Mental Health Bill [ Lords ] (Seventh sitting)

Jen Craft Excerpts

Committee stage
Thursday 19th June 2025 Public Bill Committees

[Dr Evans]

The hon. Gentleman is spot on. We do not want people making decisions about their care when they do not have capacity. The whole point of what we are trying to do—as is the Government’s intent—is to allow people to make advance care decisions when they have capacity, so that when they are not lucid in the future and come back into contact, their preferred decisions are already set out. The clause does allow for a handbrake mechanism for clinical safety, to overstep them. However, what I am worried about is finding ourselves in a situation where patients never even find out that they have the right to create one of these ACDs.

The hon. Gentleman will know, as I do from my time, that good clinical practice is to ensure that patients have a plan. We do that for asthma: we expect patients to have an emergency plan for what happens, who they contact, where they go, what they take and what it looks like, personalised to them. Why should mental health be any different? My amendment actually gives ACDs legal footing, rather than simply saying that the system should offer it to them.

The amendment is cost-effective. Evidence suggests that ACDs can reduce the use of coercive powers, prevent relapse and improve continuity of care. That reduces costs, not adds to them. It is already good clinical practice; many mental health trusts already encourage care planning conversations. Our amendment would simply raise the standard across the country.

The Opposition understand that the Government have the numbers on this Committee. Will the Government clarify the role of the code of conduct? Do the Government intend to issue national guidance or benchmarks to ensure that ICBs do not apply widely different criteria for who is appropriate to be informed or held? Could the Government explain further, in response to the letter and in this Committee, why they do not accept ACDs as a basic right, narrowly defined, for only the most vulnerable individuals to be offered this opportunity? What mechanism will be used to monitor compliance with these new duties? How will patients know whether they are being fulfilled?

To my eyes, Government amendments 34 and 35 will do the same as amendments 32 and 33, but covering the Welsh system and local health boards, so I will not rehearse the arguments that we have just had. However, I would be interested to know whether this creates an issue for data collection on compliance across the two countries. We touched on this in relation to clause 2, but if different health authorities take different approaches to monitoring data, does that not risk making it even more opaque when we try to see both good and bad performance? Could the Minister address that point?

[Jen Craft (Thurrock) (Lab)]

I rise to speak briefly to clause 45, Government amendments 32 and 33, Lib Dem amendment 18 and Opposition amendment 46. I am very supportive of clause 45. The ability to make an advance choice document is incredibly important to people who may come under the scope of the 1983 Act and be subject to detention under mental health legislation.

We have spoken at length about the importance of patients’ input into their care and the improvements in outcomes when they feel that they have been involved and their wishes and feelings are taken into account. An advance choice document allows someone at risk of being detained under the Act to set out their choices, thoughts and opinions before becoming so unwell that they may need to be admitted to hospital. Other hon. Members have spoken about how an advance choice document can help prevent detention in a mental health unit, as it can stop issues escalating to the point where there is no option but detention, to ensure patient safety or the safety of others. I am broadly supportive of clause 45, and I urge the Committee to be.

I turn briefly to Opposition amendment 46. I have heard the thoughts of the hon. Member for Hinckley and Bosworth. My understanding is that clause 45, along with Government amendments 32 and 33, will effectively create the rights for those who should have an advance choice document to be able to take advantage of them. Government amendments 32 and 33 will go further in ensuring that people who may benefit most from an advance choice document are informed of their ability to do so.

I note that Government amendment 32 will put a duty on an integrated care board to bring information to such people as it deems appropriate. I welcome the duty being on an integrated care board or commissioner locally, particularly because there are such nuances in localised care and localised populations. There are areas of the country in which the prevalence of things like learning disability and autism is higher than in others. The amendment will allow an ICB or local commissioner to consider what may be appropriate for the population in their area.

[Dr Evans]

I appreciate what the hon. Lady is saying. There are differences—rightly so—and regional variation. By definition, different regions will take different approaches to dealing with this issue. My argument is simply that someone with a learning disability should have the right to decide to make an ACD, as should someone with bipolar disorder or anorexia. There should be no regional variance in that; it should be a right given to the individual there and then. Regional discrepancy should not come into the system to deal with this. I appreciate that there will be regional discrepancy, but, fundamentally, we want to engage the right, not just the responsibility for the ICB to decide who it thinks is appropriate. I am interested in the hon. Lady’s take—I think this goes to the heart of what we are trying to do.

[Jen Craft]

I agree on the notion of a right; where we vary is that I think that the Bill as written, and Government amendments 32 and 33, enshrine the notion of a right without it having to be spelled out as such. Local variation includes localised populations, such as those from marginalised communities. We might consider different translations of support that is available. That will not be the case across the board—it will vary from area to area. This does not remove people’s ability to make an advance choice document; it simply gives local commissioners the ability to determine what is most appropriate for their area, how that support should look and how it will be targeted.

Without getting ahead of the Minister, I hope that he will say what guidance on best practice for local commissioners and ICBs will be set out, particularly in relation to those with learning disabilities and autism. We have spoken about easy-read documents, for example, which should probably be made available, as should advice on how commissioners can best make sure that all those who might benefit from an advance choice document are meaningfully engaged and informed of their right and ability to do so.

The Minister has agreed previously to make sure that he works with disabled people’s organisations, including those run by and for people with learning disabilities and autism, on bringing forward a code of practice on the Mental Health Bill. Input on patient experience into how best to contact and meaningfully engage people who would benefit from an advance choice document would be particularly beneficial.

Very briefly, the aim of Liberal Democrat amendment 18 is to include consideration of financial circumstances in an advance choice document. I have looked into this—in my opinion, it is outside the scope of what an advance choice document does. An advance choice document sets out how an individual would wish to be treated if they became so unwell that they were unable to make those decisions for themselves. I am not fully sure how one’s financial circumstances fit into how one would be treated relative to detention or, potentially, in a community-based setting. I understand that financial circumstances have an impact on people’s mental health—we have talked about that in debates on other clauses—but they do not necessarily have a place in this specific part of the Bill.

I encourage the Committee to support clause 45 and to adopt Government amendments 32 and 33. This is, once again, a big step forward in ensuring that those with serious mental illnesses are able to input into their care and treatment in a real and meaningful way.

[Dr Danny Chambers (Winchester) (LD)]

It is a pleasure to serve under your chairship, Sir Desmond. In the previous sitting of the Committee, I spoke extensively about the close link between money worries and poor mental health. That link is why I have sought, through amendment 18, to ensure that advance choice documents include a specific section on money. This would give people greater choice and control over their finances when they are in crisis. Without that provision, financial worries could be an even greater hurdle to recovery.

We have talked a lot about financial problems being a major contributor to mental health crises, and they can make it much more difficult to recover from one. I will not go through all the details again, but the numbers show how significant the problem is. Last year, nearly 21,000 people in England alone were struggling with problem debt while in hospital for their mental health, so it is not a small cohort of patients for whom this is a specific issue. Ensuring that people’s finances are taken into consideration when they are in a mental health crisis will prevent future illness, reduce waiting lists and help people to return to daily life more smoothly, including to work. If we ignore it, that will end up costing the NHS more in time and resources.

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

It is a pleasure to serve under your chairmanship, Sir Desmond. I rise to speak in support of amendment 46, tabled by the shadow Minister, my hon. Friend the Member for Hinckley and Bosworth, which seeks to strengthen clause 45, an already welcome and progressive clause, by creating a statutory right for all eligible patients to create advance choice documents if they so wish.

Let me begin by saying that I think everyone on the Committee recognises the importance of advance choice documents. They are an excellent initiative, and I am glad that the Bill introduces a framework to support their use. I hope we can all agree that they represent a constructive and compassionate shift in how we think about mental health care—one that puts the patient’s voice at the centre. ACDs are fundamentally about empowerment. They allow individuals, while they are well and have full capacity, to record their wishes, preferences and concerns regarding their treatment, so that during future periods of unwellness, when they may lack capacity, their past self can still be heard and respected. As Bipolar UK has rightly put it:

“The idea behind an ACD is that you use your past to plan your future.”

That simple principle holds immense power. Individuals with lived experience of severe mental illness like bipolar disorder are often experts in their own care. They know what works, what does not and what signs to look out for. An ACD allows that hard-earned knowledge to be recorded, shared and used to guide clinical decisions. By identifying early warning signs and outlining preferred treatments, ACDs can enable families, friends and professionals to intervene earlier, potentially avoiding a crisis or reducing the severity of an episode. This is not just about better care; it is about safer care and, crucially, more timely care.

The research is persuasive. Studies suggest that ACDs can reduce rates of compulsory detention under the Mental Health Act by up to 25%. That is not a small statistic; it is a significant reduction in trauma for patients, in the use of force and in resource pressures on services. It is hard to think of a better example of a policy that both improves outcomes and reduces system strain. ACDs can also play a vital role in reducing inequalities, especially among racial minority groups, who, as we have all said, are statistically more likely to be detained under the Act. Ensuring that those patients can express their wishes in advance gives them greater agency and helps to address long-standing disparities in the system.

ACDs are not just a useful administrative tool; they are, as Earl Howe put it in the House of Lords,

“are a major component part of one of the Bill’s key strands, which is to give mental health patients better control over their own care—which, of itself, carries a therapeutic value.”—[Official Report, House of Lords, 27 January 2025; Vol. 843, c. 79.]

I absolutely agree, which brings me to amendment 46. The clause as drafted places duties on NHS England and integrated care boards to consider making information about ACDs available, and to help those people whom they consider “appropriate” to create one. That is a start, but it falls short of what is needed. The shadow Minister’s amendment would take us further and create a statutory right for eligible patients to create an advance choice document. It would define clearly who is eligible—for example, those previously detained under the Act, those diagnosed with a condition that may require future detention and qualifying informal patients—and would put a clear duty on NHS bodies to inform these patients of their right and to help them to exercise it. This is not about placing a burden on services; it is about ensuring that everyone who stands to benefit from an ACD knows that they can make one and is supported to do so if they wish.

I appreciate that the Government have tabled amendments 32 and 33 to clause 45, and I welcome the intention behind them. Amendment 32 requires that NHS England and integrated care boards must bring the availability of this information and help to the attention of such people “as it considers appropriate.” Amendment 33 expands on how that might be delivered, including through conversations with qualified individuals and by having specific regard to the benefits of ACDs in the 12 months following discharge from hospital.

Although these are improvements, I must respectfully say that they stop short of what is needed. They continue to frame the duty in terms of who the board considers appropriate, yet the very point of ACDs is that we should not be gatekeeping access. We should not be making assumptions about who would or would not benefit from having one. Every eligible patient should be offered the choice, not just those whom the system deems suitable. We are dealing here with people’s autonomy and right to shape their future care, and if we start from a place of selective provision, we immediately disempower many of the very individuals we claim to support.

[Jen Craft]

I would welcome the hon. Lady’s thoughts on where clause 45 or the Government’s amendments allow for selective provision. My understanding is that they place an onus on mental health commissioners to make sure that all those who are deemed appropriate to be in receipt of an ACD should be given the ability to make one. I do not think that is selective; it is very much related to the purposes of the Bill, and it spells out who may come under the provision.

[Aphra Brandreth]

The hon. Lady has just made my exact point: that it is who they deem appropriate. That is the point I am trying to make. It is for the individual—of course, with support of people looking after them—to decide whether it is appropriate for them and to be offered it.

[Jen Craft]

Will the hon. Lady give way on that point?

[Aphra Brandreth]

I will make progress, as I know that a few Members wish to speak on this point, and we have a long day ahead.

I will touch briefly on amendment 18, tabled by the hon. Member for Winchester, which suggests that ACDs should include a person’s financial circumstances. I recognise the sentiment behind the amendment. As both I and the hon. Member for Winchester have said in Committee, financial stress can be a major factor in mental health, but I gently suggest that prescribing the content of an ACD in this way is unhelpful. The point of the document is choice. The individual decides what they want to include, not us. That is the strength of the approach. It is personal and voluntary; it is theirs.

Amendment 46 respects that principle. It does not tell patients what to include in their ACD; it simply gives them the right to make one, and ensures they are informed of that right and supported to act on it. ACDs can be lifesaving, and they help people to stay well, safe and in control. They are especially valuable for those who have been detained before or who are at risk of detention in the future. We know that they are already supported by a wide range of stakeholders and experts by experience.

The question for us is not whether to support ACDs—I think we all do. The question is: do we want to make access to ACDs a universal right for those eligible, or do we want to continue to leave it to the discretion of the system? I believe the answer is clear: we must empower people, honour their voice and do so not only when they are well and able to speak, but when they are unwell and most vulnerable. That is what the amendment seeks to do. I urge all colleagues on the Committee to support amendment 46 and strengthen clause 45. Let us make the right to create an advance choice document a reality for everyone who needs one.

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[Zöe Franklin (Guildford) (LD)]

It is a pleasure to serve under your chairmanship, Sir Desmond. I rise to speak to new clause 21, which would place a clear statutory duty on integrated care boards to offer advice and support to families or carers of patients receiving aftercare under section 117 of the Mental Health Act.

I thank the Minister for his comments about the new clause. I acknowledge what he says about the statutory guidance and code of practice, but I hear from far too many patients and their families living in my constituency of Guildford that advice and support is often not being provided and that authorities are falling short.

This new clause is rooted in a very simple principle: good mental health care does not end at the point of discharge. Recovery is often long, fragile and dependent on support at home, yet families and carers—the people holding things together day in, day out—are often left behind with little or no guidance. This clause seeks to change that: it would ensure that carers are given clear information about the patient’s condition and recovery journey, supported in helping to prevent relapse and readmission, linked to relevant support systems, including housing and social care, and provided with a route to raise concerns if they believe that someone is at risk in future.

[Jen Craft]

Having looked at new clause 21, I have a rather large concern about consent. The hon. Lady is setting out what the integrated care board would have a duty to do, including giving information about a “person’s condition and recovery” to

“the family or carers of the person discharged”.

I have a significant concern that the person being discharged may not have the kind of relationship with their family or carers that would make that helpful. The clause, as drafted, does not seem to make allowance for consent, except where

“the person is at future risk of detention”

under part II of the Mental Health Act. I would welcome the hon. Lady’s thoughts on that.

[Zöe Franklin]

The hon. Member makes a really good point. There is definitely a place for ensuring that we work on this further to make sure that it covers that. I will come on to that later, if she will allow me.

We know that early intervention is key. We know that families, carers and those around an individual are often the first to spot the warning signs, and that they need to feel empowered, not sidelined. I hear time and again, as I am sure hon. Members across this Committee Room have heard, from people who have been left out of the discharge planning for their loved ones. They say that they have received no clear information and that they feel unsupported and unable to fully support their loved one when they return home.

Importantly, the new clause sets out a process whereby, if a family member wants to raise a concern, the team must consider whether that individual should be added to the register of persons at risk of detention under part II of the Mental Health Act. We believe that this is a sensible, joined-up approach to prevention, spotting risks early and acting before a crisis point is reached. Finally, the new clause would require the Secretary of State to publish national guidance and ensure consistency and clarity across the system.

We often speak of carers as the invisible workforce of our NHS. The new clause would make their contribution visible by recognising their role and giving them the information and support they need to fulfil it well.