Question for Short Debate (Lords) on People with Learning Difficulties and Autism: Detention in Secure Settings - Oct 28

Asked by

Baroness Hollins
To ask Her Majesty’s Government what plans they have to prevent people with either (1) learning difficulties, or (2) autism, from being detained in secure settings when an assessment has recommended they should live in the community.

Baroness Hollins (CB)
My Lords, more than 2,000 autistic people and people with learning disabilities are currently detained in hospital, mostly inappropriately. Two years ago, the then Secretary of State asked me to review the care of 77 people who were at that time detained in long-term segregation. The number is now 100. My ICETR oversight panel includes people who have experienced long-term segregation themselves, family members, and experts in mental health, housing and social care. Those 77 people have all now had independently chaired education, care and treatment reviews.

We examined the first 26 of the 77 reviews in depth. What we found was profoundly shocking, and we identified several areas for urgent improvement, published in a thematic review. Typically, they had past histories of poorly commissioned education, therapy and care. There was little clinical continuity between hospital and community services, no clear therapeutic purpose for admission, and inadequate clinical assessments, with little recognition of previous trauma or its implications for mental health and behaviour. The oversight panel and NHS England have worked with the Royal College of Psychiatrists to develop a new clinical contract to try to ensure active management and therapeutic benefit.

More than half of those we reviewed were autistic people, both adults and children, but the hospitals where they lived, and those responsible for helping them move back home, lacked much understanding of the autism-friendly environment or care needed by autistic people. Most of the people reviewed were ready either to be discharged or to start a transition process back to their community.

Repeated past commissioning failures were compounded by poor commissioning responses to the ICETRs. Apathy and bureaucratic delays were part of the problem—professionals not turning up to meetings, agreed action not taken, wrangles over who pays for what. We saw interminably slow processes keeping people in situations that were at best inappropriate and all too often violated human rights. One woman had reportedly been ready for discharge for 19 years. I ask the Minister: how will Her Majesty’s Government ensure that ICETRs are being taken seriously by commissioners and that commissioners will be held accountable?

As part of our review, we gathered and published good stories of people who had managed to live happily in their communities after being discharged. We called the document Helping People Thrive, and it was written to inspire commissioners and clinicians. Mr W was one of those good stories. Prior to his discharge, he had been detained in hospital for more than 20 years, spending most of his time in what amounts to solitary confinement. Mr W has now lived in his own home for nearly three years, near his family. His home environment and care have been built around his needs. It costs no more to support him in this way than it did to detain him in hospital. Most importantly, despite still recovering from the trauma of being in the wrong environment for so many years, he is now happy.

We are pleased that our recommendations, both for senior intervention—a form of intensive case management to assist in overseeing discharge arrangements—and for the continuation of independently chaired reviews, have been supported by Her Majesty’s Government.

Some people we reviewed had social workers, advocates and families who were trying hard to move them back home, but a lack of local housing and care providers with the expertise needed was hindering their plans. A key part to successfully supporting someone in the community is the provision of good-quality housing. Sometimes commissioners are persuaded that moving the person to a single-person residence in or near the hospital is the solution, but such interim moves make it less likely that the person will ever move properly back to their own home community, and they incur continuing high fees for commissioners. How will Her Majesty’s Government ensure that there is enough housing, without months or years of delay? We must do everything we can to give people the choice to live where they want and with whom they want, just as we all do.

Sometimes, people tell us what they are unable to put into words through their behaviour. Recognising what they are trying to communicate and helping them to find a way to understand their feelings is often what enables people to move on from patterns of destructive or difficult behaviour. Good relationships with care staff are key, as shown in Dr Rebecca Fish’s recent research.

Speaking as a mother and former practising psychiatrist in this field, I believe that more attention needs to be given to really listening to people and enabling them to communicate what is troubling them, using whatever method works for them. Books Beyond Words—I declare an interest, as it is the charity I founded—creates word-free health and social stories to help people communicate their hopes and fears through the universal language of visual communication. Respond, the only specialist charity in the country offering trauma psychotherapy for autistic people and those with learning difficulties, is overwhelmed by referrals. Medication continues to be the main response to challenging behaviour. When will Her Majesty’s Government invest in widely available psychotherapy and specialist trauma therapy for people with learning disabilities and for autistic people?

Current community mental health and learning disability teams are rarely well equipped and resourced to provide the support needed for traumatised people. This deficit contributes to people’s care arrangements breaking down and to hospital admissions. If we invested in good local care, we could properly support people being discharged from hospital and prevent a new generation being admitted because of a lack of the right community support.

The social care system is nothing without the workforce. The pandemic has shone a light on the extraordinary dedication and determination of those who work in care. It is now time to address the many issues that have faced the workforce for several years, but which the pandemic has strained to breaking point. We do not currently have enough staff with the right training to ensure that people’s needs are met—staff who can empower and support that person to life their live to the fullest, who respect and value them, and can create good relationships with them.

Back in 2016, I chaired a report for Health Education England called Care Roles to Deliver the Transforming Care Programme, but little action to introduce effective training, supervision and meaningful career pathways seems to have happened. I recently visited care settings in Germany and was impressed by parity in length of training, pay, and terms and conditions for care staff, nurses, primary school teachers, occupational therapists and others. There were no staff shortages and services were much more joined-up.

How will Her Majesty’s Government ensure that care providers with expertise to support people like Mr W are available all over the country? Will they consider changing the rules, so that care workers can enter under the skilled worker immigration scheme? I hope the Minister will reassure me and the Committee that the expected reforms to the social care workforce and the promised cross-departmental strategy will tackle training as a priority. Could the noble Lord confirm whether recent recommendations from my oversight panel, and from all the other recent high-profile reports, are being taken forward in the Government’s new strategy?

Finally, I ask the noble Lord whether Her Majesty’s Government will consider making it a statutory requirement to report restrictive practices, including long-term segregation, and to publish details of commissioning organisations that still have patients in long-term segregation. Noble Lords may be surprised to know that many commissioning organisations that I have asked do not know if they have people in long- term segregation.

They could do this, for example, by making an annual report to Parliament about the numbers of autistic people and people with learning difficulties being detained in hospital, including those in long-term segregation, naming the responsible authorities, and reporting about the action being taken to develop effective care and support in the community, so that crisis admissions to hospital due to local service failures no longer happen.

We have debated this issue many times and read so many shocking reports. It is time to end scandals and tragic deaths and to give people back their lives. The new strategy needs political support. It needs resources to untangle the bureaucratic web and to reverse the perverse financial incentives that seemingly trap people in hospital. I am grateful to noble Lords for speaking in this debate and for helpful briefings from Mencap, Rightfullives, the Challenging Behaviour Foundation, the National Autistic Society and the Royal College of Psychiatrists. I look forward to hearing everybody’s contributions and the Minister’s response.

14:11:00

Lord Addington (LD)
My Lords, this is one of those occasions when I almost feel like saying, “You’ve heard the noble Baroness, and that’s about it”, but I will indulge myself by following on from much of what she said, particularly about training and staff.

Looking around this room, I see many people who have done more on autism than I have, but anybody who has realises how difficult it is for somebody with autism, especially at the lower-functioning end, to interact with the outside world. Some can get through it and make you understand what they are doing, if you give them the time and if you have some training. I have less experience of learning disabilities but, if we stick with autism as a factor, these are people who have communication and perceptual difficulties, meaning that they cannot interact well with you. If they have got themselves in a position where people cannot cope, often because they are becoming adults and their demands on society and their expectations are realistically higher, you must have people who are properly trained to interact with them.

If you do not have those people and everything gets terribly difficult and occasionally frightening, pushing them away into a darkened corner is a perfectly understandable response. I can see why people do it. It is wrong, damaging and expensive, but people do it. However, once you are shoved away into a corner—and the point that the noble Baroness made about opening up everything is probably one of the keys here—if you do not know what is going on, how can you possibly intervene to change it? The idea that you should open up is key.

The Government have accepted that the situation that we had a few years ago at Winterbourne View is unacceptable, and they have made some progress, so congratulations for that. Whenever congratulations come, as the Minister has been here long enough to know, then comes the criticism behind it. It is not there yet, and it is about getting people not only outside but sustained outside.

So how are we doing with training? Has it become the norm that a person in a controlled unit is trained in how to de-escalate a situation without reverting to a chemical cosh or physical restraint? What is the relationship in the numbers between those people? I recently had a conversation with a young man of about 23 who went to a unit training in how to deal with this type of person, and he said that they spent most of their time in arm locks, and he was one of the oldest people working in that environment. This cannot be right. Do we have a situation where people are trained to do the communication, de-escalate and ensure that you can have a civilised conversation? Are they there on all occasions? If they are not, you are just playing Russian roulette and something will escalate and go wrong. That is almost a guarantee. Once something goes wrong and you have the problems that I have inarticulately described, somebody will be even more frightened than you or I would if we were being contained. Trauma and its effect on mental health are almost guaranteed; it is just a matter of how bad it will be in individual cases.

We have a situation where we all accept that something should happen. We are even reasonably agreed on what should happen, which is getting a person out to live as independently as they can with enough support to do it. What action are the Government taking to make sure this happens and that, when something goes wrong when they are living independently, we can intervene and correct it without getting into more conflict, fear and trauma? That is what is required. It is the fact that you can communicate with that person.

Across the disabilities sector, this is a very common structure. If you have somebody who does not quite fit into the bracket you are talking about, and you try to make them fit, putting square pegs in round holes—we can throw our own clichés at it—we will always get this trauma, lack of communication and outcome. This leads to things such as legal costs, lack of things and other greater costs. Will the Government please give us an idea of what they are doing to make sure that staff are trained to intervene and guide people towards correct—or perhaps I should say better—solutions?

People have a right to live independently and securely. With a little help, most of this group can do it, at least for long periods of time. If the Government are not making that intervention, they are probably wasting money, first and foremost. Can the Government give us an assurance that they are taking steps to make sure that this waste of money, which leads to a lack of human dignity and human rights, is being corrected? Without it, they are offending everybody at every level.

14:17:00

Baroness Bull (CB)
My Lords, I am very grateful to the noble Baroness, Lady Hollins, not just for her comprehensive introduction to this important debate, but for her work over so many years for people with learning disabilities and autism. I also pay tribute today to Professor Sir Michael Rutter, who died this week and whose work in this area gave hope to so many families, including one known to me. It was Professor Rutter who diagnosed their four year-old son and offered them hope of a life in which, with the right support, he would be able to flourish, despite his challenges. As that young man turns 30, that same hope is in painfully short supply. He is among the 2,085 people with a learning disability and/or autism currently confined in an in-patient setting—a number that has risen by 40 over the past month. The average stay is 5.4 years. He has been detained since 2011, with around one-third of that time in locked seclusion.

As we have heard, many of these people are not there because they need in-patient mental healthcare; they are there because the right kind of community support is simply not available. For some, these settings are not only inappropriate; they are deeply triggering environments in which they can be subjected to profoundly damaging practices that compound existing trauma, including segregation, restraint and seclusion. The environment can be horribly reminiscent of the extreme deprivation suffered in early years: no furniture, no personal belongings, no family contact except through an intercom, treatment delivered through a small Perspex window, no activities, no stimulation, no choice.

The NAO has estimated that in a single year, 2012-13, the NHS spent £557 million on in-patient services for people with learning disabilities whose behaviour can challenge. These are vast amounts to spend on keeping people in situations that, far from helping, are causing untold harm. There are perverse financial incentives underpinning this. While responsibility for community provision typically rests with local authorities, in-patient care costs are met by the NHS. The Commons Select Committee heard that this is a disincentive to local authorities to invest in community provision, as it would lead to more patients becoming their financial responsibility. This makes no sense. The Care Quality Commission estimates that hospitalisation costs roughly three times the price of community-based care.

The Government promised transformational change after the 2011 Winterbourne View scandal, but progress has been unacceptably slow, with the target of a 50% reduction in in-patient beds now pushed out a further five years to 2024. In the meantime, vulnerable and blameless individuals continue to suffer.

When will the Government produce a robust, detailed, costed, evidence-based, cross-departmental plan to deliver on this long-overdue commitment? What will they do to ensure that the right community support is in place, not just to enable successful discharges into the community but to prevent admission in the first place? What steps will the Government take to build the much-needed capacity and skills in the workforce about which the noble Lord, Lord Addington, just spoke? Will they act to remove the perverse financial incentives and redirect funding flows from poor care models to the development of robust community services? Will they stop commissioners buying places in services that are failing to meet appropriate models of care?

Also, will the Government deliver reform of the Mental Health Act, under which the vast majority of in-patients are held? Currently, people with a learning disability can be detained if they display challenging behaviour. However, all too often, this behaviour is not because of a complex mental health problem, but because one or more of someone’s social care, communication, environmental or sensory needs are not being met. Once admitted, their quickly get stuck in a system in which effective routes for challenge are hard to find. What will the Government do to ensure that care, education and treatment reviews take place and involve the right expertise, as well as families, and that recommendations are followed within specified timescales?

As we have heard, in the end, this is a question of human rights. The Joint Committee on Human Rights stated:

“The detention of individuals in the absence of individualised, therapeutic treatment risks violating an individual’s … right to liberty and security.”


It also found that

“their rights to private and family life … and their right to freedom from inhuman and degrading treatment”

are threatened. Sadly, in my limited experience, all of these ring horribly true. Those individuals who achieve their ambition to return to community living leave traumatised by the experience that they have undergone, with their families equally traumatised and, frankly, exhausted by their unrelenting fight to improve their loved ones’ situations.

It cannot be right that any one person should be failed so many times: failed by the absence of appropriate services, then failed again through the treatment they have received in a place where they ought not to have been. I think that 2,085 is too high a number, but it is also low enough that the development of individualised pathways to support community living should, in a civilised society, be an achievable goal. The costs might be high but the costs of the alternative are far, far higher.

14:22:00

Lord Touhig (Lab)
My Lords, I declare an interest as a vice-president of the National Autistic Society.

Autism is not a mental health condition, but many of Britain’s estimated 700,000 autistic people develop mental health problems and too many reach a crisis point that could be avoided. This is often because they cannot access the support in the community that they desperately need—a point well made in the opening remarks of the noble Baroness, Lady Hollins.

Due to way the Mental Health Act currently works, autistic people are at risk of being admitted to hospital and detained not because they have a separate mental health condition but because they are autistic. Not having enough services can be the reason for an autistic person’s detention or for preventing their discharge. Yet, as we know, the Mental Health Act code of practice clearly states that hospital is unlikely to be helpful in supporting autistic people.

More than 2,000 autistic people are currently in in-patient facilities, and more than one-third of them have been flagged as no longer needing care. Once detained, the average stay is almost five and a half years. This is an abuse of human rights, a point well made by the noble Baroness, Lady Bull, just now. As a former member of the Council of Europe, a body that Churchill helped to set up to protect human rights, Britain should be ashamed of its record in this respect.

I welcome NHS England’s long-term plan to reduce the numbers to below half the 2015 levels by March 2024. However, since the plan’s publication, there has been no significant reduction in the number of autistic people in mental health hospitals. Indeed, for much of the time, the number of autistic people in such hospitals was increasing. In 2015, autistic people made up 38% of the number; now, it is 59%. Autistic people should be able to live full lives in their communities with their families and friends. The Government must change the Mental Health Act to make sure that autistic people are not detained inappropriately in hospital.

Changing the definition of mental disorder to remove autism and learning disability in non-criminal justice-related matters is definitely the right step and to be welcomed, but we must provide the right community service support for autistic people with mental health needs. This must be underpinned by legal duties to have the right levels of support available in every part of the country—it cannot be some sort of pick-and-choose system. We must make sure that all mental health services have the right training fully to support autistic people, and there is a huge gap.

I welcome the rollout of the Oliver McGowan mandatory training in autism and learning disability, which is currently being piloted, but it must go further by promoting best practice, such as work recently done by the National Autistic Society in collaboration with Mind. More than that, we need to give talking therapists the guidance they need to make those vital early interventions work much better for autistic people. What steps have the Government taken to make sure that autistic people are not left behind in in-patient mental health hospitals when they should not be there in first place? How will the Government make sure that all mental health services have the right training to provide quality mental health support to autistic people because they do not have it now? In particular, will the Minister commit to funding the full rollout of the Oliver McGowan mandatory training? How will the Government guarantee that the right community services are available in every area for autistic people with mental health needs? Will the Minister commit urgently to review and improve the commissioning of support for autistic people and people with learning disabilities? Finally, will the Minister commit to develop clear guidance for commissioners in each area and provide commissioning support for those areas that need it most?

Locking up autistic people in the way we do now is a stain on British society. We should be ashamed of it, and we should put an end to it.

14:26:00

Lord Crisp (CB)
My Lords, I, too, congratulate my noble friend Lady Hollins on getting this debate. I want to spend a moment on those congratulations. At a time of Covid, climate change and geopolitical tensions, it is really important that we do not neglect some of the smaller-scale issues. This issue affects 2,000-plus people and their families, but it is not millions, and it is not the billions who live on this earth. In that sense, it is small scale, but for these families this is massive and all-embracing. I also note that Covid has affected people differently and has been a healthy reminder of the inequalities in our society, and this is a massive and rather hidden inequality. So I congratulate my noble friend on the way she opened the debate, spreading out all the issues that are involved.

I want to say a few words about the current situation and focus on the plan, the non-existent plan. We are talking here about 2,000-plus people, 210 of whom are children who have learning disabilities and/or autism. I have been out of touch with this sector for some time, but I sense from the briefings that I have been getting that all we are doing is warehousing these people. They do not need to be there. They are admitted because there is nowhere else for them to go, and they cannot leave because there is nowhere else for them to go. Meanwhile, while there, they deteriorate. It is a dangerous environment for many, and goodness knows what it does for the children and their education, socialisation and development.

I know that similar things are happening to acute adult mental health admissions because I have done a recent review on that, and people are stuck in adult in-patient units, but the difference is that we are talking about people being in this situation for 5.4 years on average. They go in now and come out, possibly in 2027, or, looking backwards, they would be coming out into today’s world from the very different world of 2015, or, as a child, growing from 11 or 12 to 16 or 17 through the early years of adolescence. We can all imagine the personal tragedies behind these bald figures.

So what is the plan? I mean “what is the plan?” and not “what is the policy document?” My noble friend Lady Bull made the terribly important point that this is small enough to count. They can all go on somebody’s list and somebody can tick them off when they are moved out of hospital.

I have had a lot of great briefings from organisations, great descriptions of the problem and great advice. We know what good looks like. There are lots of overlapping recommendations. There is a lot of discussion of inspection and holding to account, but I do not see anything about personal responsibility and who is responsible for delivering the change.

I joined the NHS in 1986 from a background in industry and charitable sector as—in those days’ language—the unit general manager of a mental handicap unit and I am familiar with this sort of problem because in those days we had a target to remove children from mental handicap hospitals. I make these comments as a manager.

Public sector planning can just mean a document all carefully worked through with timelines, targets and many wise words. A plan is not a document but something that is going to happen, but it does not mean anything if there is not somebody charged with implementing it and for whom there are consequences, frankly, of both success and failure. I was staggered to hear the noble Baroness, Lady Hollins, point out that some of the people who appear to be responsible for implementing this do not know how many people they are responsible for in this situation.

We need money to sort some of this out, I am sure, but a person is the most important first step. Money can be wasted, and a responsible person can fight for the money. Of course, quality and safety are also vital; this is not just about getting people out of one bad situation in hospital or inpatient unit and putting them in another bad situation in the community.

I will not labour what happened 35 years ago—but it happened. There was both money and responsibility and it happened. I remember quite a lot of pressure coming down the system to me as a unit general manager to make sure that it happened. At that stage, no more children were living in hospitals. It may not be quite like for like for where we are today, but it is tragic to hear how far backwards we have gone in 35 years.

Therefore, my questions for the Minister are of course: what is the plan and who will be responsible for delivering it? Will whoever is personally responsible also be impacted by their failure or success in achieving the plan? Let me add that this is just the sort of small-scale thing where ministerial leadership can make a massive difference. If a Minister took an interest and wanted to make it happen, they could really make it happen. I know it is not the Minister’s brief, but will he raise this with his ministerial colleague, the Minister for Care? My simple point is: who is going to get a grip on this?

14:32:00

Baroness Brinton (LD) [V]
My Lords, I congratulate the noble Baroness, Lady Hollins, on securing this important debate, especially with her expertise following the excellent review that she led two years ago. I declare my interest as a vice-president of the Local Government Association.

The Health and Social Care Select Committee’s report published on 13 July this year makes it absolutely plain that, 10 years on from Winterbourne View, the provision for autistic people and those with learning difficulties sees far too many placed in residential settings, which is unacceptable.

Jeremy Hunt MP, the chair of the Select Committee, said:

“Despite commitments by governments over the years, the totally inadequate level of community provision means that autistic people and people with learning disabilities are wrongfully admitted to inpatient facilities and detained for a shocking average of six years … it is time to recognise that a voluntary approach to reducing the numbers has failed and long-term admissions should now be banned with alternative community provision set up in their place.”


The Select Committee report follows on from the oversight panel review of the noble Baroness, Lady Hollins, saying once again that this is an emergency and needs dealing with immediately. I start by asking what is probably also my final question: can the noble Lord the Minister say when the Government will announce not another plan, but the recommendations and how they will be delivered?

I welcome the comments from the noble Lord, Lord Crisp, about what happened 35 years ago; 25 years ago, when I was chair of education in Cambridgeshire, it really felt as if this country was beginning to become progressive in its approach to ensuring that those with learning disabilities and autistic children should, wherever possible, be living with their families or in their communities with support and going to their local schools. We believed that we had changed things. The evidence is—as the noble Lord, Lord Crisp, said—that too many people are being warehoused in unacceptable settings.

For some people, specialist residential provision has been developed over the years, but there are now complex commissioning rules with health and local government again fighting over the costs—as we heard about in our previous debate. Additionally, the lack of funding from central government to local government for this specialist provision, as well as the general funding crisis that local authorities are facing following cuts of about 30% to their overall budgets, means that there is a real problem and it appears that short cuts have been taken.

Noble Lords have also spoken about the further worry of restrictive practices. The horrors of the Winterbourne View covert videos, showing staff treating in-patients badly, were seared on the public’s soul. Everyone said that this must never happen again. But the evidence is that it continues. Indeed, there was a video of a staff member dragging a young autistic person by his hair only last month in a school. As both the noble Baroness, Lady Hollins, and my noble friend Lord Addington have said, this speaks to the lack of supervision and a lack of training of staff in these institutions. As the Select Committee report said:

“None of this is worthy of a 21st century healthcare system”.


I am grateful to the noble Baroness, Lady Hollins, for giving a successful outcome for one patient, now living successfully and happily in the community. The problem is the inertia and structural problems with commissioners and funding, meaning that 2,000 are still in inappropriate settings at best, and at worst living their lives with their human rights ignored. Immediate action is needed now.

14:36:00

Baroness Merron (Lab)
My Lords, I thank the noble Baroness, Lady Hollins, for her sensitivity, her work on this crucial matter, and today for her use of her voice in giving voice to those who do not have a voice. The manner in which this debate has been conducted has spoken volumes.

When people are in the wrong environment, they suffer trauma, deep unhappiness, ill health, abuse of their human rights and lack of dignity—the list goes on. I ask myself: why is it that those who have learning disabilities and/or autism are seen to be less worthy of the right environment than those who do not? My noble friend Lord Touhig said that we should be ashamed of the years of failures and that this is a stain on British society. I agree with him because we are judged as a society on how we treat those in greatest need, to whom we owe the most.

The noble Lord, Lord Crisp, spoke of people getting stuck and their situation deteriorating because of the so-called care environment in which they have been put. This is not acceptable. It is a sorry and lengthy catalogue, which I hope the Minister will today commit to put an end to—a sorry catalogue of missed targets. Every figure that we refer to is not just a figure; each one of that number represents a person—and not just a person but their family, friends, colleagues and communities. They all carry that suffering along with the person.

I found myself shocked, as I am sure many noble Lords did too, by what I understand of the situation. The noble Baroness, Lady Bull, made a very good point that shocking though the figures are, they are actually small enough to make an impact. I hope the Minister will outline to the Committee today how he will undertake, with his colleagues, to put an end to this outrage once and for all.

The figures that shocked me were not just that there are over 2,000 people with a learning disability and/or autism in in-patient units or that there are 210 children there, but that the number of people in units has gone up by 40 from the end of September. So we have seen no sign of change. The figure that really tells the story that we are here to address is that the average length of stay for people with a learning disability and/or autism in in-patient units is 5.4 years. That is 5.4 years that no person will ever get back.

We have heard in the debate about the thousands of reported incidents of restrictive interventions—physical and chemical restraint. The most recent data show that in one month alone, July 2021, we saw over 4,000 reported incidents, 930 of which were against children. I go back to the point that has been made repeatedly in this debate, which I ask the Minister to address: much of this is because of the environment, nothing else. How can it be justifiable when we know, as the noble Baroness, Lady Hollins, said, that the costs of keeping somebody in an inappropriate environment are no less than to keep them in a caring, happy and appropriate environment? The finances do not stack up, so can the Minister address how the finances are worked out, as well as the quality?

We find ourselves in a shocking situation. We know, for example, that the mental health White Paper, issued in January 2021, took the important step that learning disabilities or autism will no longer be grounds for detention under the Act, but can the Minister update us on the timetable for bringing forward the legislation? We know that recently, in June, the Government published the results of the consultation on the White Paper, and there were positive responses on the necessity for these reforms. It would help to know, first, when that legislation will come forward but, secondly and key to this debate, when and how will there be a grip on this and by what means will the Minister measure the right progress having been made to protect and advance the interests of every individual about whom we are speaking today.

14:42:00

The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
My Lords, I thank the noble Baroness for securing this important and heart-wrenching debate, and for leading the work on the independent reviews of people with a learning disability and autistic people in long-term segregation. I also thank the oversight panel that works with the noble Baroness on this vital issue for its report and recommendations, which the Government wholeheartedly welcomed and responded to in July this year.

Some of the stories we heard were heartbreaking. I am extremely concerned to hear about the number of people who remain in long-term segregation and, in too many instances, the unacceptably poor care to which they are subject. As the noble Baroness rightly says, no one should be detained where they do not need to be and where they can live a full life in the community but, sadly, we know that this is still happening and, frankly, it is not good enough. The Government are committed to taking action, both for those already detained who can and must be discharged, and to prevent people who do not need to be admitted from being so in future. We must move away from responding to crises to ensuring that the right care and supporting legal framework are in place from the very beginning of someone’s life.

We are determined to reduce the number of people with a learning disability and autistic people in mental health hospitals, which is why we are investing more than £90 million of additional funding in 2021-22 in community services and support for discharges. The Government are also undertaking wider action, which I will set out as I address the important points raised in this debate. I aim to address as many of noble Lords’ points as possible today.

The noble Baroness, Lady Hollins, started the debate by talking about housing. There is clear evidence that the right housing arrangements can deliver improved outcomes and meet people’s preference to remain in their own home. We agree, as the noble Baroness said, that the right housing for people with learning disabilities and autism is not always available, or available as quickly as we would like. In England, we are providing funding to build specialised housing through the Care and Support Specialised Housing Fund—CASSH—for older people and adults with learning and physical disabilities or mental ill health. We have provided £71 million for the fund in 2021-22.

Also in England, we fund the disabled facilities grants to support eligible people, including people with learning disabilities and sensory impairments, in adapting their homes to make them safe and suitable for their individual needs, subject to a means test, eligibility criteria and their needs assessment; £573 million has been provided for this in 2021-22. Housing is one of the six priority work streams of the Building the Right Support delivery board, and will form part of its upcoming action plan.

The noble Baroness, Lady Hollins, and the noble Lord, Lord Addington, mentioned training and expert staff. We accept that the right workforce is critical in enabling the highest standards of care and support for people with learning disabilities and autistic people. Skilled staff, leadership and creativity can be key in supporting someone towards discharge. For those in long-term segregation, the launch of a senior intervenors pilot is vital. Senior intervenors are being recruited, and we hope that they will help to remove barriers and bring creativity to planning and moving people towards discharge. The role will bring with it the necessary expertise and experience to assist in overcoming some of the barriers to progress.

More generally, we have provided £1.4 million of funding for the development and trialling of Oliver McGowan mandatory training to improve awareness and understanding of learning disability and autism for health and social care staff. Hundreds of staff have already been trained through the trials. The Government recently announced at least £500 million over three years to fund social care professionalisation initiatives to improve workforce well-being and other issues, especially for those who work with patients with autism and learning disabilities.

As we set out in Right to be Heard:

“Our vision is that in future all professionals will, before starting their career or through continuing professional development, undertake training which covers a ‘common core curriculum’ for learning disability and autism so that we can be confident that there is consistency across education and training curricula.”


The Government are currently working with Health Education England, the Medical Schools Council, regulators and medical schools to establish the best approach to developing a core curriculum. In addition, to improve patient services supporting autistic people, we are investing £1.5 million to develop training for staff in adult in-patient mental health centres. I know that the noble Lord said that there are much wider issues around mental health, but it also includes supporting autistic people, in line with tier 3 of the core capabilities framework.

As part of the Oliver McGowan mandatory training in learning disability and autism programme, we are working with a number of people, backed by that £1.4 million investment. Subject to evaluation, this should be available to all of the 2.8 million health and social care staff on autism and learning disability. As I said, the workforce is one of our six priorities. Also, as part of the new national autism strategy, we are taking a number of steps to improve the understanding of autism among educational professionals, as well as the training that we have already announced.

There are a number of incredibly important reports and recommendations, especially those by the Joint Committee on Human Rights, the Health and Social Care Committee and the CQC oversight panel. The Building the Right Support delivery board has been established to drive further and faster progress on the exact issues that a number of noble Lords raised today. We are considering how to bring these recommendations together as part of the Building the Right Support action plan; this will require a cross-government, cross-system effort, as many noble Lords have said.

We also want to ensure better reporting on the number of people being detained. The Government are fully committed to reducing restrictive practices and poor care for people with learning disability and autistic people. Reporting on our progress on the use of these restrictive practices is an important part of that, which is why the Mental Health Units (Use of Force) Act statutory guidance, on which we recently consulted, set the reporting requirements for restrictive practices under the Act. That guidance makes reference to the mandatory requirement to report this information, in line with current NHS England and NHS Improvement requirements. We will publish the final guidance, reflecting feedback from the public consultation, later this year.

The noble Baroness will be aware of existing reporting data which is also already published. NHS Digital publishes its annual Mental Health Bulletin, a monthly public dashboard about the use of restrictive interventions and assuring transformation data about the number of people with a learning disability and autism in in-patient settings.

The noble Baroness, Lady Hollins, and perhaps one or two other noble Lords, also raised the issue of changing the rules so that care workers can enter the skilled worker immigration scheme. We should all acknowledge the valuable role that immigrants play in our economy. Within the social care workforce, nurses, occupational therapists and social workers are eligible for the health and care visa. The new health and care visa will make it cheaper, quicker and easier for eligible social care professionals from around the world to come to work in the UK. We hope to attract the best talent from around the world.

The noble Lord, Lord Addington, asked whether we have training for staff to de-escalate and minimise restrictive practice. NHS England and NHS Improvement have commissioned the rollout of the HOPE(S) model, a national training model to be delivered through NHS-led provider collaboratives to reduce the use of restrictive practices and long-term segregation and to develop positive cultures. The HOPE(S) model will follow a human rights-based approach, be person-centred and be informed by experiences of trauma. A number of noble Lords raised the issue of trauma and we think it is important that we address it. I would welcome feedback from noble Lords across the Committee who take an interest in this issue to make sure that we are on the right path.

I want to dwell on the senior intervener role, which is being trialled in response to the recommendation of the noble Baroness, Lady Hollins, for the introduction of an additional senior person to support local services to plan discharge, guide where there is challenge and agree actions to facilitate a reduction in restrictions. It is important that we do this planning and that we are planning for discharge as the ultimate goal. The project builds on the positive evaluation of the pilot of children and young people’s senior interveners. The ultimate goal of senior interveners is to establish and oversee this robust programme, making sure that we are all working towards discharge from long-term segregation and hospital.

I was asked by a number of noble Lords, especially the noble Baroness, Lady Hollins, about independent case reviews. We have accepted the recommendation made by the noble Baroness, Lady Hollins, and the oversight panel to resume independent case reviews for those in long-term segregation. We are working with NHS England and the CQC to ensure that IC(E)TRs will be restored as soon as possible. It is important that the reviews that take place are high quality and that we have the right panel of experts in place. We are trying to work on this as fast as possible in the context of the Covid-19 pandemic.

A number of noble Lords asked about Winterbourne View and targets. We have a clear target in the NHS long-term plan of a 50% reduction by 2023-24 and are taking action across several fronts to achieve this. There have been more than 10,000 discharges since March 2015 and a 28% net reduction in in-patient numbers. We accept that this does not meet the target of a 35% reduction previously set out in March 2020, but we hope to continue and to make real progress.

The noble Lord, Lord Touhig, talked about mental health issues and Mental Health Act reform. Reform of the Mental Health Act is important and a White Paper was published in January 2021. We have consulted publicly on the proposals, and we published a response in July 2021.

I will try to answer the other questions. The noble Baroness, Lady Bull, and the noble Lord, Lord Touhig, talked about limiting the scope of detaining people with learning disabilities or autistic people. The proposed reforms will create new duties for commissioners to ensure an adequate supply of community services and make every local area understand and monitor the risk of crisis at individual level.

I would like to say more about commissioners, if I may, but, if I have not answered noble Lords’ questions in the time allotted, I hope that they will write to me, so that I can give them all a more thorough response.

I end by thanking the noble Baroness, Lady Hollins, for this important debate. I think all noble Lords agree that all parts of the system must play their part and take action, so that no one is detained when they do not need to be. Hospitals must always have a therapeutic purpose and detain people only for as long as is absolutely necessary. We hope that the actions we have set out today for both the long and short term—I will write to noble Lords about our significant reforms—demonstrate the range of activity already under way or planned. We hope that this will help to ensure that we prevent people with a learning disability and autistic people being detained when they could live a full life in their community with their friends and family, as every one of us deserves.

Once again, I thank the noble Baroness, Lady Hollins, for securing this debate. I look forward to working with her in future.