Guidance

Letter from Maria Caulfield MP, Women’s Minister (GEO) and Parliamentary Under Secretary of State for Mental Health and Women’s Health Strategy, to Baroness Hollins, Chairperson of the Independent Care (Education) and Treatment Review

Published 8 November 2023

Applies to England

8 November 2023

Dear Baroness Hollins

I want to first thank you and members of the Oversight Panel for your commitment to improving the lives of people with a learning disability and autistic people. Since the Independent Care (Education) and Treatment Review (IC(E)TR) programme was set up in 2019 you have all worked incredibly hard to use your extensive expertise to help reduce the use of long-term segregation (LTS) in mental health hospitals. While the impact of COVID-19 extended the length of the programme, I am pleased that we were able to adapt during this period, and the programme as a whole has enabled us to gather considerable evidence to make long lasting changes. 

Over the last 4 years, the IC(E)TR programme has brought welcome attention to the reasons why people with a learning disability and autistic people are being placed in LTS and understanding of the impacts that people have experienced as a result. I am appalled by the poor and unacceptable outcomes that were found for a number of people. I agree with your finding that the IC(E)TR programme has highlighted that LTS is being overused and we have seen that when people are discharged from LTS, all too often someone else takes their place. I note that IC(E)TRs have, in some cases, identified instances of such concerning care that regulatory action was taken.  

I am pleased that IC(E)TRs have helped to make a difference for some people, with 48 out of the 114 people who had an IC(E)TR in the second phase having moved out of LTS by 31 May 2023 (which was the final data collection for this phase of IC(E)TRs). Nonetheless, the numbers remaining in LTS is hugely concerning.  

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. 

I have read your recommendations with great interest and it is important we take action now wherever we can, if not already doing so. In particular, you highlighted the importance of the continuation of interventions designed to support individuals with a learning disability and autistic people in LTS. I am pleased to announce that my department will provide funding to the Care Quality Commission (CQC) to continue IC(E)TRs for an additional 2-year period, with CQC leading on their delivery, with support from NHS England. This will help to preserve the positive impacts of the IC(E)TR programme, including the greater oversight and understanding of the use of LTS it has given us and adopt learning from the programme to date including improvements to the approach. The continuation of IC(E)TRs will ensure that some of the most vulnerable people in society can continue to benefit from this enhanced scrutiny of their care. As part of their delivery of IC(E)TRs, CQC will be considering how best to report on the progress made through IC(E)TRs.

You also recommend that any use of LTS must be notified to the CQC. We recognise the importance of reporting the use of LTS to improve accountability and enhance safety of patients. I can confirm we are considering changes to the CQC regulations (which would be subject to Parliamentary approval) to improve reporting and notifications by providers to CQC on use of specified restrictive practices. Once in place, the intention is that this will provide a better flow of information, supporting CQC to convene an IC(E)TR as soon as possible where someone is moved into LTS. The IC(E)TR will make recommendations to support safe care and treatment in the least restrictive setting. 

Your report also identifies that culture change is needed across the health system to reduce the use of long-term segregation and improve outcomes for people with a learning disability and autistic people. I agree and am pleased that we are acting on this through NHS England’s Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme which was established in 2022. This programme aims to make improvements in quality and safety, so that all patients experience good and meaningful care. The programme is co-produced with stakeholders, especially people and their families, and has a strong focus on cultural change and supporting staff to reduce restrictive practices. This programme will complement and further support NHS England’s existing commitments to improve the quality of care for people. 

Several of your recommendations require further work before they can be delivered. This includes the continuation of interventions such as the Senior Intervenor pilot which has been independently evaluated and the HOPE(S) programme which is being piloted until December 2024. We will need to consider the findings from their evaluations to understand the effects and best models for future delivery. I have asked my officials to continue to work closely with NHS England and CQC, using your report to inform this work. 

As you know, some of the recommendations will require consideration of more significant reforms, at the relevant time. For example, we will use your report and accompanying framework code of practice to inform updates to the Mental Health Act 1983: Code of Practice when it is next reviewed. This will allow us to consider changes to the definition and standards of LTS which are currently set out in the code of practice. I have requested that your report is used to inform this work at the relevant time. I can also confirm that we have considered all of your recommendations in turn, not just those highlighted here, and our response is set out in annex A.  

Once again, I thank you for your tireless commitment to improving the quality of lives of people with a learning disability and autistic people. All of the invaluable knowledge you and the Oversight Panel have shared will continue to shape the ongoing work to address the over-use of LTS and support people with a learning disability and autistic people to receive safe and high-quality care that is right for them.

Maria Caulfield MP
Women’s Minister (GEO) and Parliamentary Under Secretary of State for Mental Health