’ rating at Northumberland Tyne and Wear is thrown into relief by the CQC’s criticism of other trusts’ restraint practices. CQC, and specifically Paul Lelliott CQC Deputy Chief Inspector, substantially criticised West London Mental Health Trust and rated it as ‘Requires Improvement’:
“We were concerned at the apparent overuse of physical restraint, and the failure to keep proper records. Staff must use restraint only as a last resort, and minimise the use of restraint in the prone (face-down) position.”
However, pre-inspection data obtained by CQC showed that West London Mental Health NHS Trust (WLMHT) had about a tenth of both restraint episodes and prone restraint episodes compared to NTW. This is a significant difference because WLMHT’s number of bed days approaches that of NTW’s.
Also of note, 6 weeks after CQC’s recent ‘Outstanding’ rating on NTW despite high levels of restraint and prone restraint, the CQC rated The Spinney hospital ‘Outstanding’ on 19 October, citing low use of restraint as part of CQC’s reasons for this rating. 
In contrast to CQC’s criticism of WLMHT and other trusts, CQC’s report of the recent NTW inspection  – led by Paul Lelliott – noted NTW’s high use of restraint but did not acknowledge the steep increase in restraint. CQC’s report was silent as to the efficacy of any measures by NTW to address its high restraint use. CQC only reported that the trust had a strategy on reducing restrictive interventions, but gave no judgment of its quality or its implementation, beyond noting that staff training was provided. CQC made no requirements of NTW on its overuse of restraint and prone restraint other than a recommendation that the trust should review its use of mechanical restraints. The CQC noted use of emergency response belts and handcuffs in children’s services, but no specific figures were given on frequency of use. The tone of the NTW inspection report contrasts with CQC’s stern instructions to other trusts. For example, this rebuke to North East London NHS Foundation Trust (NELFT), issued only 26 days after CQC’s favourable report on NTW:
“The trust had not implemented a reduction strategy to reduce the use of restraint and prone restraint….The trust must ensure there is a reduction strategy implemented to reduce the use of restraint and prone restraint.”
In 2014/15 NELFT reported only 9% of the restraints and 12% of the prone restraints that NTW reported. Similarly, CQC’s pre-inspection data for NELFT revealed only 15% of the restraints and prone restraints that the pre-inspection data for NTW revealed.
The various data above, derived from 2014/15 FOI figures and collated pre-inspection data supplied in CQC inspection reports on mental health trusts are uploaded here:
CQC has acknowledged in principle that Safeguarding service users from abuse is core to maintaining fundamental standards of care, and that preventing unwarranted and avoidable use of force is an integral part of this. 
It is a Safeguarding issue if the regulator is arbitrarily down playing serious risks to patients, and it is inimical to a just culture if the regulator does not maintain consistency and fairness in how it treats regulated bodies. It begs a question of whether the regulator serves a useful purpose for the public.
Joint guidance by CQC and NHS Confederation indicated that CQC would include specific review of providers’ restraint practice in its new style inspections as part of the government’s drive to reduce restrictive measures and prone restraint.  However, CQC’s reporting on the use of restraint and prone restraint is inconsistent and incomplete. Review of new style CQC inspection reports on mental health trusts shows that:
- The CQC does not always report on restraint practices by mental health trusts, even though this is a pivotal parameter in assessing the quality of care and the protection of vulnerable patients’ rights and safety.
- In its inspection process, the CQC samples variable intervals for data on restraint activity by trusts. It mostly reports on short periods of six months and does not often give specific information on longer trends.
- The CQC does not consistently report the numbers of restraint and prone restraint episodes. The CQC does not give data in terms of numbers of restraint episodes per 1000 bed days etc., when this information would allow the public to make more sense of the numbers, and to more easily compare trusts.
- The CQC only occasionally comments on the accuracy of trusts’ restraint data and only occasionally gives information to confirm that it has checked accuracy.
- The CQC does not consistently indicate whether trusts’ restraint activity has improved or whether trusts have effective governance in place to track and reduce the number of restraints.
Please see the uploaded data above, for the basis of this summary of CQC’s reporting on restraint.
This all makes it hard to get a complete national picture, to track progress and to compare trusts. This is not the first time that CQC’s incomplete and opaque safety reporting has been evident.   Campaigners and bereaved families have had to obtain mental health restraint data by FOI, which rather says it all about CQC’s handling of safety data and accountability to the public.
Dr Minh Alexander
cc Public Accounts Committee
Public Administration and Constitutional Affairs Committee
 FOI data obtained by Norman Lamb’s office, published by MIND
 Mental health crisis care: physical restraint in crisis. MIND June 2013
Northumberland Tyne and Wear NHSFT’s restraint data for 2011/12
 Positive and proactive care: reducing the need for restrictive interventions. Department of Health April 2014
 Comments by Paul Lelliott CQC Deputy Chief Inspector in a CQC press statement about care failings at West London Mental Health.
“Chief Inspector rates service at West London Mental Health Trust as Requires Improvement” CQC 16 September 2015
 CQC inspection report on The Spinney, 19 October 2016
 CQC inspection report on Northumberland Tyne and Wear 1 September 2016
 CQC inspection report on North East London NHS Foundation Trust 27 September 2016
 CQC statement of its role and responsibilities in Safeguarding June 2015
 Joint NHS Confederation and CQC guidance September 2014 on implementing Positive and Proactive Care: Reducing the need for restrictive intervention
 How safe are NHS patients in private hospitals? Prof Colin Leys and Prof Brian Toft November 2015
 CQC Deaths Review: All fur coat. Minh Alexander 13 August 2016