Luke Evans MP: speeches

Speeches

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  I would be grateful if the Minister could comment on the certificates being combined. There is a concern, if we go from two certificates to one, that the reason why two certificates were chosen in the first place could be lost, especially if the certificates are competing. There could be an incumbent preponderance towards one decision, when there were actually two conflicting decisions in the first place. I understand that this is about trying to reduce the administrative burden and having all the information in one place. Equally, however, it does make clinicians think twice, especially when they are supposed to be independent, about what is happening and why.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  There are a few questions to be answered. Given the nature of acquired brain injury—for example, the capacity of someone who has had a stroke can fluctuate—it is very hard from a clinical position to know where the benefit of treatment starts or finishes. We must future-proof the Bill. We have an ageing population, so we will see more people with dementia, strokes and acquired brain injuries for various reasons. There is a natural tension there, but it is only going to get worse over the next 20 or 30 years. How do the Government plan to address that? It is a concern.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  I cannot resist the opportunity to probe the Minister on something so important. He said that NHS England will predominantly look at this, but changes are happening there. Will he ensure that Gillick competence and the assessment of capacity will be at the heart of this? It is unclear now, given that it will take two years for NHS England to be abolished, who will take that on. Will he ensure that that is given due attention, as we have with physical health?

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  The Minister makes an excellent point, and that is part of the reason why the Opposition did not want to spring this question on the Government in an amendment or a vote, but rather to have the conversation first, because this is an important clause to get right. The two sides can be worked on in parallel when considering public safety more widely. Regarding safeguarding issues, as a GP dealing with children it is very common to share information with social services to allow them to have that central point, so that things are not missed. The principle of the checklist is to ask whether we are thinking about the individual patient. We have heard from patient testimony that that has to be paramount— No. 1—and that is the prima facie reason for having these provisions in the Bill. But, as we are considering this clause, given some of the cases and some of the holes, should we not consider asking clinicians, in statute, to think specifically about the risk, and wider risk, and what could be involved in the treatment? As the Minister rightly pointed out, if it was considered that certain individuals were not conforming with their medication regimen, or that there was a risk of them not doing so, or that they had a violent tendency when they relapsed, and had not met a threshold because they had never actually gone to prison or been through a court, but were known to police services, that grey area might pick something up if it were simply added to the checklist. I cannot think of many things, bar the patient—who is No. 1—more important than public safety. I put that point to the Minister to consider further in the light of those cases. I do not want to go into specifics, because it is not right to do so and he will be much closer to details than I am, but there is a widening principle over what we can do in this space.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  If the Minister will forgive me, I was not being facetious when asking for numbers; I was simply using it as an example. I am grateful to his officials for providing the numbers so quickly when I asked for them during the debate on clause 6. When he has the chance, could he write to Opposition Members setting out how that interaction works with the Ministry of Justice and what the numbers might look like? Forgive me if I have missed it, but I could not see it in the impact assessment. There is an implication not only for health, but for the justice side, which, as my hon. Friend the Member for Solihull West and Shirley said, makes a difference. My question was more to make sure that we are pragmatic in our approach, rather than getting into hardcore numbers at this stage.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  I welcome the Government’s recognition that modern technology can play a valuable role in improving care in the mental health system. The move to allow remote interviews and examinations for second opinion appointed doctors, through live audio or video links, reflects the realities of healthcare today and the potential for greater flexibility and efficiency. In particular, the so-called hybrid model, as set out in the explanatory note, could help speed up access to important second opinions and reduce delays in treatment decisions. That is especially welcome given the well documented pressures on mental health services and the vital role of second opinions in safeguarding patient rights. While the intention is laudable, however, I have a number of concerns to go through, because I believe that the House must consider them carefully. First, the clause leaves the clinician significant discretion to decide whether a remote assessment is appropriate, but it does not set out clear criteria or safeguards for how that decision should be made. Given the serious nature of second opinion assessments, which often authorise treatment without consent, we must ensure that the discretion does not lead to inconsistent or inappropriate use of remote methods. Secondly, mental health patients are a diverse group, and many face particular communication challenges. For example, a patient who has experienced a stroke may have speech impediments or difficulty understanding complex questions. Others may have conditions such as autism or dementia that make remote communication difficult or distressing. This was a really big topic in the other place, particularly as there are several esteemed colleagues who are part of the speech and language therapy fraternity, so it warrants a bit of attention. For example, we need to look at access to speech and language therapists. We also think about how these important communications needs will be assessed and accommodated. Will there be a statutory requirement for a clinician to consider patients’ communications abilities and preferences before opting for a remote interview? I am concerned that, without such safeguards, patients may be subjected to assessments that do not fully capture their conditions or views, undermining the quality and fairness of the process. The Minister—I think—hinted that this may be covered in the code of practice. I hope it is. Thirdly, the clause does not specify the role of patient consent or objection to remote access. Should patients have the right to request an in-person interview if they find remote contact unsuitable? This is not simply a matter of convenience; it is a question of whether we ensure the dignity, respect and meaningful participation in decisions about their own care. There is much debate in primary care about the role of video calls versus seeing a person face to face, and I would be interested to understand where the Government sit on that point. The Bill lacks any specific provision for regulatory oversight or standards to govern the use of remote assessments. How will the regulator—presumably the CQC, but I would be grateful for clarification on that point—monitor whether remote assessments are being used appropriately, given the vulnerability of these types of patients? What mechanisms will patients or their advocates have to raise concerns or complaints if they feel remote assessment was not adequate or, even worse, harmful? Finally, while technology can bring great benefits, it should never become a default substitute for face-to-face contact in mental health treatment decisions, especially where the stakes are so high. I assume the Minister appreciates that. Will this be set out clearly in the code of practice? Whose job is it to enforce that? Will there be a right to request an in-person interview, should the patient choose to? Has an equality impact assessment been undertaken to ensure that remote access does not disproportionately disadvantage those who suffer with communications difficulties or other vulnerabilities, or is that something that the Minister will implement in the code of practice? I would be grateful for some clarifications on those points, because it is really important to get it right when it comes to difficulties in communication, especially in this patient cohort.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  Forgive me, Mr Vickers; I will get to the point a little more briefly, but the whole point is that the person has to be appointed through the CQC. The CQC will make that decision, because by definition it is the body that makes such decisions. If it is not resourced properly or if it has problems, regulatory or otherwise, we will find ourselves in a very difficult position, which is why I am raising the issue. I am happy to curtail my speech.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  I appreciate the answer that the Minister gave, but we would like to probe the opinion of the Committee, given the principles that are enshrined in the Bill and childhood trauma is an example of something with a causal factor. Amendment proposed: 44, in clause 8, page 15, line 17, at end insert— “(iii) seeks to minimise the patient’s distress and promote psychological wellbeing and recovery from any childhood trauma;”.— (Dr Evans.) Question put, That the amendment be made.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  The Minister makes an excellent point about the services that are required, but key to all this is the underlying research. Has research already been commissioned into this? If not, would he look at commissioning in the space of ethnic minorities, the impacts of CTOs and mental health? That might shine a light on what further services will be needed, the reasons, and preventive measures, which the Government rightly put at the front of the agenda.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  My hon. Friend is a shrewd surveyor of legislation, and even foresees the amendments that I have tabled, which may well expose and shine a little light on something that might make a difference. In essence, he is right: trying to future-proof the Bill, while ensuring that it is robust and applicable, was at the heart of the first day’s debate and seems to be at the heart of today’s debate. As I said, the Mental Health Act confers extraordinary powers to detain and treat without consent and to deprive someone of their liberty, but in exchange there needs to be a clear, evidence-based justification for doing so. The clause goes some way to strengthening that justification, but only if the principle of therapeutic benefit is applied rigorously and not just diluted. Let me turn to amendments 44 and 45, tabled in my name on behalf of His Majesty’s Opposition, which speak to what my hon. Friend the Member for Farnham and Bordon just said. They seek to embed trauma- informed principles into the definition of “appropriate medical treatment” under the Mental Health Act. These amendments aim to ensure that medical treatment for mental disorder not only addresses symptoms but actively minimises patient distress, promotes psychological wellbeing and supports recovery from childhood trauma. There is robust and compelling evidence demonstrating that childhood trauma is a causal factor in the development of a wide range of mental health conditions. The “Adverse Childhood Experiences Study”, by Felitti et al. in 1988, demonstrated a strong dose response relationship between the number of traumatic experiences in childhood and the likelihood of developing of mental health disorders later in life, including depression, anxiety, psychosis and substance misuse. Neuroscientific studies such as Teicher et al. in 2016 have revealed how early maltreatment alters brain structures and functions critical to emotional regulation and stress response. A review of trauma and psychosis by Read et al. in 2005 identified childhood trauma as a significant risk factor for several mental illnesses, including psychiatric disorders. Furthermore, clinical guidance such as NICE’s 2018 recommendations emphasises the importance of assessing trauma history and incorporating trauma-focused interventions into care. These findings are reflected in UK health policy, with the Department of Health recognising trauma-informed care as essential for effective mental health services. We also know from clinical studies that trauma history influences treatment outcomes, with trauma-uninformed care risking re-traumatisation and poor recovery. It is vital to stress that recognising trauma as a causal factor is not about excusing behaviour but about understanding behaviour. Such understanding enables clinicians and services to respond more compassionately and effectively, supporting genuine recovery and healing, rather than merely managing symptoms or controlling behaviour. Embedding trauma-informed care in law is a progressive step that aligns with modern mental health best practice and respects the lived experience of many retained under the Act, the majority of whom have experienced significant trauma in their lives. If the Government do not accept these amendments, can the Minister clarify what steps they will take to ensure that trauma-informed approaches are embedded in mental health services? Will there be guidance, training or oversight in the mechanisms to ensure that patient distress is minimised and psychological wellbeing promoted?

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  I am frantically trying to find the exact point in the explanatory notes—I think it is in either paragraph 114 or paragraph 115—about where the second opinion comes together. There is a reference to having a combined certificate. That seems to be a practical solution, but I worry about the crossover relating to who may or may not be affected. If the Minister wrote to me on that point, it might be easier to move the Committee on.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  I will speak to clause 8 first, then work my way through the other provisions in the group. The clause will introduce a statutory requirement that medical treatment under the Act must have a reasonable prospect of therapeutic benefit for the individual. This is a significant and, I believe, welcome development, bringing the law into closer alignment with modern principles of person-centred care and clinical justification. Again, the intention is clear: to ensure that no one is detained or treated under compulsion unless there is a realistic chance that they will benefit from the treatment. That is another laudable aim, and as a doctor myself, I fully support it. Significant concerns have been raised that individuals, especially those with complex or treatment-resistant conditions, have been subject to interventions where the purpose was therapeutic but the likelihood of benefit was minimal or uncertain. By introducing a consistent legal definition of appropriate medical treatment early in the Mental Health Act, and ensuring its application across both civil and forensic pathways, the clause marks a step forward in rights protection and clinical accountability. I welcome the shift away from vague references to appropriateness towards a test that is both objective and patient specific; however, several important questions remain, and I hope the Minister will address them. The first is on defining a reasonable prospect in practice. While the term “reasonable prospect” is a flexible one, that flexibility cuts both ways. The explanatory notes clarify that clinicians do not need to conclude that the benefit is more likely than not, only that it is reasonably possible, but what guidance will clinicians receive to ensure that this threshold is applied consistently and fairly across the country? Will the updated codes of practice provide clear examples or scenarios, and will the guidance be subject to consultation with patients, carers and professionals? When it comes to forensic patients, and equity and safeguards, I welcome the fact that the clause applies equally to part III patients, who are involved in the criminal justice system. Historically, this group has sometimes been subject to more coercive and less scrutinised care pathways. Will the Minister confirm that the same therapeutic benefit test will apply at every decision point—initial detention, transfer, conditional discharge and recall—so that forensic patients are not denied the safeguards enjoyed by civil patients? When it comes to legal remedies and review, what mechanisms will be available to patients who believe that the reasonable prospect test has not been met? Will this be a justifiable cause in tribunals or courts? Will mental health tribunals be empowered to scrutinise the clinical judgments behind this test, and if so, what training will be provided to tribunal members? While I welcome the statutory clarity that clause 8 brings, we must be mindful that legislative change is only the first step: implementation will be critical. I would hope the Government will publish a clear timetable for updating the codes of practice, as well as plans for training, auditing and evaluation. Without that, there is a risk that the reasonable prospect test becomes, again, a box-ticking exercise rather than a meaningful safeguard. Finally, I want to focus particularly on how the measure will apply to people who have long-term, complex or non-degenerative mental conditions where there may be limited, if any, prospect of clinical improvement through medical intervention. These include, but are not limited to, some forms of autism, learning disabilities and personality disorders, particularly those for which trauma-informed approaches may be more appropriate than medical ones. What about acquired brain injuries, or individuals with treatment-resistant psychosis or chronic conditions for which medication has been ineffective? Under the Mental Health Act, such individuals can be and are detained for prolonged periods, sometimes years, even when no clear therapeutic progress is being made. Families, advocates and patients themselves frequently describe a sense of clinical limbo—being held under compulsion with little hope of change, because the system has no better option. Of course, that is one of the big reasons for the Bill in the first place, and it brings with it an entirely new set of problematic scenarios that need careful consideration. In short, the prize of clause 8 is that that limbo should no longer happen: detention and compulsory treatment should occur only when there is a reasonable prospect of actual benefit. How will clinicians be expected to assess the prospect of benefit in cases in which a condition is not considered medically treatable in the conventional sense? For example, if a person with autism is detained during a crisis, but their underlying condition is not one that responds to medication, will the presence of social support or behavioural interventions be considered sufficient to meet the threshold of therapeutic benefit? Will the Government clarify that detention is not justified when the primary issue is risk management, rather than therapeutic progress? There is a long-standing concern that individuals are being detained primarily because of perceived risk, even when there is no viable treatment plan likely to improve their condition. Clause 8 provides an opportunity to set a clear boundary: that risk alone is not enough; there needs to be a reasonable prospect of improving the person’s mental health through treatment. How will the new test interact with decisions around discharge and the renewal of detention? If a person has been detained and the anticipated benefit of treatment has not materialised, will the failure to have achieved a benefit trigger a presumption of discharge, or at least a fresh review of the justification for ongoing detention? Will there be specific guidance in the revised code that addresses how the new tests apply to conditions such as brain injuries? After a recent question, I know that the Government are continuing with the brain injury strategy, but has there been any work on how that can be incorporated? Those are not mere technical questions; they speak to the ethical foundations of the Mental Health Act, which confers extraordinary powers to detain and treat without consent and to deprive someone of their liberty.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  I will resist the temptation to go back to the start of my speech; I am sure that the Committee’s memories of it will have lasted over our short lunch break. I was saying that although the Government’s reforms are, on the whole, positive, we must remain vigilant. The consideration of risks must be applied carefully and consistently to avoid unintended consequences such as deterring clinicians from using community treatment orders when they are genuinely needed or, conversely, enabling an overly cautious approach that restricts patients unnecessarily. We should also be mindful that some patients may find the process of extension and review stressful or confusing. Clear communication and patient involvement, as mandated, must be prioritised to uphold dignity and autonomy. Will the code of conduct aim to ensure a clear and definitive process for keeping patients and their advocates informed as to their rights in the process and what to expect? The Committee must also address a key reason why this part of the law is being amended and why there is so much concern about the current state of mental health legislation: racial disparities. This concern is well documented. There is disproportionate use of CTOs on black men. We have known for years that black people, particularly black men, are more likely to be detained, more likely to be diagnosed with a psychiatric disorder and more likely to be subject to coercive interventions under the Mental Health Act 1983. Those things are clear for all to see, but the reasons are not so clear. We should address the well-documented racial disparities in the use of CTOs. The 2018 independent review of the Act makes it clear that black African and black Caribbean people are disproportionately detained under the Act and subject to CTOs. Despite representing a small percentage of the population, black patients account for a disproportionately high number of CTOs: digital data from the NHS in 2019-20 shows that they make up 13% of CTOs, compared with just 3% of the population. That is supported by research published in BJPsych Open , which found that black patients are roughly two to three times more likely than white patients to be subject to a CTO. The Care Quality Commission has highlighted the disproportionate impact of CTOs on the black and minority ethnic community, raising serious concerns about trust and engagement with mental health services. What does not seem so clear is the reason why. Although we are observing clear disparities in outcome and treatment experiences among ethnic minorities in the UK health system, including in mental health care and beyond, the precise cause remains complex and not fully understood. The patterns that we are seeing, such as disproportionate detention rates, difference in access and poor outcomes, raise serious concerns about care in the UK. However, it is important to recognise that correlation is not causation. These disparities may arise from a range of factors, including biological or genetic factors, socio-economic inequalities, cultural differences, health status or presentation and geographical settings, and there is even the possibility of biases within the service. To develop effective solutions, we must invest in rigorous and independent research that moves beyond correlation to explore the underlying causes and mechanisms. Only then can we decide on interventions that truly address the roots of inequality, rather than just the symptoms. To that end, what steps is the Minister taking to better understand what is happening with CTOs in the field of serious mental health specifically? What concrete action will the Government take to collect better and more granular data on the disproportionality? It is not just about the numbers; it is about understanding the root cause. Will the Government commit to commissioning quantitative as well as qualitative research into the lived experience under CTOs of black patients in particular? Will they consult community organisations as part of that work? I worry that not fully understanding the cause of the problem will mean that, at best, we might slightly mitigate it and, at worst, we will compound it or create a new problem that is harder to treat. Clause 6 represents a thoughtful step towards balancing patient liberty with patient safety and clinical necessity. It will strengthen safeguards, clarify criteria and promote regular oversight, all of which are crucial for the ethical and effective use of CTOs. However, in using CTOs, we must better understand what is happening in the real world. We must not jump to a simplistic cause of systemic bias without truly understanding that cause, and not simply the correlation. I look forward to hearing from the Minister on that point. With that in mind, I turn to Government amendment 30, which will remove the review of CTOs. It was tabled in the other place by the Lib Dem Lords but received support from across the House. The amendment would remove subsection (3) from clause 6. Subsection (3) is designed to introduce statutory safeguards around the use and duration of community treatment orders. In the Lords and more widely, there is, rightly, much debate about CTOs and their place and use. When used appropriately, in a careful and considered context, they can provide a less restrictive alternative to hospital detention and enable patients to continue their recovery in the community. However, the key word is “appropriately”. That is why the Opposition have concerns about the removal of the subsection. It contains reasonable, proportionate safeguards that do not undermine the purpose of CTOs but strengthen their legitimacy, transparency and accountability. Under the Government’s proposal, those safeguards—such as a 12-month maximum duration, regular six-month reviews, and the requirement to consult independent psychiatrists before extending a CTO—would no longer be set out in statute. Instead, we are told that clinicians will be guided by a code of practice and existing professional standards. However, why rely on guidance when we can legislate for clarity and protection? Will the Minister explain why the Government prefer a non-binding code of practice over statutory time limits and reviews, particularly as CTOs involve a significant curtailment of liberty? Does he believe that that is congruent with the principles now enshrined in the Bill? The stakes may be too high to depend on discretion alone. CTOs are one of the few mechanisms in the health system through which someone can be compelled to comply with treatment in the community and can potentially be recalled to hospital, even if they are not in crisis. That makes clear oversight essential. The Government assert that tribunals will serve as a safeguard, with more frequent referrals. However, as many colleagues have pointed out, tribunals often defer to the clinical judgment presented to them, which risks creating a loop. Forgive me, but will the Minister tell the House how many tribunals overturn or terminate CTOs at those reviews? Does he believe that they are robust enough to act as an effective check? Are they simply a procedural step? To that end, what steps is the Minister taking to better understand what is happening specifically in the field of serious mental health? What concrete action can we expect in order to better collect the data? When the Government proposed the amendment that would remove subsection (3), they introduced important safeguards about the duration, review and oversight of community treatment orders. I acknowledge the Government’s position, and Ministers have been clear that they are responding to the concerns raised by stake-holders—including clinicians who support patients with eating disorders, and clinicians in forensic settings—that a rigid time limit on CTOs might remove necessary support from those who are still benefiting from them. That position was reflected in the letter circulated on 11 December 2024 by Baroness Merron, following the debate in the other place. It says that a “strict time limit risks removing support for those patients who were benefiting from Community Treatment Orders.” It continues: “This wouldn’t feel in keeping with the principle of treating the person as an individual.” I understand that concern. We all want a mental health system that recognises nuanced personal need and clinical judgment. However, the Government amendment goes well beyond preserving flexibility. By removing subsection (3), it strips away a carefully balanced set of protections—not just time limits but essential oversight that will prevent CTOs from drifting on indefinitely, without structured review or patient involvement. Removing subsection (3) is a backward step. As things stand, CTOs can be renewed, year after year, with limited scrutiny. The evidence from the 2018 independent review of the Mental Health Act suggests that CTOs do not demonstrate reduced readmission rates. Yet many patients, especially those from racialised communities, remain under CTOs for far longer than may be clinically justified. Subsection (3) did not ban long-term CTOs. It simply said that if a clinician wanted to go beyond 12 months, they must consult the patient, their nominated person and other professions involved, review whether the order was still working, and get a second opinion from a GMC-registered psychiatrist. That is not inflexible; it is good clinical governance. The code of practice is not enough. The Government say that they will address concerns in the code of practice. In the same ministerial letter, we are told: “We will set out the expectation that Community Treatment Orders should end after two years...whilst highlighting that this should take into account clinical discretion.” We all know that an expectation is not a guarantee. The code is important, but it is not binding. There is no requirement to follow it—only to “have regard” to it—and there are no consequences for ignoring it. Where is the accountability? The amendment deletes a provision that would have created a real legal framework for oversight and replaces it with possibly just a promise and a footnote. Tribunal oversight is not a substitute. The Government’s letter also highlights a plan to increase automatic tribunal referrals. That is welcome, but tribunals are not a substitute for proactive clinical reviews. Patients often lack the means or confidence to engage in hearings, and tribunals can only act on the evidence presented to them. Subsection (3) was about making sure reviews happened automatically, in a transparent and collaborative way—not at the point of breakdown or challenge, but as routine best practice. If a code of practice expectation is ignored, what recourse does a patient have? Why is it acceptable for a CTO to continue indefinitely without any formal review of its effectiveness? Why is a second clinical opinion seen as burdensome in mental health, when it can often be standard practice in many other areas of medicine? Given the maths of the Committee, we are unlikely to keep the subsection, but if the Government are determined to remove it, I urge them seriously to consider alternatives. For example, that could be a statutory requirement for annual review, especially after the first 12 months, mandatory consultation with the patient and key professionals before extension, or a duty to record and publish anonymised data on CTO use, disaggregated by duration, diagnosis, and ethnicity. If we are to “keep CTOs under review”, as the Government promised in their letter, why not put that commitment into legislation, with timelines, transparency, and lived experience input? Returning to the issue of the disproportionate use of CTOs on black men, we have known for years that they are more likely to be detained. I gently ask the Minister what concrete actions the Government will take to collect better, more granular data on that disproportionality, not just in terms of numbers, but the root cause. As my noble Friend Lord Kamall rightly asked, what do we know, what do we not know and what do we need to find out? Those are vital questions, but research alone will not solve the problem unless we embed fairness and accountability into the system now. The safeguards in subsection (3) are not bureaucratic red tape. They are vital protections to ensure that CTOs are used only when necessary, and that they are time-limited, reviewed regularly and subject to independent scrutiny. If a CTO is working and genuinely benefiting the patient, then what harm is there in requiring a transparent, collaborative review process to justify its continuation beyond 12 months? Those safeguards would also ensure that patients and their advocates, including their nominated person, are part of the decision making. That is entirely in line with the broader ethos of the Bill: respect, dignity, and least-restrictive care. The Bill is about modernising mental health law. CTOs sit at a crossroads of care and coercion. That is precisely why they demand more scrutiny, not less. The clause, as originally drafted, struck a sensible, balanced compromise. To strip it away is not clinical freedom; it is a loss of legal safeguards for some of the most vulnerable people in our care. I urge the Committee to retain these statutory provisions. They strike the right balance between preserving the appropriate use of CTOs and protecting patient rights and promoting accountability. We owe it to those who are subject to the powers, who are often some of the most vulnerable, to ensure that their care is just, proportionate and based on evidence.

• 12 Jun 2025 · Mental Health Bill [ Lords ] (Fourth sitting) · Hansard source

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  I am grateful for the opportunity to scrutinise clauses 13 and 14. Clause 13 will make significant amendments to how medical treatment is administered under the Mental Health Act 1983 in circumstances in which a patient refuses, or is deemed to have refused, that treatment. The clause points us to significant questions about autonomy, capacity and compulsion. I hope that we can explore those issues in a way that does justice to the patients affected and to the clinicians working under the framework. Under current law, in particular section 63 of the Mental Health Act, a patient detained under the Act can be given medical treatment for their mental disorder without their consent, even if they have capacity to refuse. That includes in situations where the patient has made a valid and applicable advance decision, or where a donee under a lasting power of attorney, a court-appointed deputy or indeed the Court of Protection itself has indicated that the treatment should not be given. That power is curtailed only for certain treatments, such as electroconvulsive therapy, which falls under section 58A, and some surgical procedures under section 57, where either consent or a second opinion is already required. We will be debating those separately. Moreover, in the case of psychotropic medication under section 58, treatment can typically be given for up to three months without any second opinion, even if the patient objects. The clause will introduce a proposed new section 57A, significantly shifting the landscape. It will extend safeguards to cases in which a patient has capacity but refuses treatment, a valid and applicable advance decision refuses treatment, or a refusal is issued by a donee, a deputy or the Court of Protection. In such cases, treatment could be given only if a second opinion appointed doctor certifies that the treatment is clinically appropriate; there is a “compelling reason” to give it, such as no acceptable alternative; and the process has followed a newly required clinical checklist. This is a clear move to give greater legal weight to patient choice and prior decision making, echoing the long-standing principles of the Mental Capacity Act 2005. It would also mark a significant tightening of powers under section 63, making it harder to override refusals of treatment, and in effect it would end the practice of giving compulsory medication in the first three months without external oversight, at least where a refusal or conflicting decision exists. It is worth touching on the interaction between the Bill and the Mental Capacity Act. We have talked about that framework before, but it allows for advance decisions to refuse treatment and recognises the authority of donees under a lasting power of attorney, court-appointed deputies and the Court of Protection to look at best interests. Historically, however, the Mental Health Act 1983 has operated in parallel, and at times in conflict, by allowing compulsory treatment for mental disorder, even in cases where patients have capacity. By inserting proposed new section 57A, the clause attempts to bridge that gap by preventing certain treatments from being administered where they would conflict with an advance refusal or decision. That represents a welcome shift, but there are some concerns to which we need to turn our attention. For example, the “compelling reason” threshold is undefined in statute and could allow significant variation in interpretation. There is a reference to the checklist in section 56A, but—forgive me—I do not believe that that quite covers the definition. There is also a risk that, in practice, time pressures or institutional cultures may erode the intended safeguards, in particular if urgent treatment provisions under section 62 are overused, so I will discuss those a little further in detail. I recognise that the intent behind clause 13 is to place the principle of autonomy and choice at the heart of mental health care—that is a welcome and overdue shift—but given that it introduces the concept of compelling reason to override a refusal of treatment, will the Minister clarify how “compelling” will be interpreted in practice? Will statutory guidance define the term to ensure consistency, or will it be left to the discretion of individual clinicians and the second opinion appointed doctor? Secondly, the clause strengthens the role of the SOAD, requiring not just clinical oversight but legal and ethical judgment, including engagement with advance decisions and decisions of legal proxies. What training and support will be provided to SOADs to equip them for the expanded roles? How will the Government ensure that the system is properly resourced to avoid delays? Thirdly, will there be a clear right of appeal or review for patients or their legal representatives when an SOAD certifies treatment in the face of an objection? I am conscious that there are real-world examples. For instance, let us take the case of a patient with bipolar disorder who is detained under the Mental Health Act. When they are in a stable state, they might clearly and calmly refuse a particular medication because they have experienced harmful side effects from it in the past—the Minister even used that as an example. At that point, they have capacity and their decision is valid. However, during a later episode of acute illness, they might temporarily lose capacity, and in that window the clinician would potentially override their earlier decision, even if it was made with full understanding. This amendment aims to protect such refusals, but unless the law is clear about how to treat prior capacitous decisions during periods of incapacity, there is a risk that well-considered patient choice could still be sidestepped. This problem will get only more common, given the number of people with dementia and acquired brain injuries. Fourthly, the clause enhances safeguards, which is crucial, but it could result in unintended harms. What assessment has been made of the risk that necessary treatment may be delayed or denied in complex cases, especially where SOAD access is limited or where there is disagreement about whether an advance decision is valid or applicable? Although I support greater emphasis on patient autonomy, we must consider those at the greatest risk of harm. Do the Government believe that clause 13 strikes the right balance between protecting liberty and ensuring prompt, effective care for the most acutely unwell? Have they any concerns about what that could mean for public safety? Has an impact assessment been carried out on what that could mean in the real world and the implications, given the recent high-profile cases that we just talked about? Clause 14 shortens the period before a second opinion is required for certain types of treatment from three to two months. That is a positive step in principle, and ensures that patients who either lack capacity or have not consented are not left too long without independent oversight. It also allows, where clause 13 applies, for a single certificate to be issued by the second opinion appointed doctor, which covers both standard review under section 58 of the Mental Health Act and the more complex safeguards in proposed new section 57A. That may help to reduce duplication and administrative burdens. The table on page 25 of the explanatory notes gives an overview of how that might work, but I would welcome reassurance on a few points. How will the distinct legal tests, such as assessing a patient’s capacity, rather than determining a compelling reason for overriding an advance decision, be kept clear and robust in one single combined certificate? What safeguards will be in place to ensure that streamlining does not weaken the new protections in clause 13? Let us imagine that a patient has made an advance decision to refuse a particular antipsychotic medication—let us call it medication A. They are detained under the Mental Health Act, and the clinical team wants to give them medication A anyway. Because the patient lacks capacity and the proposed treatment goes against a valid advance decision, the special safeguards under proposed new section 57A apply, yet at the same time it has been nearly two months since the patient started treatment, so a second opinion under section 58 is also needed to check whether any medication is appropriate more generally. Clause 13 allows for those two approvals—one for the general treatment under section 58 and one for treatment despite the patient’s known refusal under proposed new section 57A—to be combined into one certificate. The concern is that, in streamlining, the different legal and ethical issues might be collapsed into a broader decision, making it harder to see whether the patient’s advance refusal was properly considered and whether the decision to override has met the compelling reasons test. Can the Minister specify how that might work, given that there will now be one certificate? Clinicians and reviewers might unintentionally treat the refusal as just another case of lack of capacity, rather than the serious, rights-based objections that require extra scrutiny. On the issue of practicality, with the review period being brought forward by a month, are the Government confident that a second opinion system is resourced to meet the demands without compromising quality? I could go on, but for the sake of the Committee, I will not.

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  The Opposition appreciate the timescale taken to skill-up in this area, but the workforce plan is soon to be announced by the hon. Member’s Government. Has any consideration been made of what the capacity might look like, and of the crossover between having this legislation not quite in place—although likely to happen, upon Royal Assent—and its impact on updating the workforce plan on mental health?

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  The Minister is right that there is shared working. However, part of the problem between devolved nations, such as Scotland and Wales, is that the datasets and definitions of data are often changed. Actually, the comparison of data across the UK can be quite hard to manage. Given that we are talking specifically about mental health, including some of the most at-risk people with the most severe mental health illnesses, will the Government commit to pushing for shared data that is comparable between Scotland and Wales, which we are legislating on in this case, to ensure that there is data transparency, so no one country can hide behind a different comparison or by saying, “We are looking at apples and pears”?

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  I rise to speak to Liberal Democrat amendments 1 to 7 and 51 to clause 4. I welcome the intention behind the amendments, which aim to enhance the care and treatment review process for people with autism and learning disabilities, particularly by addressing housing and accommodation needs and ensuring that key advocates receive reports. There are positive elements of the amendments that are worth highlighting. I understand the good intent of including housing and accommodation considerations explicitly in reviews, as it recognises that a person’s living situation is often central to their wellbeing and recovery. Additionally, ensuring that nominated persons and independent mental health advocates receive reports promptly promotes transparency and patient advocacy. Shortening the review intervals from 12 to six months could lead to more responsive care planning. However, I have some significant reservations about the statutory implications of blurring housing, for example, so directly with the care and treatment review process. Housing is traditionally managed under separate statutory frameworks from health and social care, so to embed housing as a statutory element within these reviews risks creating confusion about which agency holds responsibility and may expose health bodies or commissioners to legal obligations that they are neither funded nor structured for. I have a few questions for the Liberal Democrats. In their eyes, how would the Government ensure clarity over the statutory duties applied to housing recommendations arising from the reviews? Would that not risk delaying or complicating discharges if housing issues became a statutory sticking point within health-led care reviews? Moreover, housing provision often depends on local authorities and housing departments that have their own complex eligibility criteria and resourcing constraints. Are we confident that ICBs and responsible commissioners would be able to co-ordinate effectively across these boundaries, especially given the patchwork of funding and powers in play?

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  I entirely agree, and I hope that data is and will be shared. The question is about the definitions and standards, such as those used for waiting times. We often use the A&E waiting time of four hours. When it comes to the most vulnerable patients who will potentially be on waiting lists, or looking at specific data, if it is categorised differently in Wales, Scotland and England, that makes it very hard to see where best practice is so that it can be shared. That is the Opposition’s concern. I know that both sides of the House have shared that concern in my five years in Parliament. Is there a mechanism to address that issue either in the Bill or in the Minister’s wider portfolio?

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  I agree with the Minister. Does the Department have a rough idea of the timetable for putting in place the code of practice? How long will the consultation need to take? When will it be implemented? How many rounds go with it? How wide is it to be—will it consult across England and Wales, or just in England?

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  I want to expand a little on the practicalities and respond to the question asked by my hon. Friend the Member for Farnham and Bordon about local authorities. I declare an interest because Leicestershire is one of the 21 county councils going through a devolution process. About 85% of its budget deals with special educational needs and social care. It is part of an ICB where the mental health team and primary and secondary care come together, but there is oversight from NHS England. With so many moving parts, including the legislation we are putting in place, the budgetary constraints for ICBs, and the fact that we are getting rid of NHS England, there is a real worry among Opposition Members that things could drop through the gap, or more likely, that because we are moving all these things at the same time, we do not decide which is the fixed point that leads where others follow. If we are trying to cut costs in the ICBs, if NHS England is going over the next two years, and if devolution of responsibilities is also happening over the next couple of years with unitary councils forming, we will create a sticky situation for who is actually leading on this issue. At the heart of it are the clinicians and the patients who could fall through the gap. What consideration has been given to the top-down strategy for how to incorporate all that? The Minister has talked about a red thread that runs through it all, but is there a running plan? Different Departments, agencies and areas of the country are involved. They are trying to come together to manage their budgets, legislation and policies. It is a complex situation to work through. The imperative part—the legislation—is almost the easier part to get in place; it is the delivery that is all-important. Can the Minister explain further how those three things tessellate?

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  The hon. Member is absolutely right. The key part is about trying to change not only the legislative framework, but the culture around clinicians and society as a whole. We saw that impact in 1983, we saw it in 2005 with the update on capacity, and we saw it in 2007. Now is the right time to look again at this, and it is well overdue. I am glad that it has taken a while to ensure that the Bill has been thoroughly thought out. As we heard in the House of Lords debate, this is exactly the kind of framework that we need to make sure that society moves forward in a collaborative way that puts the patient at the centre, but also protects the wider community. Given some of the high-profile incidents that we have seen, we must also make sure that relatives, the community and the wider public at large are all protected. As the Minister has rightly highlighted, the core principles must be the default for everyone. Clause 1 therefore represents an important step forward: by requiring the Secretary of State and the Welsh Ministers to include the four principles explicitly in the code of practice and by making it a legal duty for decision makers to have regard to them, the clause will strengthen the ethical foundation of mental health law. However, we must be honest about the challenges. The success of the principles depends on the culture, not just the codification. Training, supervision and leadership across clinical settings will be essential to bringing the values off the page and into practice. These principles will also require resource backing. We cannot call for the least restrictive or most therapeutic interventions while community mental health services remain as they are. A plan for investment and a timeline for delivery will be imperative, or else we risk embedding principles we cannot fulfil. Members on both sides of the House understand that. I know that the Minister will have to think carefully about setting out a timetable, but it is key. We must also guard against tokenism. We must guard against lofty principles being left unenforced and becoming rhetorical wallpaper. If we are to legislate for these values, we must look for accountability, with regular auditing, patient feedback mechanisms and a duty on the provider to report on how the principles are being upheld. Those are all areas that His Majesty’s Opposition will scrutinise. To that end, I wish to raise several important questions for the Government and the Committee to consider. The first is about enforcement and accountability. How will the Government ensure that decision makers truly have regard to the principles in practice, and is there a robust mechanism for monitoring compliance and addressing breaches? The second question is about balancing conflicts. In some cases, principles may conflict: for example, the imperative to respect patient autonomy may clash with the need to impose restrictions for safety. How does the code intend to guide practitioners to navigate these difficult trade-offs? The third question is about care and interested parties. Although the clause highlights patient involvement, what explicit protections and roles will be afforded to carers and other interested parties, and how will their sometimes divergent perspectives be balanced? The fourth question is about training and resources. Embedding the principles requires more than words on paper. What investments are planned to equip practitioners with the skills and understanding necessary to apply these principles sensitively and consistently? The fifth question is about the timeline and consultation. The explanatory notes mention that the code must be consulted on and presented for scrutiny. What is the proposed timeline for that process, and how will people with lived experience continue to be involved?

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  Will the hon. Gentleman give way?

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  I rise to speak to amendment 56, tabled by my hon. Friend the Member for Runnymede and Weybridge. The amendment proposes to grant the Secretary of State the power to update the definitions of “mental disorder”, “autism”, “learning disability” and “psychiatric disorder” by secondary legislation, subject to affirmative resolution by both Houses of Parliament. Currently, the Bill sets out fixed definitions of those terms in the primary legislation—the Mental Health Act, as amended. Those definitions can be changed only through further primary legislation. That means that any further change, reflecting new scientific knowledge or evolving clinical consensus, would require a full legislative process. Given that the Act was passed in 1983, and we are here more than 40 years later, I think that the problem is clear.

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  Those are exactly the kind of practical questions that we really need to think about when we definitively put into legislation what that would look like. My constituency now has several boundaries across the borders with Warwickshire and Staffordshire, which causes problems when it comes to deciding who will look after what. On the criteria, my hon. Friend raises another point: will there be a regulatory fight or even infighting between the ICB and the local authorities to determine whose criteria cover what, and who trumps who? To top that off—I raised this matter with the Minister earlier—I would be interested to understand how the Liberal Democrats would deal with that problem, given that the Government are pushing through their devolution agenda. We have already heard about the complexity of everything tessellating together. That makes it very interesting, to put it politely, to consider how it would work in practice. On the related point of the duty imposed on ICBs and local authorities to have regard to review recommendations, I note that amendment 7 would insert the phrase “have a duty to carry out”. I have concerns in this area too, which I will raise in later comments, but let me explain a little further. The aim is to address accountability, but the Liberal Democrats’ solution would change the provision from “must have regard to” to “have a duty to carry out”. There is an important distinction here: a duty to “have regard to” requires that recommendations may be properly considered and responded to but does not legally compel implementation; a duty to carry out, however, would impose a legal obligation to act on every recommendation, regardless of feasibility, availability or agreement. That raises a crucial question: if the Government intend to hold ICBs to account for meeting those needs, how would they ensure that the necessary resources, powers and accountabilities for the mechanisms are in place? What oversight would the Liberal Democrats establish to guarantee not just consideration but effective delivery, and how would conflicts be resolved where recommendations are impractical, or local capacity is lacking? Perhaps a more balanced approach would be to strengthen the duty to respond with clear timelines and a requirement for transparency about decisions, while investing in cross-sector co-ordination mechanisms and adequately resourcing local authorities and housing providers. We could provide statutory guidance to clarify roles and responsibilities, and enhanced oversight to monitor outcomes, rather than simply prescribing an inflexible duty to implement. In essence, a duty to respond means that the responsible body, whether an integrated care body or the local authority, must formally consider and reply to the recommendations arising from the care and treatment review. It does not legally compel it to carry out every single recommendation, but it requires the body to explain what it will and will not implement, and why it cannot implement a recommendation. That promotes transparency and accountability without creating unrealistic legal obligations. For example, an ICB might say, “We will implement recommendations 1, 3 and 5 within six months, but recommendation 2 is not feasible due to current resource constraint.” That kind of structured response is both practical and responsible.

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  Would my hon. Friend speculate on a question that I hope will be answered by the hon. Member for Winchester? It is about the evidence base behind choosing six months instead of 12. GPs would do learning disability reviews every year, for example, and it is an annual thing with asthma and in similar areas. Is the hon. Member for Winchester aware of an evidence base for why it should be six months? There may not be one—often these can be arbitrary, in terms of just giving a clinical judgment—but I wonder whether there is a specific reason for choosing to reduce the period between reviews to six months.