In-patient Mental Health Care: Learning Disabilities and Autism
(6 months, 2 weeks ago)
Lords ChamberRead Hansard Text Watch Debate Read Debate Ministerial Extracts
Baroness Hollins
To ask His Majesty’s Government what assessment they have made of progress towards achieving the target in the NHS Long Term Plan to reduce the number of people with learning disabilities and autism in in-patient mental health care by 50 per cent by March 2024, relative to 2015 levels.
Baroness Hollins (CB)
My Lords, this debate follows quickly on the heels of the topical debate about my report, My Heart Breaks, and the debate from the noble Earl, Lord Russell, on the state of children’s mental health a couple of weeks ago. This debate should be more optimistic than earlier ones, because it is about the Government’s flagship programme, Building the Right Support, which launched back in 2015, and their 2022 action plan. I declare an interest, as I have been asked to continue as a member of the action plan delivery board, which I previously attended as chair of the Independent Care (Education) and Treatment Reviews oversight panel.
I am grateful to all noble Lords who have signed up to speak and to the Minister for responding to all these debates, for writing to Members about issues raised and for arranging very helpful round tables for further discussion.
To give some background, in 2015, there were 2,905 people with a learning disability and/or autism in hospital. The target in the NHS long-term plan was for this number to be halved by March 2024. There has been a 30% reduction. Also, local commissioning systems were to have no more than 30 adult in-patients with a learning disability and/or autism per million of the adult population by the same date, but for some of the 42 ICSs, more people are now in hospital than were previously recorded. Recently, His Majesty’s Government have highlighted welcome progress in reducing the number of people with a learning disability in hospital. However, Mencap suggests that at the current rate of discharge it will be 2029 before the 2024 target is reached, and data shows that the number of autistic people without a learning disability has increased since 2015. So, what is the plan post March next year?
In August this year, 5,025 restrictive interventions were recorded among this group of people, 1,140 of which were used with children. That is physical, chemical and mechanical restraint and the use of solitary confinement, as described in my recent report. Lengths of stay are unacceptably high and much longer than for the general population. The average length of stay is now 5.2 years. NHS Digital data shows that 310 of the 2,035 people currently in hospital have been there for between five and 10 years, of whom 70% have a learning disability, and 360 have been detained for over 10 years, of whom 80% have a learning disability.
Let me tell noble Lords about Ash—not their real name. Ash was admitted to a psychiatric ward two years ago at the age of 14 and diagnosed with autism after admission. Ash can take joy and pleasure from activities but on the same day become very distressed. Ash is biologically female and, like so many autistic young people, has been identifying as transgender for the past two and a half years. In primary school, Ash was described as being shy, anxious and having low self-esteem. It was challenging for Ash to move to a large secondary school, with lots of transitions to manage —moving between classes, for example.
In primary school, there had been good support from teaching assistants, but Ash felt isolated in secondary school without this support and was bullied by peers in year 7 and overwhelmed by the challenges of travelling to and from school on the bus. Ash did not share this with their parents, finding it difficult to communicate the feelings they were experiencing, and the impact of Covid-19 restrictions led to more feelings of isolation and loneliness. Ash started to self-harm and made several attempts to end their life. After being reviewed in A&E and discharged with some community support, unfortunately Ash made a further serious attempt to end their life, was admitted to the psychiatric ward and has remained an in-patient since that time.
Ash continues to engage in regular head banging and does not want to engage in therapy. Understandably, Ash’s parents do not feel they can have Ash home, due to ongoing safety concerns and worries about the lack of support for them at home, despite asking for help in the past. The hospital says that it has been trying to find a new “placement” for Ash for at least 18 months—but calling it a placement may be part of the problem: it is a new home that Ash needs. Meanwhile, Ash is stuck on the ward and the uncertainty about their future just leads to further anxiety and more attempts to self-harm. One child too many is spending their teenage years on an adolescent ward, missing out on opportunities to develop independence during adolescence.
Could this admission have been prevented through earlier autism diagnosis, earlier recognition and support at school, and robust community mental health support from the start? Are current waiting lists for assessment setting the scene for more stories like Ash’s for years to come, and more long admissions to hospital? The action plan summarises several cross-agency commitments, as well as providing guidance for commissioners to help them to commission for people’s lives, not just to commission services for people to be fitted into.
Long-term hospitalisation is a result of failures in our social care system, in the flexibility of our community health responses and in our education system—which is too ready to exclude children with complex needs—and of a lack of suitable housing. It often follows traumatic experiences in a person’s life, such as the death of a close family member or being the victim of an assault. This debate allows us to question why the target has failed and, indeed, whether it was the right target in the first place. Is it the number of people in hospital that is the issue, or the purpose of the admission and the quality of assessment and treatment that they receive in hospital? I have consulted a few leaders in the learning disability world. One suggestion is that a better target would be based on equality. For example, the proportion of people in in-patient settings and their length of stay should be no higher than it is for the rest of the population.
The truth is that there has been insufficient focus on improving community support to prevent admission. The measure of success is not about what action has been taken or what has been spent; it is about people’s experiences. What is being done to address this? What investment is being made to pilot new ways of working in the community? Are evidence-based models from other countries being piloted in the UK and, if so, where?
There is significant concern that there has been a lack of focus on people providing direct support who are not part of any professional body and do not have necessary training and experience to support people in crisis. Too often, people in crisis with high support needs are supported by agency staff with minimal experience of supporting people with learning disabilities and autistic people. What is being done to improve the quality and suitability of support for people who need more specialist skills?
One central reason why the March deadline will not be met is the failure to tackle perverse incentives in the system. Social care is underfunded, and this is creating conditions in which people with a learning disability and autistic people cannot access the right support, and can then move quickly towards crisis. Very few integrated care systems have created safe spaces to avert crises, and avoid either criminalisation or hospitalisation.
My letter to the Secretary of State regarding my report set out the need for pooled budgets between health and social care providers. These are needed to break down the bureaucratic barriers that too often prevent discharge. The RedQuadrant report Building the Right Support: An Analysis of Funding Flows makes the same crucial point:
“Strong partnerships, pooled budgets, and joint commissioning arrangements significantly improve performance on achieving discharges for people”.
We are not short of evidence. The issues are clear, as are the solutions. Action and will are needed to bring about change. Some of that is cultural change: a willingness to include people who are different in our communities, and to go the extra mile to help them to stay at home. The financial cost would be less, and just think of the improvements in the quality of people’s lives. We need the change, and I very much hope the Minister will show us his will in concluding this debate and responding to the questions that I know noble Lords will ask. I beg to move.
Baroness Bull (CB)
My Lords, I thank my noble friend Lady Hollins for securing this important debate; we are so fortunate to have her expertise in the House, and I pay tribute to her tireless work over so many years. I have had the privilege of participating in other debates in her name on this subject since I joined your Lordships’ House. I do so not as someone with personal experience or expertise in this area but as someone who cares deeply about fairness, equality of opportunity and the protection of human rights for the more vulnerable in our society.
The Joint Committee on Human Rights has made clear that the detention of individuals in the absence of individualised, therapeutic treatment risks violating their right to liberty and security. It found that rights to private and family life and to freedom from inhumane and degrading treatment are frequently under threat for people with learning disabilities and/or autistic people detained in in-patient units.
The Government’s 2019 manifesto committed to addressing this through reform of the Mental Health Act 1983—an important Act, but one that has failed to keep pace with changes in understanding of and attitudes towards mental health since it passed into law 40 years ago. Like other noble Lords across the House, I was deeply disappointed that the Bill failed to find a place among the legislative priorities for this Government’s last Session. In its absence, we need to know what urgent action they will take now and in future to end the human rights scandal of this inappropriate and unnecessary detainment in in-patient care.
NHS data from October 2023 reveals that there are 2,035 people with a learning disability and/or autistic people in in-patient mental health units. Over half have been there for more than two years, and under half had a date planned for them to leave hospital. As my noble friend told us, Mencap’s analysis of the data suggests that, at the current rate, the ambition to reduce the number of in-patients by half will not be met until 2029—a full five years after the target date.
The statistics are startling, but they are also sterile. Each number represents a person locked away from family, friends and the day-to-day opportunities and experiences that most of us are privileged to take for granted. With an average stay for current in-patients of 5.2 years, inappropriate detention in mental health hospitals is devastating not just to the person locked away but to the people who love them and want to see them thrive. The reality, as we have heard, is that too many autistic people and people with a learning disability are held in mental health hospitals not because they need in-patient mental health treatment but because of the sustained failure over many years to invest in the right community support.
The shape of the support required for those individuals to return safely to community life is set out clearly for commissioners in NICE guidance and in Building the Right Support. For example, it requires care providers with the right skills, suitable housing, intensive support services to help prevent and manage crisis situations and appropriate respite. Having a service model is one thing, but implementing it is another. Eight years on from its introduction, too many families still face issues in accessing the support that will enable successful discharge into the community or, better still, prevent the need for admission in the first place. The future of Building the Right Support is unclear. Looking beyond March 2024, can the Minister say what will happen to the associated action plan, the delivery board and the national targets? How is this being communicated across the health and care system?
At yesterday’s Oral Questions, we heard once again about the woeful underinvestment in social care and the social care workforce. One effect of this is that people with a learning disability and/or autism struggle to access the right care packages and the support of staff with the appropriate skills and expertise for their needs. During the passage of the Health and Care Act, I was part of a cross-House coalition arguing for the importance of reforming and fixing social care for working-aged disabled adults and addressing the issues facing the workforce. Our amendments to address this did not make it into the Bill and, on top of this, the Government have delayed implementation of much of their social care reform programme. The hard-working and overstretched social care workforce remains on its knees. Will the Government commit to creating a national workforce plan for the social care sector that identifies and addresses the skills and the funding gap, so that people with a learning disability and/or autistic people can receive the care and support they need in the community, and reduces the likelihood of their being admitted to an in-patient unit?
Lack of suitable housing is also a key factor, and it is the other main reason cited in NHS Digital data each month for delayed discharge. What assessment has been made of the capital funding required to enable the discharge of people from in-patient units? Are the Government monitoring the provision of suitable housing to meet their needs? Without the right housing, alongside social care, too many people will continue to end up in crisis situations that see them inappropriately admitted, or readmitted, to in-patient units.
I have no doubt that we all share the same ambition: that people with a learning disability and autistic people should be able to live fulfilling lives in the community without fear of being admitted, potentially for long periods of time, to in-patient units—places where there is often excessive use of restrictive interventions, including physical and chemical restraint, and increased risk of abuse and neglect.
The 2024 target to reduce the numbers in in-patient care by 50% is an important step, but it is a step towards a broader ambition. However, I struggle to see how real progress can be made unless we get social care reform back on track. This means making sure that the social care system works for all those who need it, not just those who develop care needs in later life but working-age adults with long-standing needs, who rarely find themselves front and centre in discussions about social care reform.
I noted earlier that, in October, there were 2,035 people with learning disabilities and/or autistic people in in-patient mental health units. I am sure we would all agree that that is an unacceptably high number, but it is also surely a low enough number that, in a civilised, compassionate and relatively affluent society, if the will was there, the development of individualised pathways back into community-supported living could be an achievable goal. The right to enjoy a “gloriously ordinary life” should not be too much to ask.
Baroness Jolly (LD)
My Lords, we have heard two quite outstanding speeches, and I am fairly anxious about putting my toe in the water. Some years ago, I had the privilege to chair a national charity called Hft, founded in 1962 by a group of families with a vision for creating a better life for their relatives who had learning disabilities. They pioneered the idea that everyone could have choices about how they live. They called it Home Farm Trust, and it became known as Hft. This role changed my perspective and understanding of learning disability.
At present, there are around 2,000 learning-disabled adults being held in mental health in-patient units. These individuals are detained under the Mental Health Act, even though they do not have a mental health condition, in a secure hospital setting, often far from their community, and they can be subject to restraint and overmedication. Today, Hft supports more than 2,000 people across England and Wales, from those living independently in their own homes to day-care opportunities from a few hours a week right up to 24 hours a day. For every person it supports, it is committed to working with them to realise their best life possible.
Despite repeated commitments from the Government to transform care and end this practice, they have repeatedly missed their targets over the past 12 years. The latest commitment set out in the NHS long-term plan—to reduce the number of people with learning disabilities and autism in in-patient mental health care by 50% by March 2024—is likely to be missed again. The Government must bring forward a mental health Bill which prevents the inappropriate detention of learning-disabled adults under the Mental Health Act. It was highly distressing that this was not included in the King’s Speech and is not on the Government’s legislative agenda, despite a 2019 manifesto commitment to
“make it easier for people with learning disabilities and autism to be discharged from hospital and improve how they are treated in law”.
Ensuring social care is funded properly, so that everyone can receive the right care, is also critical. This will ensure that everyone who needs social care can receive the right support at the right time, and should prevent admissions to in-patient units.
Social care faces financial challenges, from poor quality and unmet need to low pay and high turnover. Central government grants to local authorities fell by 37% in real terms between 2009-10 and 2019-20, from £41 billion to £26 billion in 2019-20 prices. This results in local authorities with less to spend on adult social care despite demand, and therefore costs remain high. In 2019-20, local authorities had to meet a funding gap of £6.1 billion to meet the cost of care, resulting in £4.1 billion of cuts to adult social care at local authority level.
Ultimately, the impact of financial pressure is felt by those who draw upon and work in the sector. The consequences of this are numerous. It causes unmet need: with funding squeezed, social care is more often being commissioned only for those with the highest needs, leaving those with lower needs without essential support. The number of adults waiting for social care is still incredibly high, estimated at 400,000 people.
There is an impact on the NHS: a lack of suitable social care can affect health services, for example, by delaying discharging people from hospital or not having suitable or any care in the first place leading to admission. According to the Care and Support Alliance, one in seven people have needed hospital treatment due to a lack of care.
The financial pressure also contributes to workforce pressures: 81% of providers reported that local authority fee increases did not cover the rising cost of the national living wage, let alone a higher, more competitive wage. Pay of social care providers is uncompetitive. This is largely due to the fact that, in general, the amount local authorities pay providers to deliver care does not allow for substantial pay increases.
The knock-on impact of this is high vacancy rates, due to the necessary use of expensive agency staff and turning away of admissions due to insufficient staffing. We are aware that the twin impact of funding cuts and the pandemic has had an impact on commissioning trends. We have seen instances where commissioners are using the closure or reduction of day services as a reason not to recommission, consequently saving money.
The importance of the social care workforce cannot be underestimated. For many of the 1.5 million people in the UK with a learning disability, it provides support to ensure they remain healthy, can remain in employment and be an active member of their community. Tackling longstanding recruitment and retention issues within the social care workforce is one of the most fundamental challenges for the sector. It impinges on both the viability of services from a health and safety perspective and can have a huge impact upon the care received by people with a learning disability.
During 2022, the adult social care sector saw an average vacancy rate of 21%. Some 42% of providers saw a decline in the number of applications for care staff in 2022, which saw an average turnover rate for the sector of 25%. The Government have taken several steps to address this, including pledging £500 million to support and develop the social care workforce. While this will fund positive initiatives such as a new knowledge and skills framework and a portable health certificate, it will not address the most pervasive cause of high turnover and vacancy rates, which is uncompetitive pay. When surveyed, providers told us increases in pay would make the biggest difference to workforce challenges. Invaluable social care staff should be paid a wage which remunerates them for their skill and recognises inflationary costs. The increase in the national living wage is therefore a welcome step.
Yet, too often, this is not sufficiently reflected in local authority funding, with 80% of learning disability care providers stating that the fees they receive to deliver care do not cover the increased cost of wages. This requires providers to make up the shortfall, adding to existing financial pressures—such as energy and agency costs—and precluding any ability to pay a higher wage to alleviate the recruitment and retention crisis.
What changes are needed? First, we need a reform package for the social care system to deliver high-quality, person-centred care but which also supports and appropriately remunerates those who work within it. It must provide long-term and sustainable funding for social care. This must factor in a fully funded minimum pay rate for social care to reflect the complex and demanding role the workforce plays, as well as the increased cost of living. The Government must publish a comprehensive social care workforce strategy akin to the NHS workforce plan, co-produced with people who use the service and those who work in social care. The Chancellor is aware of the chronic underinvestment in the social care sector and the required national action to prevent further pressures on the NHS. To support the sector, we should see the introduction of a fully funded minimum pay rate for social care, as recommended by the Migration Advisory Committee and which is already in place in Scotland and Wales. Can the Minister confirm that this is on his wish list too?
Baroness Merron (Lab)
My Lords, I congratulate the noble Baroness, Lady Hollins, on securing this important debate today, particularly as it comes so soon after the publication of her report, My Heart Breaks, which focuses on the fact that solitary confinement in hospital has no therapeutic benefit for people with a learning disability or for autistic people. However, I also want to congratulate her, as the noble Baroness, Lady Bull, did, on her tenacity in ensuring that this House and the Minister cannot overlook what is in fact a disgrace to our society. That disgrace is the damage caused to those with learning disabilities and/or autism, with often misunderstood and challenging behaviour, whose needs tragically continue to be unmet. The noble Baroness herself, along with many of us in this House, has made many times over the strongest of cases for reform of the Mental Health Act, which will be crucial to attending to this.
In her introduction, the noble Baroness, Lady Hollins, set out a number of disturbing statistics, which were amplified by the noble Baronesses, Lady Bull and Lady Jolly. If I had to pick out just one of those tragic statistics, it would be this: at the end of October this year, over 2,000 people with a learning disability and/or autism were in mental health hospitals, of which 210 were children. Even more shockingly, within that number, some 670—that is nearly one in three—had been in in-patient units for over five years, and the average length of stay for those in this group is 5.2 years.
The noble Baroness, Lady Bull, repeated a call I have heard a number of times before, and I would rather not keep hearing it, because, as she reminded the Minister, while this is a shocking number, it is not so large that it cannot be dealt with by a focus on it. She called, as has been called for many times in this House, for individualised plans. Can the Minister inform your Lordships’ House what progress has been made in this regard? I emphasise the point that the noble Baroness made that these are not just statistics. Every one of the people we are talking about is a real person who is part of a household, a family, a community and an organisation, and they too are very much affected.
Perhaps the key point in the debate today is, as the report of the noble Baroness, Lady Hollins, pointed out, that long-term segregation lacks any therapeutic or rehabilitative benefit for the most vulnerable in our society. I was particularly struck that the report described long-term segregation as just one part of a four-stage failure. The four failures include a lack of community-based support. We have heard a lot today, and I endorse the comments, of major failings in adult social care and the need to provide for a properly trained and rewarded social care workforce that is planned in the same way as we have in the NHS workforce plan. The second failing is where there is a failure in the hospital to provide the support needed by the individual, because without providing that there is more trauma, disorientation and restrictions for the patient. The third failure is in the use of restrictive practices, including solitary confinement. The fourth failure is a lack of clarity about responsibility for commissioning and funding the skilled support in case management that is needed, which goes back to the accountability called for in the report. I emphasise those four points to the Minister in order to ask whether this four-pronged approach will be taken in addressing the situation before us, to reduce the number of people with learning disabilities and autism in inappropriate settings.
As has been said not just today but on a number of occasions, the Government had promised to tackle this shocking ongoing scandal through the reform of the outdated and discriminatory Mental Health Act 1983, yet that was nowhere to be seen in the King’s Speech, which was the last opportunity for this Government to bring this much-needed reform forward in this Parliament. That opportunity was missed. Once again from this Dispatch Box I say that, should Labour be in government after the next election, we will bring it forward in our first King’s Speech. I hope that commitment will provide some small comfort when looking forward, because it has been devastating to all those who were so involved in developing the discussions on improving mental health care, including all the charities, the other organisations, the Joint Committee on the Draft Mental Health Bill and many others who contributed so much to the draft Bill.
It is highly unlikely that the Government will meet their target of halving the total number of people with a learning disability and/or autism in mental health hospitals by March 2024 from the 2015 levels, and analysis by Mencap, as the noble Baroness, Lady Bull, said, suggests that the target will not be met before 2029. There is no plan at all for this after next March, so I find it hard to see what change will be made.
If the Government are still committed to a reduction in the total number of people with learning disabilities and/or autism in mental health hospitals, what is the future beyond March 2024 of the Building the Right Support action plan, which previously set out these targets? The noble Lord the Minister and Minister Caulfield held a welcome meeting with noble Lords yesterday and referred to changes that might be made in the absence of government legislation. I put it to the Minister that the culture and practice reflected in a Mental Health Act that is some 40 years old are so far from what we now need that any changes must have at their heart ensuring a change of culture, as well as practice, to make any difference. It would be helpful if the Minister could give that reassurance, not just about the focus on change of culture and practice but about how this will be reported to this House, so that noble Lords can be updated and continue to take a very focused and important interest in this.
I will conclude my comments by picking up some points in a recent letter from the Minister, dated 8 December. Can he provide further detail on the pilot models of culturally appropriate advocacy that this letter said would provide tailored support to people from ethnic-minority communities being treated under the Mental Health Act? The Minister’s letter also highlighted the patient and carer race equality framework launched by NHS England. How will the Government evaluate its impact, not only on the wider scale but on how it is implemented across different mental health trusts? This is, as we always say, an important matter to debate; it is today and has been on previous occasions. I hope that the Minister will once again hear the wisdom that has been put forward and that we will have a response, in the absence of the legislation we have been promised.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
I too add my thanks to the noble Baroness, Lady Hollins, for her terrier-like qualities—I hope that is seen as a compliment—in getting and maintaining our attention. I feel that this has been an excellent series of debates that have complemented each other and added to that basis of knowledge. I had useful feedback from the round table yesterday, and I hope the feeling from it is that this is a not a one-shot deal: it is an ongoing conversation with ongoing engagement.
One of the things that probably struck me the most —the noble Baroness, Lady Merron, mentioned it as well—was the change in the culture. When we think of where we were in the 1980s, and of all the things that we know need updating from the Mental Health Act 1983, we need to make sure we are reflecting that change of culture in all this. I will not pretend that we have an answer to that, but I think we are all committed. We need an Act; I understand everyone’s disappointment in that. We know we need to correct this at the earliest opportunity, but the round table was a good way of starting to talk about the things that we could do. We saw some very promising examples, particularly the Somerset model, which I am looking forward to hearing more about.
The point we need to reflect and come back better on is how we are changing those cultural attitudes as well. The example of Ash, given by the noble Baroness, Lady Hollins, sets out very clearly that these are real people, as the noble Baroness, Lady Merron, said. Thankfully, in some ways, they are not a large number of people, but this brings home what needs to be done. The figure of 5.2 years as the length of stay really struck us all.
It is a good question and challenge: are we setting the right target with 50%? It is a round number, and I am not saying that in any way to try to move away from it, but is it the right target? As we have said, we all care about whether we are building the right support going forward. To answer the question raised, I can confirm that there is commitment to this beyond March 2024. In some ways, the figure of 50% by March 2024 has almost created a false sense of “That is a deadline, and what happens beyond it?” Candidly, we all know that this is an ongoing problem, which will work only if we have the supply.
It is well recognised that adult social care is a crucial component to the supply of places, as mentioned at Questions yesterday. Post pandemic, we had first to put in place action to stabilise adult social care. That is what the investment has been about, so that we are finally at a place where we have managed to increase the supply of places and increase the staffing there. It is only when you are on that stable footing that you can then look to the reform action that needs to come in, of which the care excellence certificate is very important. I will freely admit that we are at the start of that journey to completion.
The second part of that is the individualised mental health supply. That is what the £2 billion investment is all about, with the 2 million extra places that we need to provide in the community for people, including 300,000 young people. In that, we all have experience that a stitch in time really does save nine. If we can get there early, then that really helps and supports people.
As other noble Lords have pointed out, while progress is being made on the number of people who have a learning disability without the autism diagnosis, the real challenge is the autism diagnosis in-patient numbers. That is the one where we need to really understand what action is needed. That is why, as I say, the Building the Right Support delivery board is an ongoing thing, not something that stops in March.
On that supply, that is what the £121 million investment in community support people is about, and making sure that every integrated care board has to have an executive lead on learning disabilities and autism. Those are the people we are really holding to account in all of this, to make sure that support is there at a local level.
On the point made by the noble Baroness, Lady Merron, the dynamic support registers are all centred on the individualised plans that need to be given to these people, so we can make sure that dynamic support is there for them all. A national development team for inclusion has been commissioned to work in 20 areas to give the bespoke support that is needed.
I reassure the House that we will continue to take forward non-legislative commitments to improve the care and treatment of people detained under the Act, as the noble Baroness mentioned, and in particular to pilot models of culturally appropriate advocacy, which will provide tailored support to hundreds of people from ethnic minorities to better understand their rights when they are detained under the Mental Health Act.
The importance of the right workforce has rightly been raised, to make sure that people with a learning disability and autism get the right support at the right time. That is what the strategy to put people at the heart of care is all about. Comments have been made about whether we have got that strategy right and whether it is covered in the long-term work force plan. It is harder in this area, as we know; as I mentioned yesterday, there are 17,000 independent providers in the adult social care setting and so co-ordinating across it is harder. But again, that is what the reforms and the care certificate are all about, and the digital platform that has been put in place to provide the qualifications and the payment mechanism is key to all of that.
I hope from these comments we are showing that we are alive and responding to the ongoing conversation and dialogue that the noble Baroness, Lady Hollins, has set in place and which will continue. I will not pretend for one moment that we have got all the parts in place. That is why it needs to be a continuing dialogue, to which I am committed. As noble Lords saw yesterday, Minister Caulfield is definitely committed to this as well. We look forward to further round tables in the new year and increasing our knowledge from them. Noble Lords can rest assured that the Building the Right Support action plan is an ongoing live document that does not stop at March. It is key to everything going forward.
At this point, I thank all noble Lords, and especially the noble Baroness, Lady Hollins, for her continued dedication to this.