Leading change

The Practice Lead for Learning Disability and Mental Health Services at Turning Point led the development and implementation of an action plan for STopping Over Medication of People (STOMP) with a learning disability, autism or both. This was in synergy with positive behaviour support (PBS) within the organisation. Turning Point is a UK based not for profit organisation providing health and social care services. The initiative has improved outcomes, staff and individual experiences and use of resources.

Where to look

NHS England explain STOMP, which stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national programme, being supported and implemented across many different organisations who are demonstrating improvements regarding advocating a reduction where appropriate of use of these medicines. STOMP is about helping people to stay well and have a good quality of life.

Psychotropic medicines affect how the brain works and include medicines for psychosis, depression, anxiety, sleep problems and epilepsy. Sometimes they are also given to people to manage their behaviour. People with a learning disability, autism or both are more likely to be given these medicines than other people. Whilst these medicines are right for some people, for others there are alternative options for supporting their symptoms so that they need less medicine or none. The STOMP programme aims to reduce the use of these medications where appropriate to do so in a safe way.

Public Health England says that every day about 30,000 to 35,000 adults with a learning disability are taking psychotropic medicines, when they do not have the health conditions the medicines are for. Children and young people are also prescribed them. Psychotropic medicines can cause problems if people take them for too long, take too high a dose or take them for the wrong reason. This can cause side effects like:

• Putting on weight;
• Feeling tired or sedated;
• Serious problems with physical health.

To support the programme, the Voluntary Organisations Disability Group (VODG), NHS England and sector stakeholders developed the STOMP Pledge for Social Care. This aims to improve the quality of life of people with a learning disability, autism or both by supporting providers to ensure they only receive psychotropic medication for the right reasons and in the right amount.

At Turning Point, the Practice Lead for Learning Disability and Mental Health Services identified this described unwarranted variation in practice. The practice lead saw the opportunity to implement the programme locally to utilise the evidence described in STOMP to provide safe services for the people Turning Point supports.

What to change

Turning Point is a UK based not for profit organisation providing health and social care services in over 300 locations across England. Working with people who need support with their drug and alcohol use, mental health, offending behaviour, unemployment issues and people with a learning disability, they aim to inspire and empower individuals to discover new possibilities in their lives. Through provision of high quality, person-centred services in the right location at the right time, the services aim to make a real difference for the people and communities they support. The Specialist Community Outreach Team (SCOT) provides support and advice to support staff and individuals with complex needs and behaviours of concern.

Signing up to the STOMP pledge, Turning Point’s practice lead embraced the opportunity to work towards supporting people in their medication use, as well as making sure people with a learning disability, autism or both are involved in decisions about their health and treatment. This prompted the SCOT to consider individuals who were being referred into their services because of high incidents of challenging behaviour, which were for some resulting in high use of psychotropic mediation to manage these behaviours.

The SCOT leads began work with individuals and their support teams to actively promote alternatives to the use of psychotropic medication such as active support, intensive interaction and Positive Behavioural Support (PBS). The aim was to be able to clearly evidence that by using positive strategies, support staff can be enabled to support a person without using physical interventions and use of medication.

The Practice Lead for Learning Disabilities and Mental Health (LDMH) services worked closely with the support team to look at what needed to be achieved to:

• Reduce the level of incidents that were being experienced;
• Ensure the team had a good understanding of behaviours, what they communicated and have proactive strategies to support individuals to reduce challenges;
• Develop alternative PBS strategies that would move away from the use of psychotropic medication to manage behaviour;
• Support individuals to be more relaxed and settled in their environment and as a result enable them to engage in activities that they enjoy;
• Support managers to further develop staff knowledge, confidence and resilience;
• Support team members to have a better understanding of the clinical use of psychotropic medication;
• Enable the support team to discuss the prescribing of psychotic medication with the relevant members of the multi-disciplinary team and prescribers; and,
• Implement the STOMP action plan with the underpinning values.

How to change

The Practice Lead worked with the SCOT team to implement a STOMP action plan. Initially work was done to raise awareness about the impact of psychotropic medication and how PBS can provide alternative, person-centred and proactive strategies that can eliminate the need for PRN use. This supported managers to discuss the STOMP initiative in team meetings and staff supervisions, encouraging them to reflect on their own practice. This also helped the support team to understand the aims and values underpinning STOMP and PBS support. The Practice Lead identified how the SCOT team could work with the support team to implement PBS approaches to support them to work in a different way for individuals.

The PBS practitioners spent time observing existing practice. They provided workshops on facilitating reflective practice and coaching skills to start developing PBS plans for individuals. Staff were involved in writing the plan, which empowered them to not only understand why this way of working but also how they would use the PBS strategies to achieve the intended outcomes for individuals. Throughout the whole process, the Practice Lead organised regular feedback opportunities with the team manager, PBS lead and risk and assurance to review progress around the development of the STOMP action plan and how this was being embedded in practice.

PBS approaches were implemented to capture and measure success:

• Identifying behaviours which inform strategies used to de-escalate incidents without having to use PRN medication;
• Developing proactive strategies as part of a PBS plan to support individuals and the team;
• Recording and reflecting on successful diversions when there was an incident and staff did not administer ‘as needed’ medication – ‘what had gone well and what could be done differently’;
• Data collection methods were reviewed to advocate more detailed information regarding incidents;
• Analysing incident data which further informed PBS plans;
• The ‘as needed’ medication protocol was reviewed so managers and support staff could provide meaningful feedback to the relevant medical professionals; and,
• Incident reporting was reviewed prior to and following initiative implementation.

Adding value

Better outcomes – In the 5 months prior to implementation, there were 10-21 incidents each month, with ‘as needed’ medication being administered between 5-15 times. Following engagement with the STOMP and PBS initiatives, the incidents over the next 5 months reduced from 10 to 0 with ‘as needed’ medication being administered between 0-6 times. Evidence collected showed that there was a significant decrease in the level of incidents and use of ‘as needed’ medication. Other strategies and ways to engage the individual were successful. Detailed plans of support are now developed with individuals and their circles of support to make informed decisions about what health support individuals want.

Better experience – Staff have developed a greater understanding of the principles of PBS and how they can apply this in practice to support individuals, which had led to support staff feeling more confident in their way of working. Supported individuals have reduced anxiety and are better supported to manage different situations. There have been fewer incidents of behaviours requiring ‘as needed’ medications. The work has positively impacted the quality of individuals’ lives, with some being more able to engage in positive activities. Levels of engagement are higher and individuals can look at other activities and opportunities they can experience that may not have been possible before.

Better use of resources – Teams have changed their practice, taking positive steps in supporting individuals when they feel anxious. Support staff have access to training to improve their knowledge around meeting health needs, including training from specialist providers to enhance knowledge. Information is provided in a way that is accessible to an individual. All of this supports the aim of using resources more effectively. Support from the SCOT team is helping outcome monitoring and checking that improvements are sustained.  The PBS plan and STOMP action plan are reviewed regularly to observe progress, which supports the team and individuals alike.

Challenges and lessons learnt for implementation

It is important to have good communication and planning to ensure that everyone knows what they are doing and there is a clear plan. With the introduction of the STOMP initiative, it was clear that this needed to be done in a planned way with the staff team and mangers over a period of different sessions. It was important that the team understood the underpinning knowledge and how this could impact service user care.

This work was done over a period of weeks involving intensive input, including delivering multiple training sessions to capture all staff and practitioners working across the service.

Full commitment from stakeholders is vital for progress and achieving positive outcomes.

For more information contact

Stephanie Draper
Practice Lead for Learning Disability and Mental Health Services
Turning Point
stephanie.draper@turning-point.co.uk