Mental Health Bill [ Lords ] (Fifth sitting)

Gregory Stafford Excerpts

Committee stage
Tuesday 17th June 2025 Public Bill Committees

[Dr Luke Evans (Hinckley and Bosworth) (Con)]

It is a pleasure to serve under your leadership, Sir Desmond, especially on such a warm day. I hope that there is not too much hot air in the Committee to keep us even warmer.

Clause 22 will introduce a series of important amendments to the operation of community treatment orders under the Mental Health Act 1983. The clause has the stated aim of strengthening clinical safeguards and ensuring continuity of care between hospital and community settings. The Opposition support these goals in principle.

Let me set out the current legal position. At present, decisions to place a person on a CTO require two professional inputs: the patient’s responsible clinician and an approved mental health professional. The responsible clinician can vary, suspend, recall or revoke the order, often with no statutory obligation to consult the clinician who will be managing the patient’s care in the community. 

Clause 22 will change that. It introduces the new role of the community clinician—defined as the approved clinician who will oversee the patient’s care in the community—and requires their involvement at key decision points in the life of a CTO. Specifically, it requires a written statement from the community clinician that the CTO criteria are met, where they are not the responsible clinician. It obliges the responsible clinician to consult the community clinician before varying conditions, recalling or revoking a CTO, unless such consultation would cause unreasonable delay. It also includes the community clinician in the process of renewing a CTO, again via a written statement. 

These are not insignificant changes. They mark a shift towards multidisciplinary accountability and a greater emphasis on the continuity of care between in-patient and community settings. The Opposition strongly support both principles. However, there are several points that I would like to probe constructively, and I hope the Minister will respond in the spirit of improving what is clearly a well-intentioned clause. 

First, the term “unreasonable delay” appears multiple times in the clause as an exception to the duty to consult the community clinician, but I cannot see it defined in the Bill or in the explanatory notes. Could the Minister clarify what constitutes “unreasonable delay” in practice? Will guidance be issued to ensure consistency across trusts and clinicians? We must ensure that this exception does not swallow the rule or become a loophole in time-sensitive situations.

Secondly, what happens when clinicians disagree? The clause requires the agreement of the community clinician in writing before a CTO can be made, but it is silent on what happens when there is disagreement between the responsible clinician and the community clinician. This is not a hypothetical concern; differing clinical views are common and can be a healthy part of multidisciplinary practice. Could the Minister confirm whether there is a proposed resolution mechanism where clinicians differ? Would the decision default to a tribunal or a second opinion, or is the CTO simply not made?

Thirdly, as the Minister has mentioned, on the operational readiness to implement this clause, the new duties on community clinicians are not trivial. They are being asked to produce written statements, engage in formal consultations and be available to advise on time-sensitive decisions such as recalls and condition changes. Can the Minister reassure the Committee that a workforce impact assessment has been or will be conducted? Will there be investment in community mental health staffing and digital infrastructure to ensure that this duty is workable?

Fourthly, I want to raise the issue of handover and role clarity. The clause will introduce a new statutory role—the community clinician—but patients often transition rapidly between settings. There may be uncertainty about who holds that responsibility at a given time. Will guidance ensure that community clinicians are formally designated and that responsibilities are clearly recorded at the point of discharge?

I want to end on a constructive note. Clause 22 is a step in the right direction. It reflects many of the recommendations of the independent review of the Mental Health Act, including the emphasis on least restriction and on therapeutic benefit. I encourage the Government to consider defining or clarifying unreasonable delay in regulations or guidance, introducing a clear process for resolving professional disagreement, and committing to publish a plan detailing workforce support, guidance and digital infrastructure to ensure that this takes place.

Clause 23, which is linked to clause 22, will introduce two important amendments to the operation of community treatment orders under the Mental Health Act 1983. As things stand, section 17B(2) allows a responsible clinician to attach conditions to a CTO if they are necessary or appropriate, to ensure the patient receives treatment, to prevent risk to health or safety or to ensure engagement with services. Such conditions can include where the person lives, their attendance at appointments and even lifestyle restrictions such as abstaining from alcohol or drugs. However, we know that these conditions can be seen as coercive. Patients often feel that breaching them means automatic recall to hospital. In practice, some CTO conditions may drift toward overreach rather than clinical necessity.

The clause responds to these concerns in two ways. Subsection (1) will remove the words “or appropriate” from section 17B(2), meaning that CTO conditions must now be strictly necessary, not just advisable or convenient. The Opposition support this narrowing of the threshold. It sends a clear message that CTO conditions must be clinically justified, proportionate and tailored to the individual’s needs. However, I ask the Minister how clinicians will be guided in applying the new “necessary” test. Will the code of practice be updated with examples and scenarios? Crucially, what measures will be taken to ensure that patients are clearly informed that a breach of a CTO condition, in itself, is not automatic grounds for recall?

[Gregory Stafford (Farnham and Bordon) (Con)]

It is a pleasure to serve under your chairmanship, Sir Desmond. Taking a step back to my hon. Friend’s point about “necessary”, is he concerned, as I am, that it is not clear to those responsible what “necessary” means? We could open ourselves up to potential legal challenges and disputes, which would give lawyers lots of money but would have no benefit for the patients.

[Dr Evans]

My hon. Friend makes an incredibly important point. Some later clauses try to address a problem where a patient was consenting to a community order, but the restrictions were so tight that it worked out as deprivation of liberty. My hon. Friend is absolutely right that knowing what is necessary is important to provide a clearly defined structure for the patient. Patients worry that if they breach that protocol, they will be automatically recalled. That might prevent them from breaching the conditions in the first place, but on the other hand it is a sword of Damocles above them. In no way does that create a beneficial therapeutic environment for them.

--- Later in debate ---

[Dr Chambers]

I am really looking forward to the 10-year plan and reading about how it will improve mental health. We shared Labour’s manifesto commitments to mental health practitioners in each school and mental health hubs, so we certainly support that.

The hon. Member for Hinckley and Bosworth made some very good points and said that this proposal should possibly not be in primary legislation. I accept that integrated care boards do not have control over how every part of the service is delivered, so I am happy not to press the new clause to a vote, but I think the second part, which says that integrated care boards should have a duty to assess and report on the resource needed to meet the demands on services every two years, is important.

[Gregory Stafford]

I rise to speak to clauses 22 and 23 and to Liberal Democrat new clause 4.

As my hon. Friend the Member for Hinckley and Bosworth said, the Opposition support clauses 22 and 23 generally. Clause 22 addresses the concern that community clinicians—essentially, those responsible for overseeing a patient’s care outside hospital—have historically had limited formal input into decisions about community treatment orders, even though they are central to the patient’s ongoing care. It ensures that community clinicians not only are consulted but, in some cases, must provide written agreement before key decisions are made. It aims to improve continuity of care, ensure decisions reflect the realities of community-based treatment, and reduce inappropriate and poorly co-ordinated use of CTOs.

The benefits of the clause are obvious, but they are worth restating. Clearly, it improves the continuity of care and ensures that clinicians with direct knowledge of the patient’s community care are involved in those key decisions. It enhances safeguards, adding an additional layer of professional oversight before coercive measures are imposed or suggested. It promotes collaboration by encouraging joint decision making between the hospital-based and community-based clinicians, and it reduces the risk of inappropriate CTOs by ensuring they are used only when genuinely appropriate and supported by those delivering care.

However, I ask the Minister to touch on three points. First, requiring a written agreement or consultation could delay urgent decisions if not managed efficiently, so will he explain how, under the clause, any potential delay—a disagreement or just administrative inertia—can be removed to ensure treatment is not delayed?

That moves me on to the administrative burden. Clearly, the clause adds a level of complexity and requires more documentation and co-ordination. Although I understand that that is a necessary outcome, I would again be grateful for the Minister’s thoughts on how to ensure effective and speedy implementation.

As my hon. Friend the Member for Hinckley and Bosworth said, the ambiguity in the roles of the two clinicians may create confusion or disputes over responsibilities if they are not clearly defined or agreed. My reading of the clause is that there is no such clear definition; will the Minister look to provide one through other agencies, or will he put something into the clause in Committee or later in the Bill’s proceedings?

Clause 23, on the conditions of community treatment orders, addresses the concerns that the threshold for imposing conditions on community treatment orders has been too low, allowing conditions that may be clinically unnecessary or overly restrictive. By removing the “appropriate” test, the clause will tighten the legal standard to ensure that only necessary conditions are imposed.

Additionally, the clause will empower tribunals to play a more active role in scrutinising CTO conditions by allowing them to recommend that clinicians review specific conditions, even if the patient is not discharged. This reflects the Bill’s broader aim of enhancing patient rights and removing unnecessary restrictions.

The clause is a welcome addition. It will ensure that CTO conditions are imposed only when strictly necessary, meaning that there are stronger safeguards, and it will enhance the role of tribunals in protecting patient rights without requiring full discharge. It will reduce clinical overreach by preventing the use of overly broad or vague conditions that may not be clinically justified.

However, as with the previous clause, I have some questions. First, the tribunal power is limited in that it can only recommend, not require, the reconsideration of conditions. Is that the intention, or will the Minister strengthen the clause at some point to ensure that the tribunal can require a reconsideration of conditions? If he will not, what issues does he see arising from there not being a reconsideration?

Secondly, as I mentioned in my intervention on my hon. Friend the Member for Hinckley and Bosworth, I have a concern about the potential ambiguity in the shift from “appropriate” to “necessary” leading to uncertainty or dispute over interpretation. As we touched on in relation to other clauses, clinicians will need additional guidance or training to apply the revised standard consistently. Where will that revised training and guidance be located, and what is the timeframe for its implementation? We need to ensure that all clinicians are fully trained and ready to use this new power.

I will briefly touch on new clause 4, tabled by the Liberal Democrats, because although I understand that the hon. Member for Winchester may not press it, somebody else might. It would place a general duty on integrated care boards to ensure that services in the community have the necessary level of resource to meet demand such that the provisions of the Bill function as intended, and to assess and report on this every two years. As my hon. Friend the Member for Hinckley and Bosworth mentioned, the Opposition generally support the overall aims of the new clause, but as ever, there are some issues with the detail, so I have five questions for the hon. Member for Winchester if he responds, or for the Minister to answer in his summing up.

First, if we imposed a statutory duty on ICBs to ensure sufficient resources for the CTOs, what mechanisms would there be to monitor and enforce compliance? Secondly, what would be the consequences if an ICB failed to meet this duty? Would there be formal accountability or a sanction process? Thirdly, how would the duty interact with existing NHS budgetary constraints and competing priorities? Would it become a statutory obligation with no clear means of redress if unmet? Fourthly, could the duty set a precedent whereby Parliament mandates resource guarantees without providing additional central funding? Finally, what constitutes “sufficient” resources in the context of the CTOs? Who defines that standard, and it is defined locally or nationally?

[Stephen Kinnock]

The term “unreasonable delay” is subject to review by the courts, and further guidance will be given in the code of practice. On what happens if the responsible clinician and the community clinician disagree, the addition of a third decision maker is not about overruling the responsible clinician, who continues to have overall responsibility for the patient on the community treatment order. Including the community clinician at the point of putting someone on a community treatment order helps to ensure continuity of care for the patient. Involving the community clinician in other decisions around the community treatment order, particularly recall, revocation, renewal and discharge, means they can provide an additional insight into the patient’s status while in the community.

--- Later in debate ---

Amendments 54 and 55 would alter the balance by stipulating that in all cases involving patients under 16, the nominated person must have responsibility. That would, in effect, significantly narrow the pool of eligible nominees. I understand the rationale for that: by legal definition, children under 16 are minors. Their capacity to make decisions about their healthcare is rightly subject to additional safeguards. The nominated person who has access to personal information can object to the treatment or detention and can challenge decisions. They wield serious influence.

[Gregory Stafford]

I thank my hon. Friend for his comprehensive analysis of the provisions under discussion. Does he understand amendments 54 and 55 to mean that, although there would be a narrowing of who can be chosen as the nominated person, there would still be some flexibility for the child to choose? Does he have any concerns about a situation in which a minor—someone under the age of 16—may, for whatever reason, choose somebody who the health professionals believe is not the most appropriate person, and does he have any sympathy with the idea that, given a parent has responsibility for the child in every other aspect of their life, the parent should have that same responsibility in this context?

[Dr Evans]

My hon. Friend has identified the nub of the issue, and his intervention leads me on to an example that demonstrates the problems that we are talking about. I have chosen to debate these provisions in the order shown on the selection list because I wish to understand whether the Minister believes that Government amendments 40 and 41 will deal some of the issues that I am about to raise. There clearly has to be flexibility in dealing with these situations, but it is worth exploring what could go wrong. The nub of the issue is that they may well go wrong. Let us take an example.

Say that A is 16, and she is struggling with anxiety and behavioural issues. She has had serious suicidal episodes and previous drug use. She lives at home with her loving, supportive parents, who have always acted in her best interests and want to engage constructively with her care, but A is under pressure from a 19-year-old boyfriend. He is controlling, and discourages her from speaking to her parents or professionals. When asked to nominate a trusted adult, A names him. Under the Bill as drafted, the nominated person could be accepted, provided A is deemed to be competent. That would give her boyfriend access to her care decisions and significant legal standing. Under amendments 54 and 55, that would not be possible because he does not have parental responsibility, and therefore could not be appointed.

That example illustrates why the amendments matter. Children, especially those in crisis, may be vulnerable to coercion, grooming, or misplaced trust. Loving parents, who have legal obligations to protect and care for their children in every other walk of life—as my hon. Friend the Member for Farnham and Bordon pointed out—could find themselves legally sidelined.

Are there risks in amendments 54 and 55? We must consider the edge cases. Not all children under 16 live with those who are trusted and have parental responsibility. There are estranged families, kinship carers, informal fostering arrangements and situations of abuse. A strict parental responsibility requirement could exclude the very people relied on by a child. I ask the Minister whether there is flexibility in the amendments for exceptional cases in which someone without PR may be appropriate, with oversight. Do Government amendments 40 and 41 already address that point? Forgive me if I have misinterpreted, but they seem to be bridging amendments. Would guidance or a statutory code of practice provide a better mechanism to balance protection and flexibility? What assessment has been made of children in care or informal arrangements, where parental responsibility might technically lie with a local authority or estranged parent, especially under the changes proposed by Government amendments 40 and 41?

There are potential routes forward. One option might be to require PR by default but allow exceptions if the child expresses a clear competence preference, the AMHP agrees that a person is suitable and poses no safeguard risks, and a senior commissioner or legal oversight has sign-off. That is a possible way of keeping amendments 54 and 55 alive, and it would keep within the spirit of the amendments by protecting children from harmful influence without removing their voice in complex or marginal cases. We could also explore adding an explicit safeguard power to override a child’s nomination where there is concern of coercion or abuse, regardless of parental responsibility status. Again, I think that may be what Government amendments 40 and 41 are trying to do, but I would be grateful to see whether that is the case.

--- Later in debate ---

[David Burton-Sampson]

It is a pleasure to serve under your chairship, Sir Desmond. I rise to speak to clauses 24 to 28, and I will start by sharing the story of two of my constituents: Carol and her husband John.

John had been an active member of the local community before he was sadly diagnosed with dementia. As his dementia progressed, John was settled into a good care home and Carol was happy with the care that he was receiving. Due to a change in his medication, Carol was told that John had become more agitated and aggressive than usual. She was asked whether she would agree to John being assessed. Although she did not really understand what that meant, she did not see any reason to refuse.

From that point on, Carol says that she felt like she had lost control over her husband’s care. John was assessed by four strangers, and Carol was told that she could not be present. Following the assessment, Carol was told that John would need to be detained under the Mental Health Act within the next two weeks. Carol was very concerned to hear that John would be detained, but despite having power of attorney, she was not able to overrule that decision. She hoped that he would be able to get help with his medication and that he would be discharged.

In the end, Carol had only half an hour’s notice that John was going to be detained. She rushed to the care home to see her husband, who had been sat in the garden having a cup of tea with some friends, being abruptly put into a van by two men and taken away. She was not allowed to come with him, and for the first time in her life, Carol had a panic attack. She could not imagine how traumatic it was for John, who was disorientated and confused because of his dementia, to be taken by people he did not know to a strange place.

John was taken to a secure mental health ward that was very different from the familiar environment of his care home. Carol was told that she could not visit him, but she was insistent and turned up anyway. She was then allowed to meet his doctors on his first day and was reassured to hear that he would be detained for only two weeks while his medication was reviewed.

In the end, John was detained for eight months. Carol continued to visit every day, spending as much time as possible with him. She had specially adapted her home to accommodate John’s needs, but she was not able to have him discharged to either his home or a care home. Precious time was taken up with the endless fight to get John into a more appropriate environment. Sadly, John’s health significantly declined while he was detained. He lost the ability to walk and speak, and Carol felt that, in his declining state, he could not pose any danger to himself or anyone else. However, it was only after he was admitted to hospital for a catheter fitting that Carol was able to get him discharged, thanks to a doctor telling her that she could use her power of attorney to take him home—something she was told she was unable to do in the mental health facility.

She took him to a care home, where, sadly, he died two weeks later. John’s cause of death was listed as Parkinson’s, but Carol feels strongly that the anxiety and fear of his final months contributed to his death. Carol understood that her husband was dying; all she wanted was to be included in making decisions about his care. She knew very clearly what she wanted for him. She told me:

“I wanted him to die in a bed with clean sheets, with a window open and with me by his side.”

Those wishes were not taken into account.

As John’s wife and carer, Carol spent every day with him, yet she felt excluded from the decision-making process for his care. She should have been able to focus on what was important: spending time with him. The changes in clauses 24 to 28 would have helped Carol to feel more involved in representing John during his time in care. Clearly, there were failures to allow Carol, as John’s nearest relative, the rights that she was entitled to in order to support him.

With the move from “nearest relative” to “nominated person”, the new rights afforded by the Bill would have given Carol even greater engagement. Given that she had power of attorney, it is likely that she would have been appointed the nominated person by the AMHP. However, moving forward, it is important that those rights are properly afforded to the nominated person, so that we do not have another situation like John and Carol’s.

Although I welcome and fully support the changes in clauses 24 to 28, I seek an assurance from the Minister that all efforts will be made to ensure that the rights of nominated persons are fully recognised and assigned, and that nominated persons will be made fully aware of their responsibilities and powers, allowing advocacy for the patient under care.

I turn briefly to amendments 54 and 55 and Government amendments 40 and 41. I agree with the Government’s view that if a child has capacity, they should be able to have the choice to appoint their own nominated person. I appreciate the intent of the amendments from the hon. Member for Runnymede and Weybridge, but I think that the Government’s approach is more appropriate.

[Gregory Stafford]

I appreciate that the hon. Gentleman sees the potential benefit in the amendments standing in the name of my hon. Friend the Member for Runnymede and Weybridge. However, my hon. Friend the Member for Hinckley and Bosworth gave an example, which I do not think is entirely distanced from reality or possibility, in which a person could well choose someone who is deeply inappropriate. In that situation, the person or people—that is, the parents—who had in every other part of life had responsibility for that child would now potentially not have responsibility for the child, in what is probably the most important part of that responsibility.

Does the hon. Member for Southend West and Leigh really not have any concerns about that? If he does, does he not support at least the intentions behind those two amendments, if not the exact wording or drafting? If he does accept those intentions, would he like to see the Government table similar amendments, drafted in a way that he would find more appropriate?

[David Burton-Sampson]

I appreciate the hon. Member’s intervention. He makes the point that there may be situations in which the young person’s request might be inappropriate. However, on the flip side, there may be a situation in which it might be inappropriate for the person with parental responsibility to be the nominated person. They could have been involved in the situation that has led to that young person entering a mental health spiral—an abuse situation, for example, which has not been discovered by the authorities. That person would still have parental responsibility at that time. I think it is important that the young person can choose the person to support them in their ongoing care. I will be supporting clauses 24 to 28 and Government amendments 40 and 41.

--- Later in debate ---

[Aphra Brandreth (Chester South and Eddisbury) (Con)]

It is a pleasure to serve under your chairmanship, Sir Desmond. I rise to support amendments 54 and 55, tabled by my hon. Friend the Member for Runnymede and Weybridge, but I will first briefly speak to clause 24, which is an important and long-overdue step towards modernising the Mental Health Act 1983, crucially strengthening the rights, dignity and autonomy of individuals subject to it.

The reform of the existing nearest relative provisions, replacing them with a new system that allows for the appointment of a nominated person, is an important part of ensuring that individuals get the right support, and modernises an outdated system. The current model is based on a rigid and outdated hierarchy in which the role of the “nearest relative” is determined by law, not by the wishes of the patient. This one-size-fits-all approach fails to account for the complexities and nuances of individual relationships. It can result in someone unsuitable, or even actively harmful, being placed in a central role in a person’s care and treatment journey. Indeed, the limitations of the system have been acknowledged by practitioners, patients and policymakers alike. It is too often disempowering, and the patient can lose agency at a time when they need to be empowered to feel in control of the situation as much as possible.

As the shadow Minister says, clause 24 is the cornerstone of the reforms. It is an important change to the current legislation to reaffirm the commitment to patient-centred care, to dignity and to the principle that those receiving treatment under the Mental Health Act should have a voice in decisions about their support network. The aim of the clause—to put the patient first—is important. It acknowledges that the person best placed to advocate for the patient may not be their closest relative. In some cases, family dynamics are fraught. In others, the designated relative may hold views about treatment that conflict with the patient’s wishes or medical advice. We have seen real-world examples in which the imposition of the “nearest relative” role has led to tension, distress and, ultimately, a breakdown in trust. That is not the kind of environment in which recovery is fostered.

Amendments 54 and 55 would address the specific issue of nominated persons and those with parental responsibility for children under the age of 16. It is important that we consider situations in which a young person may be in a vulnerable position and their decision on who their nominated person should be may not be in their best interests. We have a particular duty to ensure that children are safeguarded. Clause 24 as it stands will allow under-16s to choose someone who is not the parent to have significant power, including the ability to discharge the child from hospital.

We must listen to and actively try to support any young person who needs that kind of intervention—it is not that their views should not be considered. However, there is a very real risk that a vulnerable child or teenager might be coerced by or under the control of an older partner, for example, as my hon. Friend the Member for Hinckley and Bosworth pointed out. Perhaps they might choose an older friend. We need to consider that a decision made by the nominated person, such as an older friend, may have implications for those with parental responsibility. For example, that older friend may decide to discharge a child from hospital and into the care of the parents, who would not provide advocacy or be part of that decision making.

The Minister said that safeguards will be put in place, but can he expand on that? There are some real concerns here. Let us consider a situation in which there has been a decision by a court to determine which parent has responsibility for the child. If complex family issues have already been considered by the family court, it is right that the decision be followed. I respectfully ask the Minister to reconsider this point. We must respect the fact that parents of those under 16 are best placed to advocate for, support and act for their children. This is about capacity, consent and, ultimately, safeguarding.

[Gregory Stafford]

My hon. Friend makes a powerful point. I remember the comments made by the hon. Member for Southend West and Leigh, who is chuntering from a sedentary position—I think he disagrees with my hon. Friend’s point. In his reply to my intervention, he made the point that there are situations in which things are the other way round, where those who have parental responsibility are not necessarily the appropriate persons.

Does my hon. Friend agree that, on first principles, the parent should have parental responsibility in all areas of life, including the ones that she is talking about, unless there are specific reasons, such as the court decision to which she referred, that suggest that the parent is not the correct person to have responsibility? Surely, in the balance of danger or risk, there is a far greater risk if the nominated person is not a parent than if the nominated person is a parent.

[Aphra Brandreth]

My hon. Friend makes an important point. If parents are not acting in the best interests of their children, there is a wider safeguarding issue that needs to be considered. One would question why such parents had been left in a situation in which they have responsibility for their children and are potentially harming them.

That leads me nicely to another point, which is that introducing the additional wording would bring mental health in line with physical health. For someone under the age of 16, it is their parents who have the responsibility to act in the best interests of their physical health; it seems to me that one would expect the same for mental health. I therefore urge the Committee to support amendments 54 and 55.

Let me return briefly to the overarching aims of clause 24. I underscore the point that the wider principle at stake—patient autonomy—is one that I support. The ability to make informed choices about one’s care should be a central component of our care system. In mental health, where individuals can feel particularly vulnerable, that becomes even more essential. Granting patients the power to nominate someone who will advocate for them, advise them and represent their wishes is a powerful act of empowerment. Moreover, this change enhances safeguards for patients. It ensures that the person acting on their behalf is someone they have chosen and trust. It reduces the potential for conflict and opens the door to a more collaborative and compassionate model of care.

If the Committee agrees to the amendments, which would provide the necessary safeguards for children, who I believe should be considered separately to adults, my overall view is that clause 24 represents a pragmatic, compassionate and patient-focused update to the Mental Health Act. It aligns with our modern understanding of mental healthcare and puts trust, respect and dignity at the heart of our legislative framework.