In-patient Mental Health Care: Learning Disabilities and Autism

Baroness Jolly Excerpts

Wednesday 13th December 2023 Lords Chamber

[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?