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1. 12 Jun 2025·Parliament·Dr Luke Evans

   Mental Health Bill [ Lords ] (Third sitting)

   My hon. Friend is right: we agree that this is not a place for the police unless there is an absolute sign of criminal intent. The problem is that what happens is a member of the public sees something, reports it to the police and, naturally, it is the police, the fire service or the paramedics who come forward. If a person is unsure about someone behaving in an irrational manner, which by definition someone with a mental health issue could well be doing, the likelihood is that they will call the police and the police will be the first responders. We know that they tend to be the fastest to respond. Slightly widening and refining the definition of who can respond would allow us to build a framework and culture that might encourage a first responder—we often say that the AA is the fourth emergency service; it may well be that mental health services would be the fifth emergency service and could respond. That is what we need for service provision. The idea behind this is to try to crowbar the police out of that position, unless absolutely necessary, as my hon. Friend rightly says. Allowing a new framework would be good for safety and good for the police, because they would be freed up to do other stuff. More importantly, it would get the care as quickly as possible to the people who need it the most.

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2. 12 Jun 2025·Parliament·Dr Luke Evans

   Mental Health Bill [ Lords ] (Third sitting)

   The hon. Lady makes an incredibly important point about the range of people who can and do respond in such cases. The Opposition are not saying that is a problem; we want to support them by giving them the legal backing and framework to step up to be the first port of call. Unfortunately, by default it is always the police, because they are the only ones whose ability to deal with such situations is covered. The amendment aims to create a culture so that the people she mentions have the confidence to deal with them, and the accountability so that we can say, “The police should not be there first; it should be the first responders that we have.” We are starting to see cross-fertilisation; we are simply providing a legal framework that says that this should be the way forward by default and design, not an exception where people are working around the system. I think we are on the same page here. It is about the nuances of how we do this, and whether it requires primary legislation. The House of Lords voted that it requires primary legislation, and the Opposition share that belief. That is why I am asking Government Members to reconsider when the amendment comes to a vote whether the balance is right because we would give people the security, legal certainty and ability to do exactly what they want to do, which is to care for patients, not worry about whether there will be some criminal side to the situation, and what the police interaction could be.

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3. 12 Jun 2025·Parliament·Dr Luke Evans

   Mental Health Bill [ Lords ] (Third sitting)

   The hon. Lady points to the fact that the police are named, as they should be. Imagine if we took out the police completely—whowould then have the power to restrain, restrict and detain people under the Mental Health Act? That is the whole point of having the provision. What we are trying to do is refine and constrict the definition to make it clear for everyone in this country exactly who is entitled to do what. Emergency incidents could happen outside this House—would the police and mental health responder be there? That will come down to the clinical judgment of the 999 responder, the call handler and the clinician there, so I do not want to make it too restrictive. At the same time, we have to consider the evidence that is right under our nose, which is that 95% of the time the police are being called out inappropriately for mental health conditions. I guess that is the rub of what we are trying to sort out. Our responsibility in this House is not only to write good law, but to enable better systems of care. That means ensuring that the law empowers the right professionals to act at the right time, and centring the needs of the individuals in crisis, not just managing risk from the top down. I therefore ask the Minister to reconsider the amendments. Instead of deleting the definition of “authorised person”, let us work to try to strengthen and clarify it to support a wider, safer and compassionate response to mental health crises. Let us seize this opportunity to reset the balance between policing and care, which the police themselves are asking for and our continents desperately need. Much was made of the amendment in the other place, and I am grateful to the Lords Minister, Baroness Merron, for writing to Baroness May with an explanation of her concerns about the changes. The letter is dated 3 June and a copy was kindly laid before this House and the Committee. It is worth working our way through some of the issues raised. I fully recognise the Government’s concerns within it, and I agree with the need for extreme care when legislating on the deprivation of liberty, but I express reservations about the Government’s decision to overturn the amendment. According to the letter, the Government’s central concern seems to be the unintended extension of police powers. The Government argue in the letter: “Your amendments to clause 5 would give the police additional powers under the Mental Health Act. We do not support extending police powers in this way, and we understand that the police do not support this extension either.” That is also what the Minister has said in Committee. Respectfully, that is a mischaracterisation of the amendments. The original Lords amendments do not extend the powers of the police; they reflect current practice where the police are often involved in detaining individuals in mental health crises.

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4. 12 Jun 2025·Parliament·Dr Luke Evans

   Mental Health Bill [ Lords ] (Third sitting)

   I bow to the hon. Member’s expertise on this; the problem is that all the evidence shows that the police are the first there. I would like to see much more of him and his colleagues being able to respond and carry this out. We are giving them the legal certainty to do so. That is the argument for making sure that we have codified safeguards around who is and is not able to make such decisions. At the moment, it is purely the police who are called out to these situations, but this gives us another legal weapon with which we could fight this inappropriate use. The aim is to codify the safeguards around who can exercise detention, ensure accountability and, importantly, enable health-led alternatives to police detention. Are the Government confident that the decision does not leave a legal grey area around which profession or agency has the statutory power to detain, especially during urgent community or hospital-based crises? On the authorised person category in the section 135 and 136 powers, the Government say in their letter: “Extending these powers to ‘authorised persons’…could potentially lead to staff, patient and public safety issues. That is precisely why the Lords amendment included a tightly defined category of authorised person, subject to the Secretary of State’s regulation, mandatory training and safety provision. The intent is to ensure that when a professional, such as a trained mental health nurse, is better placed to respond than the police, they can do so lawfully and appropriately. The Government say: “Section 135 and 136 powers have been designed for police officers who have specific training, equipment and access to rapid support”. Many frontline NHS and social care professionals, including AMHPs, crisis team members and community psychiatric nurses, already respond to acutely distressed patients in highly volatile environments. They lack the police powers, but not the clinical expertise. The amendments would bring clarity and lawful backing to the situations they already manage. Take, for example, a mental health nurse in a community who arrives at a person’s home to conduct an urgent assessment. The individual is clearly experiencing psychosis, and is at immediate risk of self-harm. Under the current law, the nurse must call the police, delaying the care and potentially escalating the situation. Under the amendment, they could lawfully detain, provided they are authorised and trained. There are also confusions over the emergency response roles. The Government letter states: “There is a very real risk of confusion over who should respond in an emergency if multiple agencies have the same powers, which could lead to delays.” That concern is valid, but confusion is far more likely under the current law, where roles are unclear and NHS professionals must sometimes act unlawfully or wait for overstretched police. A regulated and accountable authorised person category, established in law and detailed in the code of practice, would clarify responsibilities, not blur them. Have the Government done any modelling of the delays and safety risk caused by not empowering suitably trained healthcare professionals to act in urgent situations? The letter also highlights concerns from stakeholders that this is “a radical proposal with a number of serious and potentially dangerous consequences and should not be pushed through without proper consideration”. These proposals were not developed in isolation; they were advanced in the House of Lords, where the former Mental Health Act reviewers, legal experts and mental health professionals carefully considered their scope. They are also consistent with the direction of the 2018 independent review, which emphasised reducing coercion, racial disparity and the overuse of police powers. The “right care, right person” initiative already expects health professionals to step in, but—unless I stand corrected—the initiative is not underpinned by any legal reform. Without amending the Act, health staff are still expected to take on crisis care without the powers of protection that they need to safely or lawfully do so. How can we expect health-led responses to mental health crises without giving health professionals the power in law to act? Turning to guidance and the code of practice, the Government say that they will issue further guidance on police handover protocols and the legal frameworks. While guidance is welcome, it is not a substitute for statutory reform. Guidance cannot grant powers to detain or protect professionals from liability. We can have legal clarity with this framework. If the Government want to push ahead with removing the amendments, will the Minister consider committing to a formal consultation with NHS England, the AMHP leads, frontline staff and patients on creating a legally robust authorised persons role? Would he consider piloting models of community-based urgent response teams that include AMHPs and trained nurses with delegated powers? Would he legislate for police exit strategies in A&E and community crisis responses that are enforceable, not just guidance based? Given our discussion about new clause 24, there is clearly scope for a sensible piece of work in the grey area to improve the interface for patients, clinicians and police. I think that is one we can all agree on.

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5. 12 Jun 2025·Parliament·Dr Luke Evans

   Mental Health Bill [ Lords ] (Third sitting)

   My hon. Friend is absolutely right. Under the last Government, the “right care, right person” initiative was launched with the Humberside police force to try to ensure appropriate care, but that is an example in isolation. One solution would be to include guidance in the codes of practice, but it would not have the statutory footing to allow that legal certainty, which is the concern. Another would be to include something in the annual statement that we will receive from the Government. We should work collaboratively to try to find a decent piece of work to look for the evidence base and build a delivery plan to help the police extract themselves from situations, when appropriate, and care givers to insert themselves. It is admirable to share a problem that is difficult not just in England but in Wales, Scotland and Northern Ireland. I agree that the Government are right to proceed with caution, but caution is not the same as inaction, especially when lives are at stake and the law no longer reflects the reality of mental health care. The amendments are not about expanding police powers; they are about reducing the need for police involvement by giving others the lawful authority to act. Although maths may not be my strong point, I am not blind to the make-up of this Committee; I realise that the change will inevitably happen. I want to press the Minister on how he proposes to reduce the burden on the police to safeguard them from thousands of hours spent dealing with mental health crisis issues. In extreme cases, they are not appropriate responders. This is the key issue to improve so many aspects of our society. We could improve the working life of the police, allowing them to do what they are paid to do, trained to do and passionate about: policing and protecting their communities. We could improve life for the public, because it would free up the police to tackle crime and keep them safe. Most importantly, we could provide the correct care to those patients at their biggest time of need. I hope the Minister will set out how the Government plan to achieve that.

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6. 12 Jun 2025·Parliament·Dr Luke Evans

   Mental Health Bill [ Lords ] (Third sitting)

   Maybe it is my clunky naivety as someone stepping into the legal statutory framework, but I was hoping the Minister would guarantee he could take that away to look at with the team. I know from my clinical experience and from speaking to colleagues that it is one of the hardest things to measure and look for. Later, we will discuss areas where there are good case examples of people who have shown the problem of escalating behaviour that is missed by the authorities. This might be a clumsy and clunky way of trying to highlight that point, which is why we have not yet come up with amendments, but I would appreciate the commitment to look further at that when the Government takes the point away. It is really important to make sure we can give clinicians more certainty around what this looks like.

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7. 12 Jun 2025·Parliament·Dr Luke Evans

   Mental Health Bill [ Lords ] (Third sitting)

   I rise to speak to clause 6 and Government amendment 30. Clause 6 will make important amendments to conditions for community treatment orders under the Mental Health Act. CTOs are a tool that allows certain detained patients to receive ongoing treatment in the community rather than in hospital, providing continuity of care and supporting recovery outside institutional settings. Since their introduction in 2007, they have offered a mechanism to maintain contact with mental health services and prevent relapse while balancing the patient’s right to live more freely. However, CTOs have not been without controversy. There is concern about their overuse and their disproportionate effect on black and ethnic minority patients. There are also a number of questions about the evidence for their effectiveness in reducing relapse or readmission. Moreover, concerns about coercion and the infringement of patient autonomy have been raised repeatedly. The 2018 independent review recommended tightening their use. Some also argue for going further by abolishing them completely. Clause 6 seeks to address many of those concerns. It will introduce stronger safeguards, clear risk-based criteria and a maximum 12-month duration to prevent indefinite or inappropriate use. It will mandate patient involvement through consultation and regular review, promoting shared decision making. Accountability is enhanced by aligning CTOs with a code of practice and introducing external oversight. Crucially, CTOs will now be used only when there is a clear and necessary risk, focusing on clinical need and safety. Challenges remain. The new requirements bring complex administration and an increasing workload for clinicians. Despite reforms, CTOs remain a form of compulsory treatment, raising concerns about ongoing coercion. Their success depends heavily on the availability of community services, which are not always adequately resourced. Finally, terms such as “serious harm” may be open to interpretation, risking inconsistency. To unpack all that, we must take a closer look. Clause 6 rightly seeks to update and clarify the legal framework governing CTOs to ensure that their use is proportionate, justified and consistent with evolving standards of care and risk management. It does so primarily by aligning the grounds for making and renewing a CTO with the new, more precise risk criteria for detention. It specifies that a CTO should be made only if there is real risk that “serious harm may be caused to the health or safety” of a patient or others without treatment, and if that treatment is necessary given “the nature, degree and likelihood of the harm”. Again, there is an argument about the definition of “serious harm”, and the same discussion as the one we had under clause 5 about escalation of behaviour or cumulative concerns applies here. In the light of that discussion, it might be helpful if the Minister clarified the interface between CTOs and grounds for detention. Is there scope for the code of conduct to cover the management of risk, both to the public and to patients themselves, across both? Given the emphasis placed on real risk of serious harm, clause 6 aligns CTOs more clearly with the threshold for detention, with the aim of reducing the inappropriate use or overuse of CTOs, which is much more welcome. It will help to safeguard and protect patients from unnecessary restrictions on their liberty, while maintaining the ability of a responsible clinician to act decisively when there is genuine risk.

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8. 12 Jun 2025·Parliament·Dr Luke Evans

   Mental Health Bill [ Lords ] (Third sitting)

   Spot on. The hon. Gentleman will have used them far more than I ever have, and that was exactly the point of them when they were brought in in 2008. The reason they have been so contentious is their misuse, misapplication and ongoing use. That is what we are trying to highlight. With clause 6 the Government are trying to streamline their use. That leads me neatly on to why the Lords introduced clause 6(3), which Government amendment 30 would remove. It is about how to ensure that there is adequate oversight so that people do not remain on CTOs in perpetuity or, more likely, have them applied inappropriately. Concerns have been raised about racial disparities in the use of CTOs—particularly for black men, but there is also work to be done on those from other communities who find themselves on CTOs. The hon. Gentleman is right: that is the ethos behind ensuring that we push people to community care. The problem is how to set that against the legislation on CTOs and how to provide the resources to enable an appropriate setting for that care.

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9. 12 Jun 2025·Parliament·Dr Luke Evans

   Mental Health Bill [ Lords ] (Third sitting)

   Yes. As the Minister pointed out on the Committee’s first day, legislation sets the culture. One the main reasons for the Wessely report was the racial disparities that had been found. We still have to look into the cause and effect of that, but one of the big markers was that CTOs were increasing indefinitely and seemed to hit certain communities disproportionately, without there being a full understanding of why. That was why in the House of Lords some argued that we should get rid of CTOs completely. The Opposition do not agree with that; we agree that clause 6 is important and that CTOs serve a purpose, for the reason that the hon. Gentleman explains so eloquently. The emphasis is on getting people into community treatment where we think it will be better for them, but ensuring that CTOs are not an undue burden on clinicians or patients and are not used inappropriately. Clause 6(3), introduced in the Lords, sets out a maximum duration of 12 months for CTOs, after which an extension would require thorough review. That process would demand consultation with the patient, their nominated persons and relevant mental health professionals, and the written agreement of a qualified psychiatrist. That multi-layered review process is vital to ensure that any extension is based on clear therapeutic benefit and necessity rather than routine or bureaucratic inertia. Moreover, the requirement of regular reviews every six months to extend CTOs would further strengthen oversight and accountability. The involvement of tribunals, which may recommend variations or terminations, would add yet another layer of protection for patients’ rights, as the Government and Opposition both acknowledge. While the 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 CTOs when they are genuinely needed. Ordered, That the debate be now adjourned.—(Taiwo Owatemi.)

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10. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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11. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    The hon. Lady is making an excellent speech and an excellent observation, and she clearly understands the rationale for the amendment. I just wonder, given that the use of a CTO is currently a clinical decision, why we find ourselves facing this problem in the first place. Ensuring a review and putting it on a statutory footing would hopefully stop that, because despite clinicians’ best intentions, more of these have been rolled on. This provision is simply a mechanism to try to stop that. What are her thoughts about how to make sure that that is the case?

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12. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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13. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    I rise to speak on an essential aspect of our mental health system: the role of mental health tribunals, and the proposed changes to the grounds upon which they can discharge individuals detained under the Mental Health Act 1983. Each year in England and Wales, about 20,000 people come before a mental health tribunal. These individuals are not criminals, but patients—often vulnerable, often voiceless—detained in hospital or living under community treatment orders, sometimes against their will. The function of the tribunals is clear: to act as an independent safeguard, to scrutinise the legality of detention, to test whether the continued deprivation of liberty is justified, and to ensure that care is being given within the bounds of both clinical necessity and human rights. Each tribunal consists of a legal judge, a psychiatrist, and a specialist lay member. Together, they form a check on the powers granted by the state to detain and treat people on mental health grounds. Therefore, tribunals are independent bodies that review whether a person should remain detained under the Mental Health Act. Historically, while an imperative, there have been concerns that modernisation is needed. The criteria they used were broad and inconsistent with modern principles of least restriction and patient rights. The 2018 independent review of the Act recommended aligning tribunal powers with clear risk-based criteria to ensure the detention is only maintained when absolutely necessary. The clause seeks to change the criteria that these tribunals apply when making decisions about discharge. Specifically, it would align the discharge tests used by tribunals with the statutory conditions for detentions—those found in section 2(2) in the 1983 Act for assessment, section 20(4) for treatment and section 17A(5) for community treatment. On one level, this is pragmatic reform. It simplifies the legal framework and avoids confusion caused by duplicative or overlapping tests. It creates consistency between the reasons someone can be detained and the reasons their tribunal must use to determine whether they should remain so. I would, however, caution the Committee not to treat simplification as neutral. While the administrative clarity is welcome, legal clarity can also narrow discretion. In tightening the grounds for discharge to mirror the detention criteria exactly, the clause may reduce the tribunal’s ability to consider the broader context, including, for example, the patient’s progress, their lived experience or the factors not strictly enumerated in statute. There is a risk that tribunals become passive reviewers of statutory boxes, rather than active assessors of individual liberty and clinical justification. Tribunals may ask whether the criteria are still met, rather than whether continued detention is truly necessary or proportionate. Moreover, I believe—although the Minister may have to correct me—that the clause applies retrospectively, including to individuals detained under forensic sections or already living under CTOs. We must ask whether it is right to shift the legal test midway through someone’s treatment or tribunal process, potentially raising the bar for their discharge. I welcome the intent behind the clause to create coherence to improve the legal precision of our mental health law, but will the Minister reflect on its practical effects? Will it make discharges harder? Will it reduce the tribunal’s role to tick-boxing? Will it truly serve the interests of the patient? Mental health tribunals are not merely administrative bodies; they are guardians of liberty for people who are often too unwell to speak for themselves. Any change that touches their powers must be approached with care, compassion and rigorous scrutiny. I ask the Minister to clarify how the clause will affect discharge rates in practice. Will tribunal members retain discretion to consider the individual circumstances of the patient beyond the bare statutory criteria? How will that be monitored? Has an impact assessment been carried out on the proposed change? Finally, in the Minister’s speech on clause 6, he said that he expects more people to be automatically referred. How many more does he expect the Government to see? I believe in his answer he said that 129 out of 4,000 were overturned. Is there any work to be done to see how many more automatic referrals would come in, how many more would be challenged, and what the impact of that would be? We must be mindful that mental health law is about not only treatment, but trust, autonomy and justice, so let us ensure that these reforms reflect that.

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14. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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15. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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16. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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?

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17. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    It is an excellent and eagle-eyed point. I would point to the evidence base that I cited, starting from 1988 onwards. That is three and half decades’ worth of evidence that points to a causal factor. In my clinical background, I have seen patients that I think it relates to. Perhaps I will stand corrected, but I am not sure that domestic violence has been shown as a causal factor of mental health conditions. We know that in the developmental stages that children go through, when their brains are developing and growing, as the 2016 study showed, there are intrinsic changes. That is why the Opposition chose to put that wording in. I agree that the definition could be wider, and we discussed that on the first day of debate with the Liberal Democrat definitions. I see the hon. Lady’s intent, but the main point is the evidence base. Maybe in the future that would be something, if we have evidence, that the Minister could consider taking forward. At this point in time, I think it is undeniable that childhood trauma makes a difference, and that is why the amendments specifically say “childhood trauma”, not anything wider.

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18. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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19. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    I think I see where the Minister is coming from, but to take the example that he chose last time we spoke about this, there could be someone with a severe eating disorder. At the moment, there are in-patients with an eating disorder whose care is seen as palliative. Part of the problem lies in how we decide what is a reasonable prospect of benefit and where the boundary lies. What should be done if someone forcibly refuses food? Where do we draw the line on putting in nasogastric tubes? I mention that not to get a specific answer from the Minister but to point out the difficult nature of the balance that the Bill is trying to achieve—where is the therapeutic benefit, and who is making the decision on it? With the system being patient-centred, the patient may well challenge it and say, “That is not for me; I don’t want this treatment.” But as the Minister said two days ago, the Government take a slightly paternalistic view on overruling that when it comes to someone’s capacity. So here lies the rub, and I would be grateful if the Minister could write to me if he cannot answer now. In the case of that example, which is live now, how do we balance the prospect of reasonable benefit—that would be evident in the case of someone with an eating disorder having food—with the reality of a patient feeling that they are not deriving any benefit from it from their perspective? If they wanted to challenge that, who would they turn to? I would have thought that a clinician would take the same position as the Minister—that they should have some treatment—but their capacity gives them the right to say “No, I won’t”.

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20. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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21. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    I am grateful for the opportunity to speak to clause 10, which addresses the nomination of the responsible clinician under the Mental Health Act. As we have heard, the responsible clinician is a pivotal figure in the operation of the Act, holding substantial legal powers in relation to detention, treatment and discharge. The Government’s explanatory notes make it clear that the clause is intended as a clarification, rather than a reform, of how a responsible clinician is designated by formally acknowledging that they are nominated by managers of the relevant hospital. That may well reflect current practice, but in legislation as sensitive and consequential as this, particularly where it relates to rights and liberties of people with serious mental illnesses, even clarification warrants scrutiny. I would like to raise a few points of constructive concern and seek reassurances from the Minister. First, although the clause is presented as technical, it alters the statutory language around who is responsible for nominating the RC from an implied clinical judgment to an explicit managerial nomination. Even if that reflects what already happens, there is still a de facto risk of blurring the lines between clinical decision making and administrative oversight. Can the Minister confirm that this change will not give hospital managers discretion to override clinical suitability in selecting the responsible clinician? Secondly, the clause distinguishes the responsible clinician from the soon-to-be defined community clinician role, which the Minister touched on. Although that separation may be helpful, it might help to guard that from confusion. Will clear published guidance accompany this change to explain to professionals, patients and families how roles are differentiated and how nominations are made? Thirdly, on the matter of transparency and accountability, will patients be informed when a responsible clinician is nominated for their care? Will there be a mechanism for a patient to raise concerns if they believe that their nominated clinician is not appropriate for their needs and, if necessary, to change them? If so, what will that mechanism be? Finally, although I accept the Government’s assertion that the clause is primarily clarificatory, we should keep it in mind that the Mental Health Act should not be amended lightly. The responsible clinician is not merely an administrative figure; they are central to the person’s liberty, treatment and legal rights. Have the Government considered whether additional safeguards could be introduced, in either guidance or statute, to ensure that this clarification does not lead to unintended consequences or the dilution of clinical independence? The clause may be a small piece of a much wider reform, but, as ever with mental health legislation, the details matter. They shape people’s experience of care and of coercion.

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22. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    Clause 11 will introduce new section 56A into the Mental Health Act 1983. The clause represents an important reform to the framework for how treatment decisions are made to detain patients under part IV of the Act. The clause effectively establishes a statutory clinical checklist. It imposes a duty on the approved clinician in charge of treatment to consider a set of factors before giving medical treatment to the patient—whether or not the patient consents, lacks capacity or is refusing treatment. It applies to all treatments under part IV and to patients of all ages, including children. As the Government’s explanatory notes set out, that duty includes considering alternative treatment options, taking steps to assist and encourage the patient’s participation in decisions, giving proper weight to the patient’s past and present wishes, feelings, beliefs and values, including advance statements, avoiding the reliance on discriminatory assumptions such as those based on a patient’s age or behaviour, and consulting others involved in the patient’s life, such as families, carers, nominated persons or advocates. Importantly, where a patient lacks capacity, the clinician is still required to consider what the patient would want if they had capacity. We welcome the fact that it reflects a commitment to person-centred care, even in the most complex clinical situations. I recognise and welcome the intention behind the clause. The principle that patients should not be passive recipients of care but active participants in decisions about their treatment is well established in modern mental health practice. The clause gives that principle a stronger legal footing, aiming to embed it in everyday clinical decision making. The Government rightly acknowledge that many patients have felt, in the past, that their views and preferences have been overlooked. Proposed new section 56 is intended to prevent that and promote autonomy, dignity and respect, even where coercive treatment is being considered. I note that clause 11 amends the existing provision on second opinions and treatment certification, such as sections 57 and 58 of the Mental Health Act. It would appear that clinicians must now confirm in writing that they have complied with new section 56A checklists. Could the Minister confirm that that is correct? If so, that is a welcome move towards accountability and transparency. I want to raise a few areas where further clarification or strengthening might be needed. First, the clause still leaves substantial room for clinical discretion. Much of the checklist is qualified by what is “reasonably practicable” or “reasonably ascertainable”. That is understandable from a legal drafting perspective, but it raises questions about how robustly the duties will be applied in practice, particularly in under-resourced or overstretched services. Can the Minister confirm what support will be given to clinicians, such as the statutory guidance or training, to ensure that new section 56A is implemented meaningfully and consistently across the system? Secondly, although clinicians must now record that the checklist has been completed, the patient or their family currently have no direct route to challenge non-compliance. There does not seem to be an appeal mechanism, so I wonder what or who might fulfil that role. It would be helpful if the Minister could set out the process. Is there a formal role for advocates in contesting whether the process was followed properly? If found wanting, are there sanctions for failing to comply? Is it perceived to be part of the integrated care board commissioning role, for example? Could the Minister say more about what resources are available to patients or carers who believe their views were not properly considered? Would the Government consider a statutory right to request a review where the checklist appears to have been bypassed? Thirdly, I note that the clause applies only to patients treated under part IV of the Act. It does not apply to patients subject to community treatment orders, unless they are recalled to hospital, yet those patients may still face significant pressure to comply with treatment, often under the threat of recall. Forgive me if I am a little muddled, but I would welcome some clarification on the rationale for excluding CTO patients from these protections. Are the Government open to extending these duties to cover community settings, particularly as part of future of reform, especially as they did not accept the amendments tabled in the Lords? Fourthly, the checklist applies to all ages, including children and young people. That raises important questions about how capacity, consent and participation will be judged in younger patients, and how the duty to consult parents or carers will be balanced with the rights of the child. Will specific guidance be issued to support clinicians applying this clause in cases involving children and adolescents? Further still, while proposed new section 56A emphasises consultation and participation, the weight to be given to the views of others—whether an advocate, nominated person or family member—remains at the discretion of the clinician. That may be clinically appropriate, but it raises the question: how will clinicians be supported to navigate competing or conflicting views, and will they be required to provide reasons for how they have balanced those perspectives? I will not delve into it now, but when we come to nominated persons, there is a reason that this particular point is poignant. We need to understand how decisions are being made when there are challenges. While I welcome the clear emphasis in clause 11 on patient voice, autonomy and dignity in treatment decisions, I must raise a matter of considerable concern and spend a little bit of time on it: the absence of any explicit reference to public safety or risk to others within the proposed new section 56A. It could be argued that this is not a minor omission. As legislators, we have a duty not only to protect the rights of the individuals in clinical care but to safeguard the wider public. While risk to the public is rightly a key consideration in detention decisions under sections 2, 3 and 20A of the Mental Health Act, it is not reflected at all in the new duties governing treatment decisions, even when the treatment may directly affect behaviour inciting compliance. We sadly know that the stakes here are not hypothetical. When we were discussing clause 5, the Minister turned around and asked what the point was of over-embroidering the Bill, especially if such duties already exist in these cases. I will tread carefully here, because there are both legal and emotional sensitivities, but there are good examples of why this really matters. A deeply troubling case, and one that continues to resonate when we talk about risk, public safety and clinical decision making under the Mental Health Act, is that of Nicola Edgington and whether the Bill does enough to address it. In 2011, Nicola Edgington, a woman with a diagnosis of paranoid schizophrenia, walked into a police station and an A&E department in south-east London. She told the staff that she was relapsing and desperately begged to be detained, warning them that she posed a danger to others. Despite her history—she had previously killed her mother during an earlier episode—she was allowed to leave hospital. Within hours, she murdered a complete stranger, 58-year-old Sally Hodkin, and seriously injured another woman. Serious incident reviews concluded that the risk she posed to the public was severely underestimated. Professionals focused on her current presentation, not the pattern of risk, and key warnings were missed. She asked to be sectioned; she was not, and someone died. Since that case, there have been some important reforms, including stronger guidance on the risk assessment, improved information sharing between agencies, and enhanced care co-ordination through the care programme approach. Crucially, even today, there is still no statutory duty requiring clinicians to explicitly consider risk to the public when making treatment decisions under the Mental Health Act, including decisions about whether to detain or treat someone who is deteriorating. That brings me to clause 11 and proposed new section 56A. The Government rightly propose a clinical checklist for treatment decisions—one that includes a patient’s wishes and beliefs, as well as views from family or advocates. These are welcome steps, but the checklist is silent on public protection. It recognises autonomy, but not risk to others. It includes past preferences, but not past violence. Should we not at this moment consider an explicit legal duty to assess and document the risk that a patient may pose to others when treatment decisions are made, especially for those with a serious history of violence or relapse?

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23. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    I appreciate the hon. Lady’s insight, both as a politician and as a patient. I guess the Opposition are concerned that there is no explicit duty here, which is why legislating for that is so important. There was a huge number of inquiries about the case from 2011. There have been sufficient changes, but in 2023, as we saw in Nottingham, there was yet another case. There are still ongoing proceedings, so I will not comment too much on that, but this is an opportunity that the Committee should seriously consider. This harks back to what I was talking about on Tuesday. It is another step—an escalation—in this concerning pattern of behaviour, and it is hard, from a clinician’s point of view, to work out whether something is going to happen. I see this as part of the checklist to make sure that consideration is there, or, if public safety is not there, that it does not fall into a statutory role as it would anywhere else. Those are my concerns. We have not put down an amendment, but I am interested in the hon. Lady’s thoughts on how that should be approached from both the politician and the patient side.

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24. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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25. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    It is a relief that we have not dropped clause 11, an important clause. Equally important is clause 12, on the appointment of a doctor to provide a second opinion. The clause will introduce the new framework for appointing second opinion appointed doctors under the Mental Health Act, which is indeed important. I begin by acknowledging the Government’s efforts to clarify and strengthen the role of these doctors, who play a vital part in safeguarding the rights and wellbeing of patients subject to compulsory treatment. The emphasis on the independence of the second opinion appointed doctor is a positive step. Ensuring that that doctor is not the patient’s responsible clinician or treating doctor reinforces impartiality. Furthermore, the clear responsibility for this doctor to assess therapeutic benefit and to verify that clinicians have followed the clinical checklist, considering patients’ wishes and preferences and treatment alternatives, reflects an encouraging commitment to embedding autonomy and choice in the clinical discussions. Having said that, I would like to raise some constructive points and seek clarifications on certain operational aspects that I believe are critical to the clause’s effective implementation. First, the Bill requires the regulatory authority, namely the Care Quality Commission in England and Care Inspectorate Wales, to appoint the second opinion doctor “as soon as reasonably practicable”. The absence of a specific maximum timeframe could raise concerns about potential delays. Given the importance of timely second opinions in safeguarding patient rights, will the Minister clarify what safeguards are in place to prevent undue waiting times? Forgive me: I could not find it, but has any clear data been recorded on timings for second opinion appointed doctors? Has any consideration been given to whether a timescale should be implemented in legislation in order to ensure that there is no slipping through the cracks? That may be appear to be overkill; I defer to experts in the Department, but given the acute needs of some patients who will encounter the legislation, it is worth considering. Secondly, the role of the regulatory authority is pivotal in the process. In England, that role falls to the Care Quality Commission, so it is worth spending a few moments reflecting on the CQC’s role not in general terms, but specifically in relation to mental health settings. Strangely, I speak today from a position of both continuity and change. Having been a Government Member during a period when there was reform of the CQC and it was under active discussion, I now speak for the Opposition, but with an equally strong commitment to ensuring that reforms are delivered and that people with mental health needs receive care that is not only safe, but dignified and therapeutic. It is no secret that mental health services, particularly in-patient units, have faced significant challenges in recent years. Some high-profile failures in care, including abuse and neglect in mental health hospitals, have understandably shaken public confidence. As a regulator, the CQC has struggled at times to respond quickly or decisively enough. In some cases, failings persisted despite earlier inspections raising concerns. We need to be honest about the fact that the pace of regulatory response has not always matched the urgency of the risk, particularly for detained patients, who are among the most vulnerable people in our society and our care system. Two recent independent reports—the Dash review, which began in May 2024 just before the election, and the follow-up work by Sir Mike Richards on its findings—have offered a candid but constructive diagnosis of what went wrong inside the CQC. They have identified serious weaknesses: a sharp reduction in inspection activity; delays in publishing reports; an overcentralised system that dilutes expertise in specialist areas such as mental health; and a lack of transparency that sometimes makes it difficult for families and professionals alike to understand how services are monitored. Both reports were also forward-looking, however. They have informed a programme of reform, which began under the previous Government and is, I hope, continuing under this Government. What has changed? The CQC has started to take action. It now has a renewed commitment to sector-specific expertise, which should help mental health, with dedicated inspection teams for mental health returning. The backlog of unpublished reports has been significantly reduced and the CQC’s digital systems are starting to be overhauled. Perhaps most importantly, the regulator is beginning to work on increasing transparency in order to engage better with service users and staff in mental health settings. These changes are welcome, but fragile. Reform takes time and momentum can easily be lost. Context matters when we are considering giving an organisation more work in primary legislation, which is why I have raised the issue and given a potted history. The Bill gives us the opportunity to ensure that the rights and safety of people subject to detention or treatment under the Mental Health Act are properly safeguarded, but legislation alone will not guarantee good care. The role of the CQC as a proactive and trusted regulator is essential. That means ensuring that inspections are sufficiently frequent, especially in settings in which patients are detained and find it hard to raise concerns; ensuring that de-escalation, restraint and seclusion practices are being scrutinised not just in policy, but in practice; ensuring that the voices of patients and families are actively heard in regulatory processes; and ensuring that any concerns that are raised, whether by whistleblowers, staff or external professionals, are acted upon promptly. I do not say all this to assign blame. Indeed, many of the problems that the CQC has faced have been years in the making, and I accept that some of them arose while I was on the Government Benches. However, I am saying this now because I believe that there is cross-party agreement that regulatory failure is not an option for mental health services. As we look ahead to implementing this legislation, I hope that the Committee will keep it in mind that a reformed Mental Health Act must be matched by a reformed regulatory framework that is resourced, responsive and rooted in the lived experience of those it is designed to protect. We know that the CQC has undergone significant changes and is under new leadership after the concerns, complaints and issues. Do the Government have faith in the CQC? I ask the Minister to provide assurances that both the CQC and—

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26. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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27. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    You have actually caught me at a perfect point, Mr Vickers. The concept of therapeutic benefit is central to the second opinion doctor’s assessment. However, in clinical practice, interpretations of therapeutic benefit can vary considerably. How do the Government propose to ensure consistency and fairness in such assessments? Will there be clear and standardised guidance for the training of doctors giving a second opinion, to avoid subjective discrepancies? The introduction of the clinical checklist is a welcome enhancement, especially the requirement to consider patients’ past and present wishes and available treatment alternatives. However, it is essential that the checklist is not just a mere bureaucratic box-ticking exercise, as we have discussed. What mechanisms will be in place to monitor compliance with the checklist? What recourse will patients have through the assigned second doctor? Finally, I note that the clauses following clause 12 move towards tailoring safeguards around patients’ capacity or competence. That seems more humane and targeted than a one-size-fits-all approach, but this added complexity may increase administrative burdens on second opinion doctors and treating teams. Have the Government considered the potential impact on workload? Are there plans for adequate training and support to manage the transition effectively? In conclusion, clause 12 represents an important evolution in protecting the rights of patients undergoing compulsory treatment. The Opposition recognise that progress has been made. However, the effectiveness of the reforms hinges on clear operational frameworks, adequate resources and a robust regulator. I look forward to the Minister’s response to my questions and hope that the Government will take them on board to strengthen the Bill.

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28. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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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29. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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30. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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31. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    I rise to speak to clauses 15, 17 and 18 and Liberal Democrat amendment 13. Clause 15 will amend section 58A of the Mental Health Act 1983 in regard to ECT. It is worth understanding the law as it stands. At present, if a patient lacks capacity to consent to ECT, treatment may be administered only if a second opinion appointed doctor certifies that the treatment does not conflict with any valid advance decision, or a decision made by an attorney, a deputy or the Court of Protection. That acts as an important safeguard, ensuring independent scrutiny of patients’ prior wishes or of proxy decisions before such an invasive treatment can proceed. This clause will shift the responsibility. Under the Bill, the initial determination about whether ECT would conflict with any advance decision or proxy decision is moved from the second opinion appointed doctor to the patient’s approved clinician. Only if the clinician finds no conflict would the SOAD then be involved to certify that the patient lacks capacity, that the treatment is appropriate and that the clinician’s decision aligns with proposed new section 56A safeguards. The Government’s explanatory notes clarify that that reflects the unique nature of ECT: if a valid refusal exists, treatment must be prevented outright. The clinician therefore acts as a gatekeeper before SOAD involvement. Clause 15 marks a significant shift in the role of the SOAD with respect to ECT. The whole point is to transfer the responsibility to ensure that treatment does not conflict with advance decisions or refusals. That contrasts with the approach under proposed new section 57A, under which the SOAD must certify the presence of a valid decision before compulsory treatment. The rationale, as explained in the Government’s notes, is that for ECT, the mere presence of an advance refusal should prevent treatment, whereas in the case of other compulsory treatments, the content of the advance decision is integral to deciding whether treatment can proceed. I recognise the rationale for the change and the introduction of a clinical checklist—I assume that we are talking about new section 56A—but I have some questions for the Minister. Does shifting the initial responsibility to the approved clinician risk reducing the independent oversight currently provided by the SOAD, especially given the invasive nature of ECT? How can we be confident that clinicians will rigorously check for and respect valid advance refusals or proxy decisions? What practical safeguards will be in place to ensure that clinicians have full and timely access to any relevant advance decisions or proxy appointments? Will there be a standard process for verifying those, especially where records may be fragmented? The SOAD’s role is now more focused on assessing appropriateness of treatment and capacity but, it appears, without responsibility for confirming the absence of conflicts with advance refusals. Will the SOAD therefore be empowered with sufficient information to make the judgment confidently? How will the clinical checklist be implemented and monitored across services to ensure consistent application? Can we be assured that it will effectively embed the principles of therapeutic benefit and least restrictive option, especially when dealing with ECT? What mechanisms will be available to family members or advocates who believe that a patient’s prior wishes, or proxy decisions, are being overlooked? Will there be accessible avenues by which to raise concerns or seek timely review?

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32. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    The clause will amend section 61 of the Mental Health Act 1983 on the review and treatment of detained patients. The 1983 Act requires approved clinicians to provide reports on the treatment and condition of detained patients, particularly where patients do not consent to treatment. Those reports are integral to the scrutiny and safeguarding of the patients’ rights. The Act sets out timing requirements for such reports, which generally coincide with detention renewals, helping regulatory authorities such as the CQC in England and the Healthcare Inspectorate Wales to oversee treatment appropriately. I imagine that you are expecting me to continue my speech on the CQC, Mr Vickers, but I will spare you; you are august in your understanding of the health inspectorates, so I will not put the Committee through that. The clause updates the timing and scope of the reporting requirements, and we welcome the fact that it will introduce a more structured reporting schedule. It will require reports to be provided after six months, then every six months and then every 12 months, as well as for the reports to be provided within two months of those periods. The clause also explicitly includes part III patients—those under forensic orders—especially those transferred from guardianship or those whose community treatment orders have been revoked. Importantly, the clause grants regulatory authorities the power to require reports not only from non-consenting patients but where patients are found to be consenting under certain treatment sections. That enhances the regulator’s oversight role, allowing it to request additional information should concerns arise. We acknowledge that the intent behind these changes—to align reporting practices across different patient groups and to strengthen regulatory oversight—could improve consistency in monitoring, ensure that concerns about treatment are promptly addressed and, ultimately, enhance patient safety and rights. However, several questions arise. How will the increased power for regulatory authorities to require reports, including from consenting patients, be balanced to avoid placing excessive administrative burdens on clinicians? Will the changes to the timings of reports, particularly the delay of the first report to three months for certain cohorts, risk any gaps in early detection of treatment issues? What safeguards or limits will exist to prevent potential overuse of the power to request additional reports? Could that put further strain on mental health services and regulatory bodies that are already stretched? How clear and workable are the definitions distinguishing different patient groups, such as part III patients transferred from guardianship or those with revoked community treatment orders? Might that complexity lead to inconsistent application? The clause distinguishes those groups because it assigns them different reporting schedules and rules. For example, part III patients transferred from guardianship and CTO-revoked patients after 6 months have a specific reporting timetable—every 6 months, then 12 months. In contrast, CTO-revoked patients within six months of their hospital order and other part III patients retain their existing, presumably different, reporting periods. That layering risks creating complexity. The Bill uses technical terms, and references to a patient being transferred from guardianship under section 19 or to a community treatment order being revoked are not immediately clear and may not be uniformly interpreted by all clinicians and regulatory staff. Why is that a potential problem? If these terms or categories are not clearly defined and communicated, or if the practical implications are not straightforward, there is a risk that clinicians might misclassify a patient’s status, leading to incorrect timings or absence; regulatory authorities might struggle to apply the rules consistently; and patients might inadvertently fall through gaps in reporting. For example, let us imagine a patient who was initially under guardianship, which means that someone was legally responsible for their care, but who was then transferred to a hospital order under part III of the 1983 Act. If the clinician or regulator is unclear whether the patient fits into the “transferred from guardianship” category for the revised six-month reporting cycle, they might apply the wrong schedule, and thereby delay important reviews or misunderstanding opportunities for intervention. Concern about definitions is really about ensuring clarity and practicality and making sure that everyone involved in patient care and oversight understands precisely which patients fall under which reporting categories, so that the intended protections and reviews happen without there being confusing gaps.

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33. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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.

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34. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    Clause 20 addresses a central principle in healthcare, ethics and law: the right of individuals to make informed decisions about their treatment, and the conditions under which that right can be overridden. Let me begin by recognising the objective of clause 20 as both important and welcome. It replaces the outdated and potentially ambiguous language in the Mental Health Act 1983—language that speaks of whether a patient is “capable of understanding the nature, purpose and likely effects” of treatment—with a clearer legal standard based on whether a patient has capacity to consent, in accordance with the Mental Capacity Act 2005. This reform aligns the Mental Health Act with how capacity is already understood and applied across health and social care, and it harmonises part IV of the Act with part 4A, which already uses that language in the context of community patients. So far, so sensible. However, as the Opposition, our role is not only to acknowledge the intention, but to ensure that the implementation matches the ambition, and that patients’ rights are not merely affirmed in law but upheld in practice. What do these changes actually do? Under clause 20, we see a wholesale substitution of terminology. For example, in sections 57 and 58 of the Act, which deal with certain serious treatments such as neurosurgery and ECT, the language shifts from “capable of understanding” to having or lacking capacity to consent as defined in the Mental Health Act. It also explicitly incorporates advance decisions to refuse treatment under section 25 of the MCA, the role of a donee of lasting power of attorney, and the authority of a deputy appointed by the Court of Protection. This is a welcome acknowledgement of patients’ rights to plan ahead and to have their wishes respected, even when they later lose capacity. While the Government’s explanatory notes suggest that this is not expected to create practical change, I think we should pause and ask: what if it does? We are told that clinicians interpret “capable of understanding” as meaning “having capacity” under the Mental Capacity Act. But the MCA test is precise: it requires the person to understand the information relevant to the decision, retain that information, use or weigh it as part of the decision-making process, and communicate their decision. So are clinicians routinely applying this test fully, or are they relying on informed judgment? Can the Minister confirm, for example, whether NHS trusts have audited how consistently the MCA test is being applied in mental health settings? I was a clinician and am now an MP, so I understand the intent behind it, but the legal clarity—now with my MP hat on—is really important to ensure that we truly are interpreting the legislation we pass in this House for this country in the correct way when we are acting as clinicians. When it comes to advance decisions in acute settings, clause 20 provides that an advance decision to refuse treatment must be both valid and applicable, as per section 25 of the Mental Capacity Act, but in the real world of psychiatric in-patient care, clinicians may encounter such decisions during a crisis, when patients are at serious risk of self-harm or suicide. How will the Government support clinicians in determining validity and application quickly, safely and lawfully? I assume— I think the Minister hinted at this—that that will be part of the code of practice. On the power to override consent, perhaps most crucially the Mental Health Act allows for treatment without consent, even when the person has capacity, if they are detained under the Act. Again, we touched on this in relation to amendments discussed on the first day. That is a profound legal power. Does the clause change it in any way, or does it simply confirm that capacity is assessed, but not necessarily respected, under compulsion? If the Government intend the law to remain as it is—that patients with capacity can still be treated without their agreement—they may well need to specify and set that out. I urge Ministers to consider how we communicate that reality to patients, whose sense of agency and trust in the system may otherwise be undermined. I turn to the matter of Gillick competence for children under 16. The clause clarifies that the standard for under-16s is Gillick competence, not capacity under the Mental Capacity Act. This reflects the long-standing legal test established in the 1986 case of Gillick v. West Norfolk and Wisbech Area Health Authority. Under Gillick, a child can consent to their own medical treatment if they have sufficient understanding and intelligence to comprehend what is proposed. The Gillick test has advantages. It allows for a case-by-case assessment, not a rigid age threshold, and respects the emerging autonomy of young people. However, there are also risks: it can lead to inconsistency between clinicians and does not offer the same structured framework as the MCA. What safeguards will be put in place to ensure consistency and rigour in applying the Gillick test? Will the Government commit to updating the code of practice with guidance on assessing Gillick competence specifically in mental health contexts? I turn to deputies, attorneys and verifying authority. The clause references lasting powers of attorney and deputies—that is right and proper—but we need to ask how a clinician will verify that a donee is acting within the scope of their authority. Will the Government consider a national standard protocol to support clinicians in checking LPAs and court orders, particularly in urgent situations? For example, could this be part of the checklist, which we have already discussed, or is it implied that it will be part of that in the first place? Many of those concerns were shared in the other place. They were partly addressed in the letter for Baroness Merron, which is worth reviewing. It sought to clarify a number of concerns raised on Second Reading in the other place. I welcome the tone of the letter and the Minister’s stated willingness to listen. In particular, I acknowledge the recognition of the “challenges…to decision makers” that may be presented by “the complex interface between the Mental Health Bill and the Mental Capacity Act”, and I welcome the Government’s commitment to engage with clinicians and stakeholders during the revision of the code of practice. That is important. However, the letter also raises some further issues that deserve scrutiny. First, the Minister says: “Both Acts provide appropriate procedural safeguards to ensure that the individual’s Article 5 human right to liberty and security is protected during their detention. The nature of the safeguards provided under the two Acts are different”. That is undeniably true, but therein lies the concern: where the safeguards differ, so too may the thresholds, the review mechanisms and the practical experience of those subject to detention. In cases in which a person might meet criteria under both Acts, what clear guidance will clinicians be given on how to decide which legal framework to apply and how to ensure that the individual receives the most appropriate and proportionate protection? In the same letter, the Minister addresses the potential unintended consequences of reforms to section 3 of the Mental Health Act, namely that “people with a learning disability and autistic people, who lack capacity, could, in certain circumstances, be detained under the Mental Capacity Act rather than the Mental Health Act”. The Government’s stated intention is to prevent that outcome by strengthening community-based services. The letter states that “the proposed changes to Part 2, section 3…will only be commenced when we are assured that there are strong community services in place.” In the absence of clear statutory criteria, that could be seen as moving the target, so will the Government publish a set of benchmarks or a public readiness test? The Minister has said that the implementation will take place over 10 years, but a readiness test with criteria setting out how that will apply would help us to deal with a lot of the issues that we have talked about during the passage of the Bill.

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35. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    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?

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36. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    The hon. Lady makes an excellent point. This is especially relevant when capacity fluctuates in some patients, which we expect to see more often with the kind of dementia that will potentially come forward —for example, some of the new illicit drugs that are available can cause significant problems. Does she agree that having that flexibility is key? That is why the clause will help to ensure that the patient is empowered at all those different moments, and that there is a robust statutory framework to hold them to account. We do not want them to slip through the net, because if they do, by definition, not having these treatment plans up to date and in place may lead them to other parts of the Act, and we are trying to avoid that in the first place. That is the problem with having CTOs, or the concern that she mentioned in our sitting this morning, which has also been raised by charities. Does she agree?

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37. 12 Jun 2025·Parliament·Dr Luke Evans

    Mental Health Bill [ Lords ] (Fourth sitting)

    Clause 21 will introduce a statutory duty to provide care and treatment plans for most patients detained under the Mental Health Act in England. It is, in the Government’s own words, a cornerstone of the reform package, so it warrants thorough scrutiny. Under the current legal framework, there is no universal statutory requirement for a written care and treatment plan for detained patients. Although the care programme approach is widely used in England, and the Mental Health (Wales) Measure 2010 provides a statutory framework for care planning in Wales, provision in England is more variable. There is also the section 117 duty to provide aftercare for some patients, but there is no legal requirement to produce a personalised plan that spans care, treatment and discharge planning from the point of detention. Clause 21 attempts to fill that gap. We welcome its aim of ensuring that all eligible detained patients in England have comprehensive, personalised and reviewable care and treatment plans in place. We particularly support the requirement for the plans to address both clinical and social needs such as housing and employment. The aim to embed transparency and collaboration will ensure that patients and those close to them are meaningfully consulted when it is practicable. The ambition to create a consistent national framework, which will improve the quality and equity of care, is also commendable, as is the recognition that restrictive interventions, including compulsory treatment, should be clearly justified in the plans. Nevertheless, I have several important questions for the Minister. We have talked about the draft regulations; I assume that these plans will be encoded in them. Does the Minister have an idea of when the draft regulations are likely to be published? Given the interest in the plans, that is important. Much of the substance of what a plan must include, including how often it will be reviewed and how much information can be disclosed, is left to regulations. Without sight of it, how can Parliament be confident that the framework will be robust, enforceable and fit for purpose? I trust the Minister, but what if he is shuffled away and we get a different Minister? We may not know. I turn to timeliness. Will the Government consider setting a clear deadline in regulations, for example within seven or 14 days of detention, for the creation of a care and treatment plan? The benefit of personalised planning can be realised only if plans are produced promptly. That point leads me to enforcement and accountability. What happens if a care and treatment plan is not produced or is not updated appropriately? Will patients and their advocates have any legal recourse? What oversight mechanisms are being developed to ensure compliance? Proposed new section 130ZA(6) of the Mental Health Act requires consultation with the patient and with their family or advocate, but only where practicable and appropriate. Can the Minister explain how that will be interpreted in practice? Would the Government consider strengthening the consultation duty to require a recorded justification when a consultation does not occur? It seems to me that in most cases it should happen, so providing a justification when it does not would allow accountability and ensure that it is being put in place. How will the plans integrate within existing frameworks? Many detained patients already have a CPA plan, or a section 117 aftercare plan. How will the Government ensure that these new statutory plans complement existing requirements, rather than duplicating them? On forensic patients and privacy, the clause allows for the inclusion of information about victim and public protection arrangements in plans for patients detained under part III of the Act. I completely understand why that is, but it raises a question: how will the Government balance the patient’s right to privacy, rehabilitation and focus with safety? We support the principle that everyone detained under the Act deserves a clear, person-centred plan that outlines not only why they are detained, but how they will move forward, recover and return to life in the community. I turn briefly to the Liberal Democrat amendments. I assume that many of the points will be addressed in the regulations, so I will not go through all the individual applications, because I think that there is space there and the plan would be able to pick things up. However, I completely understand what the hon. Member for Guildford is trying to achieve. The thrust of all the amendments that the Liberal Democrats have tabled has been accountability and making sure that we consider all points. I just hope to make sure that the Bill is practicable, and I hope on behalf of His Majesty’s Opposition that we can strike a balance between accountability and practicability and ensure that we have both. The Minister clearly has support from both sides of the Committee for getting this right. I look forward to hearing his answers and hearing about how Members can work together to ensure that.

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38. 12 Jun 2025·Parliament·Dr Kieran Mullan

    Humanist Marriage

    It is a pleasure to serve under your chairmanship, Dame Siobhain, in what has been a heart-warming debate. I thank the hon. Members for Tamworth (Sarah Edwards), for Morecambe and Lunesdale (Lizzi Collinge) and for Henley and Thame (Freddie van Mierlo) for securing this debate, and the Backbench Business Committee for granting it. Marriage and civil partnerships play a vital role in fostering stable families and, as a result, more stable communities. Marriage and civil partnerships are more than personal milestones; they are cornerstones of strong, cohesive and enduring relationships—values that my party holds dear. When talking positively about marriage, I always like to point out that my parents were divorced; I do not approach this issue with some idealised view of what marriage represents and can mean, but understanding that an institution is not perfect does not mean that one cannot champion all of its benefits. I must also declare an interest in that I consider myself to be a humanist, and I am a member of the all-party parliamentary humanist group—this seems to be a gathering of humanists in Parliament today. The exact meaning of what it is to be a humanist will be different for different people, just as the interpretation and meaning of religious faith varies among individuals. To me, it has its greatest value at a community and societal level. We can all individually decide to try to lead what we consider to be moral, values-based lives, but humanism provides us with the opportunity to do so from a shared perspective. Many humanists celebrate significant milestones—births, marriages and deaths—in ways that reflect their values and worldview. As others have said, a humanist marriage ceremony is often deeply personalised, focusing on the couple’s individuality and commitment, rather than adhering just to religious traditions. Humanist ceremonies are gaining in popularity because they offer an alternative that resonates with those who prefer secular yet still meaningful celebrations. Approximately 1,200 couples a year choose to have a humanist marriage ceremony, and currently they all have to have a separate legal ceremony. The public, outward-facing nature of a marriage ceremony puts into action the idea that values can be even more powerful when shared and celebrated together as a community. Previous Conservative Governments understood and recognised the importance of marriage. We delivered the groundbreaking Marriage (Same Sex Couples) Act, which allowed gay and lesbian couples to lawfully marry for the first time. Indeed, that legislation provided for a review and subsequent public consultation on humanist marriages too. I understand that the majority of respondents to the 2014 consultation were in favour of changing the law. However, the coalition Government, which included the Liberal Democrats, decided that the legal and technical requirements of marriage ceremonies and registration in England and Wales should be considered more generally, alongside making a decision on this issue. The Law Commission was asked to review the law governing how and where people can marry in England and Wales, and the Law Commission concluded its work in 2022. The final 500-page report on reforming weddings law set out 57 recommendations. One feature of the proposed new scheme is that regulation would be based on the officiant rather than on the building in which a wedding takes place. The report also set out a scheme by which anybody could be authorised to conduct civil marriages. I have some concerns about the Law Commission’s proposals. I understand that the recommendations go beyond giving humanist wedding ceremonies legal status, and they would create a free-market, celebrant-based approach to the wedding industry. I disagree with the Liberal Democrat spokesperson, the hon. Member for Sutton and Cheam (Luke Taylor), that marriage is an entirely individual choice. We have talked about how its value sits within society; and if society does not regulate and choose how that operates, marriage loses its wider shared meaning. Alongside humanists, others have expressed that such a move could undermine the solemn nature of marriage. I understand that the current Government have also taken the view that wholesale reform is preferable. But every year that passes rightly creates further pressure, as the balance tips closer to those arguing that having specific measures to support humanist marriage ceremonies is the fairer approach. Let us not forget that Scotland and Northern Ireland already legally recognise humanist marriages. During the pandemic, the previous Conservative Government took steps to adapt our marriage laws to accommodate the social distancing regulations in place at the time. In June 2021, they recognised the need for flexibility during a challenging time for individuals wishing to marry and for wedding venues, by extending legal recognition to outdoor civil marriages on an interim basis. The measure allowed ceremonies to take place outdoors on approved premises, addressing the unique challenges posed by the pandemic. Following a consultation, that temporary reform was made permanent in April 2022, ensuring that couples could continue to celebrate their union in a safe and meaningful manner. The reform demonstrates the ongoing Conservative commitment to marriage and proves that specific adaptations to our legal framework to meet the needs of the moment are eminently possible. On a personal level, and as a member of the APPG, I share the frustration with the continued delay to marriage reform and, as a result, the recognition of humanist marriages. I also note the YouGov poll, conveniently published earlier this week, showing strong public support for recognising humanist marriages, with 70% in favour and only 15% opposed. The support is consistent across religious and belief groups of different kinds. Notwithstanding the concerns I have outlined, the Opposition are positively predisposed to the introduction of humanist marriage ceremonies. While we would need to consider any proposals in detail, we hope to be able to welcome any reform package brought forward. We are increasingly sympathetic to the need for specific measures to allow humanist marriages to take place, given the ongoing delays. A number of Conservative Members who support these measures wished to attend this debate, but as is often the case, timetables can be challenging. I hope the Minister can outline a timetable, and if she cannot, can instead explain what consideration the Government are giving to targeted reform. What do they see as the obstacles to this approach? As other Members have mentioned, the manner in which the marriage ceremonies of Quakers and Jewish groups are legally recognised provides a template for the Government. At the heart of this discussion lies a fundamental truth: marriage and civil partnerships are institutions that promote stability, responsibility and community cohesion. These are values that I, as a Conservative, champion unequivocally. I look forward to hearing the Minister’s plans for bringing them to the fore for the humanists in our society.

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39. 12 Jun 2025·Parliament·Dr Caroline Johnson

    Long-term Medical Conditions

    It is a pleasure to serve under your chairmanship, Mr Efford. I congratulate the hon. Member for Bury St Edmunds and Stowmarket (Peter Prinsley) on securing this important debate. I declare an interest as an NHS consultant paediatrician. In my clinical work, I have seen at first hand the impact that chronic conditions can have not just on the health of individuals but on their families, their carers and their wider communities. These are conditions that can shape daily life in profound and enduring ways. In some respects, the increased prevalence of long-term conditions is a success story for the medical fraternity, because some conditions that previously would have led to a patient’s death can now be managed effectively for a longer period of time, and people can continue to live happy, healthy and fulfilling lives. There is no silver bullet for tackling such conditions, but effective interventions and systems can improve quality of life, enable independence —we have heard about the importance of that—and reduce avoidable healthcare costs. Such interventions require a co-ordinated, whole-system approach, bringing together local authorities, NHS trusts, public health, education, social care and the voluntary sector. I am glad that the Government are talking about a move away from reactive and acute-based care towards prevention, rehabilitation and supported self-management in the long term. I note that the hon. Member talked about care on Teesside some years ago. As someone who grew up on Teesside, I remember the Carter Bequest hospital—I do not know whether his father had anything to do with that—which was the local community hospital providing community care for many local residents. We increasingly see patients living with not just one long-term illness but multiple long-term illnesses, known as multi-morbidity. That provides challenges, because sometimes the medication that one would ideally provide a patient for condition A is complicated because they also have condition B, for which they are taking something else that would interact with that medication. A patient might also need an operation but not be able to have it because another condition makes the anaesthetic risk too high, so the management of the second condition might have to be suboptimal as a result of the first condition. Some people have more than two conditions. One of the challenges that people with long-term conditions will face is staffing and workforce. I notice that the Government have decided to cancel, or at least significantly reduce the availability of, level 7 apprenticeships, which train our specialist nurses in advanced clinical practice, our district nurses and our community nurses. Will the Minister talk to her colleagues in the Department for Education about how there can be a move towards community care and prevention if they are going to make it more difficult to train the people who would provide that care? The hon. Member for Eastbourne (Josh Babarinde) talked about the delay in follow-up appointments. I have seen that myself. One of the challenges is that when one is under pressure to meet the 18-week pathway and there is no similar pressure on follow-up appointment timings, the consultant’s clinic inevitably ends up with more new patients and fewer follow-ups. The follow-ups get pushed back, often for many months. How will the Minister’s team ensure that the pressure to meet the 18-week pathway does not cause chronic illness to be covered less well than it is now? I was also interested in what the hon. Member for Newport West and Islwyn (Ruth Jones) had to say about exercise and lifestyle. I see a lot of children with varying conditions in my clinics as a paediatrician, and I have been amazed by how fresh air and exercise, diet and hydration, sleep, and not spending hours on computers, particularly in the evening and through the night, can make a whole range of medical conditions better. We know that the same is true of adult care in some cases. While it is not the cure for all conditions—of course it is not—in some cases it can help people to live better with the conditions that they have. I am interested that in some cases people are allowed only a few physio appointments before they get referred back to their GP. Perhaps longer courses of physio treatment could help people a little more. Multimorbidity was recognised as a priority in the previous Government’s health and care White Paper in 2022. Community diagnostic centres opened in order to play a vital role in providing quicker access to essential tests, dealing with the backlog left by the covid pandemic. There are two centres near my constituency, in Grantham and Lincoln. I visited the one in Lincoln recently, which has had very good feedback from constituents and is providing a great service. Can the Minister confirm that community diagnostic centres will continue to be well funded following the spending review? The previous Government launched a major conditions strategy in 2023, aiming to address six key areas—cancer, heart disease, musculoskeletal disorders, mental ill health, dementia and respiratory disease—but the current Government have paused work on this strategy. They came to power saying that they had a plan. They stopped the plan that we had, because they wanted to think of their own, which is fair enough. But we are now three weeks out from the first anniversary of their election, and still this magic plan has not appeared. I say to the Minister that this is too long to wait for people who are unwell. Can she, at the very least, commit that the 10-year plan will be published before we have lost one year in which the Government could have started delivering it? Musculoskeletal conditions are particularly common long-term conditions, affecting around 20 million people in the UK—that is a third of women and about 30% of men. They are the second most common cause of economic inactivity after mental health, and take a considerable toll. I thank advocacy organisations such as Versus Arthritis for their tireless campaigning on this issue. They have highlighted how these conditions disproportionately affect women and those living in deprived communities. The recent cuts to the personal independence payments proposed by the Government have disproportionately affected people with MSK conditions. Have the Government conducted an impact assessment? My concern with the PIP changes is that they were announced to meet an economic target, rather than being properly thought through. Can the Minister confirm whether they have been properly thought through? Has an impact assessment been conducted, and if so, will she ensure that it is published so that we can all study it in some detail? Mental health should be treated as a core component of long-term care. People with long-term conditions are two to three times more likely to experience mental ill health. Research shows that people who are confident in managing their long-term conditions have not just fewer A&E visits and hospital admissions but better mental health. What concrete steps are the Government taking to improve mental health provisions specifically for those with long-term conditions? Rehabilitation can be just as important to health outcomes as medicine and surgery. As was mentioned earlier in the context of strokes, some people have very good stroke rehab care, but for others that is less of the case. Rehabilitation, particularly early rehabilitation, is very important. Providing timely rehab and self-management advice would significantly reduce the number of people diagnosed with health conditions in their 40s and 50s, for example, being pushed out of the workforce, which drives both income and health inequality. Is improved access to community rehabilitation for people with long-term conditions part of the Government’s plan to shift from hospital to community care, keeping people out of hospital and in work for longer? I know that the plan is not published yet, but perhaps the Minister knows. Long-term conditions will define the health and social care agenda of the next decade. That requires a joined-up strategy across healthcare, the Department of Work and Pensions, and social care, and for the Government to support the most vulnerable and maximise the quality of life for all our constituents who suffer from long-term conditions.

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40. 12 Jun 2025·Parliament·Dr Caroline Johnson

    Long-term Medical Conditions

    There is a question that I have been wondering about. Baroness Casey is doing a report for the Government on social care, but she is also doing a report on child abuse. We were told initially that those reports would run consecutively, but they appear now to be running concurrently. I do not necessarily expect the Minister to be able to answer the question now, because she is standing in for somebody else, but it would be helpful if she could get us a written answer on what proportion of Baroness Casey’s time is currently devoted to the Home Office, and what proportion to healthcare.

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