On 28 October 2021, the House of Lords is due to debate the following question for short debate, tabled by Baroness Hollins (Crossbench): 

To ask the Government “what plans they have to prevent people with either (1) learning difficulties, or (2) autism, from being detained in secure settings when an assessment has recommended they should live in the community”.

This article explores those issues ahead of the debate.

Government policy

People with learning disabilities and/or autism who have a mental health condition or demonstrate challenging behaviour may sometimes be admitted to a hospital unit. This can either be voluntary or compulsory.

In 2012, the then Coalition Government made a commitment that everyone with learning disabilities and/or autism who was inappropriately placed in a hospital would be moved to community-based care by June 2014. This followed the 2011 abuse scandal at Winterbourne View, an independent hospital for people with learning difficulties and/or autism.

In January 2015, the Government acknowledged that this target to transfer people to community care had been missed. It said that “the process is clearly more complex than we anticipated, and the system has not delivered what we expected to achieve”. However, it highlighted other improvements that had been made to the care guidance, and accountability and inspection regimes.

In October 2015, NHS England announced a plan to reduce inpatient occupation for people with learning disabilities and/or autism by 35 to 50 percent over the following three years. Released in partnership with the Local Government Association and the Directors of Adult Social Services, Building the Right Support stated that alternative care would be provided in the community.

The plan included “core building blocks” which would, it stated, “radically change how we commission and deliver services”. These were:

  • 48 transforming care partnerships bringing together health and care commissioners, providers, charities, people with a learning disability and/or autism and their families to develop local plans by April 2016, to be delivered over three years.
  • A new financial framework, in which shared budgets across the NHS and councils deliver more joined-up services and speed up discharges, and for those who have been in-patients for five years or more, NHS funding would move with them to community services for as long as they need it.
  • A service model describing ‘good care’ for health and care commissioners. It includes nine principles that define what good services should look like, starting with ‘I have a good and meaningful everyday life’ and ‘my care is person-centred, planned, proactive and coordinated’.
  • New guidance for care and treatment reviews to prevent unnecessary in-patient admissions and lengthy hospital stays.
  • New housing guidance to support NHS and local authority commissioners to expand the housing options available.

Funding made available included £30 million transformation funding over three years, matched by clinical commissioning groups, and £20 million capital funding over five years.

The Government’s 2018/19 mandate to NHS England set a target of March 2019 to achieve the 35 to 50 percent reduction in inpatient care set out in Building the Right Support.

This March 2019 target was not achieved, though progress towards it was made. In January 2019, the number of inpatients with learning disabilities and/or autism had been reduced by approximately 20 percent. The then Health and Social Care Secretary, Matt Hancock, stated that part of the reason the target was missed was that while people were being moved out of secure settings, others were still being moved in.

The 2019 NHS Long Term Plan set a new target of a 50 percent reduction of use of inpatient beds for people with learning disabilities and/or autism on March 2015 levels by 2023/24. In June 2021, there had been a 30 percent reduction on March 2015 levels.

In 2021, the Government established a “delivery board” to oversee progress of the 2015 Building the Right Support plan, as well as a “stakeholder update forum”. The building the right support delivery board include representatives from the Ministry of Housing, Communities and Local Government, the Ministry of Justice, the Home Office, the Local Government Association, the Association of Directors of Adult Social Services and NHS England, as well as representatives of users.

Health and Social Care Committee report

The House of Commons Health and Social Care Committee found that the target for reducing the number of people in inpatient beds had not been met because there was inadequate care available in the community. In its July 2021 report, The Treatment of Autistic People and People with Learning Disabilities, the committee said it was concerned that support levels were significantly below that which was required:

Community support and provision for autistic people and people with learning disabilities, and financial investment in those services, is significantly below the level required to meet the needs of those individuals and to provide adequate support for them in the community.

The committee recommended that the Government make changes to financing the care of people with autism and/or learning disabilities. It asked the Department of Health and Social Care to set out the costs of providing care in the community for all current inpatients, and then provide the funding to meet these costs. It also recommended changes to funding incentives so that local authorities are not incentivised to pass responsibility to the NHS:

We also recommend that the Department then needs to redesign the financial incentives in the healthcare system so that local authorities do not seek to ‘offload’ autistic people and people with learning disabilities onto the NHS or place these individuals in inpatient facilities.

The committee argued that “the actions taken by the Government to date are not sufficient for the scale of this issue” and made recommendations for future work. The committee said the building the right support delivery board should not repeat the “previous mistake” of focusing on a “voluntary” approach to supporting autistic people and people with learning disabilities. It also said it did not believe the delivery board had a “clear plan for improving the practical support autistic people and people with learning disabilities receive when living in the community” in order to avoid future admissions or readmissions to inpatient units.

The Government has not yet responded to this report.

Recent developments

The Government has said that it intends to bring forward legislative reforms to reduce the number of autistic people admitted to inpatient mental health settings. The Government’s National Strategy for Autistic Children, Young People and Adults: 2021 to 2026, published in July 2021, said these changes would mean that autism alone is “no longer a lawful basis for ongoing detention in inpatient care” and would enable people in inpatient care to be discharged as “soon as they are well enough to leave”.

The Government also acknowledged that lack of good community care has led to more people with autism being admitted to secure settings even as others are discharged. The autism strategy states that people with autism “often struggle to access community support, including social care, mental health and housing support before their needs escalate”. It outlines measures the Government is taking to provide better community care and reduce the amount of time people spend in inpatient facilities, including:

  • Over £40 million in 2021 to 2022 to prevent avoidable admissions and improve community support. This includes £25 million to improve the capacity and capability of 7-day specialist multidisciplinary and crisis support for autistic people and people with a learning disability in every area of the country.
  • £15 million to put in place keyworkers for children and young people with complex needs in inpatient mental health settings, as well as those at risk of being admitted to these settings.
  • Improving autistic people’s access to housing and social care that meets their needs by increasing the provision of supported housing, enabling more people to access adaptations to their homes and reforming the social care system so it is fit for purpose.
  • £62 million community discharge grant to tackle the financial barriers and disincentives to discharging people from inpatient care.
  • Increasing respite support and providing help for autistic children and young people in schools to prevent suspensions or permanent exclusions.
  • Improving the quality of inpatient care, including reducing the use of restraint, seclusion and segregation.

In response to an oral question asked on 19 October 2021, Minister for Care and Mental Health Gillian Keegan said that the Department of Health and Social Care would publish an action plan which would outline “all of the plans that we have, how we will improve outcomes and how we will enable people to live well in our communities”.

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Cover image by Michael Jasmund on Unsplash.