Assessment and Treatment Units: Vulnerable People

Caroline Dinenage Excerpts

Tuesday 6th November 2018 Commons Chamber

[Barbara Keeley (Worsley and Eccles South) (Lab)]

(Urgent Question): To ask the Secretary of State for Health and Social Care to make a statement on the long-term seclusion and deaths of autistic people and people with learning disabilities in assessment and treatment units.

[The Minister for Care (Caroline Dinenage)]

I want to address the care that the NHS and social care system gives to some of the most vulnerable in our society. The millions of people who work in the NHS and social care do so every day with compassion and commitment to care for us all, but sometimes the system gets in the way, and when we see that, it is our task and our duty to change it. That is the case with the care given to people with some of the most significant and complex needs, such as those with learning disabilities and autism who are in-patients in assessment and treatment units and other mental health in-patient settings across the country. The care received by some of the people with the most significant needs quite simply is unacceptable.

With respect to in-patient care in assessment and treatment units and other in-patient settings, I absolutely share Members’ concerns about reported deaths, and I want to restate my Department’s commitment to reducing the number of preventable deaths among people with a learning disability. NHS England is ensuring that relevant investigatory processes have been followed in respect of each and every one of the cases it has responsibility for, and it is seeking assurance from all relevant clinical commissioning groups that they too have ensured appropriate investigation. As it stands, there is no indication that any of the deaths were untoward or that due process was not followed in every single case, but we are double-checking each and every one.

The hon. Member for Worsley and Eccles South (Barbara Keeley) mentioned seclusion. Like everyone in the House, I have been incredibly moved by reports of the care for Bethany and by the dignity of her dad, Jeremy, who has described the daily battle he has fought to get her the best possible care. It is completely unacceptable for seclusion to be used in this way. Restrictive practices must only ever be used as a last resort, and we must strive to totally eliminate them. With that in mind, the Secretary of State has instituted a serious incident review in Bethany’s case, and we will act to ensure that she gets the best possible care for her.

However, this is not just about individual cases; it is about the system. Three years ago, the Government committed to reducing the number of people with learning disabilities or autism detained in mental health hospitals by at least a third. The latest information we have shows that the number is down by around 20%, but that is not nearly enough. Today, 2,315 people with a learning disability and/or autism in England are held in mental health hospitals. I want to see that number drastically reduced, and in the first instance I want us to meet the target of reduction by a third. I want to see everyone who can be cared for with their family living as normal a life as possible.

The Secretary of State has instituted a wide-ranging review into the inappropriate use of prolonged seclusion and long-term segregation as restrictive practices. He has asked the Care Quality Commission to initiate that review immediately, and it will be undertaken in two stages. Furthermore, he has asked the NHS to address this issue in the long-term plan that it is writing for the future of the NHS, and I know that NHS leadership shares our passion to get this right. We will also address the role of local authorities in the social care Green Paper, and both of those will be published before Christmas.

[Several hon. Members rose—]

[Barbara Keeley]

I want to put on record my disappointment that the Secretary of State tried to shoehorn an issue of this severity into an NHS policy announcement yesterday, and my thanks to you, Mr Speaker, for allowing this urgent question.

The treatment of people with autism and learning disabilities in assessment and treatment units is nothing short of a national scandal. Six years ago, these units were described by the then chief executive of NHS England and the chief executive of the Care Quality Commission as a model of care that has

“no place in the 21st century”.

Seven years after the Winterbourne View scandal, the Government have not rid the country of these units or substantially cut their use. Indeed, as the Minister said, there are still 2,315 people in assessment and treatment units, including 230 children, and the number of under-18s has been increasing.

A Sky News investigation last week revealed that, since 2015, at least 40 people with a learning disability or autism have died while in assessment and treatment units, and nine of those who died were aged 35 or under. Some of the country’s most vulnerable people are being exposed to physical abuse in institutions that the chief inspector of mental health services described as being

“in danger of developing the same characteristics that Winterbourne View did.”

Can the Minister tell us why the NHS is still sanctioning the use of settings that expose thousands of vulnerable people to abuse, at a cost of half a billion pounds, despite the Government pledging to close them?

The transforming care programme has manifestly failed. What are the Government going to do to ensure funding is available for cash-strapped local councils to pay for community placements with care support for autistic people and people with a learning disability? The Times has revealed that the private companies running these units are making millions of pounds out of detaining vulnerable people in unsafe facilities, in one case funnelling £25 million into a secret bank account in Belize. Can the Minister tell us what the Government are doing to immediately stop private companies that have a vested interest in keeping people with learning disabilities in these Bedlam-like conditions from doing that?

On Saturday, as the Minister has outlined, the Secretary of State ordered the Care Quality Commission to undertake a thematic review of assessment and treatment units, and he has ordered a serious incident review in the case of one young autistic woman, Bethany. Reviews are not urgent action, there are very many Bethanys trapped in seclusion, and 40 people have died in these units. Will the Minister tell us the timetable for the completion and publication of the CQC review and what urgent action can be taken to free all the young people and adults trapped in these appalling conditions?

[Caroline Dinenage]

Hon. Members will be very aware of and concerned about the report published this week by University College London. As the hon. Lady said, the report, which was commissioned by the NHS, draws attention to how people with learning disabilities die on average 15 to 20 years sooner than the general population, often for reasons that are not an inevitable consequence of any underlying medical condition. I was reassured that this report shows that programmes and opportunities that Government are putting in place to improve outcomes for people with learning disabilities and autism are addressing some of the concerns. However, I share very strongly her views and the views of this report that there is still much further to go and that now is the time to take action.

As hon. Members will know, the LeDeR report—the learning disabilities mortality review—is looking into the deaths of all people with a learning disability. It published its second annual report in May and in their response in September the Government accepted all the recommendations and included detailed actions for implementing them. NHS England has also committed that the long-term plan for the NHS will include learning disability and autism as one of the four clinical priorities. The long-term plan will also set out the future of the transforming care programme, which the hon. Lady raised.

Government policy on restrictive practices, including seclusion, is to reduce their use. Where such interventions have to be used, they must be a last resort and the intervention should always be represented as the least restrictive option to meet immediate needs. Incidents of restrictive intervention are recorded in the mental health services dataset and this data is published. The Mental Health Act code of practice highlights the particularly adverse impact of seclusion on children and young people. It advises careful assessment and periodic reviews.

I want to turn to the Care Quality Commission review into the inappropriate use of prolonged seclusion and long-term segregation. The first stage of the review will focus on settings that relate most closely to Bethany’s circumstances, focusing on people of all ages receiving care on NHS and independent sector wards for people with learning disabilities and/or autism and on child and adolescent mental health wards. That will start immediately and this stage will report in May next year. It is very important that service users, their families and people with lived experience are able to contribute to that. The second stage will report in the winter and will examine other settings in which segregation and prolonged seclusion are used. That stage will include NHS and independent sector mental health rehabilitation wards and low secure mental health wards for people of all ages, as well as residential care homes designated for the care of people with learning difficulties and/or autism. As I have said, individuals who have been subject to segregation and/or long-term seclusion and their families and carers will be invited to provide evidence, including through interviews. The Care Quality Commission will make recommendations at the end of both stages, which will seek to eliminate system-wide inappropriate use of prolonged seclusion and long-term segregation, and ensure that vulnerable adults and children supported by health and social care are accorded the best possible care.

I should point out that not all the numbers that the hon. Lady spoke about are in separately identified assessment and treatment units. The data reports there being 2,315 in-patients with a learning disability and/or autism in mental health in-patient settings as of September, but some 360 of them were in in-patient settings described as for people with acute learning disabilities

It is important that commissioners should be able to access very high-quality, value-for-money care in their local area, whichever organisation provides it. We recognise the concern that people have expressed about what happens in the transforming care process, but I see it very much as a process and not as an event that will continue. The NHS has transferred more than £50 million to ensure that the right care is put in place in respect of community support, so that people are better cared for when they are out in the community.

[Dr Sarah Wollaston (Totnes) (Con)]

Does the Minister accept that, fundamentally, far too many people are ending up in terrible conditions in secure settings because of the inadequacy of social care? Will she commit to include in the Green Paper, which is to be brought forward before Christmas, the Green Paper for young adults as well as for older people? Will she absolutely commit to that coming forward before Christmas?

[Caroline Dinenage]

My hon. Friend is absolutely right to recognise that the cases in which people end up in a long-term residential setting often reveal a failure of joint working—of the wraparound services that people need to keep them in the community. We are looking at working-age adults as part of the social care Green Paper, and it will be published before Christmas.

[Mr Barry Sheerman (Huddersfield) (Lab/Co-op)]

The Minister will know that I chair the autism commission, which has been looking at health and fake medicine—some serious reports. Will she expand her vision? There is obviously something seriously wrong in the justice system and the fact that police are not trained to recognise and understand someone on the autism spectrum. We need Health and Justice to look into the issue thoroughly, because something is going wrong. We need to train people, and to train them now.

[Caroline Dinenage]

The hon. Gentleman makes a good point: training is fundamental. We have already accepted the LeDeR review’s recommendation that all health and social care staff should have mandatory training on how to care for people with learning disabilities and autism. I would very much like to see that sort of training spread more widely out into society.

[Mr Philip Hollobone (Kettering) (Con)]

Why has the number of children detained in assessment and treatment units more than doubled in the past three years, from 110 to 230?

[Caroline Dinenage]

That is a really good question. We are looking carefully at how we can support children much better so that they do not go into these sorts of units at all. As I say, it is about the wraparound services that can identify much earlier somebody who might be at a crisis point, and making sure that the care and support is put in place to prevent people from having to be admitted to units of this kind.

[Norman Lamb (North Norfolk) (LD)]

Does the Minister agree that the Care Quality Commission needs to look into the endemic use of force in these institutions, as well as at the use of exclusion? Does she agree that unless and until we find a mechanism to transfer money from spending in these institutions to support in the community, we will never solve this problem?

[Caroline Dinenage]

The right hon. Gentleman has done so much work on this issue and cares about it intensely. NHS England has transferred more than £50 million, up front, so that clinical commissioning groups that are planning to close beds can start to provide the community provision that is crucial to keeping people well in the community and out of residential settings.

[Norman Lamb]

And use of force?

[Caroline Dinenage]

We are absolutely clear that force should not be used at all.

[Andrew Bowie (West Aberdeenshire and Kincardine) (Con)]

Learning disabilities and autism are no respecters of “devolved” or “reserved”, so will the Minister join me in calling for NHS Scotland and NHS England to work more closely together, pooling resources and expertise, so that all patients needing in-patient care across the United Kingdom can receive the best possible care?

[Caroline Dinenage]

Yes. I think this speaks to the whole theme of people working together, communicating, collaborating, and putting the care that is needed in place for people when they need it. The ability to work across borders is fundamental to that.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

It was over seven years ago that we came to this House to reflect on the incredibly disturbing “Panorama” footage of what happened at Winterbourne View. We have had countless statements in this House. I obtained an urgent question about this two years ago. We have seen data about the deaths that have occurred, and the fact that the numbers have not reduced. I would echo the question asked by the hon. Member for Kettering (Mr Hollobone). The number of children in these units has doubled in the period in which the Government told us they would reduce the number by 50%. It is, frankly, a dereliction of duty, and Ministers should be apologising to the people outside this House, in this country, who are detained in those assessment and treatment units.

Can the Minister tell us categorically, and actually answer the question—why has the number of children in these units doubled, and what exactly are she and her Government going to do to ensure that she meets their target of reducing it by 50% by next March?

--- Later in debate ---

[Caroline Dinenage]

I do not see this as a dereliction of duty. I think of the fact that the Secretary of State has triggered a serious incident review into Bethany’s case, that more broadly there is this thematic review, and that we are building the right support by means of the ongoing transforming care process. There is a meeting today, which I have not been able to attend because I had to be here, between all stakeholders in this area, but also with the Department for Education and the Department of Health and Social Care, so that we can work together to ensure that children, above all, are protected.

[Anna Soubry (Broxtowe) (Con)]

I welcomed the Secretary of State’s words yesterday, when he made it very clear that he understands that the situation now needs urgent action. My constituent’s daughter died at the age of 25, having been sectioned, living in a padded cell; her weight rose to 26 stone when she was apparently being cared for. Does my hon. Friend agree that it is not just about money and how we can better spend it; it is about the involvement of families, and a profound cultural change as well?

[Caroline Dinenage]

Yes. I completely agree with my right hon. Friend. I think that the setting she describes that her constituent was in has now been shut, but the point is well made, and actually it is not just about keeping people safe; it is about treating them with dignity and respect, and providing care that is compassionate.

[Helen Hayes (Dulwich and West Norwood) (Lab)]

Several months ago, the Minister met my constituent Isabelle Garnett, whose son Matthew became seriously unwell as a consequence of the treatment he received at St Andrew’s Hospital in Northampton, where Bethany is also receiving such appalling treatment. Matthew’s parents were so worried about his health in St Andrew’s that they thought he would die there. He suffered a broken arm, bruises and other injuries and lost a catastrophic amount of weight.

Matthew is now, thankfully, thriving in a community setting, at significantly less cost than the £12,000 a week that the NHS was spending on completely inappropriate care at St Andrew’s. St Andrew’s is not a fit for purpose location for young people with autism and learning disability. Despite the testimony of Isabelle and many parents like her, why have hospitals like St Andrew’s been allowed to expand, while there has been no expansion of the type of entirely appropriate community provision that is needed?

[Caroline Dinenage]

The hon. Lady brought Matthew’s mum to meet me and I was very disturbed by the photographs she showed me of how poorly he looked when he was in the St Andrew’s setting, and how much happier and so much better he looks now that he is in the right kind of community provision. It speaks volumes about exactly what we are trying to achieve—to get people out of such settings into the right kind of community provision. That is what this is about, but people can only be moved out of settings like St Andrew’s—which is a place that does require improvement—about which the Care Quality Commission is concerned, when the right provision is available in the community. That is why we are putting the money through NHS England into local provision.

[Mrs Anne-Marie Trevelyan (Berwick-upon-Tweed) (Con)]

I welcome the Secretary of State’s recent request to the CQC for an immediate review; it is very timely. Can the Minister assure the House, however, that the Government and the NHS are prepared to hear the uncomfortable truth, and change to find the right and compassionate care for those with autism and those with learning difficulties?

[Caroline Dinenage]

I thank my hon. Friend for that question, which gets to the root of the issue. It is not enough to ask people what they think and set up commissions and reviews; we have to listen to what people are saying but then we have to act. The thematic review the CQC is starting straight away is reporting back in two phases. That is important as it means that, as soon as the first phase comes back, we can start action straight away.

[Liz McInnes (Heywood and Middleton) (Lab)]

Can the Minister say what resources will be made available to local councils to enable people with learning disabilities and autism to move out of the units as a matter of urgency and into community placements?

[Caroline Dinenage]

NHS England transferred over £50 million up front to CCGs that are closing beds over the course of the financial year, so that they can invest in community alternatives. In addition, between 2015 and March 2019 it will invest another £50 million in transforming funding to put in place things such as the much needed crisis prevention teams, which are focused on supporting children in the community.

[Kevin Foster (Torbay) (Con)]

The number of people with learning disabilities and autism in secure mental health hospitals is unacceptable and I welcome the commitment to reduce it. Can the Minister confirm exactly how she will monitor that and keep the House updated on progress?

[Caroline Dinenage]

That is the thrust of the whole transforming care and building the right support programme. We know that in some cases during the course of the programme people who have left residential units and gone into the community have gone back in to the units again. We have to keep a very close eye on the figures and ensure that the right package of support and care is provided so that once people leave a secure unit and go into the community, they are able to stay there.

[Several hon. Members rose—]