It also seems to me that some of the seclusion indicators for which data is available, for example “seclusion hours per 100k Population”, appear to be of very limited utility for understanding how and when seclusion is used. I would note that good data is absolutely essential if any meaningful change is to be achieved. I would also suggest that transparency is a critical element for achieving any change. I was concerned about the quality of the data and responsiveness in our interactions with the Ministry of Health. Frequency and length of seclusion events Despite the stated intentions and best efforts of many individuals and bodies, and funding to facilitate efforts to reduce and eventually eliminate the use of seclusion in mental health, the overall picture from data and submissions provided to this review was one of persisting use, disproportionately with Mäori and Pacific Peoples service users. Space does not allow detailed examination or discussion of why seclusion and restraint practices persist despite efforts to limit and eventually eradicate them. Institutional change is difficult to achieve, and staffing pressures undoubtedly make change even more difficult. As noted above, the lack of reliable data made it difficult to assess changes since the original review, but data from the national KPI dashboard11 demonstrated that the goal of eliminating the use of seclusion and restraint in health and disability facilities had not yet been met. Between 2016/17, when the initial review took place and 2018/19, the average number of seclusion events per person rose from 2.12 to 2.86 seclusion events per person (Dashboard data). On a positive note, the average length of seclusion events slightly reduced, but remained over two days. 10. Seclusion is defined as: ‘Where a person is placed alone in a room or area, at any time and for any duration, from which they cannot freely exit’. New Zealand Standards. Health and Disability Services (Restraint Minimisation and Safe Practice) Standards. Ministry of Health. 2008. Personal restraint is when a service provider(s) uses their own body to limit a service user’s normal freedom of movement. New Zealand Standards. Health and Disability Services (Restraint Minimisation and Safe Practice) Standards. Ministry of Health. 2008. Environmental restraint is where a service provider(s) intentionally restricts a service users’ normal access to their environment, for example where a service users’ normal access to their environment is intentionally restricted by locking devices on doors or by having their normal means of independent mobility (such as wheelchair) denied. Health and Disability Services (Restraint Minimisation and Safe Practice) Standards. Ministry of Health. 2008. 11. The New Zealand Mental Health and Addictions KPI Programme (KPI Programme) 40

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