People with learning disabilities are facing unnecessary suffering and even death because existing laws and guidance are not being followed by trusts.
This stark warning is the conclusion of an independent inquiry into health services for people with learning disabilities, led by former Guy's and St Thomas' foundation trust chief executive Sir Jonathan Michael.
He said: "We do not need a new framework. The legislation is already in place. The challenge is to make it work as effectively for people with learning disabilities as anybody else."
The inquiry urges the Department of Health to amend its core standards for better health to require "reasonable adjustments" to services to improve accessibility for people with learning disabilities.
It also calls for more regulation and inspection, better data and information systems, and compulsory education and training. The government should set up a new confidential inquiry and public health observatory and trust boards should be able to demonstrate that effective, legal, "reasonably adjusted" services are in place.
People with learning disabilities and their carers should be involved in delivery of care, as should "local experts" for strategic assessments.
Other demands are for increased partnership working and more direction for commissioners from government.
Sir Jonathan said a nationally negotiated incentive for GPs, known as a directed enhanced service, was the "only way" to achieve this last recommendation.
He said: "If the Department of Health accepts the recommendation about the directed enhanced service, the PCT will have to commission the DES, which will include regular health checks, data and information."
Speaking about the need for more regulation, he said: "People like the Care Quality Commission or the Healthcare Commission are used to asking organisations to give them evidence and provide statements of compliance with legislation. They just don't do it at the moment."
And he said PCTs should be assessing the needs of people with learning disabilities "within the context of the joint strategic needs assessment".
The report came as the department unveiled Anne Williams, Salford city council's strategic director and former president of the Association of Directors of Adult Social Services, as its new national director for learning disabilities.