Mental Health Bill [ Lords ] (Seventh sitting)

Debate between Jen Craft and Luke Evans

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.

Mental Health Bill [ Lords ] (Fourth sitting)

Debate between Jen Craft and Luke Evans

Committee stage
Thursday 12th June 2025 Public Bill Committees

[Dr Evans]

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?

[Jen Craft (Thurrock) (Lab)]

On a point of clarification, I note that the amendments tabled by the shadow Minister specifically say

“recovery from any childhood trauma”.

Why has he opted for the word “childhood”, rather than general trauma-informed care? A number of female in-patients in mental health units are recovering from past sexual trauma or domestic violence—I know such abuse is not committed exclusively against women, but it tends to be more prevalent in that group—and the mental health unit can potentially exacerbate that traumatic experience. I seek clarification on why childhood trauma has been made so prominent, as opposed to general trauma.

[Dr Evans]

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.

--- Later in debate ---

[Jen Craft]

I rise to speak in support of this important clause, which puts patient experience and individual choice at the heart of treatment. It is a brilliant focus on seeing the individual as a person, and ensuring that they have a strong role to play in deciding their treatment pathway going forward.

I very much welcome the development of a clinical checklist that includes looking at a patient’s past and present wishes and feelings. That is important because, when someone is in a mental health crisis, they might not be in the best possible place at that moment to articulate what their wishes are. Looking at how they may have acted in the past, or may have opted for treatment when not at a crisis point—including, I note, through the introduction of advance choice documents, allowing people to choose how they would like to be treated if they have lost the ability to make those decisions for themselves about the best way forward and, indeed, if they have to be detained—and taking their wishes into account, as well as their beliefs and values, is important in developing an individual treatment plan that allows them to be seen as an individual deserving of care, in order to achieve the best possible outcome for them. Across the House, we have noted the important fact that, when patients are involved in developing their treatment plans, they are much more likely to engage and have significantly improved outcomes.

I do not want to get ahead of the Minister, but I want to address a few points that the shadow Minister raised. I want to say this as someone with lived experience of severe mental illness; it is important to have someone on the Committee that can speak to that, so I probably should when I can. This clause speaks to the patient experience. There are other parts in the Bill that deal with potential risk to the public and risk of harm. In the first example the shadow Minister gave, he mentioned that the woman in question said that her wish was to be admitted to a secure unit. I would say that, under this clause, had they had regard for her wishes and how she wanted to be treated, that would have mitigated some of the risk.

I know that there are times when people will act in a way that may be at odds with the risk that they pose to the public, but these matters are properly addressed elsewhere in the Bill. What the clause speaks to, and what we should try not to dilute, is the patient experience.

[Dr Evans]

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.

[Jen Craft]

I welcome the hon. Member’s intervention. On Tuesday we discussed clauses on who can be detained and when, and earlier today we discussed the necessity of detention, and there was some debate about the amendment in the other place. Other bits of the Bill focus on when it is necessary to detain an individual for public safety and not just for their own treatment; I will not re-litigate who should be performing that function, but earlier clauses deal with that.

The importance of this clause is the patient perspective. There is a significant stigma associated with severe mental illness. I have been reticent about my own conditions in the past because of that, and because of how I would be perceived. It has been particularly hard to be open about the fact that I might be subject to in-patient mental health treatment; I probably see that as a likelihood in my future at some point, although I hope it is not and I work very hard every single day to avoid that. However, it is important that there is a part of the Bill that speaks to me as an individual. I speak to the Committee today as an articulate individual—I do not want to say intelligent; I will not blow my own trumpet—who can say what treatment option I would like.

It is incredibly important to recognise that people who are subject to detention under the Bill are individuals who have opinions on their treatment. I have lived with these conditions for the best part of two decades, and the biggest expert on them is me. If I was in a mental health crisis, I might not be in a place to articulate the best treatment for me, but right now I can say what works. I will not go into that, because it is private, but I know that the best course of care for me would involve someone taking advantage of my knowledge of my condition and working with me to allow me to get the care I need to get better.

The point is that the clause’s stand-alone focus on the patient experience deals with some of that stigma. It puts the patient’s experience at the heart of treatment, it speaks to some of the issues mentioned about what happened in Essex, which is now the focus of the Lampard inquiry, and helps to deal with some of that. It sees us as individuals.

Mental Health Bill [ Lords ] (Second sitting)

Debate between Jen Craft and Luke Evans

Committee stage
Tuesday 10th June 2025 Public Bill Committees

[Dr Evans]

I shall be interested to know what the hon. Lady’s rose-tinted spectacles show when we consider Scotland or Wales. One of my biggest frustrations in debates about the NHS is that in each nation health is devolved, each is run by a different political party, and each has challenges. We in this place enjoy the political football, scoring points without seeing what is blindingly obvious: that across the board, across all the countries, health and mental health services are struggling to keep pace and keep our population healthy with the workforce and technology provided.

[Jen Craft]

Will the hon. Gentleman give way?

[Dr Evans]

Let me address these points, then I will be happy to give way. When we come to clause stand part, I will address the other amendments, but I specifically said that my comments would be on new clause 11. When scrutinising the Bill, it is important that we talk about how we will deliver, as the hon. Member for Shipley rightly pointed out. It is entirely right to try to put together a plan to ensure that the Government are held accountable. We are not saying how the plan should be formulated; we simply stipulate that a plan should be formulated and introduced. That is a very different argument.

My concern about previous Lib Dem amendments was that they were too specific. We have to get the balance right. New clause 11 simply provides that the Government have 18 months to introduce a fully costed plan, so that we can again have a debate in this House. Especially as a spending review will, I believe, be announced tomorrow, we need to consider how we will match budgets in the future. We accept that it is a 10-year project.

[Dr Evans]

I am still addressing the hon. Lady’s first point. The Conservatives understand that it will take a long time to put in place, but a credible plan is needed. There was a credible plan in place, as I have said, in the 2011 and 2016 strategies, with the funding to match. I use that as an illustration because it is provides an apt evidence base for the new clause. Otherwise, I might well be challenged by someone saying, “What is your evidence base of a delivery network and a delivery ability from a Government?” I hope that by talking through these points, I am giving the Government the chance to learn from the mistakes we made and from the way we took forward mental health. Regardless of political party, I hope hon. Members that the debate has moved on a long way from when we started in 2010 with the work done partly under the coalition Government. I will now take the intervention.

[Jen Craft]

I thank the hon. Gentleman for reflecting on the fact that mistakes were made by the previous Government—acknowledgment of that is often sorely lacking. I respect the fact that he says that the debate has moved on, but does he accept that while the debate may have moved on, policy to enact actual change for people who are detained under the Mental Health Act, particularly those with learning disabilities and autism, has not kept pace? The number of people in locked units, under detention, has remained solid, without much wavering, for the past 14 years. Despite the acknowledgement that this is a scandal, and we should all hang our head in shame that it continues to this day, not much has been done to get them out of those units.

While we look back on the history of the past 14 years, focusing specifically on the people who are detained under the Mental Health Act, let us remember that Lord Darzi pointed out in his report that some of the facilities are more redolent of the Victorian era than of a modern mental health care service. Perhaps those who were in government in those 14 years should reflect on why that is the case.

[Dr Evans]

There is quite a lot to unpack in the hon. Lady’s intervention. As I pointed out, reflecting on what the previous Government learned is also important—for example, when considering Wales. Objectively, the data shows that Wales is struggling more than England, and the same is true of Scotland. Wales and Scotland have been run by different parties from England for a long time, so my natural inclination is to attack back and say, “Well, actually, the Conservatives did better,” but my fundamental point is that we all need to do better because we have seen the problems rising. As I mentioned, over the last 10 years the number of people turning up in mental health facilities has increased by a quarter.

On the hon. Lady’s point about people with autism and learning disabilities, I sat on the Health and Social Care Committee that looked specifically at that issue. We looked at some of the best models in the world, including that of Trieste, where community care is in place. When we took evidence, we found that most people were supportive of that model, but fearful people did come forward to say that the community was not the best place for their daughter, son, husband or wife. Managing the nuance is really important. It takes time to get this right. In 2018, when the last Government looked to legislate on this issue, there was pre-legislative scrutiny, which does not always happen in this place. It was done because there was fundamental agreement that we must get the legislation right, because it applies to the most vulnerable people.

The hon. Lady is right that Lord Darzi identified three shifts that will be really important, but when he looked at this issue, he missed a fundamental point. His report starts from 2010, but when I was a junior doctor— I qualified in 2007—we had issues that affect the culture now: for example, how we managed MRSA and C. diff. That was not a brilliant time to be a patient. The medical training application service fiasco affected doctors applying for jobs so much that in 2004 the Government had to apologise and change the system, because so many people who wanted to get into specialist training could not go through that service.

We are still paying for IT infrastructure that the last Labour Government tried to introduce. The last report, in 2018, said that that cost the taxpayer almost £14 billion. We wonder why, when we try to make a shift to introduce more tech, as recommended by Darzi, people in the NHS are reticent, but they have been burnt by IT projects before. They have seen what happened under a Conservative Government, a coalition Government, and a Labour Government. All that has an immediate and impregnable effect on the legislation and the practicalities that we are dealing with today.

I am not trying to talk facetiously about the legislation; the point is to give some pragmatic direction and to actually say something tangible. On that basis, I look forward to the Minister hopefully supporting proposed new clause 11, which would give the Government the flexibility to have a plan that they choose, as is their democratic right, but also the safeguards to know that it will be delivered and we will not have more delay. There is a balance between making legislation in haste and making sure that we avoid inaction. Would the hon. Member for Shipley like to intervene?