2050 autistic people and people with a learning disability are locked up in long stay hospitals and assessment and treatment units today.
The average person has been locked up this way for five years. 330 of them for ten years or more. A third (32%) are more than 50km from home. Only half (54%) have a family to speak up for them. Most are on strong medication. Many will not understand why any of these things are happening to them.
The transforming care programme, designed to end the culture of locking people up in the wake of the Winterbourne View scandal 13 years ago, has moved excruciatingly slowly. It is a complex problem to solve.
And that is why we welcome the long-awaited and oft-delayed reform of the Mental Health Act, the second reading of which is Monday 25th November.
What’s welcome
Overall the Bill is very welcome both in its aspiration to keep people with learning disabilities and autism out of hospital, and to support swift discharge via mandatory discharge plans in equally mandatory Care and Treatment Reviews. People with a learning disability and autistic people with no co-occurring mental health conditions can only be detained for up to 28 days.
Detention
The Bill limits detention for people with a learning disability and autistic people with no co-occurring mental health condition.
People with learning disabilities and autistic people can still be detained under section 2 of the Act (up to 28 days) if they have a co-occurring “psychiatric disorder” that warrants hospital treatment. But not under section 3 (up to 6 months.)
People cannot be made subject to a Care and Treatment Order solely because of their learning disability or autism.
There are some risks. Jason Bardell, Dimensions head of Clinical Practice said:
Care and Treatment Reviews
Care and Treatment Reviews (Care, Education and Treatment Reviews for young people) are already mandatory but not legally enforceable. The Bill gives statutory backing to these. This is important; half of all inpatients’ CTRs are out of date and 15% do not have one at all.
Discharge
Further, the Bill mandates the inclusion of a discharge plan within those CTRs. That means that every patient must have a plan for discharge, a very welcome step given that currently 64% of detained people do not have any sort of discharge plan in place.
Our concerns are not around the policy, but around its implementation. CTRs are expensive and difficult, requiring good planning from a multidisciplinary team. Will we see quality, or lip service?
‘At risk’ register
We welcome the new duty on integrated care boards (ICBs) to keep a register of people at risk of admission under the Act. The aim is to ensure that adequate community services are available to reduce unnecessary hospital admissions.
Our concern is that this duty is not extended to those who are at risk of being detained under a criminal section. This is a missed opportunity, and it will limit the proactive approaches multidisciplinary teams can take for people in this position.
Better support for the individual is also likely to be the result of a requirement for the hospital clinician and the community clinician to agree decisions together but it could also cause delays in decision making if there is no consensus.
Individuals in the criminal justice system
People with a learning disability in the criminal justice system can often be better supported in their local community than in either hospital or prison. We demonstrate better outcomes for such people every day.
For that reason we are concerned that the option for a community disposal (possibly with restrictions on liberty) as a valid alternative to detention in hospital has not been considered within the Bill.
Housing
Currently, there is a severe shortage of suitable bespoke housing to support people well. And in relation to people locked up in hospital the situation is particularly challenging: over half (56%) of delayed discharges are due to a lack of housing.
Next steps
The bill will be debated and must be approved by both Houses of Parliament and amendments are likely to be made during its passage through parliament. It is estimated that full implementation may take 10 years largely because of the requirement to train additional clinical and judicial staff. There are also considerable costs associated with these changes and this begs the question about whether it will happen.
Data
All data is from NHS Digital: LD_AT_DataTables_Oct2024.xlsx