I know quite a lot about learning disability. I know about it as a parent, a psychiatrist, a policy maker, and I also chair a charitable organisation that creates communication resources about life and relationships for people with learning disabilities. First, I commend the Government on their report, for the programme of action signed up to by 50 organisations, and for setting out what good care should look like. I also commend the serious case review conducted in such a painstaking way by my former colleague Dr Margaret Flynn.

The BMA under my presidency recently commissioned an expert round table in your Lordships’ House at which Dr Flynn spoke. I shall draw on the notes from that meeting in what I say. There is a story to tell which begins with a question: why were these very vulnerable people at Winterbourne View at all? The existence of Winterbourne View and similar hospitals represents a commissioning failure. Hospitals such as Winterbourne View have been considered unsuitable for more than 20 years. Jim Mansell’s first report on challenging behaviour in 1993 criticised the widespread core practice of exporting people with behaviour that challenged. A drawn-out, long-stay hospital programme that originally began after institutional scandals in the 1970s and 1980s was completed only just three or four years ago.

Even before the closure programme had been completed, new mainly private hospitals were already touting for business. As a policy adviser in 2001 I drew attention to this trend, as did others, but there were no incentives in place to encourage local providers to develop adequate local support for people. With some notable exceptions the practice of exporting patients similar to those who ended up in Winterbourne View continued. The sad journey of most of these patients began long before they arrived in hospital. The serious case review showed that. There were many lost opportunities to provide better, more personal and local care, but they were missed. Why were they placed such a long way from home? Typically a crisis happens just before a weekend and risk-averse professionals seek an emergency hospital bed somewhere, anywhere.

Many of these adults have had sad lives; they may have been abused, bullied or have had a traumatic bereavement. Such dislocation to a distant hospital can further disturb and re-traumatise them. On entering hospital, vulnerable adults depend on the nurses to get to know them and to understand and meet their needs, and on the other members of the team to draw up an active treatment plan. We have heard a great deal about the lack of compassion in different types of hospitals, but Winterbourne View was the site of systematic abuse by poorly paid and untrained staff with the wrong attitudes. They were unable to understand

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the communicative function of their patients’ behaviour; they lacked the skills to support them in a respectful and safe manner.

I am pleased to see the roles envisaged for Health Education England, the professional senate on learning disability and Skills for Care to turn this around. However, I agree with the noble Baroness, Lady Jolly, and the noble Lord, Lord Addington, that these staff need to be better supported. Some will need therapeutic supervision to enable them to care better.

Distant placements make it difficult for families and carers to provide oversight and protection, and yet the best safeguards for people with severe learning disabilities are the people who know and love them. I am glad that the DH final report and the concordat recognise that services must be provided locally and that containment must give way to personal care and personal treatment plans. The ordinary life that campaigners such as David Towell have argued for for so many years seems to be within the reach of even those whose behaviour challenges. Does the Minister believe that the timescale proposed to get people back home is realistic? I hope so.

Choice—an OFT-heard mantra—is a key principle of the Health and Social Care Act, but what sort of care would service users choose if they were able to? This is the question that those who commission and provide services need to ask. I am encouraged that the report expects people with learning disabilities and family carers to be involved in future CQC inspections.

Too often those close to vulnerable adults—many of whom wish to help—are still excluded from decision making. Personal budgets and direct payments provide one mechanism for more personal care but for people with behavioural challenges pooled budgets are needed to avoid financial arguments about whose responsibility it is to provide effective and timely care and support. People were placed at Winterbourne View by the NHS largely, but the NHS looked to the local authority to take responsibility for funding their rehabilitation. Where was the incentive? They were out of sight and out of mind. Does the Minister think that the new plans will provide adequate incentives to get people home?

NHS-funded care, whether in hospitals or the community, should deliver high-quality assessment and treatment and it should be evidence based. Winterbourne View was a hospital; its patients had mental health needs. Most were detained under legislation but they received little in the way of specialist health care. It seems to me that people with severe learning disabilities are still seen as second class citizens and not afforded the same rights as other citizens. The 2001 White Paper, Valuing People, challenged those assumptions and raised the hopes of people with learning disabilities and their families, but access to the same health care as others is still denied to many. This is as true of mental health services as physical health services.

Underfunding, a lack of 24/7 working, the separation of specialist learning disability services from primary care and mental health services means that even those specialist services cannot support and deliver the safe and timely care that people need. For example, in the

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case of specialist psychological therapy services, IAPT services and highly specialist psychotherapy services have not been adapted for people with learning disabilities. This is especially important for people whose behaviour challenges. Can the Minister clarify the expectations of the Government with respect to the mental and physical healthcare of this group? Does parity of esteem apply to this patient group too? It is disappointing that there is so little in the report about the range of mental health treatments that people need.

My first boss in learning disability, Joan Bicknell, recruited me back in 1981 because I was a medical psychotherapist and a family carer. She lectured extensively about the emotional lives of people with learning disabilities. I remember how sceptical her audiences were. How could people with little spoken language have feelings? Is this the same attitude that makes it possible for so-called carers to abuse the people they are caring for? Some of my research studied the effect of abuse and bereavement on people’s behaviour and emotions. To help their carers understand their inner world, I turned that research into picture books about life experiences for them to read together. More research is needed to help us understand what happens in people’s homes and what leads to behaviour that challenges. Can the Minister tell us whether there will be substantial investment in research, similar to that being used at King’s College to develop a care home research network for people living with dementia?

Winterbourne View hospital failed to meet the needs of these adults. How can we be sure that this time we do not forget; that the lessons from this tragedy are truly learnt and safeguards are put in place?

5.45 pm

Lord Maginnis of Drumglass: My Lords, I echo what has been said on the importance of closing these large impersonal assessment and treatment centres for people with a learning disability. Good-quality provision that is developed and delivered locally must be our aim and we must keep a watchful eye on local authorities, clinical commissioning groups and the Government to ensure that this happens. I am grateful to the noble Lord, Lord Rix, for raising this matter this evening, despite his domestic pressures. Perhaps I may say to him that we hope and pray that Lady Rix is soon well again.

I want to focus on what happened to the 48 patients who were in Winterbourne View hospital over the years from the time it opened in 2007 until it closed last year. That will, I believe, highlight the extent of the challenge that the Government’s programme of action faces. The Government’s report shows that in March of this year, 26 former Winterbourne patients had moved into a range of social care supported arrangements and 22 patients were in various in-patient facilities. I am sure I will not be alone when I say that one learns with considerable anger how 19 of these people have had to be subjected to a safeguarding alert in their new location.

In September 2012 the Government again looked at former patients and found 32 in a range of social care settings and 16 patients in in-patient settings. There

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were initial safeguarding alerts or active safeguarding procedures for six people. One of these people, Simone Blake—then just 18—faced some of the most outrageous and inhuman abuse at Winterbourne View. This included being drenched in water and left shivering and shaking on the freezing ground outside. You may recall her story from the follow-up “Panorama” programme earlier this year.

When Winterbourne closed, Simone was moved to a National Health Service hospital, Postern House in Wiltshire. Postern House was just 40 minutes’ drive from her parents, allowing them to visit her several times a week. In June this year, her parents received a letter from Ridgeway Partnership, the health trust that runs Postern House, telling them that Simone was again the subject of a safeguarding alert and that four members of staff had been suspended. However, the fact that two-thirds of the former patients have now been moved into social care settings shows what is possible and gives further credence to the Government’s programme of action to move all those inappropriately placed in hospitals to social care settings by June 2014. None the less, the fact that a significant number of former Winterbourne patients, such as Simone, have had to be subjected to further safeguarding alerts is shocking and should not be forgotten, and nor should it be overlooked that 27 people have required support subsequent to the trauma experienced at Winterbourne View hospital.

What assurances can the Government give that, as they seek to move those inappropriately placed in hospitals into community settings, they will be kept safe and offered support by appropriately skilled professionals? This challenge applies not only to the former patients at Winterbourne View but to every one of those others that the Government, through their programme of action, intend to relocate. Forgive me if a note of cynicism creeps into my voice, but at a time when Prime Ministerial apologies are coming two a penny on time-distorted issues from the distant past, one expects a great deal more than that in respect of this existing problem. What is so wrong must be rectified on an immediate and ongoing day-to-day basis. I want the Minister’s assurance we are not merely going to pay lip service through a process that is delegated and forgotten about until we reach an accounting period in 2014. Can she reassure us that 2014 will be an effective staging post on a journey that has progressed with full government support and participation based on professionally led community care that is delivered locally? We do not want a token start date for the Government’s programme of action. The year 2014 is too far ahead if you are someone like Simone Blake.

5.52 pm

Baroness Emerton: My Lords, I, too, congratulate the noble Lord, Lord Rix, on initiating this debate, and I congratulate my noble friend Lady Kidron on her outstanding maiden speech. I want to concentrate on the management of change in the situation that we find ourselves in, and perhaps I may take noble Lords back to the beginning of Winterbourne. I was called in with Professor Jim Mansell to look at the footage before it was put out on television and asked why in

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the late 1970s we had been able satisfactorily to relocate 1,115 and 1,112 patients respectively from two large institutions, all suffering from learning disabilities, after 10 years; and why, in 2011, we find the same things happening now as happened in the late 1970s.

I want to raise the issues that we found. First, what were the principles and what were the things that needed to be looked at? We needed a multi-professional team, a strategy, a programme and research. We had no idea that the project would take so long, but we set about it. I was most fortunate in recruiting the then young Professor Mansell as a psychologist and researcher. It was his first post, other than working at the Kushlick centre, since leaving university, having changed his degree after the Ely inquiry. He was outstanding in the field of care for those with learning disabilities and continued his research right up to his sad death last year. The principles were that patients should return to their district of origin; that they would be individually assessed and diagnosed with their treatment set out; that they would work to a programme; that the staff would be trained to meet that programme; and that accommodation would be suitable to the need. Membership of the project team was large—we had a psychiatrist, a psychologist, a researcher, members of social services and we set up a university department. The principles were clear—that no patient would be discharged without an assessment, training programme, support programme and suitable accommodation.

The barriers were enormous. The psychiatrists at the hospital were totally against it being closed and the patients themselves were not happy about going, because it had been their home for a long time. The relatives became very edgy because they thought that it was a safe haven and that going into the community would be unsafe and the recipients in the community had a little of the “not in my backyard” attitude. Finance was an issue but at the time it was government policy and we were able to get funding. On the question of accommodation, we had to look at all the different types of accommodation that might be available—houses, housing association flats, and very small units.

The patients with less challenging behaviours were the easiest to relocate. Those with more challenging behaviours were more restricted: specialist skills were required to care for them. Fortunately, because we had Professor Mansell, we were able to relocate all of these with the right treatments and staffing levels. The training programmes were for support workers, who were trained but obviously not registered, at that stage, since they had never been registered. We also had trained nurses and social workers and we went through the programme. Resistance was overcome by influence, persuasion and personal visits to local councils, social services and parents themselves, and by going to hear what the patients had to say. We made sure that the team, which worked extremely hard, remained committed to overcoming the barriers.

Near to the closure of the 1,500 bed hospital, most of the patients had been relocated back to the sites from where they had originally come, but some—mostly those with challenging behaviours—remained. We had to persuade those within the counties and the districts: we had seven local London districts as well as Kent and Sussex. It took time to persuade them that it was

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possible, but Professor Mansell was instrumental in persuading people that even those with the most severe challenging behaviour could be housed in the community. We eventually succeeded in getting them out—the decisions were taken and the assessments went on—and the communities began to accept them and were happy. We found, through visiting them, going round to tea with the residents, that they had settled and that the community had accepted them. The budgets were sorted and the patients were happy. I remember a flat in Camberwell where three elderly gentlemen who had been in hospital for 30 years said what a treat it was to be able to go to a fish and chip shop; they also invited us to tea.

The programme would not have succeeded without the leadership of Jim Mansell and the rest of the team. It would not have succeeded had we not used leadership, influence and persuasion, or if we had not trained the staff. Today, the noble Baroness, Lady Jolly, and other Members have mentioned the need to register support workers. We cannot go on without having that registration of support workers, who are trained to understand the special needs that go with learning disability.

The point of making this reminiscent therapy that I have gone through is that today we face the same barriers and issues, and we have to overcome them. I am grateful that we have been able to see the report from the Government but we need to address these barriers urgently. If we do not, it will be those who suffer from learning disabilities who will be disadvantaged.

6.01 pm

Lord Hunt of Kings Heath: My Lords, first, I pay tribute to the noble Lord, Lord Rix, who for so long has been a champion of people with learning disabilities. I always remember the late Lord Carter, who was the Chief Whip a few years ago, advising me that the noble Lord, Lord Rix, always gets his way in the House. That was certainly my experience as a Health Minister and my advice to the noble Baroness, Lady Northover, is to reflect very strongly on the points that he raised. I also very much welcome the maiden speech of the noble Baroness, Lady Kidron, which was excellent. We look forward to her contributing to our debates in the future.

The noble Lord, Lord Rix, made a number of very powerful points about the shocking events at Winterbourne View. He started by drawing attention to the contrast between policy and implementation. I suggest that that gap is what lies behind the unease clearly felt by many noble Lords today. We have had the welcome news from the Government that all current hospital placements are to be reviewed by next June and that everyone there who is inappropriately placed will move to community-based support as quickly as possible, and no later than June 2014. I would have thought that any assessment is likely to mean that many people will need to move to locally-based community care. Like the noble Baroness, I ask whether this is a realistic timetable in the circumstances in which health and social care finds itself at the moment.

We are going to expect a lot of commissioners, yet commissioning has led many people down. It is these commissioners who have been prepared to pay for

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people with learning disabilities to go miles and miles away from home and who have then forgotten about them. Does the noble Baroness, Lady Northover, really think that the commissioners are in a position to do what is required?

I would also refer to the changes in the National Health Service. I do not think that the primary care trusts can say that they dealt with this matter with any distinction but, my goodness me, what are clinical commissioning groups going to do? Can we be assured either that this is going to be done at a national level—or at least through the local offices of the national Commissioning Board—or, if it is to be done by clinical commissioning groups, that they will have the people with expertise? I am sceptical because there is no sign yet that clinical commissioning groups have people with enough seniority or expertise to do this kind of commissioning.

The noble Baroness, Lady Browning, made an important point about the owners and directors of these private institutions and their responsibilities. I have received a brief from Castlebeck, the people concerned with Winterbourne View, which details the actions it has taken and says that a new board of directors is in place. It also says that the shareholders who owned Castlebeck at the time of Winterbourne View have never drawn a return at any time and have now lost all their investment. However, there are still some serious questions about owner responsibilities. I refer noble Lords to the serious case review, which stated:

“Castlebeck Ltd appears to have made decisions about profitability, including shareholder returns, over and above decisions about the effective and humane delivery of assessment, treatment and rehabilitation”.

The review’s authors also say that,

“the corporate responsibility of Castlebeck Ltd remains to be addressed at the highest level”.

I would be grateful if the noble Baroness could say a little more about how the Government intend to do that. At the very least, will the Government require private companies to name the owners and members of the boards and details of their financial structure before they can be licensed and registered to provide publicly-funded care?

I will not labour the point on the regulation of health and social care workers. This will be the third time this week that the issue has arisen. There was also the Statement on Monday and the debate on nursing launched by the noble Baroness, Lady Emerton, only two days ago. However, persuasive arguments are being put forward for the regulation of these workers. On Wednesday, the noble Earl, Lord Howe, relied on the kind of voluntary registration that he proposed during the passage of the Health and Social Care Act. He also made it clear that the Independent Safeguarding Authority can take action to bar care workers from working in regulated activity. The point is that there are many circumstances where such workers may not have been brought to the attention of the Independent Safeguarding Authority, but may have been dismissed by, perhaps, the National Health Service or an institution and can simply go on to work in another place. We have examples of where that happens. The noble Earl

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also said—this is in relation to the NHS but it is just as relevant to Winterbourne View—that nurses,

“who are themselves subject to professional regulation … should not be asked to undertake a task for which they are not trained”.—[

Official Report

, 11/12/12; col. GC 295.]

He also said that healthcare assistants come under the supervision of those nurses. That ignores the strength of the employer as opposed to those healthcare workers and nurses. I accept that regulated nurses clearly have responsibilities, but to blame them for delegating responsibilities to healthcare assistants is wrong and unfair.

My noble friend Lord Touhig made some good points about hate crime and the challenge of care in the community. I want to end on that point. Care in the community has been the policy of successive Governments for more than 30 years. We now have a situation where money is very tight, particularly in local government, but also in the health service. The National Audit Office today signalled some of the pressures in the system. I ask the Minister this question. Do Ministers really understand what is happening on the ground? I do not think they do. They are living, not in a dream world, but one which has no link with the reality, the pressures and the strains. I end, as I started, with doubts about how on earth this change can be made within 18 months when the whole system is under such acute pressure.

6.08 pm

Baroness Northover: My Lords, I, too, congratulate the noble Lord, Lord Rix, on securing this debate. I am glad to see him back in his place and wish him and his wife well. He has a formidable record in this area and we are pleased to see him back here. He has been fighting for a long time for the rights of people like Simon, whom he mentioned.

There can be no more important issue for us as a society than how we treat our most vulnerable people, as my noble friend Lady Jolly and others emphasised. I, too, was impressed by the maiden speech of the noble Baroness, Lady Kidron. It was very moving and she absolutely rightly emphasised that this debate is about cases like that of Louise. If we cannot get things right for people like Louise and her family, we are not getting anything right.

I thank the noble Baroness, Lady Hollins, for her praise for the report issued this week. I assure the noble Lord, Lord Maginnis, of the huge commitment of my honourable friend Norman Lamb in this area. That commitment shines through in this uncompromising report. Stimulated by this terrible case, it does not just deal with Winterbourne View but looks at the whole sector with its radical proposals—which I am glad so many noble Lords welcomed. Noble Lords have, if anything, asked if those can be done and delivered, rather than questioning whether this is the right route to take. There is a firm and detailed timetable of action. I hope that noble Lords have marked that, including the noble Lord, Lord Hunt. I am sure that noble Lords will hold us to account. My honourable friend Norman Lamb will oversee this. He will leave organisations in no doubt of his commitment in this area.

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The scandal that unfolded at Winterbourne View was devastating but it has spurred us into action. Straight after the abuse was exposed, the Government commissioned an in-depth review. Noble Lords have referred to the report published earlier this week. As we said then, the Winterbourne View abuse was criminal. Staff whose job was to care for people instead routinely mistreated and abused them—as my noble friend Lady Jolly, the noble Lord, Lord Maginnis, and others said. Management allowed a culture of abuse to flourish. Warning signs were not picked up, and the concerns of residents’ families, and of a whistleblower, went unheeded.

As I have said, this case made us look again at how we care for one of society’s most vulnerable groups of people. Winterbourne View provided care for people with either learning disabilities or autism, together with mental health problems or challenging behaviour. Around the country some 15,000 people have similar needs, of whom some 3,400 are in in-patient settings. Many people receive good care in these settings but—as my honourable friend Norman Lamb, the noble Lord, Lord Touhig, and others have said—hospitals are not where people should live. Across the country, far too many people with learning disabilities or autism are in hospital and staying there too long. As the noble Lord, Lord Rix, and others emphasised, we have known for a long time that with the right support the vast majority of people with challenging behaviour who also have autism or a learning disability can live happy, fulfilled lives, close to their families and in their own communities—as Simon now is. When someone needs to be in hospital, it should be for a short period, in a small unit as close to their home as possible. I, too, pay tribute to Jim Mansell for all the work that he did on this.

We know what change is needed. It is now time to make sure it happens. First, owners, boards and senior managers must take responsibility for their services. I assure the noble Lord, Lord Rix, that we will examine how corporate bodies and their boards can be held to account for the provision of poor care and for harm experienced by people using their services. We will consider both regulatory and criminal sanctions, and will set out proposals in this area in spring 2013. I look forward to the noble Lord’s comments on those proposals. Of course, the noble Lord, Lord Hunt, is right to focus on the corporate responsibility of Castlebeck and other companies. I am sure that he will also scrutinise with great care the proposals that we bring forward. In addition, we will explore whether we can introduce a test to ensure that directors are fit and proper persons to oversee care. The CQC will consider a best practice model of care as part of its regulation of services from 2013. It will also check whether all providers are following national guidance or similar good practice. Where standards are not met, it will take enforcement action.

We will also stop people being placed in hospital—unless hospital is actually the best place to be. All current hospital placements, as noble Lords have referred to, will be reviewed by June 2013. Everyone who is there inappropriately will move to community-based support as quickly as possible—and no later than June 2014.

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6.15 pm

I assure the noble Lord, Lord Rix, and other noble Lords, of the involvement of parents and families in the review; they will have a key role. Additionally, every area will develop a plan to make sure that this group of people receives high-quality care. As a result, we expect to see a dramatic reduction in hospital placements. Noble Lords have made reference to that. The noble Lord, Lord Touhig, asked how we would ensure that we do not end up with people simply on the streets and the noble Lord, Lord Maginnis, and others hoped that moving to the community would ensure better care—putting a question mark over that.

I emphasise that the department has published good practice guidance and will be publishing further guidance and working with the CCGs and local authorities that are commissioning suitable care through joint improvement teams. As I mentioned, the involvement of families and advocates in what happens to family members is absolutely key. However, as the noble Baroness, Lady Kidron, points out, this cannot mean—must not mean—that families themselves find that they are the ones who are picking everything up.

The noble Baroness, Lady Hollins, and the noble Lord, Lord Hunt, asked about the timescale of getting people back home. We agree that the timescale is challenging, but we believe that it is realistic. It is vital—that is something which came through in noble Lords’ contributions. They have been waiting decades for this to happen. We must not slow it down now.

In terms of incentives to return home, we agree that people need to be in appropriate settings. The department will work with the improvement team to monitor very closely and report on progress nationally, including reporting comparative information on localities. A follow-up report will be published by December 2013 and repeated in December 2014.

I can assure the noble Lord, Lord Hunt, the noble Baroness, Lady Hollins, and others that this will be closely monitored. I can confirm to the noble Baroness, Lady Hollins, that parity of esteem does, of course, apply to this group of people. They deserve to have their rights respected—just like anyone else—and to have access to whatever mental health treatments they need. I also note what she says about the King’s College research networks and I will make sure that that is fed in to the department.

We will support a positive and open culture, where staff provide excellent care. As part of this, it is crucial that the staff working with people with challenging behaviour are properly trained in essential skills. We expect commissioners to assure themselves that providers are meeting proper training standards. Contracts should be dependent on assurances that staff are signed up to the proposed code of conduct that the Department of Health has commissioned, and that minimum induction and training standards for health and care assistants are being met. Noble Lords have referred to the regulation and training of workers in this area. A number of noble Lords expressed concern and it is indeed crucial that they meet these standards. Contracts within any remaining learning disability and autism centres or hospitals should be dependent on assurances that staff are signed up to these codes of conduct, which the

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department has commissioned from Skills for Health and Skills for Care. As I say, minimum induction and training standards will be required.

My noble friend Lord Addington also asked about this. I assure him that owners, boards of directors and senior managers of organisations must take responsibility for ensuring the quality and safety of their services. This is also an area that we are looking further at. From April 2013, Health Education England will have a duty to ensure that the system of education and training is supplying a skilled and high-quality workforce.

I realise that I am running short of time. With regard to autism, I say to my noble friend Lady Browning that we are currently putting together our plans for a review, which will be a priority for the Government. We are working closely with people with autism and their families, with service commissioners and providers and with relevant voluntary organisations to assess what impact the strategy has had in improving support and outcomes for people with autism and to consider what further action is needed. We will pay close attention to what she says, given all her experience.

My noble friend also asked about the Mental Capacity Act. There was post-legislative scrutiny of the Act in 2011, when a report was laid before the House of

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Commons. We absolutely agree that families are best placed to understand their loved ones’ wants and needs, and we are determined that there should be a closer partnership with families. There will be a further opportunity to look at this as we consider the Care and Support Bill. I am sure that my noble friend will look at it with all her experience and expertise, and we look forward to discussions on it with her.

All noble Lords agree that this is something that has to change—and change fast. I assure noble Lords of our enormous commitment, and of that of my honourable friend Norman Lamb. We will make these changes as quickly as possible. A concordat signed by more than 50 organisations set out the specific actions that each organisation committed to deliver. The NHS Commissioning Board and the Local Government Association will lead an improvement programme to supervise changes, and Norman Lamb personally will oversee progress. We must use the tragic events at Winterbourne View as the spur to make things better. There are places that are already getting this right. They show what can and should be done for all, and that a better life for people with learning disabilities and autism is within our grasp.

House adjourned at 6.21 pm