Winterbourne View Hospital and the Transforming Care Programme

Mark Harper Excerpts

Thursday 10th June 2021 Westminster Hall

[Mr Mark Harper (Forest of Dean) (Con)]

Thank you, Ms McVey. First, let me put on the record a declaration of interest: I chair the all-party parliamentary group on learning disability, so that is the context in which I am speaking. Mencap, which provides the secretariat for the APPG, has provided a very helpful briefing for the debate, which it has made available to all Members.

It is a great pleasure to follow the hon. Member for Worsley and Eccles South (Barbara Keeley). I do not propose to repeat everything she said, although I agree with the large bulk of it and the thrust of her remarks. I want to focus on the specific commitments that the Government have made. I am afraid—I say this with no great pleasure as a Government Back Bencher—that the Government have missed commitments on a number of occasions. I want to put on the record some very specific questions for the Minister about what the Government are doing to ensure they hit the revised targets that they have set out. I also want to remind people listening that the Government have now made a clear commitment to introduce proposals to reform social care this year. I know the Minister is well aware, as is the shadow Minister and everyone present, that social care does not just include care for older people; it includes care for people with disabilities.

I say that is because, when the public conversation happens, after about five seconds it immediately turns into a discussion only about older people—usually older people in a residential setting. We tend not to talk about older people who receive domiciliary care that enables them to stay in their homes, and the media do not focus on the fact that, actually—I think it is still the case—the majority of public spending on social care in England is not on older people; it is on people of working age. If we are to introduce social care reforms, they will not be worth having unless they properly encompass people of working age, including people with learning disabilities or autism. They will need to be very different reforms from those that deal with older people, because although many older people, though not all, have assets that enable them to make a contribution—obviously we will have a debate about the appropriate level of contribution—people of working age do not have such assets, particularly if they have been disabled from birth. If we were to have a means test of any description, we would simply build in a new barrier to people of working age with learning disabilities or autism getting into the workplace and working, which is what most of them want to do. Most of them are able to do so if we provide the tools.

I want to focus specifically on some questions for the Minister. I am mindful about what you said about ensuring we can get everyone in, Ms McVey, so I will try not to make my remarks too lengthy. The hon. Member for Worsley and Eccles South set out the various targets that have been missed. As I said, I take no great pleasure in that as a Government Back Bencher, so I will not repeat all the misses. I want to focus on the latest target in NHS England’s long-term plan, which is to deliver a 50% reduction in in-patient beds by March 2024.

First, I want to ask the Minister whether the Government have done any thinking about whether the 50% reduction is ambitious enough. It would be ideal if we did not have anybody in such settings and we were able to support almost everybody in the community. Perhaps the Minister could comment on whether the target remains ambitious enough. Given that the original target was to deliver a 35% to 50% reduction by March 2019, and that another five years has been added on and we are only in 2021, is March 2024 an ambitious enough target to hit the 50% reduction? Given that the previous targets have been missed, I accept that it might seem ridiculously ambitious to talk about introducing the latest target. However, given that we have let it slip by another five years, I want to test whether it is actually the right target.

The second thing is to focus on how we will reach the target. The hon. Member for Worsley and Eccles South rightly said that the only way we can really stop people being in those institutions is to provide proper support in the community. The Government have set out how they will do that with their transforming care plan and objectives about building the right support. I understand that the intention is that a cross-government action plan will be produced, so it will be helpful if the Minister will tell us how that is going and when it will be published. To what extent will the proposals to reform social care that are being worked on improve or transform care in the community for people with learning disabilities and autism? Will the decisions to be taken this year—alongside the comprehensive spending review, I presume—provide an opportunity for a step change in getting this ambitious target delivered on time?

The Minister will be familiar with the fact that the cross-party Joint Committee on Human Rights said in its report that it had no confidence that the Government would hit the target in the NHS long-term plan. It proposed a No. 10 unit with Cabinet-level leadership to ensure reform. I listened carefully to what the hon. Member for Worsley and Eccles South said about a commissioner, but I am slightly traditional and old-fashioned, and I think that accountability in government is held by Ministers. They are elected and accountable to both Houses of Parliament, and political responsibility for delivering on the proposals sits with the Secretary of State and the Minister. I am not keen on having a commissioner as another person who feels that it is their job to chivvy Ministers along, because that is our job, collectively, in Parliament.

I do want to know, however, what mechanisms are in place whereby the Secretary of State for Health and the Minister for Care can monitor what NHS England is doing. At present—this will not be the case under the proposed legislation—NHS England is an arm’s length body with a chief executive, so what are the Secretary of State and the Minister doing, on a regular basis, to hold NHS England to account to ensure that it delivers on this ambitious timetable, and perhaps achieves a more ambitious one?

My experience in government is that if something challenging has not happened in the past, there is only one way to get it done: Ministers making it clear, and saying, that they care about it; and, most importantly, showing that they care about it by focusing on it regularly, asking for information about delivery across the country—Mencap’s report shows that delivery is inconsistent throughout the country—and getting regular updates on progress, putting a bit of stick about when things are not on track. To do that, they need a plan with regular milestones so that progress towards a target can be measured. It would be helpful—there is no reason why it could not be done—if progress towards such milestones were not just shared with the House, but published, so that the families of people who have been badly treated, including those at Winterbourne View, can see that we are making progress.

Before I conclude, I wish to focus on the use of restraint, seclusion and segregation. I understand that a trigger for the Joint Committee on Human Rights inquiry and a CQC investigation was a BBC Radio 4 “File on 4” programme revealing the shocking use of restrictive practices in in-patient units. The CQC report, which was ordered by the Secretary of State, revealed widespread and frequent use of restrictive practices, including physical and chemical restraint, long-term seclusion and segregation. I understand that we are still waiting for the Government’s response to the report, so it would be helpful if the Minister would set out when it will be published so that we can find out what the Government will do as a result.

I hope that the Minister will set out a plan to make sure that we deliver against the new target so that we will not sit here in a few years saying, “The target that was set has been missed and rolled forward again,” with the families who have been subjected to unacceptable care feeling that no one is listening to them, and we are back on the hamster wheel with nothing having been done. If the Minister can focus on that, we will have taken a big step forward.

--- Later in debate ---

[The Minister for Care (Helen Whately)]

It is a pleasure to serve under your chairmanship, Ms McVey. I thank the hon. Member for Worsley and Eccles South (Barbara Keeley) for securing this important debate, for opening the debate and for her committed campaigning for people with learning disabilities and for autistic people. I also thank all Members who have spoken powerfully today, both in the Chamber and virtually, and shown the strength of feeling on the issue among parliamentarians. I particularly thank my hon. Friend the Member for Bexhill and Battle (Huw Merriman), as he has taken on the role of chair of the all-party parliamentary group on autism following, as he said, the very sad death of our right hon. Friend Dame Cheryl Gillan. She is missed so much by all of us, both as a colleague and for her work for autistic people, which has made such a huge difference over the years, although there is clearly much further to go.

The appalling abuse uncovered at Winterbourne View has no place in our society, and I share the shock and anger that hon. Members have expressed today. It was rightly described as heartbreaking and disgusting by my hon. Friend the Member for Broxtowe (Darren Henry), and it should never have happened, as my hon. Friend the Member for Filton and Bradley Stoke (Jack Lopresti) said. None of us accepts this kind of cruel and abusive treatment of people with learning disabilities and autistic people, and none of us wants people to be in-patients unnecessarily when they could be better off living in the community. I will use my time to talk about the work of Government, the NHS, the CQC, local authorities, and others we are working with to stop poor and—worse still—abusive care, and to improve care. As part of that, I will talk about what we are doing to reduce the number of people with learning disabilities and autistic people in in-patient units, which we know are rarely the best place for those people to be. As I do so, I will seek to respond to questions raised by right hon. and hon. Members.

First, I will talk about the approach we are taking to stopping abusive care. We are working with the NHS as care commissioners, local authorities, and of course the CQC, which plays a critical part. I fully support the much tougher approach that the CQC is rightly taking through its more robust inspection regime and updated methodology, which includes speaking more to patients and families and really digging into the culture of providers. It is in some of these closed cultures where there has been such concerning treatment of patients, and the CQC is taking a robust enforcement approach, including wasting no time in closing down services when it uncovers unsafe care. The sad truth is that this tougher approach by the CQC has exposed more cases of poor care, and I fully support the CQC in taking very robust action in those cases.

A significant number of people with learning disabilities and autistic people in in-patient units, about 59%, are autistic. As my hon. Friend the Member for Bexhill and Battle said, an in-patient unit is rarely a good environment for someone who is autistic, and can often be a really inappropriate one. I am clear that no one should be in an in-patient unit if it is not to their benefit—if they are not receiving some form of therapeutic treatment that helps them. Even then, their time in an in-patient unit should be as short as possible, and that unit should be as close to home as possible. Our target is to achieve a 50% net reduction in in-patients by 2025, from a base starting in 2015. Back in 2015, there were 2,895 people with learning disabilities and autistic people in in-patient units; that figure has come down to 2,035, which is a 30% reduction. England is divided into 44 transforming care partnership areas, 17 of which are on track to achieve the target, but that means that 27 are not on track. I take that failure very seriously.

My right hon. Friend the Member for Forest of Dean (Mr Harper) asked whether our target of a 50% reduction is ambitious enough, and whether we should be aiming for zero in-patients. That is a question that I have asked myself, and I have also asked it of the NHS and of clinicians. It has been made clear to me that there are times when people with learning disabilities and autism may need to be in an in-patient unit, when they have a mental health condition that could benefit from in-patient treatment. As such, I do not think it would be right to say that it is never appropriate, but it should be rarely considered appropriate, and alternatives should be tried wherever possible. I must also mention to my right hon. Friend that just under 30% of the numbers I am talking about are individuals who are under Ministry of Justice restrictions, so that is another challenge to discharging them. Those are net figures, however, and in the period that we are talking about, there have been more than 10,000 discharges, so it is not a static population. Of course, given that reduction of 30% and more than 10,000 discharges, there have also been a large number of admissions.

When I became the Minister for Care, with this in my portfolio, I straightaway asked the question, right back at the beginning of the pandemic, why are we behind the target? Why have we not made the progress that we should be making? Why is it taking so long? What needs to be done to fix that and to get back on track? We need to have a plan that we can all be confident in—all of us in the Chamber and the families of in-patients.

[Mr Harper]

Before the Minister moves on, may I test her? She said that she asked whether the 50% target was right. After all those conversations and yes, accepting that there might be some need for in-patient units, is the Government’s position that the 50% reduction is the right end state, or is there a different number? If it is 50%, will she publish the analysis that sets out why that is the right number?

[Helen Whately]

I can tell him that achieving the 50% will be hard. I am all for being ambitious, but in fact, from everything I have seen, achieving it will be hard, partly because some are more easily discharged—I pause as I say that, because it has been difficult to discharge many because we have complex situations here. We have seen some people continuing to be in-patients with long lengths of stay, and it has become almost harder and harder to find a way to find the right support for them in the community. Achieving the 50% will not be easy. I will get to the other part of my right hon. Friend’s question.

When I saw the position we were in and that we were not on target, I asked why and how come. Clearly, however, this is a complex system—it involves the NHS and local authorities doing things, and there are questions about housing supply, community schools and in-patient services. I therefore set up the building the right support delivery board, to which my hon. Friend the Member for Bexhill and Battle referred—I thank him for his supportive words. That board’s aim is to bring those involved together, because, much though we all like a clear line of accountability, to point a finger at somebody to say, “Solve this!”, the reality is that solving this involves bringing different organisations and different parts of our system together.

The delivery board has identified six priorities that we need to focus on to overcome the barriers to achieving lower numbers of in-patients: first, identifying the best practice models of care in the community. What does good look like? That may sound obvious, but getting the right answers is not the easiest thing to do. What is the right care for people in the community? First we have to find out what we want to see in all our constituencies that is available for that group of people.

Secondly, we have to focus on improving the transition into adulthood, in particular for autistic young people, because that is a particular problem resulting in in-patient admission. Thirdly, we have to reduce the number of people in in-patient care with judicial restrictions who, as I mentioned, are a significant proportion. Fourthly, we have to address some of the issues with funding flows and potential financial disincentives in the system, which hon. Members have mentioned, including the hon. Member for Worsley and Eccles South. Fifthly, we have to address the lack of available suitable supported housing. Housing is often cited as the most frequent barrier to discharge. Finally, we have to ensure that we have the right workforce.

Those are the priorities. Yes, we are working on a delivery plan, which will include milestones, such as my right hon. Friend the Member for Forest of Dean rightly called for—we all need to be able to see those. Specifically on the NHS role, since the pandemic, I have asked each of the 44 areas in the NHS to review where they are on delivering against our target and to come to me with what their trajectory is. Where will they get to over the coming months and years and, to the extent that they may be below the ambition, what actions will they take to close that gap?

I hope that that addresses my right hon. Friend’s question about my similar commitment to ensuring that we have clear milestones and targets, can see who is doing what, and have a grip on getting this delivered.

[Mr Harper]

Are the milestones in the plans going to be published?

[Helen Whately]

Yes, we plan to publish the delivery plan. We want to have time for the delivery board to feed into it, because we set that up earlier this year. It is complex and cross-government, so it takes a bit of time to bring that together, but broadly yes.

I want to touch on funding, because it was mentioned a number of times as one of the barriers. As part of the NHS England long-term plan, we are investing £40 million this year in improving community support and preventing avoidable admissions. There is an initial £31 million of funding for this issue as part of the NHS mental health covid recovery package. There is £11.35 million specifically to accelerate discharges from mental health hospitals, which includes funding to strengthen advocacy for people with a learning disability and autistic people, and £19.65 million to help prevent crises from occurring and to avoid admissions into in-patient care. There is also the £62 million community discharge grant, which is a fund over three years. The first tranche was issued last year, with a further £21 million to be distributed this year and next. That is particularly to cover some of the double running costs involved when a discharge happens. Someone may need care as an in-patient, but it also has to be set up in the community.

My right hon. Friend the Member for Forest of Dean also asked about the response to the CQC’s “Out of sight” review, which was requested by the Secretary of State for Health and Social Care and which reported back in October last year. It was a review of the use of restraint, seclusion and segregation. My right hon. Friend the Member for Forest of Dean asked when we would respond to it, and I can say that we will do so imminently. I hope he finds that reassuring, even if I cannot give a specific date.

I am mindful of the time, so I will wrap up. I thank all right hon. and hon. Members who have contributed to the debate. I know we are all deeply committed to ensuring that everybody with learning disabilities and autistic people get the care and support that they need. None of this is easy. Some of the individuals we are worried about have really complex needs, but I do not accept that as an excuse for poor or, worse still, abusive care. I will continue to work with the CQC, the NHS, local authorities and other Government Departments, and with the families and user representatives, who play a really important part and are part of the delivery board. I will work together with them to bring an end to this and make sure that autistic people and those with learning disabilities get the care and support that they need, and the support that their families need, to live their lives to the full.