Autism and Learning Disabilities: Hospital Detention

Baroness Hollins Excerpts

Tuesday 11th March 2025 Lords Chamber

[Baroness Merron (Lab)]

I am grateful to the noble Baroness for tempting me to agree with her comments about a mental health commissioner. We have debated that, and the noble Baroness is aware that we do not feel that this is the right way forward. However, I am sure we will return to that on Report.

With regard to not waiting for the Mental Health Bill to become an Act, of course I agree. The number of people with a learning disability and autistic people who are in mental health hospitals is unacceptable, and there are still too many detained who could be supported in their communities. We have taken immediate action in allocating funding to local areas: £124 million for learning disability and autism services. We are making sure that the workforce has the right skills and knowledge through work such as the HOPE(S) model. We are providing for the CQC to deliver independent care (education) and treatment reviews. NHS planning guidance provides a continued focus on improving mental health and learning disability care, with an objective to deliver a minimum—I emphasise minimum— 10% reduction in the use of in-patient care.

[Baroness Hollins (CB)]

My Lords, for 25 years, this woman’s detention was in long-term segregation. My review of this practice, which was commissioned by the previous Government, recommended that people in LTS must have an independent review, should have national support to reduce confinement, and be allocated an independent project manager to co-ordinate their timely discharge. But despite the unequivocal success of the ICETR programme, the HOPE(S) intervention and senior intervenors’ support, funding has been cut at the end of this year. Will the Government commit to funding these vital initiatives to end this rights-depriving restrictive practice?

[Baroness Merron (Lab)]

I am most grateful to the noble Baroness for her contribution and expertise in this area, which I know we all look to in your Lordships’ House, as well as outside it. The points she makes are quite right and important. On this particular case, which is very sad and concerning, I understand that the person is now living in the community with 24/7 care and has been since 2022. I saw at Rampton how people were being supported out into the community with the right support. On the example the noble Baroness gave, we are very keen to improve the uptake of advocacy services, and she will know that all these matters are being addressed in our discussions on the Mental Health Bill.

Mental Health Bill [HL]

Baroness Hollins Excerpts

Committee stage
Monday 24th February 2025 Lords Chamber

[Lord Stevens of Birmingham (CB)]

My Lords, building on many of the important points we have just heard, I will speak to Amendments 163 and 164 in my name. I thank the noble Baronesses, Lady Tyler of Enfield and Lady Neuberger, and the noble Lord, Lord Kamall, for their support for these two modest proposals, which are parsimoniously drafted but nevertheless potentially impactful if adopted.

The first amendment quite simply says that we will do away with “mañana, mañana” when it comes to implementing this Bill, which we have all spent so much time on and which the patients and advocates are so keen to see adopted, by putting a five-year backstop from the date on which the Bill becomes an Act through to commencement. Commencement of all its provisions must happen no later than five years after the Bill receives Royal Assent. The logic for that is that we all believe that, on balance, by the time the Bill has worked its way through Parliament, it ought to be an injection of improvement for mental health services, so why would we want to delay?

Of course, part of the answer is that there are some rate limiters, which are described elsewhere, including in the impact assessment. If we go through the impact assessment and say, “All right, what are the specific things that it suggests won’t be possible or won’t have got going until year 6 after Royal Assent?”, we will find it is a relatively modest number. For those who want to take a look, it is in table 1 of the impact assessment, at page 17. There are some changes to the second opinion doctor, to the CTOs, to the CTPs and so on, but both the pound note impact and the extra staffing at year 6 and beyond are incredibly modest compared with the overall size of mental health spending that we will incur. The incremental costs beyond year 5 are somewhere between £15 million and £25 million, on a budget that runs to billions. I believe that, in the real world, if we strain every sinew, it will be possible to get this thing done within five years.

There is another reason for thinking that it is useful to have a statutory backstop to implementation in the Act itself: the unfortunate tendency that we have seen in various other pieces of legislation that, when push comes to shove, the decision is made just to kick the can down the road a little further. I think it is fair to say that both principal parties have criticised the other for doing so with legislation that has passed. I think we had some measures in the health Act that the noble Lord, Lord Kamall, steered through on obesity and junk food. They never quite saw the light of day, despite Parliament deciding that they would be a good thing. The then Government were criticised for that. Likewise, we put the time in to create the Higher Education (Freedom of Speech) Act. I think the Opposition criticised the Government for delays in implementing it, despite the fact that Parliament had passed it. Of course, the cause célèbre is social care reform, where we have been happily kicking down the track legislation that has seen dither and delay for over two decades. That should not be the fate of this legislation. Therefore, this simple amendment would put in a backstop to save us from ourselves. Parliament is sovereign. If we want to get the job done, there is no reason to think that we cannot make these changes in less than the time it took this country to fight and win World War II. That is the rationale for Amendment 163.

Amendment 164 simply says that, during the intervening period while this Act is being implemented, it would be unreasonable to shrink the size of the slice of the pie going on mental health services, for all the reasons that we have heard throughout Committee. To make sure that there can be no argy-bargy on how the drafting is laid out, we have lifted the wording exactly from the health Act as it currently is on the statute book around the proportion incurred by NHS England and ICBs that, taken together, relates to mental health. It says that it

“must not fall as a share of their expenditure (taken together) on all health services”,

with a little kicker: to stop the Department of Health and Social Care marking its own homework, the National Audit Office will do a review after each year and provide a report that we can all scrutinise.

Here are some reasons why the Government should not object to this. First, it does not tie their hands on the overall sum of funding allocated to the National Health Service. That is a decision for the Executive and negotiated each year; nothing here would constrain the ability of the Government to increase or cut expenditure on the National Health Service. Nor would it constrain the ability of each integrated care board to make a judgment on its own priorities. It simply says that, in the round—taking the 42 ICBs and NHS England together—it would be unreasonable to think that the share of health service spending on mental health will go down at a time when there is an incredible gap between need and treatment, and when we are trying to implement this legislation.

Fortunately, just before Christmas the Secretary of State, Wes Streeting, signalled his support for the mental health investment standard. This is the opportunity to provide legislative cover for that very welcome announcement. It is possible that the current Secretary of State will not be the Secretary of State for the totality of this Parliament—nobody has a crystal ball. Looking out five years beyond Royal Assent, it is also possible that year 5 will be the first year of a new Parliament. So it is entirely reasonable for Parliament to support the Secretary of State’s intent by legislating in the way set out in Amendment 164, not least because there are some concerning signals from around the NHS that, for the first time since the mental health investment standard was introduced, it is possible that the share of funding on mental health will go down, not up, when taken in the round. We have not yet seen the figures, but perhaps the Minister can confirm whether that is correct. In any event, that simply serves to underline the acute importance of this safety net provision to ensure that the financial firepower is there to get this Act done.

[Baroness Hollins (CB)]

My Lords, I apologise for my absence from earlier debates in Committee. I will speak very briefly in support of these amendments. My noble friend said that we need to save ourselves from ourselves. Actually, we need to raise aspirations to change the culture of believing that it cannot be done and thinking that it will cost too much to take a more preventive approach, to care properly for people in the community and to achieve parity for mental health outcomes. These amendments are really important to try to achieve that, so I support them.

[Baroness Neuberger (CB)]

My Lords, I will speak very briefly in support of Amendments 163 and 164, to which I have added my name, and particularly about the length of time, the five years.

We first started talking about the reforms to the mental health legislation eight years ago, when we set up the review of the legislation under Sir Simon Wessely, and I was the vice-chair. It reported in 2018—seven years ago—and it was not even a very radical rethink of our mental health legislation. Yes, it will make a lot of difference to a lot of people—service users are very keen for this to come about, and they certainly do not want to wait longer than five years to see all the measures come into force—but this is relatively gentle stuff. At some stage we will need a much more radical rethink of our mental health legislation. Five years is quite a long time, so I rather hope the Minister can give us some comfort by saying that most of it will be done in two years, or perhaps three years at the outside.

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[Baroness Hollins (CB)]

In adding my support to these amendments, I welcome particularly the contribution from the noble Baroness, Lady Ramsey.

This debate has emphasised why the pathway of care, from the community through to any kind of hospital admission and discharge, must be considered as a whole. It is not okay to separate bits off. That is why the amendments are so important: unless we put provision in place to make sure that, when admission is necessary, it is timely and to a place which has the skills to provide the therapeutic care that people require, detention and admission will in fact be longer and costlier. We cannot contemplate making legislation that does not take account of the whole patient pathway.

[Lord Stevens of Birmingham (CB)]

I have been inspired by the previous two contributions. I will briefly pick up a point that the noble Baroness, Lady Tyler, made about Amendment 134 on the availability of community services, particularly psychiatrists. I think the Minister referred to the longer training times for psychiatrists and other mental health professionals as one of the rate-limiting factors that would affect the speed with which the measures in the Bill could be implemented.

I have a request for the Minister. It is quite hard to tease out from the impact assessment what the Government think the incremental requirements for psychiatrists will be, year by year, over the implementation period. In fact, slightly perversely, they use mixed currency: the Minister responded, rightly, to Amendment 163 by saying, I think, that there was a requirement for 400 additional psychiatrists for the second opinion service; but when you look at the table in the impact assessment, it turns out that that is a headcount number driven by a number that is not a whole-time equivalent. However, for all the rest of the workforce, a whole-time equivalent number appears to be shown.

It would be good to nail down what the incremental requirement will be for psychiatrists, year by year and on a whole-time equivalent basis, so that between now and Report, colleagues can consider what the ramifications of that might be for a backstop on implementation. If that incremental requirement could be juxtaposed with what the Government think the organic increase will be in the number of psychiatrists over that period anyway, driven by the already published NHS workforce plan, that would be supremely helpful.

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[Baroness Barker (LD)]

My Lords, I will try to draw together some of the strands that we have been discussing in this debate. When the Minister responds, please will she share with the Committee the department’s and the Government’s thoughts on workforce planning and the modelling they use for the prediction of demand?

As I listened to my noble friend Lady Parminter eloquently introduce her amendment, it brought to mind friends of mine. They have been in the position where their child was diagnosed with a very severe eating disorder, but they were told, “You are not sufficiently ill for anything to happen”. From that stage, nothing happened. If it were a physical illness, there would be some kind of process—although maybe not a care pathway. I am sorry, but I am one of those people who is very cynical about the use of the phrase “care pathway”; it is very overused throughout the whole of health, and particularly in mental health. People are diagnosed and then are just left, until they become so ill that they are in crisis and it is impossible to ignore them. We have seen the trends in the number of young people with eating disorders, which my noble friend Lady Parminter mentioned. What is the department doing to forecast the demand for specialists of that nature in future?

I want also to return to some of the conversations and debates that were sparked by the noble Lord, Lord Davies of Brixton. We know that the police are going to withdraw from being the first responders when people are in crisis. What modelling are the Government doing in terms of the community provision that is needed to deal with those people—who will still be in crisis? They are not going to stop having crises; in fact, they are probably more likely to show up in in hospitals than ever before, because that is where people go in the middle of the night when they have a crisis.

This is the sort of argument that the noble Baroness, Lady Tyler of Enfield, was trying to get to in her discussion of having a mental health commissioner. Who will be the person who is in a position to take the Government to task for their planning and preparation for demands on the health service in the future? That is the kind of thing that we are trying to get to, and which all of us, in various different ways, have been trying to get to all afternoon.

[Baroness Hollins (CB)]

Can I just say that I did not talk about a “care pathway”? Perhaps I should have said the “patient journey”, but I was talking about the patient pathway—the actual experience of the person—which is not separated in their life.

[Lord Kamall (Con)]

My Lords, I will be brief on this one. I thank the noble Baroness, Lady Tyler, for this amendment and thank all noble Lords, who made very valid points.

Clearly, this is another sensible proposal, highlighting as it does the importance of making sure that the ICBs commission sufficient mental health services in the community to meet the demand for them. As the noble Baroness, Lady Barker, said, where will people go in the middle of the night? I know that we will come back to some of these issues when we discuss the group on mental well-being but I thought it was important that those points were raised now.

The Committee may remember that this was the subject of Amendment 139 in the name of my noble friend Lord Howe, who spoke to it on the second day in Committee. The main difference between those amendments is, I think, that the noble Baroness, Lady Tyler, wishes to get ICBs focused on this very important task as soon as the Bill becomes law—and I agree with her intention on that. My only fear around the wording as it is currently drafted—I recognise that it is a probing amendment—is that

“insofar as is reasonably practical”

may provide an excuse, or, as we say, the proverbial long grass into which this duty could be conveniently kicked. I look forward to the Minister’s response.

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[Earl Howe (Con)]

My Lords, I beg to move Amendment 146 standing in my name and that of my noble friend Lord Kamall. On the previous group of amendments, I cited the experience of a child held on an adult mental health ward being subject to restraint, where undue force was applied by the staff involved, causing unnecessary pain and distress to the patient.

In fact, the incidence of restraint being used on children being treated in mental health settings—and, indeed, general hospitals—is alarmingly high. This fact was recognised in the Mental Health Units (Use of Force) Act 2018, which came into effect in 2022. However, despite the provisions of that Act, not only has there been no drop in the number of restrictive interventions that children are subject to but there has been an increase.

In 2023-24, a total of 84,626 restrictive interventions were carried out on children, which is a 51% increase on the year before. That is the highest number of restrictive interventions recorded since figures were made available in 2019, despite what appears to be a drop in the number children being treated in mental health units. It is not only that restraint is being applied in these cases; all too often, because there is a physical struggle involved in the process of restraining someone, that patient ends up with an injury.

What lies at the root of this? Blooming Change believes that restraint amounting to abuse is entrenched in the system. Unfortunately, that rather depressing view was borne out last August by the Independent newspaper, which reported that children in a mental health in-patient unit in Coventry were captured on CCTV

“being dragged across the floor”

by the staff. There surely has to be something here about the need for staff in all mental health settings to receive training in the different techniques for de-escalating a crisis, with physical restraint being regarded as a last resort.

In fact, with the two very welcome principles set out in Clause 1, “least restriction” and “therapeutic benefit”, the training of staff in appropriate techniques of control will, one hopes, become an even more important priority than before. I hope the Minister can let me have some reassurance on this very troubling set of issues. I beg to move.

[Baroness Hollins (CB)]

My Lords, I declare my interest and my experience as a retired psychiatrist, working for the majority of my career with people with learning disabilities and autistic people.

In 2019, the then Secretary of State for Health asked me to oversee an important review of the use of another restrictive intervention, long-term segregation, known as LTS, for people with learning disabilities and autistic people. The Government published the oversight panel’s report of that review simultaneously with their quite positive response to its recommendations in November 2023.

Amendments 155 and 156 in this group address critical issues highlighted in the report about the use of LTS and the measures needed to eliminate its use for people detained under mental health legislation. The amendments aim to improve oversight and accountability in its use, while pointing to the urgent need for appropriate community services to prevent delayed discharges. The proposed changes are not merely administrative; they are a necessary response to urgent human rights questions raised by the use of LTS, and indeed these other restrictive interventions covered by the noble Earl, Lord Howe, whose amendment I support.

The report, aptly titled My Heart Breaks, found that the mental and physical health of children and young people and adults detained in long-term segregation deteriorates as a direct consequence of enforced isolation. In medicine, we call this iatrogenic harm, and it is unacceptable. LTS is often used in association with other restrictive practices. There is substantial research evidence pointing to the harms of such enforced social isolation, including in conditions of solitary confinement. Nor does it have therapeutic benefit. Oversight panel members considered that LTS should actually be renamed “solitary confinement” to avoid the normalisation of the practice in healthcare settings. Currently, rather less clear terminology is used, perhaps to disguise what is really happening in practice.

It is interesting to note that not all psychiatric hospitals have rooms in which to detain people. The type of accommodation used is sometimes totally unacceptable, with people being detained in rooms with no natural light, with a mattress on the floor and no toilet facilities.

Amendment 155 would require notification of LTS to the CQC within 72 hours of its commencement. It would require that the CQC must initiate an investigation if LTS was used for more than 15 days within any 30-day period, and if it were used for a person under the age of 18, or for a disabled person whose condition would be exacerbated by its use—for example, an already psychologically traumatised person who would be further traumatised by the sensory and social deprivation caused by its use, which is probably most people.

The amendment would require that the code of practice introduced minimum standards for LTS, including access to natural light, outdoor space and meaningful human contact. As I am sure most noble Lords would agree, these are basic necessities for dignity and well-being. Psychiatric hospitals still using LTS would be required to appoint a responsible officer to review and report on its use to the CQC. They would also be required to comply with recommendations from independent care (education) and treatment reviews, known as ICETRs, as they relate to LTS.

Amendment 156 seeks to ensure that therapeutic alternatives to LTS have been properly considered by requiring independently chaired reviews for any person detained in LTS. Since the end of the Department of Health’s programme of ICETRs in 2023, which reviewed 191 cases between 2020 and 2023, the CQC was commissioned to restart the programme. The new programme includes that the independent chairs must follow up to see whether the recommendations have been implemented, but funding has been committed only to the end of this current year, while LTS continues. These reviews must be kept in place until the use of LTS comes to an end, or for as long as it is in existence, so the amendment would require ICETRs to be continued, and it outlines the role, responsibilities and authority of the independent reviewer. I hope the Minister will be able to assure the Committee that the continuation of these independent reviews will be funded.

By limiting the duration of LTS, mandating independent oversight and requiring therapeutic alternatives, we could protect people’s rights and lay the groundwork for effective rehabilitation and reintegration back into their communities. Meeting minimum standards and reclassifying such segregation as “solitary confinement” would rightly underscore its appalling and often inhumane nature. I know many clinicians dislike that term because it is equated with punishment, but it describes the conditions that we sometimes saw.

The excuse is often given that LTS is the last resort for a person, but in fact it is usually the first resort and the first response, because no appropriate care and support have been provided. I have seen systemic failures that are leaving individuals in restrictive settings due to insufficient community-based support. While commissioners and clinicians often act with good intentions, they lack the co-ordination, resources and expertise needed to deliver the care that is needed to keep people safe.

The amendments simply aim to ensure therapeutic care close to home. They require that, by monitoring the continuing use of LTS and understanding the barriers to eliminating its use, the CQC would be able to identify the themes, trends and changes that are taking place over time in the use of this restrictive intervention. I urge the Minister to support the amendments.

[Baroness Ramsey of Wall Heath (Lab)]

My Lords, I support Amendments 155 and 156, to which I have added my name. If they were approved, the Care Quality Commission would be required to ensure independent reviews of the suitability of continued segregation, with a particular focus on the potential for community support to be preferable. The amendments would also increase transparency and set minimum standards, both of which I am sure noble Lords will wish to support.

When I chaired, from 2017 to 2020, NHS England’s transforming care steering group for children and young people with learning disabilities, autism or mental health problems and challenging behaviour, I heard heartbreaking testimony from parents whose teenage and young adult children were segregated for weeks and months on end, as referred to by the noble Baroness, Lady Hollins. For example, I visited a non-NHS provider outside London that had kept one young adult woman—whose story appeared in social media at the time, noble Lords may remember—in segregation, in a room with no window and no natural light, and passed food to her through a hatch. She was completely alone.

As I and other noble Lords have already argued, investment in the right type of community support is the only humane way forward. To ensure that proper use is made of this investment, we should send out a clear message that we expect community services to be used wherever possible, rather than segregation. The way to do this is for the Care Quality Commission to oversee a process of independent review in any case of segregation of a young person under 18, anyone with learning disabilities or autism, or anyone whose segregation exceeds 15 days.

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For these reasons, I hope the noble Lords will feel able not to press their amendments.

[Baroness Hollins (CB)]

There seemed to be an assumption that long-term segregation would continue and that perhaps ICETRs are not effective, but one thing that emerges from an independently chaired review is some learning about the barriers in place and the reasons why LTS is being used, rather than more therapeutic options. That is the reason for this kind of oversight being necessary. It is not necessarily that the ICETR itself will lead to recommendations being implemented; in my report, we found that the recommendations were not being followed—they were made and then not followed through. There needs to be much more effort to try to learn from what is happening and begin to change the culture of LTS as an okay response to somebody’s distress.

[Baroness Merron (Lab)]

I understand that point, and the noble Baroness makes it very well. I simply refer her to the points that I made about needing to look at evidence, the outcomes and the value of those reviews, and whether that is the right approach for everyone. I take on board her point, but my comments probably tell the Committee that we feel that there is more work to be done in this area.

Health and Adult Social Care Reform

Baroness Hollins Excerpts

Tuesday 7th January 2025 Lords Chamber

[Baroness Merron (Lab)]

Both the points that the noble Lord makes are very welcome and shine a light on the need to be more flexible in the range of services and care provided. It should not be just an either/or. People have intermediate stages. Some of the issues about discharge are about having a position in the middle, which is more about rehabilitation, and having the things in place to allow people perhaps to return home or to some other setting.

There is also the point about having a range of settings. Currently, the offer is perhaps too restrictive, although not in all places, as there are some excellent examples. We must be much more creative in the kind of offer that is available and in the training of care workers, not just for the service that they offer to patients, which is important, but for their professionalisation and their morale in their jobs.

[Baroness Hollins (CB)]

My Lords, why is there no mention of mental health in the Statement? What happened to parity, I wonder? For example, 12,400 hospital patients a day are well enough to be discharged. I presume that this does not include the 1,500 or so autistic people and people with learning disabilities who are waiting to be discharged from psychiatric hospitals but for whom there is no social care? Community diagnostic centres are mentioned but there is nothing about the need for 24-hour community drop-in centres for citizens who have mental health problems. Social care costs for elderly people may be expected to double, but what about the increasing costs of care for disabled adults of working age?

[Baroness Merron (Lab)]

The noble Baroness makes very real and important points. Some of the points in the Statement cover mental and physical health but, if I might be honest about the situation, this is only one of the things that we are putting forward. As I said at the beginning of this Statement, how I wish that we could deal with everything immediately. It is not possible. This is just the first stage in the journey that we are on. I hope that the noble Baroness is reassured by the direction that we are taking, the commitments and the work that we have already done on mental health. The Committee stage of the Mental Health Bill next week will also be a very significant step forward. I absolutely accept that there is so much more to do, and we will be getting through that.

Mental Health Bill [HL]

Baroness Hollins Excerpts

2nd reading
Monday 25th November 2024 Lords Chamber

[Baroness Hollins (CB)]

My Lords, it is a pleasure to follow the noble Baroness. I remind the House that I worked clinically as a psychiatrist for about 35 years and had been a consultant for two years by the time that the 1983 Act was introduced. I argued then, as now, that mental handicap, as it was called, had no place in legislation—although others disagreed. Profound changes in societal attitudes, alongside advancements in the understanding and treatment of mental illness, have occurred during my career. I agree with the noble Baroness, Lady Barker, and my noble friend Lady Murphy that fusion legislation really should have been considered.

There is no minimum age limit in the Mental Health Act, meaning that its provisions apply to children and young people as well as adults. The Joint Committee, of which I was a member, recognised their unique needs, saying that this is

“a crucial opportunity for the Government to strengthen the rights and protections for children and young people”.

We must never forget that the mental health of babies, children and young people is fundamental to the mental health of the adult population, and that we cannot legislate for the treatment of serious mental disorder without taking mental health seriously from the very beginning of each person’s life.

Psychiatry’s past has included some harmful and forced interventions, rather than the preventive approaches, early intervention and evidence-based treatments that are so needed. The Bill aims to safeguard dignity and autonomy, and ensure best practices for all, including people with learning disabilities and autistic people. A major current concern for me is that there are nearly 2,000 people with a learning disability and autistic people in psychiatric hospitals. Usually, that is because of a lack of individually tailored support and housing—they have an average stay of five years—and because of the shortage of effective treatment options in the community and lack of training for the wider mental health workforce.

My Heart Breaks, the report of a review that I chaired and which was published by the Government last year, shed light on the harrowing realities faced by many of the 100 or so of those 2,000 in hospital who are detained in long-term segregation at any one time. The systemic failures we found reflected a troubling overreliance on detention as a substitute for meaningful care, despite such detentions often lacking therapeutic goals, a pattern that unfortunately affects other patient groups as well, including those with personality disorders.

Historically, policy and practice have overlooked complex intersectional vulnerabilities, including learning disability, autism, gender, race, poverty and physical health issues. Marginalised groups, especially people from racialised communities, are detained more often. Trauma histories may be compounded by the excessive use of medication and restrictive practices which contain people, with an eye to safety, but disempower and just do not support recovery. People need better-adapted psychological therapies but are less likely to access them, and poorly co-ordinated discharge processes further trap individuals in a dysfunctional system. This violates people’s human rights and ethical care standards.

As a long-time advocate for people with learning disabilities and autistic people, for me, one of the Bill’s most significant reforms is the removal of learning disability and autism as stand-alone grounds for detention under Section 3, part 2. This change is complemented by new duties on health and care bodies to provide the community-based support and therapeutic approaches needed to prevent unnecessary detentions. But legislation alone will not provide better care; the right people in the right place with the right skills are needed. So the Bill introduces mandatory care, education and treatment reviews, which aim to create personalised care plans and facilitate timely discharges. Additionally, dynamic support registers are intended to track those at risk of crisis, allowing for early intervention before issues escalate. Advance choice documents could also be valuable for choice, safety and care.

The National Autistic Society, Mencap and several other charities have welcomed the Mental Health Bill as a step toward safeguarding the rights of individuals with learning disabilities and autistic people. All stress the need for robust support systems, including housing and social care. These are essential to prevent unnecessary admissions, emphasising that the Bill’s success depends on effective implementation, accountability and substantial investment in community services. They also request a new action plan to replace the Building the Right Support action plan. This is particularly urgent, given that targets to reduce in-patient numbers of people with a learning disability and autistic people have been repeatedly missed over the last decade, and only one in five integrated care systems have currently met the March 2024 target for reduction of in-patient numbers.

Can the Minister confirm whether a plan such as that being requested will indeed be co-produced and implemented with the help of people with lived experience, families, campaigners and relevant bodies, alongside the implementation of this legislation? Both the Royal College of Psychiatrists and the BPS have cautioned against removing autism and learning disabilities as stand-alone criteria unless there are substantial improvements, warning that this could divert unsupported individuals into emergency services or the criminal justice system. Easy to say, better not to do it—but we must use this as a lever to change the culture of care and support for these groups of people.

We do not want to risk criminalising people’s mental health needs, and we do not want to disproportionately impact already marginalised groups. I ask the Minister, what assurances can Government provide to ensure adequate funding to deliver minimum safe services in the community, such as early prevention measures, rapid response teams, crash pads and effective therapeutic approaches in the community? Indeed, could these alternatives be mandated?

Compulsory detention and treatment of individuals with personality disorders under Part 2 of the Mental Health Act is another issue. Personality disorders stem from relational difficulties and cannot be effectively treated in restrictive in-patient settings. Research shows that admissions without structured, evidence-based psychological interventions provide no benefits and can indeed worsen symptoms.

Why is Section 117 aftercare limited to Section 3? Social and health care should be integrated for all patients based on need, not the section they were detained under. For example, a financial crisis causing suicidal thoughts in a farmer might lead to a Section 2, when a social prescription might have been effective. After assessment, they will return to the same situation without appropriate support, such as legal or financial advice to resolve the crisis.

The new Mental Health Bill gives us an opportunity to address the stigma that shaped policy in the 1980s and create a legal framework which keeps pace with scientific advancements. We need to reframe our focus from risk management to supporting accessible, evidence-based community interventions, ensuring that care aligns with ethical and therapeutic principles and prioritises a rights-based, person-centred approach.

Our actions now will shape mental health care for the 21st century. Let us enact compassionate and progressive reforms that future generations will respect.

Palliative and End-of-life Care: Funding

Baroness Hollins Excerpts

Wednesday 4th September 2024 Lords Chamber

[Baroness Merron (Lab)]

The noble Baroness is quite right to raise this, and I can give her that assurance. She raises the point about identification of people with specific needs. I am interested to see that there are some very good examples of local good practice—for example, in Dorset, where they have proactively gone out to identify who needs palliative and end-of-life care. By so doing, they have raised the percentage of the local population who should be receiving it. That is a model we will want to look at. With regard to those who have particular needs, as the noble Baroness describes, I think that model will be helpful too.

[Baroness Hollins (CB)]

My Lords, the Minister has rightly pointed to the growing need for excellent palliative care close to home, and I am glad of that, but I wonder whether she is aware of the Hospice UK report pointing to the number of redundancies occurring across the sector. In the context of the 2022 Act, which required the NHS to commission adequate NHS care, this seems to be rather urgent, not just to provide good care for people but to reduce the impact on the acute hospital sector of not providing palliative care.

[Baroness Merron (Lab)]

The noble Baroness is right in her observations, and we certainly recognise that times are difficult, particularly for many voluntary and charitable organisations including hospices, for example, due to the increased cost of living. We are working alongside key partners and NHS England to proactively engage with stakeholders, including the voluntary sector and independent hospices, because we want to understand the issues they face and to seek solutions to them.

Immunisation: Children

Baroness Hollins Excerpts

Wednesday 8th May 2024 Lords Chamber

[Lord Markham (Con)]

It really is about having the whole toolkit. Clearly, it is about making sure that we are using communications in 15 different languages. It is about the outreach groups and, particularly, the catch-up programmes. We have been doing one for 17 to 25 year-olds for polio and MMR. It is about all those strategies and the pop-up clinics, so that it is very easy to catch people in places that are convenient for them.

[Baroness Hollins (CB)]

Does the Minister agree that the anti-vax sentiment is a powerful deterrent with some of the misinformation on social media? Is there anything more that can be done to try to counter that misinformation?

NHS: Long-term Sustainability

Baroness Hollins Excerpts

Thursday 18th April 2024 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I qualified as a doctor 55 years ago next month, across the river at St Thomas’. Much has changed since then—some good, some bad. I applaud my noble friend Lord Patel, and I agreed with his powerful opening speech.

As well as personal suffering, there is huge economic cost when the nation becomes less healthy. As we have heard, there are more than 2.6 million working-age people out of the labour market due to long-term sickness, at huge cost to the Treasury, with additional welfare and healthcare support and lost tax revenue. Yes, the NHS needs more investment, but it is not just about that; it is about changing the health and social care offer, improving access and equality of access, and changing the balance between hospital care and care in the community.

Italy closed its public psychiatric hospitals successfully, investing in 24/7 community provision. The Royal College of Psychiatrists asked that the next Government commit to a new health infrastructure plan for mental health, with one aim of improving the therapeutic environment of mental health and learning disability and autism in-patient settings, but it also hopes for real investment and the expansion of psychological therapies in early intervention and in public mental health.

The impact of negative press about the NHS and about social care has an impact on the morale and mental health of staff and the confidence of patients. This affects staff retention. A recent survey of 3,154 doctors by the General Medical Council found that 13% of respondents said they were very likely to move abroad to practise medicine in the next 12 months. A further one in three said it is very likely that they will move abroad at some time. This points to four key areas for improving retention: workplace conditions, pay, career structures and the perceived ability of our healthcare system to meet patient care needs.

Healthcare is a different and more complex service than when the NHS was founded in 1948. Individualised medicine is here to stay. More treatments are available, some very sophisticated and expensive. There is more bureaucracy, and we live in a more litigious world. The demands and expectations of the public have increased.

I read with joy an NHS pamphlet from 1948 which outlined to the public what they could expect from the NHS and, importantly, what the NHS could expect from them. I will quote a few gems from it. In my first quote, do notice mention of mental health:

“You will … be entitled to all forms of treatment in general and special hospitals, whether as an in-patient or as an out-patient. These include, for instance, maternity care, sanatorium treatment, care of mental health, and all surgical operations”.


About dental care, it says:

“You need no application form. Just call, by appointment, on the dentist of your choice when you need him … All necessary fillings and dentures will be supplied without fee, but if you want anything specially expensive … you will pay the … cost yourself”.


On maternity services, it says:

“It will be the doctor’s responsibility, with a midwife, to give all proper care and (if he considers it necessary or is called in by the midwife) to be present at the confinement”.


How wonderful it sounds. Perhaps we need an NHS pamphlet for 2024, to relaunch a new contract between the public and the NHS about what can be expected on both sides. I suggest that, as well as maternity care, we should have palliative care added to the 2024 pamphlet.

Central to solving the problems facing the NHS will be transforming social care from a safety net for people in vulnerable circumstances to a relational system that enables people to flourish. The endless gatekeeping, signposting and managing demand within the NHS all contribute to the increased demand for and greater complexity of social care. The bureaucracy affects unpaid family carers too, as I know only too well. Kate Garraway recently said about her experience of being a carer:

“If I have any regrets, it’s every single minute that I didn’t spend holding his hand because I had to go and write an email, make a phone call, fight the system that should be there to catch you when you fall but feels when you’re going through it like it’s there to catch you out”.


We need long-term thinking, long-term funding and more consistency, so that everyone—staff and patients—knows what to expect.

Care needs to move away from glamorous, expensive, interventionist hospital care and spend more in the community. If this does not happen, more expensive hospitals will need to be built to manage people’s acute needs that could have been better prevented or better managed.

In-patient Mental Health Care: Learning Disabilities and Autism

Baroness Hollins Excerpts

Wednesday 13th December 2023 Lords Chamber

Asked by

[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.

Mental Health: Children and Young People

Baroness Hollins Excerpts

Thursday 23rd November 2023 Lords Chamber

[Baroness Hollins (CB)]

My Lords, it is my honour to follow my noble and learned friend Lady Hale, whose eminent career has included, of course, serving as President of the Supreme Court of the United Kingdom, and being the first woman appointed President of the Supreme Court.

We were brought up in different parts of the West Riding of Yorkshire, and both ended up being head girl in our different grammar schools—Yorkshire grit. I am particularly proud to have presented my noble and learned friend with her honorary fellowship of the Royal College of Psychiatrists. Noble Lords will be grateful to my noble and learned friend for explaining why her membership had to cease in 2009. This of course included a period as a non-permanent judge at the Court of Final Appeal in Hong Kong, where I am sure her wisdom benefited their system greatly.

Noble Lords will also recall when, in September 2019, as President of the Supreme Court of the United Kingdom, the noble and learned Baroness, Lady Hale, found Boris Johnson’s prorogation of Parliament to be unlawful, thus terminating the suspension of Parliament.

I congratulate my noble and learned friend on her remarkable maiden speech, of no less interest given the time since her introduction. It is so fitting that it should be about children’s mental health. I also congratulate the noble Earl, Lord Russell, for speaking so honestly, openly and movingly about the subject of children’s mental health.

I declare my interests and experience. I trained as a child and family psychiatrist and later specialised in the psychiatry of learning disability. I have served as President of the Royal College of Psychiatrists. His Majesty’s Government has just published my report My Heart Breaks—Solitary Confinement in Hospital Has No Therapeutic Benefit for People with a Learning Disability and Autistic People. We will be debating this in the topical debate to follow. I have also devoted several years to addressing child protection in families and institutions, and to considering the long-term mental health consequences of child abuse.

Why is this all so important? Childhood is a period of extraordinary potential. If we get it right, we are investing in the whole of society’s future. Pregnancy and the first five years of a child’s life are the time when the foundations of healthy development are laid. Our relationship patterns are formed in the first few years of our lives, which also impacts on our future mental health. We know that adverse childhood experiences—ACEs—are key predictors of poor physical and mental health across the lifespan, and that poverty increases the risk that ACEs will occur during childhood. Half of all mental health problems present the first time before the age of 14, which is why prevention and population health really matter.

There are rising rates of referral to mental health services. These services are overwhelmed. Social care and school staff are feeling overstretched. We know that burnout is higher in those who work with children. There are rising rates of self-harm and suicide, particularly in teenage girls. Families are struggling with the cost of living crisis. To understand the current state of children’s mental health, I suggest we need to look at their relational and physical environments. Let us think about the post-pandemic world that children are growing up in right now. What is it like for them at home, at school, online, in their local communities and in the wider world?

Thinking about a child’s home environment, we need to acknowledge parents’ own significant social and mental health needs. Many are anxious and stressed; they are worried about money, their jobs, their families and the world. But when parents feel calm, safe and connected, their emotional availability to their children increases. This enables them to listen to their children and recognise their needs and helps them develop their emotional resilience and mental health for life. Let us not underestimate the power of accompanying parents in the tough and important journey of parenthood.

Thinking about a child’s school environment, we need to develop a culture of nurture as the foundation for learning. Nurture means creating a safe environment in which all behaviours are understood as a communication of underlying needs. When we realise this, we can transform a child’s experience in school and find ways of unlocking their love of learning and forming friendships.

Thinking of a child’s online environment, we see that it is one of the biggest current dangers to a child’s mental health. The Online Safety Act will help, but it requires society to support parents and schools in making a radical change to the current status quo. Children’s friendships and the social media environment in which they meet have a toxic potential, with some children never able to switch off. The physical environment, including housing, school and transport, may all contribute to our mental health, and we often overlook chemical factors—I am thinking about a healthy diet and reducing the impact of pollution and climate change.

We need to invest time and resources in building a population health approach that addresses the huge impact of health inequalities and the social determinants of health on the mental health of children. This requires a local, skilled workforce in population and public health too. We need an attachment, family-based approach that supports early relationships and secure attachments between parents and their babies. We need universally available family hubs and local community settings where parents can meet and share the ups and downs of family life and relationships.

We need early diagnosis for autism. Too many authorities are delaying assessment of autism at the moment. It is a mistake. It is not cost-effective. We need a skilled, supported and well-paid workforce for children, including early years childcare workers, midwives and health visitors, pre-school, primary school and secondary school teachers—all the practitioners who support children’s health and development in our communities and education settings. I agree with the noble Earl that we need more psychotherapy and more family therapy.

Focus on waiting lists for treatment misses the point. I suggest that we need less focus on mental health problems and more on emotional intelligence and resilience; more on understanding that it is normal to have strong feelings of sadness, grief and anger; more in relation to life and being human; and perhaps less focus on isolation and loneliness and more focus on human connection. A child’s emotional well-being and mental health cannot be considered, however, in isolation from their family’s health and well-being, and support for parents’ mental health must also be prioritised.

For those with milder problems, respectful, relational, family, school and community-based care is more effective than medicalising individuals. Mental health needs in schools can make a huge difference, and they should be there in every school. There are some excellent school-based initiatives. For example, nurture groups and whole-school nurture programmes are being planned across Surrey next year. The charity Place2Be offers one-to-one therapies in several hundred primary schools. I declare an interest in that feelings groups in mainstream primary schools in South Yorkshire and in special schools are transforming children’s lives, using resources provided by Books Beyond Words, a charity that I founded and chair.

CAMH services are needed to help children who are more seriously unwell. There is a move away from in-patient services to services being able to offer intensive community treatment, which I welcome. They need to offer long-term continuity of care, working closely with primary care and all agencies, and to support children at home or close to home. If required, in-patient admissions should be short, focused and timely to help prevent any problems developing further.

I have been told about a young teenage girl, whom I shall call Emma. She started struggling with her mental health during her transition to secondary school; such a transition is a very difficult time. Her way of coping with difficult feelings was to stop eating. She lost weight rapidly. Despite attempts to treat her at home, she was admitted to a psychiatric ward against her will for refeeding. On the ward, she developed self-harming behaviours, in part influenced by her peers’ self-harming behaviours around her. She was then diagnosed as autistic; it was a late diagnosis.

After five months, Emma’s weight improved and an intensive community team agreed to support her within the hospital, including in a small school and a therapy group as well as during her transition back to the community. The community team supported her parents in their fight for her place at school to be restored. She has developed hobbies again and the whole trajectory of her life has been altered. Teams such as this, which can help children and young people with complex needs to recover, must be able to work in a thoughtful and flexible way. It takes commitment and perseverance from the team members, who need to provide powerful advocacy for both the child or young people and their family. Could more have been done to keep Emma at home?

In my work looking at the reasons for people with learning disabilities and autistic people being detained in long-term segregation and the reasons for delayed discharges, risk aversion in the community seemed to be a key factor. At a round table yesterday, Dr Mezzina, a leading psychiatrist in the acclaimed mental health services in Trieste, Italy, challenged our concept of risk and suggested that institutionalisation is the main risk in mental health services. He questioned why we admit so many children and young people and why we do not have an open-door policy.

What is the way forward? A number of key initiatives would make a difference, including investing in early years services, developing support hubs for young families and schools-based interventions for at-risk individuals. We also need a robust workforce plan to address serious recruitment and retention issues; that workforce must have competencies in working with children and young people with learning disabilities and autistic children.

This Monday was World Children’s Day. The United Nations annual day of action for children, by children, it marks the adoption of the Convention on the Rights of the Child in 1989 and attends to the social determinants of health and well-being, including poverty. Let us look forward to the day when every child can have a happy childhood, and let us remember that there is no health without mental health.

Learning Disabilities and Autism: Solitary Confinement in Hospital

Baroness Hollins Excerpts

Thursday 23rd November 2023 Lords Chamber

Asked by

[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.