Learning Disabilities and Autism: Solitary Confinement in Hospital

Baroness Watkins of Tavistock Excerpts

Thursday 23rd November 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as a NED at NHS England and as a qualified nurse. I commend my noble friend Lady Hollins on her thorough report on the current use of solitary confinement for autistic people and people with learning disabilities using in-patient hospital services. I remind people that the noble Lord, Lord Crisp, has written a book, Health is Made at Home, which argues that hospital should be for therapeutic intervention for short periods. This report clearly shows that that is not so for this cohort of patients.

The report raises key issues around the use and overuse of solitary confinement methods and outlines important recommendations for the improvement of care. However, rather than making my heart break, this report made me angry in the same way that another report, Sans Everything—that report was about long-term care in mental hospitals—did 50 years ago. We need to turn the anger and broken hearts into positive action.

I wholeheartedly support the concept that there should be no long-term use of solitary confinement for autistic people and people with a learning disability. However, I wish to highlight the need for discussion to consider in more detail other patients’ safety and well-being when people are in relatively confined environments. In addition, nursing staff are sometimes put at risk in understaffed, outdated clinical environments when, due to an acute autistic episode or meltdown, an individual patient resorts to violence that is difficult to cope with, often because of the reasons just given about inappropriate responses. Such circumstances can be distressing for other patients and staff.

Additionally, this debate should acknowledge the challenges that staff face due to high patient-staff ratios, which make truly individualised, person-centred care difficult to deliver in many circumstances. Agency nursing is used because it pays better but such nurses often do not know the individuals well enough to know how best to respond.

I state my full support for recommendation 12 of the report. Funding is needed to deliver person-centred interventions in order to reduce the use of solitary confinement vastly. This needs to be accompanied by funding to support staff’s continued education, training and professional development.

Although I agree that it is necessary to have formal recording and notifying practices in instances where solitary confinement has been used, I question the feasibility and staff resource requirements in the details of recommendation 6, in particular reporting immediately to the CQC. An alternative proposal could be that notifications to ICBs should be made if solitary confinement measures have been used for an individual in two or more instances in a set period, for example for more than 12 hours on two occasions within 10 days. However, reports should also be made to the boards that are responsible for the delivery of care.

Recommendation 7, which recommends that clinical contracts be agreed before admission, may not always be achievable in a situation of acute crisis. Therefore, I suggest that it should be clinical policy that contracts are agreed within five days of admission as a maximum and that pre-admission contracts are always considered best practice.

Finally, with regard to recommendation 8, which aims to secure family visiting rights for autistic people in solitary confinement, we also need to secure the rights for the autistic person to refuse such visits. Family relations can be very complex and, in some situations, abusive; therefore, in extremely rare situations, unwanted visits can lead to increased distress among autistic people and people with a learning disability. However, I must stress that I am a firm advocate of the visiting options in recommendation 8, which would also require people being cared for much closer to home than many are at the moment in order to make regular contact achievable. Too many people are sent too far from home, often to private health facilities, with possibly 10 different contractors for just one or two patients. This makes it difficult to maintain good relationships between providers and purchasers and to oversee the quality of care that is being delivered.

I ask the Minister: do His Majesty’s Government acknowledge that, although some of the recommendations may not be achievable without changes to the Mental Health Act 1983, many of them could be with additional financial investment to pilot programmes based on the suggestions in the report and to provide training for staff in order to ensure that they can safely deal with de-escalating crisis situations to reduce significantly the use of solitary confinement? We owe autistic people and those with learning difficulties more rapid change to the situation so ably outlined in this report. We would not stand for delay in introducing contemporary practice for people suffering from cancer or diabetes.