People with Learning Difficulties and Autism: Detention in Secure Settings

Baroness Bull Excerpts

Thursday 28th October 2021 Grand Committee

[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.