Long-term segregation in mental health hospitals

On 23 November 2023, the House of Lords will consider the following question for short debate:

Baroness Hollins (Crossbench) to ask His Majesty’s Government whether they plan to expedite implementing the recommendations in the report ‘My heart breaks—solitary confinement in hospital has no therapeutic benefit for people with a learning disability and autistic people’, published by the Department of Health and Social Care on 8 November.

1. The Independent Care (Education) and Treatment Review (IC(E)TR) programme

In November 2019, the then secretary of state for health and social care, Matt Hancock, announced that all “patients with learning disabilities and autism who are inpatients in a mental health hospital” would have their cases reviewed over the next 12 months.^[1] In addition, the announcement said that an independent panel would be established, to be chaired by Baroness Hollins, to review the cases of those in long-term segregation. The announcement said that this was a direct response to a recommendation of the Care Quality Commission, which in May 2019 had produced a report outlining concerns regarding the quality of care and lengthy discharge times of those subject to segregation.^[2]

Following the initial 12-month review period, Baroness Hollins requested that the Independent Care (Education) and Treatment Review (IC(E)TR) programme—set up to review the cases of people with a learning disability and autistic people detained in long-term segregation—be continued.^[3] The programme ended up running from November 2019 to March 2023 and reviewed the cases of 191 people. On 8 November 2023, the Department of Health and Social Care published Baroness Hollins’ final report, ‘My heart breaks—solitary confinement in hospital has no therapeutic benefit for people with a learning disability and autistic people’, which summarised the findings of the programme.

The independent oversight panel—appointed to assist Baroness Hollins with the review process—noted a number of lessons it had learned from the IC(E)TR programme. It said that the use of long-term segregation—a practice the report recommends renaming as ‘solitary confinement’—is one part of a four-stage failure:

1. The first is that community-based support, including education, have been insufficient to prevent a person being removed from school or their family or other home, and being admitted to hospital.
2. The second stage is the failure to provide learning disability and autism friendly, skilled and person-centred support in hospital, resulting in further trauma and further restriction on top of the person’s removal from their community, their family and their friends.
3. The third stage is the use of restrictive practices, including solitary confinement.
4. The fourth stage is the lack of clarity about whose responsibility it is to commission and fund skilled support in the community and the lack of any effective project or case management of discharge planning.

The oversight panel highlighted what it argued were the costs of solitary confinement, noting that:

Long-term segregation can be a significant interference with a person’s human rights. It involves social isolation and enforced separation from one’s peers. It may be experienced as punitive by the person themselves, is frequently traumatic and does not provide any therapeutic benefit. Being socially isolated is likely to increase anxiety and contribute to an increase in mental distress and behaviour that challenges both the person themselves and others, making rehabilitation more difficult.

The oversight panel also noted the concerns about the “extreme poverty of many of the rooms being used to confine people”. It said that these rooms often had “no access to private toilet and bathing facilities” with “no natural light or fresh air”. In addition, the panel found that staff were not always familiar with their patient’s life stories and had “low therapeutic aspirations” for them. The panel also found evidence of clinical teams which “lacked the skills and resources” needed to make timely assessments to support their patients.

Summarising their findings, the oversight panel expressed concern that they found “no therapeutic benefit to solitary confinement”. They found evidence of “traumatised people” being further traumatised by “inappropriate hospital environments which do not make provision for their sensory and communication needs”. They also said that families and friends were “too often denied access to their relative in solitary confinement” and excluded from treatment and care decisions.

Baroness Hollins and the oversight panel were “unanimous in recommending that the use of solitary confinement should be severely curtailed”, noting that curtailment should not be accompanied by increasing the use of other restrictive interventions.

The report made 13 recommendations around three main themes:

• improving care and support for people with a learning disability and/or autistic people detained in solitary confinement
• improving accountability and visibility when solitary confinement is used
• moving people out of solitary confinement and preventing future use of solitary confinement for people with a learning disability and/or autistic people

Among those recommendations were that:

• Long-term segregation and seclusion of people with a learning disability and/or autistic people should be renamed ‘solitary confinement’.
• All staff working with people with a learning disability and/or autistic people should be delivering therapeutic and human rights-based care, with staff that use any restrictive practice having received appropriate training.
• Everyone in solitary confinement must have access to independent specialist trained advocacy, specialist free legal advice and a redress scheme must be available to them.
• Solitary confinement for people with a learning disability and/or autistic people should become ‘never events’ in the following instances:
  • for children and young people under 18 years of age
  • where it does not meet minimum standards for adults (as proposed by the Oversight Panel)
  • where it lasts for longer than 15 days.
• Safeguarding processes for those in solitary confinement must be strengthened. This includes ensuring that people’s, relatives’ and staff voices are acted on immediately when a complaint or concern is raised and that family members and advocates should be able to visit those in solitary confinement at any time of day or night if they consider it necessary.
• The government must publish an annual report on the progress towards ending the use of solitary confinement for people with a learning disability and/or autistic people.
• The Department of Health and Social Care, NHS England and the Care Quality Commission should commit to funding and delivering interventions to reduce the use of solitary confinement and move people to the least restrictive setting and out of hospital as soon as possible.

2. Government response to the report

The government published its response on the same day that Baroness Hollins’ report was published, 8 November 2023. The response took the form of a letter from Maria Caulfield, parliamentary under secretary of state at the Department of Health and Social Care, to Baroness Hollins, as well as a departmental response to the individual recommendations in the report.^[4]

In the letter to Baroness Hollins, the minister said the IC(E)TR programme had brought “welcome attention” to the issue, with Maria Caulfield noting that she was “appalled by the poor and unacceptable outcomes that were found for a number of people”.^[5] She said:

The evidence you have presented to us, in your interim and final reports and through regular Oversight Panel meetings, have demonstrated a continued need to focus on reducing restrictive practices through learning and culture change. I am absolutely clear that we must significantly reduce the use of LTS and if used, it should only ever be in a way that respects human rights, where the environment is of the standard set out in the Mental Health Act 1983: Code of practice and is no more restrictive than is necessary for people’s safety. All care and treatment plans should aim to end LTS as soon as possible and patients must have access to therapeutic interventions, with regular review of their wellbeing. Urgent action should be taken when this does not happen to protect the people in LTS.

The minister said the government was already acting on some of the recommendations and considering others, but that several of the recommendations “require further work before they can be delivered”, with some recommendations requiring “consideration of more significant reforms, at the relevant time”. The minister noted that the report would be used to inform the next update to the ‘Mental Health Act 1983: Code of practice’ when it is reviewed.

3. Reaction to the report

In response to the publication of the report, Jackie O’Sullivan, acting chief executive officer at learning disability charity Mencap, said that it had shone “a vital light on system wide failures that sees solitary confinement used to ‘warehouse’ people with a learning disability and autistic people in mental health hospitals with devastating consequences”.^[6] She also said that the government must act with urgency to end this “barbaric practice”. In addition, Jackie O’Sullivan said it was “bitterly disappointing” that the government had “failed to include in the King’s Speech vital changes to the Mental Health Act that would have supported this work”.

The Challenging Behaviour Foundation—a charity focused on children, young people and adults with severe learning disabilities—said that the report “state[d] what is already known” regarding the lack of therapeutic benefit of long-term segregation.^[7] It said:

The report, and the government response to it, provides further evidence that much repeated words of “commitment” are not translating into action that addresses the underlying issue—the lack of a systemic approach to investment in robust community support and services and a skilled workforce to deliver timely and appropriate support to people with learning disabilities and autistic people.

The foundation said that the report made a number of recommendations which would “make a significant difference to the thousands of people currently detained, and to the many more who are currently at risk of detention”. However, they said this risk is “unlikely to change in the short-term following the government’s decision to abandon their commitments to pass the Mental Health Bill and reform the Mental Health Act”.

Rightful Lives—a campaign and community focused on the human rights of people with learning disabilities and autistic people in Britain—noted that three members of its administration team took part in Baroness Hollins’ oversight panel, who the group said were “pleased to be able to contribute” to the report and its recommendations.^[8] However, it said that “not for one minute had we envisaged that the government’s response would be as ineffective and insulting as it has been”. It expressed disappointment that the recommendations of the report had not been “taken seriously” and suggested that the government’s response had “merely given permission to hospitals, practitioners and commissioners to carry on as normal”.

In a debate on the King’s Speech on 9 November 2023, Baroness Hollins said that the omission of a new mental health bill from the speech was “particularly poignant in circumstances where legislation is needed to protect some of the people in the most vulnerable circumstances”.^[9] She said that she saw “no sign” of the government’s stated commitment to create parity between mental and physical health and that, “in lieu of a mental health bill in the government’s programme of work”, she had tabled a private member’s bill to address the recommendations in the report. When closing the debate, Viscount Younger of Leckie, parliamentary under secretary of state at the Department for Work and Pensions, said that he “recognise[d] the disappointment that a mental health bill was not included in the King’s Speech”.^[10] He said that in the absence of such a bill the government would “continue to take forward non-legislative commitments to improve the care and treatment of people detained under the [Mental Health] Act”.

4. Read more

• Department of Health and Social Care, ‘Baroness Hollins’ final report: ‘My heart breaks—solitary confinement in hospital has no therapeutic benefit for people with a learning disability and autistic people’, 8 November 2023
• Department of Health and Social Care, ‘Independent Care (Education) and Treatment Reviews: Government response, 2023’, 8 November 2023
• Rebecca Thomas, ‘Scandal of patients with learning disabilities locked in ‘inhumane’ solitary confinement for 20 years’, Independent, 8 November 2023

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Cover image by Freepik.