I have been working as an occupational therapist (OT) for almost 30 years, specialising in brain injury rehabilitation, paediatric therapy, and the provision of equipment and adaptations.  Having a special professional interest in postural management throughout this time, the next step of my career was to join Halton and St Helens wheelchair service in February 2015. My continuing professional development (CPD) objectives have focussed on using my core skills and prior specialist knowledge to develop expertise in postural management.

I felt very privileged to receive a bursary to attend the PMG Conference 2016 to further my development, in line with wheelchair therapist competencies.  In particular to enhance my skills in postural assessment, and to increase my knowledge of product availability, so that my clients’ needs could be met more effectively and efficiently using rationale, evaluation and clinical reasoning.

Networking with the range of professionals at PMG was invaluable, and one topic was raised on several occasions: the effect of behaviour on appropriate and successful wheelchair provision. As such, the session led by Michael Mandelstam - Safety, equipment, restraint: mental capacity and human rights - proved inspiring.   It focused on the challenges raised by the use of restraining equipment such as belts and harnesses, the reasons for its use in practice, together with a refresher on current legislation. 

The principle for the session was proportionality: a decision-making process based on multi-disciplinary assessment of risk, in line with legislation, to direct a proportional response, i.e. provision of the least restrictive option to overcome the risk. The ambiguity of the NHS Act 2006 (England) was highlighted: it states, “the CCG may provide wheelchairs”, with no further guidance.  Other, more valuable, legislation mentioned included the Care Act 2014 (adults in England), Human Rights Act 1998 and the Mental Capacity Act 1998, Section 6.

Photograph courtesy of Suzie Hunt: Michael Mandelstam presenting at PMG Conference 2016

My professional experience of working with children, with my specialist skills in postural management and the use of a sensory processing approach to treatment, made this session particularly interesting and thought-provoking. As a service, we were using a restrictive intervention assessment brought into use by Lynn Jackson, team leader, and based on the article Developing a Protocol for Straps and Harnesses by OT Lesley Purves and Susan Hillman, a clinical scientist.  The article directs the use of multi-disciplinary team assessment, and that equipment should always be supplied and used lawfully in the best interests of the person, following an informed decision-making process which tries to ensure that best practice is being followed.  

It is clear that people should not be deprived of their liberty unnecessarily and other than as a last resort, that they should not be subjected to inhuman or degrading treatment, and that their private lives should be respected. The use of postural management equipment which limits volitional movement might be considered to interfere with any of these rights. However, most of the guidance on the law concedes that circumstances exist where such equipment can be employed lawfully.  Restrictive intervention must apply minimal force and not cause pain, and should only be used in conjunction with other strategies to help people learn to behave in non-challenging ways.  Any prescription should be individualised, be implicit to the circumstances, and be subject to regular review.

As a service development for 2016/17, Halton and St Helens wheelchair service have established a goal within the commissioning for quality and innovation (CQUIN) framework.  Led by clinical manager Lynne Peters, and with support from the Advancing Quality Alliance (AQuA), this has been a whole team approach to embracing shared decision-making principles throughout our processes for assessment, provision and administration.  This is on-going, and scheduled for presentation at the PMG Conference 2017 in Cardiff.

Bibliography                                                                                               

Coulter, A., Ellins, J. (2007). Effectiveness of strategies for informing, educating, and involving patients. British Medical Journal, vol 335, no 7609, pp 24–7.

Coulter, A. (2010). Do patients want a choice and does it work? British Medical Journal, vol 341, p c4989.

Elwyn, G., et al (2010). Implementing shared decision-making in the NHS. British Medical Journal, vol 341, pp c5146.

References

Purves, L., Hillman, S. (2013). Developing a Protocol for Straps and Harnesses. PMG Journal, Winter 2013, Volume 30:2. pp 39 *

* PMG journals from 1997 to 2014 can be downloaded here.