Independent report

The Oversight Panel's interim conclusions and recommendations

Updated 8 November 2023

The Oversight Panel’s interim conclusions

This document summarises the interim conclusions of the Oversight Panel. It outlines the headline findings from a thematic review of 26 independently chaired Care (Education) and Treatment Reviews (IC(E)TRs), from discussions with IC(E)TR independent chairs, and Panel meetings. These have been grouped in to 6 ‘improvement areas’. Against each of these improvement areas we have described ‘what we want to see’ – that is what we consider to be the correct aims and objectives in those areas. The Oversight Panel has identified some actions which need to commence immediately but require a funded project plan. The Panel has also identified other actions and recommendations which need further development and would be completed for a final report in 2021.

These actions and proposed recommendations are specifically intended to improve outcomes and the immediate circumstances for people in long term segregation (LTS). However, the Oversight Panel also strongly recommends that these areas for improvement should apply more generally for all people with learning disabilities and/or autistic people who are inpatients or at risk of admission.

The Oversight Panel’s overarching aims

• to ensure that all people with a learning disability and/or autistic people who have been subject to segregation are moved out of segregation to the least restrictive setting possible and are supported to move on towards discharge and fulfilling lives in the community

• to anticipate and prevent the future use of segregation for anyone with a learning disability and/or autistic people within current models of care who might be on a pathway towards LTS

• to ensure that all proposals taken forward are values led, with a focus on developing capabilities and the best possible outcomes for people and their families, respecting the human rights of people with a learning disability or autistic people

• to put people and families at the centre of care planning and ensure that accountability is first and foremost to the people who are in or have experienced segregation’

• failure to address and prevent the use of LTS should be considered a failure of the system to respect and promote the human rights of people with a learning disability or autistic people and to provide for their needs in an environment where they feel safe, listened to, understood, respected and included

A Improvement area	B What we found (through IC(E)TRs)	C What we want to see	D Immediate actions	E Proposals to be developed for inclusion in a final report
To improve substantially the quality of diagnosis, treatment and care in hospitals	There was poor clinical leadership, lack of multidisciplinary formulations and an inadequate therapeutic offer in hospitals. There was a lack of joined up working between hospital and community clinical teams. There was a lack of appropriate knowledge and expertise in relation to autism. There was generally poor quality of care and environment in hospitals for people in LTS.	People with learning disabilities and autistic people should never be admitted to inpatient settings unless there is a clearly identified therapeutic benefit for the individual. Where admissions are absolutely necessary, they must be close to home, of high quality and for the shortest time possible, with continuing clinical oversight across both community and hospital provision. Urgent attention should be given to the risk of psychological trauma from inappropriate and excessive restriction in inpatient settings in addition to any actual or perceived physical risk to the person and others. A substantial improvement in the quality of care, in both the physical environment and the therapeutic offer in mental health hospitals for people who are or who have been at risk of being subject to segregation. Agreement about what constitutes clinical best practice, and an assurance that poor practice will be appropriately dealt with by professional bodies and by regulators. Each person in LTS must receive kind and compassionate care that meets their individual needs from appropriately trained staff (who have training and competencies in working with people with a learning disability and/or autistic people and sensory and trauma awareness). This care must be given in an appropriately designed environment.	RCPsych should define good practice with respect to admission and discharge protocols including risk sharing, adherence to STOMP and provision of psychiatrist support to C(E)TRs/IC(E)TRs; membership of quality networks; competencies in working with people with learning disabilities/autistic people and people who have been traumatised; and to identify ‘red flags’ to alert commissioners and regulators to poor quality practice. This request recognises that there is a need to pull together across professions using a holistic biopsychosocial approach involving careful assessment and formulation of needs, risks and opportunities. This requires coordination of multi-professional, multi-agency care and support, fully involving the person and their family and building on their strengths. (RCPsych). DHSC to commission NICE to develop enhanced minimum standards for LTS and inpatient environments. These standards must be specified and published with particular consideration given to therapeutic and sensory needs. (DHSC).	Good practice guidance set out by the College must be central to ongoing postgraduate education to improve understanding and competence in psychiatric practice with respect to learning disabilities, autism and trauma and the appropriate use of inpatient admissions. Good practice guidance will be adhered to and regulated by professional bodies such as the GMC. The enhanced minimum standards for LTS and inpatient environment should be regulated by the CQC. Panel to initiate discussions with the Royal College of Nursing (and other professional bodies) about minimum standards of training for nurses and other clinical staff working with people with a learning disability and autistic people in inpatient and community settings.
To commission, skilled, safe, kind and appropriate person-centred support	There was poor commissioning, poor planning for discharge, inadequate service specifications and poor transition planning for people in LTS. There was a lack of (or perceived lack of) the right housing and/or community support in both health and social care, and education (where applicable), which prevented discharge. There was a lack of understanding / attention to the legal responsibilities of the differing agencies involved, including safeguarding.	Each person in LTS must have an experienced and skilled team appointed to implement IC(E)TR recommendations when advised by the IC(E)TR chair/panel. Progress should be subject to independent scrutiny. Where there are concerns about a person’s safety and wellbeing (as perceived by any party) while they are in LTS, a robust escalation process that is transparent and generates clear action and recommendations must take place to ensure that a person’s safety is immediately protected. CCGs, LAs and community providers must share responsibility for commissioning and providing local services that holistically meet the full range of needs of people with learning disability and those who are autistic in order to prevent admission or readmission to inpatient settings or the use of segregation and seclusion in any context. This range of services should include social care, health, mental health, education/life-long learning, legal, housing, transport and advocacy services. There must also be shared responsibility for managing risk upon discharge and in transition from hospital to care in the community. NHSE specialist commissioning must clearly agree and define the essential services to be provided locally to ensure the sustainability of people’s lives after discharge from hospital, including the provision of specialist community crisis support services.	To develop and pilot the use of bespoke intensive case management and capacity building teams. Cases will be referred by IC(E)TR chairs to NHSE for bespoke expert teams to be commissioned from preferred providers. These will be dedicated teams of experts that will support commissioners to resolve ‘blockages’ in the system that prevent individuals being moved to more appropriate, less restrictive settings, and will problem solve, case manage and build capability and capacity locally. (DHSC/NHSE). The capability and skills of commissioners must be improved through mandatory training and the development and implementation of a commissioner code of practice/quality (standards) network. This training should include knowledge on what good support (that promotes positive quality of life outcomes for those with learning disability and those who are autistic) looks like. (DHSC/NHSE). DHSC’s Chief Social worker is examining the safeguarding concerns that were raised as part of the IC(E)TR process. The findings will feed into work to improve the Safeguarding Code of Practice and provide clarity on current safeguarding processes for people in LTS and strengthen the mechanisms for intervention as part of this. The Children’s Chief Social Worker at DfE should be engaged in this process. (DHSC, DfE).	A patient safety commissioner should be appointed as set out in the Cumberlege report: ‘First Do No Harm’, to include responsibility for applying relevant recommendations to people with a learning disability or autistic people who are detained/in LTS. There must be a robust process of safeguarding (for children and adults) including a strengthened Code of Practice and escalation process, that is transparent and generates clear action to ensure that a person’s safety is immediately protected. The Panel will consider how oversight and independent scrutiny can be extended to people with long lengths of stay (12months or more). Leadership development in all commissioning areas should be considered with respect to commissioning and monitoring services for people with learning disabilities and autistic people. NHS and local authority commissioners must ensure that capability and expertise on learning disabilities and autism is strengthened and sustained locally. In line with the Care Act, commissioners must ensure that they have the right providers including housing providers available locally to ensure good quality, person centred care is available for people. Consideration should be given to developing a consortium of housing providers. Panel to further consider whether any regulation for commissioners is required in light of immediate actions proposed.
To ensure there is accountability for action particularly by commissioners	There was concern over the quality of previous reviews of care and lack of follow through on earlier recommendations. There was a perceived lack of urgency and a lack of accountability in both NHS and local government organisations about the wellbeing of individuals in LTS. The role of Mental Health Tribunals wasn’t sufficiently strong in safeguarding the rights of people with a learning disability or autistic people who are being detained.	Accountability to people with lived experience must be at the centre of service commissioning and provision. There must be greater transparency and mandatory reporting of restrictive practices, with segregation being notifiable to the regulator and commissioning boards and the Secretary of State. People in LTS must have their care independently and regularly reviewed with mandatory clinical and commissioner engagement in the process and on the recommendations. There must be strengthened escalation routes and stronger levers and interventions where commissioning is poor so that commissioners are accountable for their decisions. This should include ensuring the right community support and in ensuring that funding disputes will not cause delays to discharge or to an inadequately funded transition plan.	There must be better transparency and consistency of data on the number of people who are segregated, so that those who are in scope of this work can be quickly and easily identified. This requires establishing and evaluating how and to whom LTS should be notified. (CQC/NHSE). Independent reviews (IC(E)TRs) should continue and an independent review should be undertaken within 2 weeks of the commencement of segregation with progress in implementing the recommendations subject to independent review and scrutiny every three months or as advised by the review chair. (DHSC). Clear and immediate action to be taken on IC(E)TRs and C(E)TR recommendations with formal reporting by commissioners to the DHSC/Oversight Panel if previous reviews’ recommendations have not been acted upon. (DHSC and NHSE). Feedback from individuals and families must be sought following IC(E)TRs in addition to the feedback currently requested from commissioners and providers. These findings will feed into NHSE’s review of C(E)TR policy review to ensure that C(E)TRs are more effective and serve as early interventions for people who may be on a pathway to LTS. (NHSE and DHSC).	The use of segregation must be notifiable to both the regulator and to the senior officers with designated statutory responsibilities (DASS, DCS, CCG AO and the Secretary of State). Recommendations of the IC(E)TRs must be given formal standing and mandated as part of a Care and Treatment Plan (as recommended in MHA review) and must be considered by Mental Health Tribunals as well as at board level in commissioning organisations. Where C(E)TRs are not effective or where individuals are at risk of segregation, DHSC, NHSE and the CQC must establish a clear escalation route for individual cases to be independently reviewed. Commissioner and provider boards directly responsible for people currently in LTS (that is all independent providers; Mental Health Trusts; learning disability/autism care; all CCGs; all ICSs and STPs) must report regularly on progress on reducing use of segregation. The frequency and visibility of such reporting will be reviewed and may depend on organisational circumstances. The Mental Health Tribunal’s role is currently confined to considering whether the criteria for detention continue to be met. The Panel will consider how the Mental Health Tribunal system should be strengthened to ensure that the rights of people with learning disability or autistic people who are detained are being protected.
To listen to patients and families, put them at the centre of care planning and ensure skilled and appropriate representation/ advocacy	There was poor communication, a lack of respect and engagement of the person and their family. There was a lack of independent advocacy and difficulties in accessing legal advice.	Advocacy for people with learning disabilities, autism or both who are in LTS must meet minimum standards (for example must be accessible, competent, independent of the provider) and should be offered on an opt out basis. Individuals (and where appropriate, their families or nominated person) must be meaningfully supported to be involved and for their views and their feedback to be given appropriate weight (or reasons provided where this isn’t done) in discussions and decisions about their current and future care. A working relationship of trust and confidence with the individual and their family must be prioritised. Communication with family and the individual should be accessible, honest and transparent, communicated in everyday language, avoiding the use of jargon and with the option for translation services where needed. There must be greater clarity around the NHSE complaints process so that it is more accessible and adapted to meet the needs of patients and their families.	Each person and each family of a person in LTS should have access to a genuinely independent advocate in line with the MHA and Code of Practice. (Local government). Advocates must demonstrate the necessary specialist skills to support people with a learning disability or autistic people. This will be supported through a requirement for advocates to undertake mandatory training, which must be co-delivered and coproduced by experts by experience. (DHSC/advocacy organisations). The proposed reforms to the MHA must give due consideration to improving engagement and involvement of the individual and their family or nominated person in care and treatment reviews and in developing care and treatment plans. These should look at how advocacy can be provided independently on an opt-out basis. (DHSC).	NHSE’s complaints process should be simplified and there should be clarity on when complaints can be made to NHSE. There must be an easy read guide on complaints that is shared with patients and their families when the person is admitted to hospital. An independent and accredited list of legal experts to be established to offer advice on legal aspects of individual cases where people with a learning disability or autistic people are being kept in segregation. This is in addition to, and separate from, the right to be legally represented before a Mental Health Tribunal. Where mandatory training is being provided for advocates it would need to be compliant with the standards of Oliver McGowan training. Local plans for community provision must be co-produced with experts by experience and evidence-based ways of gathering their feedback must be implemented. This must be supported by clear guidelines for coproduction.
To make money work	Funding disputes which are usually between the local NHS and local authorities are causing delays to discharge. There is a lack of clarity of responsibility as between health and social care agencies, especially in relation to the joint duty under s117 MHA 1983 and role of housing. In many cases the lack of (or perceived lack of) appropriate housing was listed as a barrier to discharge.	Funding disputes must not adversely affect the planning and discharge arrangements for individuals in LTS. There must be greater transparency and clarity over how much funding is currently being spent in hospital, and ensuring it is being spent to achieve the IC(E)TR recommendations. Adequate transition and longer-term funding must be available to everyone in segregation so that a clear plan can be developed and implemented to meet their transitional and long-term care needs.	DHSC should consult through the MHA White Paper on strengthening duties to make sure LA and CCG commissioners ensure an adequate supply of community services for people with a learning disability and autistic. There should be a clear focus on funding requirements (for example a review of s117 effectiveness and a greater use of pooled budgets). (DHSC). DHSC should require commissioning bodies to provide assurance that the right value-led services are in place for this group of people and there should also be a requirement for commissioners to report spend more transparently to increase their accountability. (DHSC). There must be transparency about the process for allocating capital for housing. The process for accessing capital for housing should be simpler and faster to support discharge plans and ensure no unnecessary delays for individuals in LTS being moved into the community. (DHSC).	The Oversight Panel will continue to develop proposals on the allocation of personal budgets dedicated to developing and implementing personalised care plans for each person in LTS. The Oversight Panel will continue to develop proposals on the effective allocation of resources. It will further explore what barriers are currently preventing capital being made available to meet people’s housing needs in a timely manner and to consider how far the use of social enterprise funding and social bonds to invest in housing capital bespoke to individual needs further to the Bubb report has been taken forward. Existing funding models will be evaluated (for example Individual Service Funds) and any learning applied to improve the lives of those who are still in hospital to support prompt and successful discharge. The evaluation should take into account the potential wider system cost savings, including cost avoidance from reductions in readmission and responding to potential legislative challenge. Panel to consider the development of a consortia/list of housing providers to be identified nationally that have the skills and knowledge to deliver the person centred housing arrangements needed and with a mix of tenures, models and funding streams, including home ownership, tenancies, extra care, supported living networks, and specially designed housing that meets environmental and sensory needs. Consider how fast track capital grants could be implemented for people in LTS where required. Capital budgets should also include an amount for adaptations to make environments better and safer. Major damage repairs need to have a standard protocol around them before the person moves in to give the landlord assurance about how future costs will be met.
To continue to provide oversight and independent scrutiny	Oversight of the independent review process is crucial to ensure that there is consistency and that the overarching principles and aims of this work are applied. Oversight needs to be more robust to ensure that recommendations from the independent reviews are being implemented and that progress is being made to move people to less restrictive settings. The continued development of wider-reaching recommendations is necessary to have a lasting impact on the lives of people who have been subject to LTS.	Independent scrutiny (through IC(E)TRs) and oversight (through the Panel) should continue to ensure that recommendations made in IC(E)TRs are implemented. The work of the Oversight Panel should continue so that the implementation of immediate actions can be supported, and longer-term proposals can be developed to ensure that tangible and lasting improvements in care can be delivered.	An evaluation of IC(E)TRs must be conducted to support their continuation and identify any areas for improvement (DHSC, NSHE, CQC). The Oversight Panel appointments and current terms of reference to be extended for 3 months (to 31 March 2021). During this time DHSC and the Panel will develop and propose new terms of reference for its continuing role as part of the independent review process and to support the implementation of its proposed actions/recommendations. (DHSC). The Oversight Panel chair should be part of BtRS governance structures to represent the IC(E)TR work and support the delivery of urgent actions and solutions to improve care for people in LTS and prevent the use of segregation in future. (DHSC).	DHSC and the Oversight Panel will consider what an oversight function for this work should look like in the longer-term.
Other proposals	The use of restrictive practice is in some cases an aggravating factor for aggressive or destructive behaviour, particularly for autistic people. Many of the patients reviewed had acquired a criminal record while in hospital.	People with a learning disability or autistic people should never be unfairly prosecuted for actions that are a result of poor care or a poor environment that is not responsive or appropriate for their needs.	None	Legal representation for people with a learning disability or autistic people should be strengthened and CPS guidance reviewed to ensure that this group of people (particularly when subjected to restrictive practice) are not unfairly prosecuted.
Other proposals	There were concerns about the inappropriate use of hospital admission under the MHA. In many cases, hospitals are being used as a last resort for people with learning disabilities or autistic people. The MHA as it is currently constructed enables very poor practice.	The MHA must be reviewed to ensure that admissions are only used where there is direct therapeutic benefit.	Consideration of the circumstances in which the MHA 1983 should apply to people with learning disabilities and/or autism must be considered as part of the MHA White Paper consultation. (DHSC).	None