Mental Health Patient Seclusion to be Scrapped After Scathing UN Condemnation
By Jess McAllen Stuff December 22, 2017
The practice of isolating distressed mental health patients in locked rooms should be abandoned within two years, according to a new target set by (New Zealand) health authorities.
The Health and Quality Safety Commission (HQSC) has written to health board bosses about ending "seclusion". Widely regarded as one of the more restrictive practices still used in modern psychiatry, seclusion is currently only meant to be used if a patient is regarded as at risk to themselves or someone else.
Plans have been in place to reduce seclusion since 2009. In 2015 the United Nations Committee Against Torture expressed concern at New Zealand's use of seclusion for punishment and discipline.
Last year, the high-profile case of Ashley Peacock's long-term confinement was reignited, while media reported on the pressures surrounding seclusion in mental health. As a result, in April this year a scathing report funded by the United Nations slammed New Zealand's use of seclusion.
More than 800 adult mental health patients and 102 young people were held in seclusion at some point in 2016 according to the latest Director of Mental Health's Annual Report.
A seclusion room at the Waiatarau mental health inpatient unit at Waitakere Hospital in 2016.
Across all inpatient services, including forensic, intellectual disability, and youth services, 990 people were secluded at least once.
The HQSC letter, sent to district health board chief executives on December 8 and released to Stuff under the Official Information Act, announced plans for a national project to attempt "zero seclusion" by 2020.
Work is expected to begin in March next year and DHBs will be invited to participate and attend regionally-based workshops.
The Ombudsman called the use of seclusion with Ashley Peacock, a mental health patient in a secure unit at Porirua Hospital, degrading. Peacock's situation captured New Zealand's attention and started a dialogue on seclusion rooms.
It is the first focus of the recently announced national mental health quality improvement team.
The team, announced in May by then-Minister of Health Jonathan Coleman, will run for the next five years at a cost of around $7.5 million. It will be funded through DHBs and there will be a review after the first three years.
The letter was signed by HQSC CE Janice Wilson and Robyn Shearer of Te Pou o te Whakaaro Nui - a mental health, addiction and disability NGO working with the HQSC to eliminate seclusion.
The HQSC is a government body focused on monitoring and improving the quality of health and disability support services.
It reports to and advises the Minister of Health.
While there has been a 25 per cent reduction in the number of people secluded in adult mental health facilities since 2009, between 2015 and 2016 the number climbed back up by 6 per cent.
"The aim is to have a consistent national approach, over the next two to three years, to achieve as close as we can to 'zero seclusion'," the letter reads.
"We appreciate that eliminating seclusion by 2020 is an ambitious goal and one that will require commitment to the improvement process and teams that are well-supported by their DHBs."
Those who support seclusion see it as a valid treatment intervention to control agitated patients while those who are against it highlight the loss of dignity and risk of re-traumatising people who have a history of trauma.
"Evidence confirms seclusion is a significant harm and safety concern for consumers, whānau and staff. The United Nations Convention for the Rights of Persons with Disabilities calls on governments to remove barriers to enable all people to participate fully in society."
THERE'S NO MAGIC WAND
Mental health nurses said there needed to be a major shake up in how the system is run if the government truly wanted to get rid of seclusion by 2020.
Problematic alternatives to seclusion involve increased use of medication in critical situations or physical restraint.
Nurses Organisation mental health section chairwoman Helen Garrick said the group supported the vision to not have people secluded "in principle" but warned there are many steps to take.
"There is no magic wand as there are barriers to making this safe for patients and nurses."
The organisation plans to survey its members to gather views on what needs to happen to achieve a safe and therapeutic environment for everyone involved.
"At this stage it is not just a matter of supporting the elimination or not," she said, "the system is very complex and much thought and work and training will be needed."
Eliminating seclusion was tied in with wider issues affecting the mental health sector, said Garrick.
To be successful, DHBs needed to look at access to services, co-existing mental health and addiction problems, skill and experience levels in acute and forensic services, and the need for well-educated mental health nurses who have the skill to provide safe interventions.
A mental health nurse, who wanted to remain anonymous, said the news is "a huge leap in the right direction".
The seclusion room at his hospital was closed temporarily two years ago but due to a lack of planning it was re-opened as soon as nurses struggled to deal with more complex patients.
"I just hope they have adequate alternatives," he said, "they'd need to do some comprehensive training for staff."
Earlier this year mental health staff at Canterbury DHB told Stuff that the focus on reducing seclusion hours in the past few years had put further pressure on nurses.
Director of Specialist Mental Health Nursing at Canterbury DHB, Stu Bigwood, said the new seclusion elimination target was a "wonderful aim".
"It will require a lot of work to meet this target but some DHBs and indeed one of our acute wards here have had spells of up to six months without seclusion use, so we know it is possible," he said.
"There is no magic bullet to achieve this but there are great resources available."
The DHB provided extra staff, training and resources such as sensory modulation and changed the ward's physical environment in their attempts to reduce seclusion this year, he said.
"We anticipate doing more of this and are constantly looking at new initiatives to help us on this journey."
Chris Nolan, Service Director of Mental Health and Addiction Services at Mid Central DHB said that, with adequate tools, "such an environment can exist without seclusion".
"Challenges to the reduction in seclusion are present," he said, "and we work hard to overcome these."
Some of the challenges included use of alcohol and drugs, particularly methamphetamine, he said.
"Other challenges relate to the level of unwellness and our move to redevelop our environment which will offer better alternatives to use of seclusion.
The hospital cared for a large number of people without using seclusion, he said.
"We see use of seclusion as a last resort, not as a first intervention.
"We hold the view that for people with mental illness it is generally degrading to use seclusion, and a seriously mentally unwell patient does not necessarily benefit from seclusion."
It is understood the 2020 target was set to be publicly announced earlier this month but there was pushback from forensic staff.
When asked for an update, Dr John Crawshaw, Director of Mental Health, said the Ministry was working was working with other agencies to improve the quality of mental health service delivery, "including priority work to reduce and eventually eliminate seclusion and restraint".