Recommendation 2 (commissioning)
In our Out of sight report, commissioning was identified as an area where improvement was needed.
The quality of commissioning is central to ensuring that people live in the best places. The standard of commissioning and the knowledge and expertise of commissioners makes the difference between people having their needs met and a positive future or living in an unsuitable place where their needs are not met.
All too often, people are moved to inappropriate places as the right ones cannot be found locally. People told us that commissioners did not always understand the needs of autistic people or people with a learning disability, which contributed to people being placed inappropriately. We therefore made recommendations to improve national oversight and ensure greater quality assurance of services and people’s care.
If recommendation 2 was fully implemented, people:
- would be in settings that are meeting their needs, rather than causing harm
- would experience more joined-up, consistent care, as there would be an effective mechanism for commissioners to be held accountable for their decisions
- with multiple needs would have a named person to make sure they receive regular reviews every three months
- would be supported in the right way in the right place because commissioners understand their needs and have had relevant training to help them develop their skills and make the right decisions
- would receive the right care in line with human rights because commissioners are checking and visiting services to ensure this.
Has recommendation 2 been achieved?
We consider that recommendation 2 has not been achieved
The appointment of a national commissioner has not been possible to achieve, because it requires a change in legislation. However, we welcome the recent announcement that a named lead for learning disabilities and autism will be on each local integrated care board.
Action needed:
- Commissioners need to develop the right services for people and with people, empowering them to lead the lives they want to lead.
- Local commissioning needs to have central accountability.
- Consideration should be given as to how this might be implemented locally alongside the new responsibilities of integrated care systems.
What we are seeing and hearing
For people with a learning disability and autistic people, the lack of a national commissioner meant there has been no-one to drive the delivery of new services and support a pace of change that is necessary to respond to the urgency of the situation. Commissioners are still not always working in partnership, and the focus remains on fitting people into available services with insufficient focus on designing the support that the person needs.
However, the appointment of a national commissioner who would have authority over health and local authorities requires a change in legislation. This has been explored and has not been possible so far. Discussion continues on the feasibility and appropriateness of implementing this recommendation.
The government recently confirmed their intention that all integrated care boards should have a named learning disability and autism lead. NHSE/I proposes to issue statutory guidance on this matter to assist integrated care boards.
People are telling us that they are not able to get the services they need, and that professionals do not listen to what they or their loved ones tell them they need.
The staffing crisis is also having an impact, as there are frequent changes in social workers. Far from the three-month reviews that we recommended, commissioners from the local authority are often not attending C(E)TRs and are not aware of when people in hospital are ready for discharge.
It can also be difficult for autistic people, who can find that commissioners do not understand their needs and therefore are less likely to be eligible for assessment and support under the Care Act 2014.
A new training qualification has been established for commissioners by Skills for Care and partners – Commissioning for Wellbeing – learning disability and autism. This is designed to support both health and social care commissioners to:
- have a good understanding of people with a learning disability and autistic people
- know what good co-production looks like
- look at innovative practices and recognising when things go wrong.
Eighty-one commissioners have so far completed the qualification so, while this is a welcome initiative, there is still a long way to go to ensure all commissioners have the knowledge and understanding needed to support people.
In response to our Interim report in 2019, the then Minister of State at the Department of Health and Social Care, Caroline Dinenage, committed to stronger oversight arrangements for people with a learning disability and autistic people in specialist mental health, learning disability or autism specific inpatient services. This led to a new host commissioning framework where, from March 2021, all inpatient services for people with a learning disability or autistic people should have a host commissioner in place, who should be a commissioner from the local area who oversees the quality of inpatient units in their area.
As part of the NHSE/I response to the Safeguarding adults review(SAR) concerning the deaths of Joanna, Jon and Ben at Cawston Park hospital, NHSE/I has committed to carrying out reviews to check the safety and wellbeing of people with a learning disability and autistic people in a mental health inpatient setting. This includes people whose care is being funded by NHS England and NHS Improvement, clinical commissioning groups and Mental Health Learning Disability and Autism Provider Collaboratives.
The intention of the reviews is for commissioners to check that people are safe and well in inpatient settings and take action if there is any evidence to suggest they are not. It is hoped that these reviews will have taken place by spring 2022. Following on from what we found in our Out of sight report, there are still concerns about how effectively hospital admissions meet some people’s needs and this needs to be further addressed by commissioners.
Recommendation 12 (monitoring restrictions)
If this recommendation was fully implemented, people:
- would have restrictive interventions monitored more closely by commissioners
- would have a plan in place that includes milestones to make sure that restrictions will end. Commissioners would check these milestones are being met. Where they are not, this would be escalated to NHS England.
Has recommendation 12 been achieved?
We consider that recommendation 12 has been partly achieved
Action needed:
- All commissioners and provider collaboratives need to ensure that people are receiving the least restrictive care possible and, where there are restrictions in place, there are clear steps to ensure these are ended.
What we are seeing and hearing
In the feedback we received from 12 senior managers in health and social care roles across eight local authority areas we heard from several that their ability to effectively monitor the use of restrictive interventions was limited. Two individuals from different local authority areas commented that the pandemic had impacted their monitoring activities.
However, some were more positive about their ability to effectively monitor the use of restrictive interventions. One commented that a multidisciplinary approach is taken to review cases involving restrictive interventions. They also noted that, where COVID-19 restrictions permitted, they would aim to visit services to ensure they see where individuals live and speak to them, as well as staff and family members.
As outlined in the chapter above for recommendation 2, there is commissioning oversight for people with a learning disability and autistic people in inpatient services. This is through host commissioning services, C(E)TRs and the Care Programme Approach. For those in long-term segregation there are additional IC(E)TRs. However, the impact of this improved monitoring and oversight is yet to be seen because people in hospital are still experiencing restrictive interventions and remaining in long-term segregation.
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What CQC has done to improve people’s experiences