Learning Disabilities and Autism: Solitary Confinement in Hospital
(5 months, 1 week ago)
Lords ChamberRead Hansard Text Watch Debate Read Debate Ministerial Extracts
Baroness Hollins
To ask His Majesty’s Government whether they plan to expedite implementing the recommendations in the report My heart breaks—solitary confinement in hospital has no therapeutic benefit for people with a learning disability and autistic people, published by the Department of Health and Social Care on 8 November.
Baroness Hollins (CB)
My Lords, I declare an interest as I have autistic family members and my son also has a learning disability. I am grateful to all noble Lords who have signed up to speak in this topical debate: all ideas on how to make progress are needed. I thank the Minister for agreeing to meet interested Members of your Lordships’ House after the debate. My gratitude is also due to the panel of experts by experience and professionals who contributed to the report we are discussing today. The report is called My Heart Breaks—Solitary Confinement in Hospital Has No Therapeutic Benefit for People With a Learning Disability and Autistic People.
It is four years since the Secretary of State asked me to review the effectiveness of a new Department of Health-run programme of independently chaired reviews called ICETRs. The aim was to speed up discharges of people detained under mental health legislation in long-term segregation, following a CQC report that highlighted serious concerns about its use. We designed the review process to include each person’s life story, the reason for their admission to hospital and to long-term segregation, any mental health diagnosis and the treatment plan.
People with learning disabilities and autistic people have a higher incidence of adverse childhood experiences, yet none of this information was routinely provided to admitting clinicians. Two phases of reviews took place, 191 in total, with 115 people found to be in long-term segregation at any one time. ICETRs ended in March this year. They were a good diagnostic tool but, disappointingly, the wider system initially failed to make the changes recommended in the reviews, so two additional interventions were introduced: senior intervenors and HOPE(S). I shall come back to HOPE(S).
There is no therapeutic benefit to isolating people in long-term segregation and we would like to rename it “solitary confinement”, which is considered internationally to be a human rights abuse. I welcome the plan for the CQC to offer an ICETR to everyone detained in long-term segregation, but will the Minister tell the House when the CQC will recommence this programme? Will he commit to fund these reviews for as long as long-term segregation is in use in mental health hospitals, not just for the two years currently announced?
Equally importantly, will he commit funding to expand and extend the culture change programme HOPE(S), which has been running alongside the reviews and has been endorsed by the CQC as outstanding? Forty-seven people receiving support from HOPE(S) have progressed out of long-term segregation, following an average stay in LTS in that hospital of 441 days. Some of these people will have been moved in LTS across a number of services, so the real duration in solitary confinement will have been longer, and eight of the 47 were children and young people.
Examples of the very real differences delivered by HOPE(S) include someone hugging a brother for the first time in two years, having their first haircut in five years, eating meals at a table rather than on the floor or leaving hospital and having a full life in the community. I was pleased to see, in His Majesty’s Government’s response to recommendation 4 in my report, a commitment to help patients and families become aware of their rights. I look forward to seeing how that is going to be done.
With no mental health Bill in the gracious Speech, the panel’s recommended changes to the code of practice need to be achieved by different means. Minimum standards are urgently needed for the accommodation and care provided for people in an LTS. The pipeline of admissions continues; discharge is only part of the story. We estimate that there are still more than 100 individuals detained in LTS. Some are alone in rooms without any natural light, with just a mattress on the floor and without toilet or washing facilities. In quite a number of reviews, serious safeguarding concerns were raised about the manner in which people were being held. If clinicians and managers know that it is causing harm to an individual, does not its continued use become a patient-safety incident? The planned use of LTS, which is currently lawful, might not itself constitute a patient-safety incident, but should not the accommodation and care provided at least meet the minimum standards proposed? How does the noble Lord suggest that minimum standards can be legislated for and providers held accountable? Could CQC’s fundamental standards be used more rigorously to regulate LTS accommodation?
I have another suggestion: would it be possible to require the Secretary of State’s approval for the use of LTS in psychiatric hospitals, without needing primary legislation? There is a precedent for such approval for under-10s entering secure welfare, because it can cause serious long-term outcomes for the child. The use of LTS in both children and adults has a similar potential to cause serious long-term outcomes. My proposal would introduce a limit of a few days for urgent use of LTS, and, after that limit was reached, an application to the Secretary of State would have to be made by the chief executives of the provider hospital and the commissioner. They would have to confirm that safeguarding referrals had been made and that commissioners had visited the detained person. This would be another way to make LTS notifiable and its use monitored. Seeing the reality of LTS for themselves would mean that commissioners knew what they were commissioning and hopefully would insist on compliance with minimum standards for the accommodation and care provided. I hope the Minister will consider this proposal very seriously.
Major concerns were the lack of accountability in the whole system for the outcomes for individuals, and a lack of project management and specialist advocacy. I suggest there is a strong case for a specialist central advocacy service for people with a learning disability and autistic people in mental health hospitals. This is something His Majesty’s Government could take forward in the absence of primary legislation, as they are doing in relation to culturally appropriate advocacy. It sometimes seems a bit like the old joke: there was an important job to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it. Somebody got angry about that, because it was Everybody’s job. Everybody thought that Anybody could do it, but Nobody realised that Everybody would not do it.
Board-level oversight of the use of LTS should change the wrongful marketing of specialist provision when, in reality, a hospital has been offering little more than warehousing people who have been failed in the community. Discharging people is one thing. Preventing their admission in the first place is even more important, but this requires government commitments to deliver on the Building the Right Support action plan. There are examples of good practice. I do not have time to describe them, but internationally we could learn from what is happening in, for example, Trieste, and the START programme in the United States, which is now in 17 different states. They focus on working with people in the community and trying to prevent hospital admission, and keeping admissions short if they happen.
The point is that without reliable and respectful family-based and relational care in the community, we as a society are knowingly increasing the chances that autistic children and adults and those with learning disability will continue to be excluded, lonely and traumatised. We will increase the chances that they will become overwhelmed at moments of transition or crisis, such as a death in the family. They will be admitted to hospital as a so-called last resort, but often a first resort, because nothing else was provided. A number of them will then be detained in LTS in a downward spiral which could have been prevented.
It is too risky to expect wise local commissioning for minority groups with poorly understood needs without some decent minimum standards for care and support to hold commissioners to account. I will end by repeating the demands of one of the experts by experience on my panel, the mother of a young man who had been traumatised by his time in hospital, including in solitary confinement. She is clear about what is needed: accountability, accountability and accountability. She reminded me that the Chancellor showed great concern about poor care in some assessment and treatment units when the right honourable Member was chair of the Health and Social Care Committee. We need the money now. I beg to move.
Baroness Browning (Con)
My Lords, I refer to my autism interests as listed in the register and to the fact that, as your Lordships know, I have a family interest in autism. I very much welcome the fact that the noble Baroness, Lady Hollins, has brought her report to the Floor of the House today. We are very fortunate in this House to have her expertise that she shares with us on this and on many other occasions.
As the noble Baroness has said, the report describes statutory confinement as being used to “warehouse” adults and children with a learning disability and/or autism. If I may, I would like to set the scene a bit on autism. It is of course a spectrum—a communication disorder that covers a wide range of intelligence, but because of the complexity of the condition, the report we are discussing can capture any of them. Failure in the community to provide appropriate support raises the risk that any one of them may be admitted and subject to all the horrors that this report exposes, particularly solitary confinement, which in every other context would be regarded as a punishment.
For many adults and children, autism-related anxiety is common. It can often be helped with medication, but that is complex. There is no one quick-fix pill. The advance of personalised medication will certainly benefit this group, but we do not have it yet. We need it. The anxiety can cause meltdowns and challenging behaviour. It is usually triggered by a build-up of anxiety. Of course, it is difficult to deal with, but it is not a psychotic episode. The triggers that create these meltdowns in autistic adults and children need to be understood. They will vary from person to person, from changing environments and many quite obscure changes. It takes time and experience to manage and support somebody who is having a meltdown. I know that it is not a psychiatric term as such, but I think we all understand, know and have probably witnessed what that means. Whatever the cause of a meltdown, to be met with solitary confinement will compound the anxiety driver, and too often, the use of the chemical cosh on top just puts off a repeat event until the next time. For many autistic people, just being physically touched will trigger a challenging behaviour.
In over 31 years in Parliament, I have been involved with medical practitioners in order to extricate autistic people from mental institutions, and I can certainly relate to the title of the report that is the subject of today’s debate, which begins with the words, “My heart breaks”. My heart has broken many times over some of the cases I have personally observed. One would have hoped to have seen more progress. Over the years there have been high-profile cases, but the Government have made promises that have not been kept and targets have been widely missed.
In reading the response of the DHSC to the recommendations in the report by the noble Baroness, Lady Hollins, I would like to focus the Minister’s attention on the scale of the problem. In particular, their response to recommendation 6 says:
“Solitary confinement should become a notifiable event to CQC as well as to the ICB executive lead for learning disability and autism and the provider board. The notification should be made within 72 hours of a person entering solitary confinement”.
The Government’s response to recommendation 8 mentions the CQC. Although I support the training mentioned in that response, if there were notification of such confinement straightaway, or certainly within 48 hours, the CQC would not have to play “catch me if you can” in its ad hoc investigations of and attendances at these institutions. There is an urgent need for these cases to be identified when they happen and to explain why an action is taken. There is such a need for more action that the Government have a role to play here, rather than just saying, “Well, these are independent bodies who make day-to-day decisions”. That may be true, but what is behind this report is all the recommendation the Government need to make sure that the action in the field meets what we in this House would regard as humanitarian standards for this group of people.
I conclude by quoting a briefing that many of us have had from Mencap, which has great experience in this area. It says that the Government
“promised to reduce the number of people with a learning disability and/or autism in mental health hospitals by 50% by March 2024. Our analysis of latest NHS Digital Assuring figures … estimates that the Government won’t hit their own target until 2029”.
It says that, of the 5,025 reported cases, in August 2023—just three months ago—the use of restrictive interventions in this one month included 1,140 reported uses of restrictive interventions on children. I say to my noble friend the Minister: surely, this is urgent.
Lord Touhig (Lab)
My Lords, I declare an interest as a vice-president of the National Autistic Society. I join my noble friend in thanking the noble Baroness, Lady Hollins, not only for securing this debate but for the commitment and dedication she and her colleagues have put into preparing the report; it is absolutely outstanding. It is a pleasure and an honour to follow my close collaborator on these matters, my noble friend Lady Browning.
“You must meet this young boy who has behavioural problems and is about to go to comprehensive school.” Those were the words of the head of a special school I visited a little while ago. The lad was autistic and, from time to time, had an emotional meltdown that could sometimes be violent and difficult to handle. His first words when I met him were, “You’ve heard I’ve got behavioural problems”. I said, “Yes, I know”. He said, “I’m, working hard to try and cope”. I said that was good. He added, “My brother is the same. He’s five and autistic. I’m helping my mum cope with him. You’ve heard I’m off to comprehensive school”. I wished him good luck. He said, “I’ve decided on my career. I’m going to become a High Court judge. If you come up before me, you’ll get a lenient sentence”.
The point is that the head told me later that this young lad and his family had worked very positively and hard to try to overcome the behavioural problems that he and they were enduring. With the right support and encouragement, that young man has a future. However, that is not so for many children and adults with autism who have been locked up in mental health hospitals, sometimes for years. More than 2,000 are being detained under existing mental health legislation. They are separated from their families, isolated and often held in locked rooms, with their human rights ignored. We in Britain should be ashamed of this injustice.
The Council of Europe is our bulwark in defending human rights across our continent, and I once had the honour of serving as a member of that body. The council has twice in recent years taken a strong stand against the detention of people in mental health institutions, and our Government endorsed that view. Some of us were encouraged when the Government pledged to reduce the number of people with learning disabilities and autism in mental health hospitals by 50% by March next year—my noble friend Lady Browning referred to what Mencap has said about that. That begs the question everyone is asking: why did the Government not include a new mental health Bill in the King’s Speech to put an end to this practice? Families of autistic people are devastated by that failure and are anguished for their children.
A young Japanese boy, Naoki Higashida, wrote a book, The Reason I Jump. In the book there are some 50-plus questions and answers from the point of view of someone who is autistic. Whenever I pick it up, I look at question 21, which was:
“Why don’t you do what you’re told to straight away?”.
This was his answer: “There are times when I can’t do what I want or what I have to. It doesn’t mean I don’t want to do it, I just can’t get it all together somehow. Even performing one straightforward task, I can’t get started as smoothly as you can, so I have to do three things. The first thing I do is I think about what I am going to do. Then I have to visualise how I’m going to do it. Thirdly, I have to encourage myself to get going. How smoothly I can do the job depends on how smoothly the process goes. There are bad times when I can’t even act as I want to. I act badly. And when my body is beyond control—I don’t mean I’m ill or anything like that—it is as if my body belongs to somebody else and I have zero control over it”.
That is an inside view from a young autistic boy. Imagine being autistic and going through this experience when being told to do something immediately, or being detained in solitary confinement in a mental health hospital and being told to do this by a person who perhaps does not understand how difficult it is for you to act to do something they have asked you to do immediately.
The noble Baroness, Lady Hollins, speaks for all of us in the title of the report she wrote, My Heart Breaks—Solitary Confinement in Hospital has no Therapeutic Benefit for People with a Learning Disability and Autistic People. The Minister is highly regarded on all sides of the House—that is genuinely felt by everyone here. All I can say to him is that only His Majesty’s Government have the power to make this change. I can think of no greater act in what is perhaps the last year of this Parliament than to pass legislation that would put an end to this wicked and evil practice.
Lord Addington (LD)
My Lords, when you have been here a while and suddenly see a pairing of people coming up in front of you on a certain subject—and it is the noble Baroness, Lady Browning, and the noble Lord, Lord Touhig, on autism—the first thing you do is to listen hard. When you get a report that has been written with such authority, inspired by this subject, that is doubly the case.
Every time we hear about confinement and control—physical restraint, chemical coshes on groups—we are basically saying, “You have got a failure”. Why have we got to that? Often because in getting to that point, people have not understood this bit of their client base; the report refers to that. The noble Lord, Lord Touhig, just put his finger on it but from what I know of autism, that would be one person’s experience of it. There will be a series of traits gathered together that are complicated and different—never the same twice, so it is not easy.
It is difficult to tell a health professional, or any professional in any sphere, “By the way, your training doesn’t cover this properly”. We all have a series of reflex reactions which we go back to. We have to make sure that people on the way up to this point—or down, depending on how you want to look at it—have ideas about where they should have better interventions, or know whether they should make them or back off. If, as a mental health professional, you are confronted with somebody in an institution or in that process, unless you know not to behave as normal you will go into a pattern of behaviour because everybody does. You have put a reflex or bureaucratic pattern in place, so why would you break it? The only answer will be from the information about what you are dealing with.
Lots of things can go wrong in this process of identification and self-identification. I remember that once I managed to get myself into a totally unnecessary row with somebody who was on the autistic spectrum, because they accused me of not doing something in very aggressive terms. They probably did not mean to. I said, “Wait a minute—this is public”, and started to defend myself. Then they had a minor meltdown and left. I know more about this than most people but still do not know anywhere near enough to understand what that person was going through. Everybody can make these series of mistakes.
My question to the Government is: what are you doing to ensure that everybody in that process better understands that normal responses will get negative results on many occasions? How can we get that idea into the system quickly? Long training programmes, the fact that we are making progress through them and the fact that we have targets: those will all come out because they will be in the Minister’s brief—they always are. However, we need to know that an awareness that something will not respond correctly is required here.
Every time I have dealt with anything to do with autism, there has been this pattern of behaviour in the criminal justice system. To put it bluntly, autism is one of the most over-represented groups in society within the prison system. It can go horribly wrong everywhere. I take the example of the noble Lord, Lord Touhig, on the process of responding: when somebody is confronted with authority, suddenly there is a conflict there, without even trying.
How can people be trained and be made aware generally in society so that they can avoid getting as far as the medical facilities, and how can we make medical facilities aware that a different type of response will be required? I would like that big question to start to be answered. If we do not address that, we do not stand a chance of addressing it in the round because even if we train all the medical practitioners, they will still have a great flood of people coming to them—people who should not have been there.
The police in certain places have had a little more training, but usually after very bad episodes: some degree of conflict has taken place or somebody has been traumatised. We are asking the Government to give us a serious plan about building up a pattern of awareness within the institutions that people bump into. If there is a certain specialist pattern, you only get x number of people going into it. Somebody who is a high- functioning autistic or functions well with learning difficulties may bump into the system only occasionally. But if they do not have support and guidance, with somebody to say, “Yes, there is a different type of response required here”, those incidents will get bigger and more frequent, and we will have to deal with them at the acute level.
The same will apply to those who are discharged from hospital. There must be an entrance and a way down. Sometimes it will be specialist provision and sometimes it will be specially trained people, particularly when you are discharged having had some damage—let us face it, we have all had some damage. I would hope the Minister can give us some pattern for the first steps in making the institutions of government aware that a different way of responding is required. That is a necessary first step, meaning that people should at least ask others, “What do we do?”. If you have that, you will have a bit of hope, which is the least that we should take away from this debate.
Baroness Watkins of Tavistock (CB)
My Lords, I declare my interests as a NED at NHS England and as a qualified nurse. I commend my noble friend Lady Hollins on her thorough report on the current use of solitary confinement for autistic people and people with learning disabilities using in-patient hospital services. I remind people that the noble Lord, Lord Crisp, has written a book, Health is Made at Home, which argues that hospital should be for therapeutic intervention for short periods. This report clearly shows that that is not so for this cohort of patients.
The report raises key issues around the use and overuse of solitary confinement methods and outlines important recommendations for the improvement of care. However, rather than making my heart break, this report made me angry in the same way that another report, Sans Everything—that report was about long-term care in mental hospitals—did 50 years ago. We need to turn the anger and broken hearts into positive action.
I wholeheartedly support the concept that there should be no long-term use of solitary confinement for autistic people and people with a learning disability. However, I wish to highlight the need for discussion to consider in more detail other patients’ safety and well-being when people are in relatively confined environments. In addition, nursing staff are sometimes put at risk in understaffed, outdated clinical environments when, due to an acute autistic episode or meltdown, an individual patient resorts to violence that is difficult to cope with, often because of the reasons just given about inappropriate responses. Such circumstances can be distressing for other patients and staff.
Additionally, this debate should acknowledge the challenges that staff face due to high patient-staff ratios, which make truly individualised, person-centred care difficult to deliver in many circumstances. Agency nursing is used because it pays better but such nurses often do not know the individuals well enough to know how best to respond.
I state my full support for recommendation 12 of the report. Funding is needed to deliver person-centred interventions in order to reduce the use of solitary confinement vastly. This needs to be accompanied by funding to support staff’s continued education, training and professional development.
Although I agree that it is necessary to have formal recording and notifying practices in instances where solitary confinement has been used, I question the feasibility and staff resource requirements in the details of recommendation 6, in particular reporting immediately to the CQC. An alternative proposal could be that notifications to ICBs should be made if solitary confinement measures have been used for an individual in two or more instances in a set period, for example for more than 12 hours on two occasions within 10 days. However, reports should also be made to the boards that are responsible for the delivery of care.
Recommendation 7, which recommends that clinical contracts be agreed before admission, may not always be achievable in a situation of acute crisis. Therefore, I suggest that it should be clinical policy that contracts are agreed within five days of admission as a maximum and that pre-admission contracts are always considered best practice.
Finally, with regard to recommendation 8, which aims to secure family visiting rights for autistic people in solitary confinement, we also need to secure the rights for the autistic person to refuse such visits. Family relations can be very complex and, in some situations, abusive; therefore, in extremely rare situations, unwanted visits can lead to increased distress among autistic people and people with a learning disability. However, I must stress that I am a firm advocate of the visiting options in recommendation 8, which would also require people being cared for much closer to home than many are at the moment in order to make regular contact achievable. Too many people are sent too far from home, often to private health facilities, with possibly 10 different contractors for just one or two patients. This makes it difficult to maintain good relationships between providers and purchasers and to oversee the quality of care that is being delivered.
I ask the Minister: do His Majesty’s Government acknowledge that, although some of the recommendations may not be achievable without changes to the Mental Health Act 1983, many of them could be with additional financial investment to pilot programmes based on the suggestions in the report and to provide training for staff in order to ensure that they can safely deal with de-escalating crisis situations to reduce significantly the use of solitary confinement? We owe autistic people and those with learning difficulties more rapid change to the situation so ably outlined in this report. We would not stand for delay in introducing contemporary practice for people suffering from cancer or diabetes.
Lord Allan of Hallam (LD)
My Lords, on a good day we learn in and through debates in this place, as we bring a mix of different experiences. I was struck by the suggestion of the noble Baroness, Lady Hollins, that there should be Secretary of State approval for certain forms of solitary confinement. That made me think of debates that we have had in a different context around warrants for the interception of communications, where critics will say, “What is the point of the Secretary of State warrant? They will just approve it, rubber-stamp it”. Of course, it is true that the Secretary of State is not sitting there thinking, “Does this particular drug dealer deserve to have their phone tapped?”
However, crucially, the instrumental part of it, the key functionality, is that the approval process then requires a group of officials to dig into the case, look at all the details and understand whether the warrant is justified. They do not want to send up to the Minister for approval something that is deficient. It made me think that if an official is willing to send to the Secretary of State a request to approve a confinement for 450 days in a windowless room on a mattress on the floor, then good luck to them, but if nobody is willing to put that forward, it should not be happening. This is a process that is well worth considering. Who ultimately signs off and takes ownership of this? Also, the process by which it is approved is critical. It should not be left to the decision of, as the noble Baroness said, a private provider somewhere who just has a problem to resolve and feels empowered, with no further external approval, to make such a fundamental decision that will have such an impact on an individual. That was interesting. I hope that the Minister will respond on it.
The other part of the report that I found helpful was the four-stage failure that is described in annexe B, which appeals to my analytical brain. There is a notion that the first failure is the community-based failure that leads to someone going into hospital, then the failure of the treatment in hospital, which then leads to solitary confinement being considered, the failure of the solitary confinement, then the failure properly to assign responsibility and ownership, which is wrapped around all this. This was really helpful from an analytical point of view.
I hope that the Minister can confirm that there will be published data on all those stages. There are certainly recommendations for there to be reporting on the use of the solitary confinement mechanism, but it is really important to understand how many people are being treated in the community and how many failures there are of that treatment which then lead to hospital treatment and how many failures there then are in the hospital, so that at each stage we understand the number and types of failures that are occurring. That will inform our ability to hold the right bodies to account and resolve that fourth failure, that of accountability. It is only through that relentless scrutiny that we can address the issue of accountability—and that relentless scrutiny depends on the data.
I want to ask the Minister about the federated data platform in this context, although today is not the day to talk about this. For noble Lords who are not following this closely, this is the new all-singing, all-dancing thing that will pull together all NHS data. It seems to me that is very much acute focused—which is a good thing—as it is very much about ensuring that we get the flow-through in in hospitals, but it seems to me that the same kinds of tools and disciplines are needed for what we are talking about here, for understanding where people are in the system including, crucially, across different providers. However, it is not clear whether the hundreds of millions of pounds that are being spent and all that effort will yield any benefits in this area where, as the noble Baroness, Lady Watkins, pointed out, you are dealing with multiple providers of services and multiple commissioners, and it seems that a lot of them have very un-joined-up systems. It may be that the federated data platform is not the answer, but the tools, practices and data models that are developed could potentially all read across very effectively to the world that we are describing today, in which we face similar challenges about understanding where people are, how they are moving through and, critically, whether those failures occurred at any point when they moved from setting A to setting B either between or within institutions.
I ask the Minister specifically: is there a group somewhere in NHS England that is working on this, looking at the data flows in mental health care, so that we can understand and benefit from all the investment that is going in, rather than potentially facing a scenario where acute medical healthcare gets the investment and mental health care is the also-ran, poor service which will only benefit at a later stage?
I am extraordinarily grateful to the noble Baroness, Lady Hollins, for the report and for analysing the problem so well and so effectively. It is a short report, which is great: there is no excuse for anybody not to understand the problem with a report that size. I am also grateful to her for providing this very clear set of recommendations, and I look forward to the Minister explaining how he will be accepting all of them without reservation.
Baroness Wheeler (Lab)
I too congratulate the noble Baroness, Lady Hollins, on securing this debate, which is a welcome opportunity to listen to the detail of her excellent report, following on from this morning’s wider mental health discussions, and to the hear the Minister’s full response to the report itself. It is also a good opportunity to focus on the long-term segregation of autistic people and people with learning difficulties, with help from the usual important and insightful contributions from my noble friend Lord Touhig and the noble Baroness, Lady Browning, who are always such strong advocates for improved services for this vulnerable group of people.
It is worth noting that some of the speakers today, including myself, were all participants in the then Mental Capacity (Amendment) Bill 2019, which replaced deprivation of liberty order with liberty protection orders, and along with it all expressing many concerns and reservations about how any new system would operate or could lead to substantial change. As we know, implementation of LPOs was subsequently deferred earlier this year, presumably because of the expectation that even the Government had then that a new mental health Act would be in place this year or next.
I welcome the Minister’s promise in last week’s Oral Question to meet on this matter with the noble Baroness, Lady Hollins, and others, including myself, from these Benches. An urgent meeting is certainly much needed. He mentioned in the earlier debate a round table on mental health. My understanding was that there would also be a separate, smaller meeting specifically on the report from the noble Baroness, Lady Hollins, so perhaps the Minister can clarify this.
The noble Baroness, Lady Hollins, has spoken powerfully about how the 40 year-old Mental Health Act results in autistic people, with often misunderstood and challenging behaviour, remaining stuck in mental health settings and assessment treatment units for long periods of time, where approaches do not fit their individual needs for care and support, including their sensory and communications needs. Understanding and support for autism has thankfully changed substantially since 1983, especially on being clear about what an autism-friendly environment looks like and should be. It is certainly not one that is often found in the mental health settings that autistic people are mostly currently held in. Can the Minister tell the House whether the Government’s decision to abandon the new mental health Bill in this Session of Parliament included an assessment of the impact this would have on patients and patient safety?
The report from the panel of experts led by the noble Baroness, Lady Hollins, highlights deep concerns, including a lack of any therapeutic or rehabilitative benefit from the use of long-term segregation for autistic adults and those with learning difficulties. It calls for the introduction of rules which would radically reduce and place a time limit on the use of long-term segregation and to ban it for children and young people as a serious “never event” that prompts an investigation. These and other key changes are proposed to the existing Mental Health Act code of practice, which will now not be considered until the Bill is before us.
To repeat what I said in the previous debate, it is very hard to understand how the Government envisage that the care and treatment of people detained under the current Act is going to be improved by non-legislative commitments, as promised by Ministers in last week’s King’s Speech debate and ever since. I am not sure whether the Minister covered the issue in the previous debate, but can he explain exactly which significant changes can be implemented in the absence of the framework of the new Bill and with the continued constraints, approaches and outdated attitudes contained in the current Act and the code of practice that the Government have no plans to review, or how the real accountability that the noble Baroness, Lady Hollins, has called for can actually happen?
The report’s description of long-term segregation as one part of a four-stage failure forcefully underlines this, as was stressed by the noble Lord, Lord Allan. The first failure is a lack of community-based support, which prevents a person being taken out of school or away from their family and admitted to hospital. These are major failings in adult social care. The second is the hospital’s failure to provide the learning disability and autism-friendly support that is needed, meaning more trauma, disorientation and restrictions for the patient. The third is the use of restrictive practices, including solitary confinement, and the fourth is a lack of clarity about responsibilities for commissioning and funding the skilled support and case management needed in the community, which goes back to the accountability issue.
The treatment of people with autism and learning disabilities under the current outdated and discriminatory legislation disgraces our society. The need for mental health reform is why Labour, if elected, has pledged to reform the Mental Health Act in our first King’s Speech. It is an urgent priority for us. The current law is not fit for purpose and must change. We want to see the Act updated following the excellent work undertaken by the mental health Joint Committee. The code must also be updated to meet the aspirations outlined today and to reflect the learning and culture change we all want to see in how autistic people and those with learning difficulties are viewed.
I have a quick question, finally, on the timetable for the CQC to commence delivery of ICETRs on long-term segregation. When will the guidance on their role and responsibilities be available? The aim is noted—to make sure that, within 48 hours of a person being put into segregation, the CQC is ready to start an investigation of its suitability—but the process needs a great deal of thought and preparation, and the minimum standards criteria of the place need to be clear. How is Parliament going to be involved and what is the process to review the CQC’s role?
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
I add my thanks to the noble Baroness, Lady Hollins, and other noble Lords for their moving, personal and passionate—especially in the case of the noble Lord, Lord Touhig—contributions, from which I have learned a lot. When the timetable came out and I saw two mental health debates together, I must admit to thinking, “That’s going to be a long day. How wise is it to timetable them together?” Actually, having the debates back to back has worked really well, and there has been a real synergy of subjects. It worked and it has added to my education.
I understand the point raised by the noble Baronesses, Lady Wheeler and Lady Watkins, and others, around the delay to reforming the Mental Health Act and their disappointment. I would like to respond to some of those points with things that I hope we can do. This will very much be a feature of the follow-up round table. To answer the question from the noble Baroness, Lady Wheeler, on how we design that, to be honest, it is up to us, and I will happily chat to her afterwards about how we want to use those forums. I definitely have a commitment from Minister Caulfield to part of that, so we can go into the detail afterwards.
I echo the point that the noble Lord, Lord Addington, made on prevention. This struck a chord with me, as I learned early in my personal experience that a normal response often gets a negative reaction. If something happens, people generally respond in a certain way, but with autism we learn that we sometimes have to completely rewire the way that we respond. We know that what we think of as a normal response can have adverse consequences.
I will resist the temptation to trot out the statistics, as the noble Lord, Lord Addington, said, but I will say that there is a recognition from the increase in the numbers of people trained in schools that it is vitally necessary. There has been a lot of growth in it, but I accept that there needs to be more and that it needs to be across the board, as the noble Lord said. A million people have taken the Oliver McGowan training, but there are next steps in that. It needs to be across health and other settings, such as education, as I mentioned, and the police.
We spoke about early support hubs in another debate, and there is a vital role for communities there. I was asked a Question last week about black and ethnic minority people being far more likely to find themselves in segregation or these sorts of circumstances. As it was explained to me, a lot of that is because they do not feel that the early support hubs are suitable for them. For whatever reason, they are not going to them. We need to do a lot of work, and in the community as well, to break down that resistance and some of the reasons that they do not go there, because those early support hubs are a key part of any prevention.
I will directly address the points about how, where there is that circumstance of solitary treatment, we can try to minimise it and really respond. The first thing that came to me, from the noble Baroness, Lady Hollins, and others, is that we really need to increase the barriers to entry, for want of a better phrase, and make them as high as possible, so that it really is a last resort. I personally like the idea of the Secretary of State’s approval. There are some logistical issues there, such as if it is out of hours or whatever. The suggestion was made of the Secretary of State’s approval being needed if it is beyond 48 hours, at which point I can see practically and logistically that you could make that work a bit better. Having the Secretary of State’s approval before someone goes in could be hard logistically, but having it beyond 48 hours allows for that planning.
I was toing and froing with the team during the debate, and I think we can have a productive conversation around it, particularly on the point that the noble Lord, Lord Allan, made. I have had some personal experience of this: in the department, I sign off all consultancy agreements on the use of consultants, contractors and everything else. I normally sign nearly all of them off, but the main point is that a lot of them probably never come to my door, because the DGs and managers who are putting them up know that they must be absolutely watertight in their cases to do it. I believe that this would be a similar mechanism of prevention, so I will definitely take it away.
On the reviews and the CQC, we want to have it all up and running next year, obviously as early in the year as possible. I will come back to be more specific on that timing. The funding, as mentioned, is for two years, but I like the suggestion that we all know that, as long as solitary confinement is happening, we will need something like this. First, we need to increase the barriers to entry but, secondly, where solitary confinement is needed, we need to increase the review process. That is the role of the CQC and the ICETRs, but it is also about the use of the data, as suggested. I do not know how much the FDP can be used in this, but I saw an example this morning of it being used quite well in the discharge space, where it is linking in with social care and the local authorities. There are some good grounds there, and I will definitely pose the question.
There is acceptance that people sometimes need to be treated in solitary confinement. If they do, it is all about reviewing and accountability, as the noble Baroness, Lady Hollins, said. On that, as my noble friend Lady Browning and the noble Baroness, Lady Wheeler, said, it is about making sure that the CQC is notified within 48 hours, so that it is on the case and reviewing it. That is another vital cog in accountability.
I was told that they plan to enter into a consultation on that as quickly as possible. I was told that they thought the timing for that was January 2025. Quite honestly, I have gone back and said two things: do we really need to consult and, if we do, does it really need to be as long as January 2025? Again, I will come back on both of those things and maybe these are some of the things we can talk some more about in the round table.
Thirdly, if we are in the circumstance whereby solitary confinement is deemed to be the right treatment method, obviously we come on to quality, and the point was made there about making sure that the quality is right, in that circumstance. Obviously, the CQC has a role in that and the Health Services Safety Investigations Body, or HSSIB, clearly has a vital role to play in all of that. We do understand that there was a feeling that the Government were not acting quickly enough in our response to the paper written by the noble Baroness, Lady Hollins, so, again, we will come back further on that.
I hope that reassures noble Lords to some extent that there are things that we can do, and plan to do, in the meantime—absent the mental health Bill—and, again, I want to use the round table to talk about that, explore it and make sure it is as actionable as possible. As I said, as ever, I will write to make sure that I have picked up all the points made in detail. I would like to end by again thanking the noble Baroness, Lady Hollins, and all other noble Lords for their contributions to what I found was another very good debate.