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Medications have historically been used to influence the behaviour of people with disability. Progress on the NDIS Commission’s vision of a reduction and eventual elimination of Restrictive Practices has been made, but the data shows we still have a long way to go.
The Annual Report released by the NDIS Quality and Safeguards Commission shows a total of 14,452 people nationwide being subject to an authorised Restrictive Practice in Qtr 4 (2023-24), an increase of 12% on the year prior. We could anticipate this number to continue growing in future years as more are discovered with mandatory registration for SIL providers, engagement with Behaviour Support Practitioners, etc. From this group of people, 8,939 (almost 62%) are subject to an authorised chemical restraint, with a further 2,446 people subject to unauthorised chemical restraints. The Commission also says ‘most people are subject to 2 or more chemical restraints’.
Historically, chemical restraints have been used as a means of controlling behaviours perceived as challenging or of risk, often stemming from institutional models of care that prioritised compliance and risk management over rights, autonomy, and therapeutic support. The Disability Royal Commission found that chemical restraints are frequently used due to a lack of appropriately trained staff, limited access to behaviour support, and an overreliance on medicalised responses to disability.
Each of these authorised chemical restraint medications will have been included in a Behaviour Support Plan (BSP) by the person’s Positive Behaviour Support (PBS) practitioner and reviewed by the authorising body of the respective states and territories, ensuring that the medications are clearly identified and justify that the use aligns with legislative requirements, including being the least restrictive option, used as a last resort only and a clear plan for monitoring, reviewing and fading out the use of the medication.
But wait a minute. Is justifying a medication prescribed by a GP or other specialist in the scope of practice of PBS practitioners?
In a recent webinar by PBSTogether on the challenges to PBS in Australia, Dr Jeffery Chan (former Senior Practitioner and Deputy Commissioner Practice Quality & Clinical Advisory at the NDIS Quality and Safeguards Commission) referred to the use of Chemical Restraint as a “Prescriber problem, not a provider problem”. Typically, the prescribers he is referring to are GPs and sometimes specialists. Personally, I understand the intention of the statement, but there are significant systemic issues from both prescribers and providers leading to the misuse of chemical restraints. In Public Hearing 6, the Disability Royal Commission emphasises various issues on the provider side, including limited access to skilled Behaviour Support Practitioners, inadequate staff training, and a culture of risk aversion that normalises the use of medication for behavioural control. On the prescriber side, issues are raised around off-label and prolonged use of psychotropic medication without clear clinical justification and a limited understanding of disability-specific best practice.
The NDIS Quality and Safeguards Commission have provided a Medication Purpose Form, which can be used by NDIS Participants and providers to liaise with their medical practitioner and to understand the purpose of a prescribed medication. The Commission explain that the form “will assist NDIS providers to support NDIS participants safely”. However, the very first sentence on how to use the form states, “This form is optional. There is no requirement for medical practitioners to complete this form”. The information collected with this form is not just valuable, it is critical for Behaviour Support Practitioners and implementing providers to determine whether a medication is a restrictive practice or not.
When these forms are being filled out they are often not done adequately or accurately, crucial details are often missing. This can include information about dosage, frequency of administrations and accurate diagnosis of the person. Important information which is required not just for authorisation and reporting purposes but, most importantly, for understanding the impacts of a medication on the individual. The Disability Royal Commission findings highlight that people with a disability may experience more side effects from medication than people without a disability, including things like nausea, headaches, weight gain or even death. If a Behaviour Support Practitioner or provider identify that there is no diagnosis to support a medication, and it’s prescribed in response to a behaviour, this is the trigger to implement PBS strategies and a plan to reduce and eliminate the use of such medications.
Using the form is not just important for authorisation purposes, it leads us to better strategies.
We have heard of GPs sometimes asking to invoice PBS Practitioners for the time taken to complete a Medication Purpose Form. We understand being paid for your time and perhaps this is driven by the multitude of documentation being requested by the NDIA and NDIS, but this highlights a gap in collaboration between the health and disability sectors. The Disability Royal Commission has emphasised the need to bridge this gap to fix the overuse and misuse of chemical restraints.
We all understand the importance of working holistically, so what can Behaviour Support Practitioners and providers do to improve their working relationship with healthcare professionals?
- Communicate (concisely!) with GPs, and explain the importance of thoroughly completing the Medication Purpose Form. This might include explaining how it enables providers to:
- Distinguish between therapeutic use and chemical restraint, ensuring compliance with regulatory requirements.
- Develop safer, more person-centred support strategies informed by clear clinical intent.
- Understand the impacts the medication might have on the person and what side effects to monitor for.
- Discuss the option for a Home Medicines Review, a pharmacist-led service that reviews a person’s medications to enhance safety and effectiveness; more information can be found on this in the Commission’s Polypharmacy Practice Alert.
- Promote proactive and non-restrictive interventions, including building a Positive Behaviour Support (PBS) environment by creating a service culture that prioritises understanding the function of behaviours, capacity building, and adjusting environments to reduce the need for restrictive practices. Emphasise, promote and support a culture and practice that uses restrictive practices as a last resort.
- Collect data on the use of chemical restraint and non-chemical restraint strategies that are working, sharing this with the prescriber provides a more objective view when reviewing medications.
- Thoroughly support providers implementing BSP’s to use non-restrictive strategies and support people to communicate their needs.
