Mental Health Bill [ Lords ] (Second sitting)

Luke Evans Excerpts

Committee stage
Tuesday 10th June 2025 Public Bill Committees

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Ms Furniss.

I thank the hon. Members for Winchester and for Guildford for tabling this group of amendments. I will address each in turn, beginning with amendments 1, 4 and 51. We recognise that a lack of appropriate housing can be a barrier to discharge for some patients. That is why we have put the important reviews on a statutory footing. I am pleased to provide an assurance that the Bill already makes provision for any relevant recommendation about a patient’s discharge, including meeting their housing needs.

Statutory guidance will assist the responsible commissioner to determine who to involve in review meetings. That will include guidance on when the involvement of partners such as housing departments and organisations may be appropriate. Placing a specific requirement to consider the housing needs of every patient would mean that housing would have to be considered in every case, even if it is not a relevant issue. Potentially, that could divert focus from factors more relevant to the patient’s care and treatment.

On amendments 2 and 5, the Bill makes it clear that a copy of the review report must be provided to those who have a legal duty to have regard to the review recommendations, so that any recommendations are implemented as appropriate. The patient should receive the report, in line with good practice. However, we are concerned that requiring a longer list of people to receive the report in every case might increase the chance of patients withdrawing their consent for a review to be held, especially if they do not wish for those people to see the report. We recognise that it is often appropriate for the report to be provided to other people, such as those listed in the amendments, but the Bill was amended in the other place to make it clear that a copy of the report may be provided to other persons not listed in the legislation, with the patient’s consent.

Amendments 3 and 6 are unnecessary. The current drafting provides that review meetings take place at least once every 12 months. That is in addition to the requirement that arrangements must be made for an initial review meeting to take place within 14 days of admission for children and for some people aged 18 and over, and within 28 days for other adults. We also know that more frequent reviews may not be appropriate for all patients. For example, for a patient who is unable to be discharged for a long time, reviews that focus on discharge may be rather distressing.

Commissioners should use their judgment to determine whether the individual needs of a patient might mean that a more frequent review is appropriate. NHS England policy makes it clear that patients, their families and advocates can request a review meeting at any point. Statutory guidance will provide commissioners with further information on factors to consider when determining whether more frequent reviews should take place. For example, current practice, in line with NHS England policy, is that children under 18 should have a review meeting at least every three months—that will be made clear in the guidance. We consider it preferable to set out that information in statutory guidance, which can provide detailed case studies and be readily updated in line with emerging best practice, including on frequency and considering particular circumstances.

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

The Minister makes a fair point about best practice. However, did the Government consider any mechanism for how best to share best practice across areas? Especially as the Bill also covers Wales, as heard this morning, it might be useful—across the integrated care boards—to understand the Government’s thinking on how to ensure that best practice in exemplar places, where care is really good, can be shared to help places where care might not be so good.

[Stephen Kinnock]

The shadow Minister is right, and one of the overarching objectives of this Government is to take the best of the NHS to the rest of the NHS. We are very keen to ensure that we identify best practice right across the board in all the services that we provide, and that it is then replicated and scaled up. We also recognise, though, that every community and area of the country is different, so it is not about exporting and importing best practice. It is more about looking at those exemplars and asking, “How could we use some of this, without reinventing the wheel?” That is absolutely the culture of how we want our health service to run—I think it is a cultural point.

[Dr Evans]

The Minister makes a good point about the differences in the country, one of which is how the Care Quality Commission looks at the standards. Especially as the CQC is under new leadership, will it be taking a role in looking at how best practice is implemented while ensuring standards?

[Stephen Kinnock]

The CQC has a key inspection role, which is an important check and balance in the system. I would rather see the incremental building of a culture of excellence across the board, including within upstream institutions, ICBs, local authorities, healthcare professionals, mental health professionals and social workers. We need to create a collaborative approach across the board so that best practice is developed within a culture of excellence. One would hope that the CQC, when it does its inspections, is then finding positive results. Of course, it also plays an important role in identifying, investigating and holding to account when things are not going as they should.

Finally, I will address amendment 7. The Bill requires named persons and bodies to have regard to the review recommendations. This is a well-established duty that clinicians, integrated care boards and other public bodies are used to applying and already exists within the Act. Where effective care and treatment is the central aim, we expect careful consideration of all recommendations. Where these bodies decide not to accept a relevant recommendation, we expect them to have a very good reason.

It is inappropriate to place an absolute duty on a body to follow recommendations in every case, as flexibility is required to depart from a recommendation where appropriate, for example if a recommendation is outside the body’s purview or not in the patient’s best interests. As currently drafted, the Bill already requires that certain named persons or bodies carefully consider the recommendations and give them appropriate weight. Where a body does not consider a recommendation appropriately, that may be subject to review by the courts. In the light of all this, I therefore thank the Liberal Democrats—

[Dr Evans]

The Minister is right about the absolute nature of the Liberal Democrat amendment, but we talked about the duty to respond requiring a body to set out why it has decided to take action or not. The Minister seemed to allude to that, but he then jumped to talking about being challenged in court. Is there a hybrid version within that duty to respond so that it could stipulate the setting out of why the body is accepting the recommendations or not, because that may well help transparency?

[Stephen Kinnock]

I see where the shadow Minister and the amendments are coming from, but there is a risk of over-embroidering the Bill if we try to load additional duties on to something that we believe is already happening. It is a very well-established duty that clinicians, integrated care boards and other public bodies are used to applying, and this already exists within the Act. I think there is an element here of “If it ain’t broke, don’t fix it.”

If there is compelling evidence that it is not working, clearly we need to intervene as a system, which is about real leadership at the ICB level. As things stand, we feel that this amendment is surplus to requirements for the reasons I have set out. I thank the hon. Members for Winchester and for Guildford for this exchange of views, and I hope that they are content to withdraw amendment 1.

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[Dr Chambers]

Unfortunately, I was busy meeting Brian May and talking about farming, so I have not had a chance to work up a really good response.

The point of the Liberal Democrat amendments is to recognise that mental ill health requires holistic care and that many non-clinical factors directly influence mental health. Although the Bill’s scope is understandably narrow, very much focusing on people once they are admitted to hospital for treatment, we need to recognise that, if someone is discharged back into the situation from which they were admitted, they are very likely to have a relapse and to need treatment again. Some of those factors are non-clinical. For example, people living in poverty—those in the lowest 20% of income—are more than twice as likely to suffer mental health issues than those on an average income.

We strongly support the Bill, but we need to recognise that, on its own, it will not improve mental health or do anything to prevent people from developing mental health issues. If our amendments are not within scope or are not appropriate for the Bill, we urge the Minister to work with other Departments, such as the Ministry of Housing, Communities and Local Government, to ensure that this good piece of legislation, which we support, can be successful.

The hon. Member for Farnham and Bordon made a point this morning about local authorities. He is right that local authority reorganisation is a challenge, especially when it comes to providing accommodation for young people and for people being discharged from mental health care centres. It is also an opportunity, because the current situation is not fit for purpose. Hampshire county council is struggling to provide the care these people need. Housing, which often affects young people’s mental health, is probably the single biggest issue that comes up in my inbox and when I knock on doors.

I thank the hon. Member for Hinckley and Bosworth. As a clinician, his point about the evidence base, especially when it comes to reviews, is really important. We are discussing a Mental Health Bill that may not be changed significantly for another 40 years, so it is important that we use the best evidence. As a long-time trustee of an evidence-based medicine charity, I am passionate about this.

I thank the hon. Member for Thurrock for pointing out that clinical guidelines suggest six-month reviews. Yearly reviews are used for many medical conditions, and I would argue that a year is also an arbitrary period, rather than one based in evidence. Why six months and not a year, or why a year and not six months?

[Dr Evans]

The hon. Member is correct to establish the evidence base and the guidance. Broadly, we need to balance that with the logistics and the impact on the clinician, the patient and the resources. Move too far one way and it becomes a tick-box exercise or more resource-heavy; move too far the other way and the safeguards that we are trying to implement are lost or watered down.

When I look at the amendments, that is the balance I am trying to understand; if the guidelines are written with that in mind, that makes sense. The job of this House is to scrutinise the numbers and decide whether we agree that they are right, or whether we should push a bit harder—whether we should tighten the safeguards or relax them a little to allow clinicians more freedom of choice.

I guess that is the purpose of the Bill—getting the right boundary between the safety of the individual patient, support for the wider public, and making sure that clinicians have the freedom to make their judgment so that we are not stepping on expert opinion or, worse, creating bureaucratic processes. I hope the hon. Member understands that is why we are probing further on the rationale.

[Dr Chambers]

I completely agree with everything the hon. Member just said. Atul Gawande did a fantastic piece of work on checklists that emphasised the need for them not to become tick boxes. They are meant to involve active thinking and decision making.

I thank the Minister for reassuring us about housing. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

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[Dr Chambers]

Amendments 8 and 9 would insert a new subsection to extend to all children and young people under the age of 18 the duty on integrated care boards to establish and maintain a register of those at risk of detention. Amendment 9 would extend the duty on integrated care boards and local authorities to exercise their marketing functions in a way that seeks to ensure that children and young people’s needs can be met without detaining them.

Far too many children are unable to access the mental health care they need, leaving them more vulnerable to experiencing a mental health crisis that then requires detention, which all too often ends in tragedy. Child and adolescent mental health services are in a state of near collapse, with many children unable to access the care and treatment they need until their mental ill health has reached the point of crisis. Waiting 15 months in great mental distress is far too long, especially for children. It is a huge disruption not only to their personal development but to their education. Waiting up to two years for treatment is a huge proportion of a 12-year- old’s life.

We are pleased that the Bill, as it currently stands, includes specific provisions to prevent people with learning disabilities from requiring detention under the Act. The Government should take that approach for more people, especially our young people. Early intervention, delivered through regular check-ups and cutting waiting times for treatment by community services, is critical. We should not pretend that acute mental health services and in-patient care exist in a vacuum. The pressures they face are directly impacted by the quality of community services. We need stronger steps to ensure that fewer people require detention in the first place, especially children.

We are pleased that the Government are taking steps towards having mental health support in every school, for which we have long campaigned. We would like them to go further by ensuring a dedicated professional in every school. We are alarmed that the targets for mental health are being dropped, so I press the Government for assurances that the upcoming 10-year plan will ensure that children who are referred can expect swift and efficient support and treatment, with binding duties on health bodies to deliver that.

Alongside this Bill, what requirements and resources will ICBs have for preventing mental health crises? As part of that, will the Department make specific changes to CAMHS?

[Dr Evans]

The hon. Gentleman makes a pertinent point about the pressure on CAMHS. In Leicestershire, about 45% of CAMHS referrals are for things like autism and ADHD, and the problem is that it takes a lot of services away from those who have eating disorders or depression, or who self-harm. Does he believe there is scope to reorganise services to make sure they are appropriate where there needs to be treatment? A child suffering with severe anxiety and self-harming tendencies should not be on a pathway with someone who has autism, for example. Has he given any thought to how this Bill might be a way of opening that door?

[Dr Chambers]

On the surface, what the shadow Minister says seems logical and makes sense. I am not a mental health clinician, so I want to be really careful about pushing in one direction. Whether someone has an eating disorder or is waiting for a diagnosis of something like ADHD, the waiting times are too long. We must better structure a system that ensures that everyone gets healthcare when they need it, rather than prioritising what we perceive as most important.

One of the most heartbreaking things that I hear from parents in Winchester, who are worried sick, is that young teenagers with an eating disorder have been told that they have to hit a lower BMI to reach the threshold to qualify for treatment. That is essentially saying that someone has to be sicker for longer. No one would ever say, “We’ll wait until your cancer reaches stage 4 before we start treatment,” but that is happening with eating disorders. The treatment will end up being longer, more complicated, more costly for the taxpayer and maybe less successful.

A question often comes up—the hon. Member for Farnham and Bordon alluded to this—about the pressures on local authorities to deliver mental health care. Actually, the question is “How we can afford not to deliver it?” People with mental health disorders are ending up in A&E or prison and costing police time. It costs £52,000 a year to keep someone in prison, yet apparently we cannot afford to give them the community interventions that might stop them going there in the first place.

[Dr Chambers]

We support all efforts to keep young people happy and healthy in their communities. I visited Winchester Youth Counselling recently, where pupils can self-refer to talk through their issues. That does not involve any clinical personnel. It is hugely impactful and cost-effective and is part of the community. We support those community hubs.

Amendment 47 would specify risk factors for detention for people on the register of people at risk of detention under clause 4, including homelessness, addiction, domestic abuse, miscarriage and traumatic birth, experience of armed conflict, and bereavement. For anyone, including people with learning disabilities, life events can have a profound impact on mental ill health and can drive mental disorders. Well over a third of women with mental health problems have been a victim of domestic violence, and 50% of rough sleepers have mental health problems. The disastrous impact that bereavement can have on anxiety and depression, which are key factors in suicide, has been well documented.

It seems obvious, frustratingly, that public services do not currently reflect that key fact. There are no registers of bereaved children to ensure that they get the right support in the community and in school. There are no registers of veterans, despite their far higher risk of mental ill health and suicide. Women who have suffered a miscarriage do not receive an automatic referral, including to mental health services. The Government need to ensure that people can get mental health assessment and support at key points in their life, including the most traumatic moments.

[Dr Evans]

We have certain registers of carers, for example in primary care. There is a stipulation about moving towards veterans being included. Who does the hon. Gentleman think might hold the register, in the light of his amendment?

[Dr Chambers]

I do not know the best place for it to be held. That is an important point. For a lot of the issues that Members are bringing up, we are not expecting there to be answers today. However, we want to ensure that they are all being considered, given that the subject might not return to Parliament for another 40 years.

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[Dr Evans]

I rise to speak to Liberal Democrat amendments 8, 47 and 9 to clause 4, which seek to expand the scope of the at-risk register, define risk factors and protect children and young people from unnecessary detention under the Mental Health Act.

Let me start by acknowledging the intent behind the proposals. There is genuine merit in ensuring that those who are at risk of detention, particularly children, are visible to the system before crisis point. That view is shared on both sides of the House. I also share the concern that we are too often intervening too late, after a child or young person has already reached breaking point; I would add families to that, because they also bear a lot of the brunt, especially when it comes to waiting. By extension, when there are waiting lists, as the hon. Member for Winchester mentioned, the clinicians themselves—often the GP—will struggle to deal with patients and families when they do not have the clinical expertise necessary for the most severe interventions.

Amendment 9, which would include all under-18s at risk of detention on the register, reflects that preventive ambition. Likewise, the proposed list of risk factors, including bereavement, homelessness and domestic abuse, rightly recognises the social determinants of mental ill health, which are all too often overlooked. However, I have some reservations about the proposals in their current form.

First, on the register for all under-18s, expanding the duty so broadly raises serious questions about safeguarding, data protection and deliverability. Children and young people are already subject to multiple overlapping systems, from social care to CAMHS and education, health and care plans. Before laying on a new national register, we should ask what safeguards will be in place, who will manage the data, and how it will integrate with existing responsibilities such as those under the Children Act 1989 and the special educational needs frameworks.

Secondly, although I agree that we must understand the drivers of detention, the list of mandatory risk factors, including miscarriage, bereavement and even armed conflict—all of which are profoundly serious—could widen the scope of the register so far that it loses operational focus, as we have heard. That is why the Opposition have tabled a later amendment to define it as childhood trauma instead, which is a more encompassing way of dealing with it. Also, we risk casting the net too wide without necessarily improving outcomes for targeting the right support or, conversely, missing something. For example, looking at that list, I would argue that gang violence or gang involvement is a key factor that Members on both sides of the House would agree is very pertinent, and yet it is not mentioned. Therein lies a problem.

Thirdly, amendment 9 seeks to prevent the detention of children and young people unless it is absolutely necessary, which is a principle that I wholeheartedly support, but how do the Lib Dems propose that it be enforced? What levers are in place if a service fails to deliver that community-based service? Without resourcing CAMHS, investing in crisis alternatives and reforming commissioning models, the duty risks being symbolic rather than systemic. In essence, the hon. Member for Winchester is trying to make the point that we should have these discussions.

Although I support the goals of the amendments—visibility, prevention and early support—I am not sure that the specific mechanisms in them are the best way to safeguard achieving them. Instead, I wonder whether consideration has been given to piloting regional early intervention panels for under-18s at risk of admission, building on existing safeguards in educational frameworks, rather than creating separate registers. Alternatively, we could include risk indicators in statutory guidance, rather than setting them rigidly in legislation, which I think was the point made by the Government. That would allow some clinical judgment and flexibility. Above all, we must ensure that ICBs are not just given duties, but held to account. How are they are going to deliver them? That means having the right metrics and oversight and a strong role for advocacy and families.

[Anna Dixon (Shipley) (Lab)]

The shadow Minister is making some useful observations about best practice. One of the real injustices that we are seeing with detention at the moment is the racial disparities in detention rates. One could argue that such a disparity is a potential risk factor, but behind it is something that we should be addressing through dealing with inequalities in the mental health system, particularly the unwarranted variation in practice from clinicians perhaps making discriminatory judgments in these cases. Does the shadow Minister agree that that is another reason why we should not be over-specifying some of these points where we see associations between risk factors and detention rates under the Mental Health Act, and that therefore we should not be including them in the Bill?

[Dr Evans]

I entirely agree with the hon. Lady’s end point and with the thrust of what she says. Causality is not causation, and we need to be very careful. When we get to the later clauses of the Bill, that will be at the forefront of our discussion.

We cannot deny the reason we are having this legislative debate in the first place: the observation that black men in particular are subject to community treatment orders far more than any other group in the country. However, we must not make a lazy causal analysis and say, “Well, just because that is the case.” For example, black men have a higher risk of prostate cancer, and white people a higher chance of coeliac disease, because of the genetic basis. Is there something in that? Is there systemic bias by clinicians, as she hinted? That all needs to be explored.

The hon. Member for Shipley beat me to the punch when it comes to my closing statement. We owe it to our children and young people not to legislate in haste, so I welcome the spirit of the amendments, and I welcome the debate, but we must be careful to ensure that we are truly legislating for and defining exactly what we know. Otherwise, we risk creating other inequalities and unintended consequences or, worse still, a system that becomes even more flabby and difficult to manoeuvre through. That is the last thing we want for our patients, clinicians and the public.

[Gregory Stafford]

It is a pleasure to serve under your chairmanship, Ms Furniss. I have some criticisms of the specifics of the amendments tabled by the hon. Member for Winchester, but I entirely support him and congratulate him on the passion with which he spoke about them. As I remember, his maiden speech touched on a number of these issues. Whether they are within the scope of the Bill is for the Clerks and the Committee to decide, but he made several extraordinarily good points that I hope the Government will take away. If the Bill is not the appropriate place for them, there should be another avenue.

The lead amendment is about the ICB register. It would insert a new subsection to extend the duty on integrated care boards to establish and maintain a register for those at risk of detention to cover all children and young people who meet certain risk criteria. As drafted, the duty to maintain a register under clause 4 may not explicitly include all under-18s. Therefore, the amendment would ensure that children and young people are proactively identified and supported before reaching a crisis point that might lead to detention.

Clearly, there are positives. As the hon. Member stated, early intervention might help to prevent unnecessary detention by identifying risk earlier, which is especially important for children. Likewise, there is a strong argument about equity and care to ensure that young people receive the same proactive planning as adults. That would clearly lead to improved safeguarding through better tracking of vulnerable minors in the mental health system. A corollary to that would be better data collection on youth mental health needs, which I think we would all support. We would be able to use that information to support more informed policymaking and resource decisions.

As my hon. Friend the Member for Hinckley and Bosworth highlighted, however, and as I highlighted in the debates on other clauses, there would clearly be a resource demand, especially on ICBs, from expanding registers and services. Likewise, there is the complexity of implementation, because defining who qualifies as being “at risk” may be subjective. I therefore ask the hon. Member for Winchester, when he sums up on the amendments, to give us some indication of how “at risk” would be defined, or whether that would simply be down to the mental health professional or some other medical professional. There are also, of course, privacy and consent concerns related to maintaining a register for minors. Again, the hon. Member may have thought about some practical things that could assuage my concerns about that.

There may also be a risk of stigmatisation. We have to be very careful, especially with children and young people, because being labelled or treated differently due to being on the register would not help their mental health. We would have to have some really strict privacy and data-sharing controls to ensure that they were protected within the proposed system.

As I said in my intervention, I entirely support the aims of amendment 47 because it would specify the risk factors for detention for those on the register of people at risk of detention under clause 4. The criteria for identifying such individuals are left to be defined in regulations as the Bill stands. The amendment would mandate in law specific evidence-based risk factors—which I agree are risk factors for the issues that the hon. Member is talking about, particularly those linked to trauma and social disadvantage—rather than leaving them to discretion.

At a general level, the amendment recognises the role of trauma and social determinants in mental health crises—I congratulate the hon. Member on clearly explaining some of the factors. Going back to our debate on the previous group of amendments, that would improve the early identification of individuals at risk, promote preventive care, strengthen equity and provide clarity and consistency. However, like my hon. Friend the Member for Hinckley and Bosworth, I am concerned about prescribing a relatively small list and therefore limiting the clause’s flexibility—there may be risk factors that are not listed in the amendment or ones that we have not even thought of.

[Gregory Stafford]

I agree with the hon. Lady; that is my understanding, but perhaps the Minister can confirm that when he sums up. The flexibility in the clause is one of its strengths.

[Dr Evans]

Does my hon. Friend share my opinion that it makes sense to agree with the Government? The impact of social media and the evidence coming out about using mobile phones and about the impact of certain sites have been debated in this House for the last five years—since I have been here—and there have been advances. Legislation has been brought forward, but there is a growing consensus on both sides of the House that it never quite keeps up. Allowing the Secretary of State to add risk factors as they come up, even in policy guidance, might be a shrewder way to future-proof the Bill against those difficulties. In 1983, we were not discussing or even thinking about the likes of Facebook, yet here we are. With the advent of artificial intelligence, who knows where we will be in another 40 years?

[Gregory Stafford]

I entirely agree with my hon. Friend. To touch on his point about social media, it is a very useful tool, but is deeply pervasive and can cause the bullying, harassment and mental health issues that he describes. As far as I can tell, the risk factors in amendment 47 would not cover something like that unless it was part of something else—for example, part of domestic abuse, armed conflict and so on.

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[Stephen Kinnock]

Again, I thank the hon. Member for Winchester for his amendments. I understand the intent behind amendments 8 and 9, but the clauses on registers and the associated duties on integrated care boards and local authorities are specifically aimed at people with a learning disability and autistic people, because of the detrimental outcomes that these groups of people may suffer when detained.

We recognise the concern around the treatment of children and young people, which is why we have several provisions in the Bill aimed at improving their care. However, dynamic support registers are particularly tailored to the needs of people with a learning disability and autistic people, and have been established in NHS England’s policy for some time. We do not have evidence that they would be an appropriate mechanism for wider cohorts.

We do recognise that bereavement, miscarriage, the experience of trauma and difficult life transitions can all have a bearing on mental health. However, access to mental health support is based on clinical need, not on the circumstances that might give rise to that need.

[Dr Evans]

The Minister is right about the registers, but I did notice that the Children’s Wellbeing and Schools Bill introduced the unique identifier number. That came about after the Lord Laming report into Victoria Climbié, who was “lost in the system.” It also builds on the work of the Children’s Commissioner, which found that around 10,000 children are not in school. Is there a role for getting some of the identifiers that we are looking at here in place along with that unique identifier number?

Equally, how does that unique identifier input into the Bill’s provisions on risk registers, now that that piece of legislation has passed Third Reading? There will be an interaction, but the unique identifier is much broader and the dynamic support register is held slightly differently. What work have the Government done to ensure that there is bridging and understanding about what that would look like, not only in the short term but in the long term?

[Stephen Kinnock]

The dynamic support register is specifically focused on people, both children and adults, who have learning disabilities and people who are autistic. I think it is quite a separate thing. I am not familiar with the detail of that education legislation but, as the hon. Gentleman says, it is a very broad identifier not based at all on the clinical conditions of the persons, as I understand it, whereas this is very focused and specific for people with the conditions that we are debating. I do not think that there would be a connection between the two.

[Dr Evans]

Let me take the example of a young person with deteriorating or fluctuating problems. They may be in school or out of school. We know that people with autism and learning disabilities are at greater risk of abuse and of being taken advantage of. If the Minister is not aware of it, would he look at how this duality could work, because clearly there is scope?

One benefit that the Government argued for in having this unique number was that it could be shared across these registers. It sounds as if there is work that could be done. The Minister is absolutely right, and I am not suggesting merging the two, but on the risk register, there could be a nice piece of crossover work to pull that all together, so that the information moves across agencies. What we know from people with severe learning disabilities, autism and mental health issues is that they are often in contact with multiple agencies at multiple times—from social services to, potentially, the police, the NHS, dentistry and, of course, educational settings, which might be multiplicitous. Is that a consideration that the Minister will take forward?

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[Zöe Franklin]

It is a pleasure to serve under your chairmanship, Ms Furniss. I am grateful to my hon. Friend the Member for St Neots and Mid Cambridgeshire (Ian Sollom), and I am sure many in this room will remember his passionate speech about his constituent Declan Morrison, who has inspired many of these amendments. I am grateful to my hon. Friend for his help with my notes.

Amendment 20 would require integrated care boards to establish and maintain appropriate crisis accommodation specifically designed for people with autism and learning disability, as one its duties in relation to registers of people at risk of detention. Currently, just over 2,000 people with autism or learning disabilities are detained in mental health hospitals for an average of five years. Over half of delayed discharges are due to a lack of suitable housing or accommodation.

The crisis provision created in Cambridgeshire after my hon. Friend’s constituent Declan passed away was operating at 90% capacity before funding was withdrawn. When we hear Declan’s story, we realise the severe implications behind the amendment and why it is being put forward. We must also recognise that there has been a significant increase in section 136 use over the past 10 years. Many of the suites being used are outdated, unable to keep up with demand and unfit for purpose.

The amendment would therefore make appropriate crisis accommodation a statutory duty, and I hope all Members would agree that there is a desperate need for such accommodation, specifically for autistic people and those with learning disabilities. It would also require there to be specialist training for staff. We have already referenced today how important training is when it comes to protecting those who are in crisis and who need support. Finally, it would provide for safe, alternative detention under section 136, preventing situations such as that experienced by the hon. Friend’s constituent, where a vulnerable person is held in inappropriate emergency settings for extended periods.

Amendments 10 and 22 are both designed to ensure that there are sufficient resources for people with autism or learning disabilities. On amendment 10, it is crucial that community services are properly resourced to meet the needs of people with autism and learning disabilities. Too many of us will have seen how inadequate community services make detention and in-patient care much more likely, which is worse for the person detained, far more costly and unsustainable in the long term. Our amendments place duties on the integrated care board at the local level, and the Secretary of State at the national level, to be transparent about gaps in provision and to take steps to eliminate them.

Amendment 22 would require an integrated care board to conduct an assessment of the availability and adequacy of the relevant services within its area for people with autism or learning disabilities who have specified risk factors for detention, and to set out a plan to respond to those findings. There is currently an absence of suitable placements, with over 100 places that were contacted having no single bed available. We cannot continue with such a situation, given the significant implications when things go wrong.

Through those amendments, we are asking for an assessment, because there is currently no systematic assessment of whether services match demand, which is crucial to ensuring that the Bill is workable in the long term. It is also acknowledged that it may take 10 years to fully implement the Bill and to ensure that additional clinical and judicial staff are trained.

Amendment 21 was also tabled by my hon. Friend the Member for St Neots and Mid Cambridgeshire. It would establish an accelerated implementation timeline for provisions related to autism and learning disabilities, requiring those provisions to be fully implemented within two years. Currently, just over 2,000 autistic people and people with learning disabilities are detained in mental health hospitals who are being let down by the system.

The Government have sadly already missed the targets, and we cannot afford to wait another decade—people’s lives are too important. In fact, the UN Human Rights Committee has called on the UK to end the detention of people with disabilities based solely on their disability. Every day that we wait means more people at risk of tragic outcomes. As I said, the amendment would establish a two-year deadline, and it recognises that these are some of the most urgent reforms in the Bill. I ask the Government to consider them as a priority.

Finally, amendment 24, which was also tabled by my hon. Friend the Member for St Neots and Mid Cambridgeshire, would establish an accelerated implementation timeline of services related to autism and learning disabilities, by again requiring them to be implemented within two years. I reiterate what we heard in the Chamber, which I am sure we will all hear in our inboxes and in conversations with our residents: it is crucial that we implement these changes at pace; otherwise, we risk failing individuals with autism and learning disabilities further.

[Dr Evans]

I will direct my remarks at new clause 11 and the amendments spoken to by the hon. Member for Guildford. New clause 11 seeks a clear, costed and consultative plan to help ensure that integrated care boards and local authorities are properly equipped to deliver the community-based services that individuals with learning disabilities and autism need and, of course, deserve, so that they are not unnecessarily detained under part 2 of the Mental Health Act.

Let me begin by recognising the good intentions across the House when it comes to reducing inappropriate and prolonged detentions in mental health settings. There is broad consensus that detention should be the last resort. However, good intentions must be matched by a concrete, deliverable plan because, as the evidence has shown, too many people are being held in hospitals or other facilities, not because of clinical need, but because the right community support simply is not there.

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[Gregory Stafford]

My hon. Friend is making an excellent case for new clause 11, which could potentially solve funding issues I have raised. He mentioned the NHS 10-year plan. Will he suggest that the Minister looks at ensuring that, if new clause 11 is not passed today, the details in it are fed through into the plan? When it is published, which the Minister has indicated will be relatively soon, the information and outcomes my hon. Friend is trying to achieve through the new clause could be in it.

[Dr Evans]

Far be it from me to tell the Minister what to do, but if I were a wise Minister, I might look at where my predecessors had benefitted from further information and where they may have stumbled. The Bill has been looked at for a number of years by many people from outside and inside the House. Many have been involved throughout its progress, including a former Prime Minister, who tabled amendments in the other place. There is definitely the ability to learn from what the last Government found and to use that information in the kinds of plans that we need.

[Anna Dixon]

The hon. Gentleman elaborates on the great history of the previous Conservative Government. From where I am sitting, the record is less rose-tinted—but perhaps I am wearing different spectacles. Might he return to the substance of new clause 11, which, it seems to me, is about community provision? I return to the points that I raised earlier about proposed new section 125E. I do not see what new clause 11 adds to the Bill in regard to duties relating to the commissioning of services. I encourage him to address the specifics of the amendment.

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[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.

[Anna Dixon]

Will the hon. Gentleman give way?

[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?

[Anna Dixon]

Yes, briefly. I was trying to get the hon. Gentleman back to the point, which is people with autism and learning disabilities, rather than mental health policy in general. The point of reference I used earlier was the failure to deal with Winterbourne View in 2012. My hon. Friend the Member for Thurrock made the point very well: if we get down to it, we are talking about community provision for people with learning disabilities and autism. Too many people remain institutionalised, too far from their family, friends and community. I was pointing at that failing. I encourage the hon. Member to get back to that point. Would you like to give clarity on what is within scope of the group of amendments that we are currently debating, Ms Furniss?

[Dr Evans]

You may want to set me straight, Ms Furniss, but as we have agreed, I will directly address those points in the clause 4 stand part discussion. The hon. Member for Shipley rightly talks about community settings, but where does she think primary care staff come from? They come through medical training. When we talk about the Darzi impact, it is important that we fully understand why people choose not to go into mental health or primary care and become a GP. Without establishing that, which is a problem that this Government have to deal with, we will run into real problems when it comes to delivery.

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

My hon. Friend is making an excellent speech. The new clause is incredibly important. We do not want vulnerable people to slip through the cracks and not receive the right support, and it is really important to ensure that there is consultation with the right stakeholders. I recently met with Down Syndrome Cheshire, and last year I met with the Cheshire West and Chester SEND accountability group. They said that one of the things they value most is being listened to so that they can inform the process. Does my hon. Friend agree that that is a really crucial part of new clause 11?

[Dr Evans]

My hon. Friend speaks to the heart of what we all know from our constituency day jobs, where many of us here in this place speak to outside organisations and families. On Second Reading, the hon. Member for St Neots and Mid Cambridgeshire talked passionately about the impacts and the sorry stories that we have all heard about. The whole point of this Bill is to make mental health care patient-centred, but also family and advocate-centred. That is a driving thrust of what the Secretary of State for Health and Social Care was asking us for, and it is why we have enshrined the individual in the first clause of the Bill.

My hon. Friend is absolutely right: if we are committed to the principle enshrined on the front of the Bill, we need co-production. That must be more than a tick-box exercise. If the Government believe that the necessary plan is already in place, will the Minister say where that is covered, and would he put that plan in the House of Commons Library? Is it fully costed? Has it been fully consulted on? Will it be published within 18 months and incorporated in the NHS long-term plan? If not, how will the ICBs and local authorities be expected to deliver? How will the changes to NHS England affect plans to deliver the legislation? Having the legal duty to produce a costed plan will provide a focal point and fulcrum to build around, to ensure that the most serious mental health conditions receive the attention they need.

I know the Minister cares deeply and wants to do his best. He wants the legislation to be enacted as swiftly as possible. I also recognise the commitments and priorities facing the country, but this new clause is about turning good intentions into action. I simply aim to strengthen the hand of the Minister when it comes to negotiating with the Chancellor about funding, so that he has the evidence base required to bolster his position. I hope hon. Members across the Committee, especially on the Government Benches, see it as a supportive, sensible, balanced and practical solution to have this debate and then campaign with the Chancellor to get the money needed for the services.

Turning to the Lib Dem amendments, I begin by recognising the genuine intent behind amendments 10, 22, 24 and 21. Addressing the needs of people with autism and learning disabilities, particularly ensuring appropriate crisis accommodation and reducing unnecessary detention, is unquestionably important. That said, I have specific concerns about legislating for service provision in the Bill.

I understand why we do not legislate for the number of intensive care units, hospices or detox centres in the health system. There is an argument that that might be a good idea. Those are critical services, yet their commissioning and capacity are generally managed through policy funding decisions and local planning, rather than through statutory duties. Introducing a statutory duty for crisis accommodation risks unintended consequences. It may limit the flexibility of integrated care boards to respond to local needs, and could impose significant new resource burdens without clear funding commitments. That risks setting a precedent for increasingly prescriptive legislation across health and social care, which we should approach cautiously. We do not want to pit one condition against another.

On the proposed requirement on the Secretary of State to produce a commissioning plan within four months, I acknowledge the desire for a timely response. The choice of a four-month deadline, however, seems arbitrary and may not allow sufficient time for robust consultation and realistic planning. We need to be mindful that rushed plans can undermine long-term success.

On the proposed reporting requirements, although transparency is vital, I highlight that new clause 11, which we are proposing, would provide stronger and more detailed mechanisms to hold the Government to account on implementation and resource allocation, while allowing flexibility. We should focus on supporting those provisions rather than layer on multiple overlapping reporting duties, which risk duplication and confusion. In conclusion, the amendments raise important points and I look forward to the Minister’s response.

[Sojan Joseph]

I will briefly trot through the proposed amendments and new clause. We all know that the closure of learning disability hospitals was a gradual process. The reason was the institutionalisation of some of those patients, as seen in the Winterbourne View scandal. The aim was to create new community-based housing to look after people with learning disabilities and autism. Amendment 20 seeks to create appropriate fully staffed crisis accommodation. Will the Lib Dems clarify whether they are looking to create more in-patient settings? Are we going back to where we were years ago, or should we work with the new plan to create more community-based accommodation?

Not all patients with a learning disability or autism need detention or community-based accommodation. Many of them are looked after by their family members, so we also need to look into the support we are providing to carers, so that we can keep those people at home with their family member’s support.

I will keep this brief: as a member of the all-party parliamentary group on adult social care, I recently met with many people who have lived experience of this. They want their views to be heard. They are not asking for more hospital settings; they are asking for more support, including for carers. I was pleased to see that the Minister for Care was there to engage with those people.

In the new NHS 10-year plan, the focus is on moving care from the hospitals to the community. Can the Minister clarify how we can make that happen? We have talked about that for many years, but we have never seen it happening. In my own experience practising in a mental health ward, many patients with a learning disability and autism were detained and, as the hon. Member said, kept in hospitals because we could not find a suitable place for them to be discharged to—it was not that they needed the hospital.

I think we are all talking about the same thing, but we need to find a solution. That is why the new NHS 10-year plan and its focus on moving care from the hospitals to the community is important. Again, can the Minister clarify how we will do that? The Government have already started the work, and the new commission, led by Baroness Casey, should also be looking into where we will find the social care support for carers and the community provision for people with learning disability, rather than just creating more crisis accommodations.

[Dr Evans]

The hon. Member mentioned Baroness Casey, for whom I have the utmost respect, but herein lies the problem: she is still currently undertaking a review for the Home Office that has now been delayed and has not concluded. This is at the same time that she is supposed to be looking at social care. The whole idea of an amendment that asks for a statutory plan is to stop these kind of slippages. Given his point about wanting to see progress, is that something that he would consider if he were voting on this new clause?

[Sojan Joseph]

I hope that Baroness Casey completes her commission work and gives us her report. It was promised in the Chamber that the initial report would be available within a year. Regardless of whether she is taking up another role, I hope there will not be any delay and that we get that report and a detailed report within three years. I am looking for a solid plan to fix this problem forever. I am not looking for sticking plasters or an immediate fix, but we need a plan, perhaps including a national care service. These are the people who are looking for a long-term solution to these problems.

The hon. Member asked about how I will vote; unfortunately, I will not be supporting new clause 11. The Government have already started some work, which is why I am specifically talking about the NHS 10-year plan to move care from hospitals to the community, along with the social care commission, which is looking into how we can get good progress on that. This is the answer; we need to get a long-term solution to this problem.

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[Zöe Franklin]

Having had a conversation with my hon. Friend the Member for Winchester, I can say that we will withdraw the amendment. However, we hope that the Minister will ensure that the provisions addressing the need for training in such situations will come soon, and with a timeline, so that all members of the Committee understand when we will see the statutory guidance. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

[Dr Evans]

It is a shame that the hon. Member for Shipley is not in her place to hear me speak to the rest of the clause 4, having considered the amendments to it first—[Interruption.] Oh, she is here just in time. I am grateful to the Government and the Chair, as the clause stand part debate allows things to be more structured.

I want to discuss proposed new part 8A of the Mental Health Act 1983, which will introduce welcome changes to provisions specific to people in England with autism or learning disabilities who are subject to detention under the Act. At the outset, let me say that the Opposition welcome the Government’s recognition that people with autism or learning disabilities require a tailored and rights-based approach within our health system. We know—the evidence points clearly to the fact—that such individuals have been inappropriately detained in institutional settings, often for years, without the care and support that they truly need. The creation of a statutory care, education and treatment review in legislation was a step in the right direction. It therefore makes sense in this part of our proceedings to discuss such reviews.

The background is really important to understanding what the measure will do. Care, education and treatment reviews were introduced in 2015 as part of the Transforming Care programme, a joint initiative between NHS England and the Department of Health and Social Care under the last Government. The TCP was launched in response to the Winterbourne View scandal, which we have heard mentioned a few times, where serious abuses of people with learning disabilities and autism in private hospitals were exposed.

The purpose of CETRs in the Transforming Care programme was to ensure multi-agency oversight of care plans for people with learning disabilities and/or autism, particularly those with complex needs detained in in-patient or secure settings. They were there to promote person-centred care by involving patients, families and a broad range of professionals; to identify barriers to discharge and support safe, timely moves to community or less restrictive settings; and to improve care quality and reduce inappropriate long-term in-patient stays.

The implementation timetable started in 2015 with CETRs introduced as a mandatory part of the TCP, initially focusing on children and adults with learning disabilities and/or autism in in-patient settings. In 2017 to 2019, CETRs were expanded and refined, with NHS England producing guidance and a framework for conducting reviews consistently. Ongoing, CETRs are now embedded across the health and social care systems, extending beyond learning disabilities to other groups with complex mental health needs, including secure mental health services.

CETRs are multidisciplinary independent reviews designed to improve the care and treatment of people with complex mental health needs, particularly those detained in secure hospitals or secure settings, such as children and young people with learning disabilities, autism or complex mental health needs, or in other in-patient settings where there are concerns about the appropriateness of their care, treatment or placement. The purpose is to ensure that the care, education and treatment plans are appropriate, person-centred and holistic; to identify and address any barriers to overcoming recovery and discharge; to promote co-ordinated working between health, social care, education and other relevant services; and to support the least restrictive care principle, one that we have now enshrined in the Bill—helping people to move to less restrictive settings where possible.

There are, however, some complications. The number of CETRs has increased over recent years, especially with the growing recognition of the need for better oversight of complex needs. Several hundred CETRs take place annually across England and Wales, primarily within secure and specialist mental health services. Exact numbers are quite difficult to pin down and vary by service user populations, health trusts, NHS England monitoring and the reporting of the activity.

What is a CETR made up of? That is really important. A typical CETR involves a multidisciplinary panel including independent clinical reviewers such as a senior psychiatrist or clinician not involved in direct care; representatives from social care services; educational specialists, especially for children and young people; advocates or independent mental health advocates; the patient or service users themselves, where possible, to ensure their voice is central; family members or carers where appropriate and with consent; and commissioners and other relevant professionals involved in the person’s care pathway.

Under the review process, the panel examines the individual care, the treatment, the education and progress. It assesses whether the current placement and treatment plan are meeting the person’s needs and whether there is scope to support transition to less restrictive or more appropriate settings. Recommendations may be made on changes to care, treatment plans, discharge or support arrangements.

CETRs are a very valuable safeguard. They bring together the independent clinicians, the social care professionals, the educators, the advocates and, crucially, the patients and their families to review the care and treatment being provided. The aim is to ensure that the treatment is person-centred, appropriate and geared towards recovery, while also exploring opportunities to move people to less restrictive environments when safe to do so. That said, while CETRs are increasingly used, questions remain about their consistency, effectiveness and impacts on outcomes. On page 12 of the explanatory notes, paragraph 46 states that

“recommendations are not always being acted upon”,

which is contributing to

“the perpetuated detention of people with a learning disability and autistic people, often without therapeutic benefit.”

That is really significant. To that end, how many CETRs are conducted annually and what are the mechanics in place to ensure that the reviews lead to meaningful change in care, rather than becoming a procedural exercise? I must admit that I struggled to find that information. If I, as someone looking into it, am struggling, there is a concern about how wide that information and data is.

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[Stephen Kinnock]

I am conscious that we will be voting imminently, so I will try to rattle through. Going back to my phrase “the red thread”, the thread running through all the shadow Minister’s questions is delivery. The proof of the pudding in all legislation is whether we convert it into action in a way that best delivers for the interests of the British people, and in a way that absorbs the risks, builds resilience in the system and ensures that we are constantly monitoring, evaluating, reviewing and learning from what is happening on the ground and, through a constant process, improving delivery.

The shadow Minister asks some very good questions, but the problem is that so many will relate to the work that we need to do at pace as soon as the Bill receives Royal Assent. This is a sequential process; we first need the legislation and the comprehensive spending review, so that we know our funding package. We then need to start work consulting on the code of practice, getting that feedback and shaping a plan that defines what good community services look like, because we all know that we are a million miles from having good community services at the current time. We are in a state of crisis and the system is on its knees; we are very conscious of all those facts. There is an immense urgency with all this.

The shadow Minister asked about evaluating and updating pathways and CETRs, duty to respond, the information collected, managing the risks, preventing paternalism and ensuring that people do not get labelled. All those things will have to be set out and explained in the project plan. That is something we will all be working very hard on as soon as the Bill gets Royal Assent.

One of the shadow Minister’s factual questions was on how many CETRs have been issued. I cannot give him that number, but I can tell him that, as set out in the impact assessment, 86% of in-patients received a CETR in the last year. If my answer that this is about delivery does not satisfy him and he thinks there are issues that relate directly to the Bill rather than to the implementation plan, I am happy to write to him on that.

[Dr Evans]

I appreciate what the Minister is saying. The blue threat, or blue and yellow thread, running through the debate is the question of how much needs to be in the primary legislation. The argument from the Conservative side has been that, while some of the Lib Dem amendments are too restrictive, the danger is that the freedom and flexibility at the Government’s end is too loose. I trust the Minister implicitly—but, having seen Ministers on our side come and go, there could be a change within Government or a change of colour of Government, and no Government are bound by the one that went before.

I am trying to get the balance right by asking questions around procedure to assess whether some of these things should be in the legislation. I agree that there has to be a balance. That is why the Opposition chose to say 18 months, as opposed to four months; it was to have accountability and safeguards in place and to urge good delivery, but not to curtail the ICBs or clinicians—the people delivering stuff—and make them simply check boxes.

I appreciate the Minister’s offer to write to me. I would be grateful for that data, because where we find it will be important in future debates and in his future written or oral statements. I hope he understands that these probes are to make sure that we get the balance right between primary legislation, what is going in the code of practice and what is well intentioned, but could be left to blow in the wind.

[Stephen Kinnock]

That is a valid question, and one that has probably been asked in pretty much every Bill Committee that has ever taken place. It is always a challenge to get the balance right, having the right level of steer to the system in primary legislation without tying the hands of the system. Everything is constantly evolving, particularly in the age of technology in which we live, so it would be foolish to tie our hands too tightly given the changing nature of the landscape we are working in.

My answer to the question—I say this personally and from the point of view of the Government—is that we are satisfied that we have the balance more or less right. That is in the eye of the beholder, and not everybody will agree, but we feel that clause 4 gets that balance right, and sends clear signals to the system through primary legislation. The proof of the pudding will then be in the eating, and that is for the code of practice, the regulations and the programme planning. On that basis, I commend the clause to the Committee.

Question put and agreed to.

Clause 4 accordingly ordered to stand part of the Bill.

Clause 5

Grounds for detention

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[The Chair]

You wanted to know what adjourning now would mean for the progress of the Bill, and it would mean that we have to restart where we finished, so Thursday could be a longer day.

[Dr Evans]

Further to that point of order, Ms Furniss. To follow up on what the Government Whip, the hon. Member for Coventry North West, said, when a vote was called—although I appreciate that it was not carried on the voices—a number of members of the Committee who have since returned were not present.

Ms Furniss, could you speak to the Clerk to clarify at what point the Committee divided? There was a very clear point at which the Adjournment was moved. I appreciate it is your call whether the Question was carried on the voices, but you said that it seemed to have been carried, which implies that the Committee should now adjourn. I appreciate that there are some difficulties.

[Taiwo Owatemi]

Members have 15 minutes to get back when a Division is called in the House. The 15 minutes had not elapsed when the Adjournment was moved. How can the vote be allowed to stand when the rules say that members of the Committee have 15 minutes to get back?

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[Dr Shastri-Hurst]

It seems a lifetime ago since I was last on my feet. I am sure the Minister was waiting in anticipation for the crescendo of my speech. He heard my observations on amendments 52 and 53, and I know he will be mindful of ensuring that the balance between intervention and detention is held in equilibrium. I would be grateful if he addressed the points I raised before the interlude in his response.

New clause 24 would amend section 5(1) of the Mental Health Act 1983 to clarify that a formal application for detention can be made not only for a patient already admitted to hospital, but for individuals who have attended or been brought to a hospital seeking help or admission. It would therefore expand the legal basis for initiating detention procedures under the Act.

The new clause makes an important distinction. While the Act currently allows for the detention of an individual who is already an in-patient, there is ambiguity about whether that applies to individuals who are on hospital grounds—who have attended A&E, for example—but have not yet been formally admitted as a patient. In those cases, the Act fails to capture people who arrive voluntarily or are brought to such an institution during a crisis.

New clause 24 seeks to close that gap by explicitly allowing an application for detention to be made in such circumstances, ensuring that a timely intervention can occur when necessary for safety or treatment. A number of significant benefits would arise from the new clause. It would provide firm legal clarity; remove any ambiguity about when detention procedures can begin; allow timely intervention, enabling quicker responses for an individual in crisis who is already at hospital but has not been admitted; reduce the risk of harm by allowing earlier application of safeguards; and align the legal framework with the reality of hospital procedures. The distinction between those who are in attendance at a hospital and those who have been admitted in a state of crisis is a false one.

[Dr Evans]

Like me, my hon. Friend has served as a clinician on the frontline. As this point is sometimes lost, can he explain the practicalities of what turning up at a hospital versus actually being admitted means? They are two distinct things. Can he walk us through what the process entails?

[Dr Shastri-Hurst]

My hon. Friend is right. An individual can attend an emergency department to be assessed and be seen by a doctor before a decision is made on whether that patient should be admitted to that hospital, transferred to a tertiary centre or discharged back into the community. New clause 24 seeks to provide clarity and certainty for practitioners on that grey area and, crucially, it seeks to provide a safeguard for patients who have yet to be formally admitted to an institution—a hospital, community placement or wherever—but need a crucial intervention.

I am not suggesting that new clause 24 would not have some challenges due to its operational impact. It might increase the pressure on hospital staff to initiate formal processes earlier than they do currently. Clear oversight, guidance and training would be needed to ensure its appropriate use. It would also require careful implementation, because any such intervention must never be used prematurely or misused to detain people unnecessarily. I would welcome the Minister’s views on the operability of this new clause, which would significantly improve the Bill by providing clarity that practitioners and patients alike would appreciate.

[Dr Evans]

Amendment 52 would amend clause 5 to introduce an important distinction in the grounds for detention under section 2 of the Mental Health Act, namely on whether a person has the mental capacity or competence to consent to admission. This amendment, tabled by my hon. Friend the Member for Runnymede and Weybridge, raises questions that go to the heart of how we balance liberty and protection, autonomy and risk in our mental health system.

Under the current Mental Health Act, and indeed under the Bill as drafted, an individual can be detained for assessment if they are experiencing a mental disorder and if serious harm could be caused to themselves or others unless they are detained. There is no distinction based on whether they have the capacity to consent to care. In other words, a person who has full understanding and decision-making ability may still be detained against their will to protect them from themselves.

The amendment proposes a change to that approach, so that if someone lacks the capacity to make a decision about admission and treatment, the current protection should apply—they can be detained if they are at risk of harming themselves or others. But if someone has capacity, understands what is happening and what the risks are, and still refuses care, they should be detained only if they pose a risk to others and not just to themselves.

I will give a brief example to try to bring that to life. Imagine a young adult, aged 22 and living with long-standing depression. They have attempted suicide in the past, but they now clearly and repeatedly say that they do not want to be admitted. They understand the risks, are coherent, consistent and judged by clinicians to have capacity. Under the Bill as it stands, that person could still technically be detained, but under this amendment they could not unless they pose a risk to someone else.

Why does this amendment have merit? There is much in it that is compelling. It puts autonomy at the centre of the mental health framework, which the Committee discussed and agreed on earlier. It aligns more closely with the Mental Capacity Act 2005, which already allows people to make unwise decisions so long as they understand what they are doing. It also echoes the principles in the UN convention on the rights of persons with disabilities, which calls for supported decision making over substitute decision making. It could reduce unnecessary or overly paternalistic detentions, especially of people from marginalised groups who are already disproportionally affected by coercive care.

[Gregory Stafford]

I am interested in the points that my hon. Friend is raising. Could he give any examples of the situations he is talking about? It would help the Committee, and certainly help me, to understand the practical realities of what he is talking about.

[Dr Evans]

I will try to elucidate a little further. We know that some people have fluid capacity, such as those with dementia or depression. How do we ensure that people have safeguards for themselves and the wider community, while respecting their capacity and allowing them to be masters of their own destiny? The Bill literally says that we want to see individual autonomy, and by definition, there is always a balance to be struck. The Bill shifts more to the paternalistic side, which brings some challenges because it could create gaps in protections, as I will explain.

There are clinical situations in which a person in mental health crisis—for example, in the early stages of a manic episode or a severe personality disorder crisis—may present with superficial capacity but be at grave risk of harm. Are we confident that clinicians can assess capacity accurately in real time, in often pressured and emergency contexts? Might we inadvertently tie the hands of practitioners trying to prevent suicide or serious self-injury? If capacity becomes the gateway to protection, what support and guidance will be provided to ensure that it applies fairly, consistently and safely?

That is important when we talk about detention, because detaining people is one thing; the next thing is how we get them out. To understand that, it is worth focusing on the crucial interaction between the Bill and liberty protection safeguards. It is worth my briefly explaining to the Committee what LPS are, how they evolved and why they matter. Liberty protection safeguards are the new legal framework that replaces the old deprivation of liberty safeguards, or DoLS. DoLS were designed to protect people who lack capacity, but had become widely criticised as complex, slow and limited mainly to hospitals and care homes.

In response, the Conservative Government introduced LPS through the Mental Capacity (Amendment) Act 2019, to simplify the process and extend protections to community settings such as supported living and people’s own homes. Given that we are talking about Darzi’s shift, that is important. With that context, I turn to the key concerns before us today: how the Bill interacts with LPS, especially when individuals move from hospital detention to community care.

To illustrate why this matters, let us consider the case of Mrs A. She is a 55-year-old woman with bipolar disorder and mild dementia. She was detained under the Mental Health Act after a severe manic episode put her at risk. While in hospital, the Act governed her detention and treatment. After several months, Mrs A stabilises enough to be discharged, but because of her dementia, she lacks the capacity to consent to her care arrangements in the community. She requires supported living, with 24/7 care, which means that she will continue to be deprived of her liberty, but now in the community. Because she is no longer detained under the Mental Health Act upon discharge, the liberty protection safeguards must authorise the deprivation of liberty in the community.

This requires careful consideration. An LPS assessment and best intention decisions are required, and formal authorisation must be in place before she leaves hospital. This transition point is critical, because without clear protocols, Mrs A could find herself deprived of liberty without lawful authorisation—a breach of her human rights. Information sharing between hospital staff, community providers and local authorities may be delayed or incomplete. There may be confusion among professionals about who is responsible for co-ordinating the handover. Training gaps might lead to the inconsistent application of safeguards.

The Bill reforms detention in hospitals, but there is some opacity regarding how the handover to LPS in the community will be managed. Will the Bill ensure a seamless transition, with no gaps in safeguards? If it does not, then how will this be provided? Will there be statutory duties to mandate information sharing and co-ordinate reassessments? How will professionals across health and social care be trained to navigate both systems effectively?

The Bill rightly aims to reduce inappropriate detentions and enhance patient autonomy in hospital, but protections under LPS in the community must be equally robust to maintain dignity and rights post discharge. How will the Government guarantee parity of safeguards across settings? The Bill also seeks to address disproportionate detention rates among ethnic minorities. We must be equally vigilant that the reforms and the wider LPS regime do not perpetuate inequalities once individuals leave hospital. We therefore need to ask the questions: what monitoring is done and what safeguards will be in place?

On detention, I gently ask the Minister to clarify the Government’s plan to manage the vital interface between the Mental Health Act and LPS, even as the Bill stands, to embed clear statutory duties, guidance and accountability to protect all individuals like Mrs A throughout her care journey.

What is the Government’s view on distinguishing between those with and without capacity in the context of detention for self-harm risk? Has the Department assessed the clinical and operational implications of requiring real-time capacity judgments before detaining someone at risk to themselves? Will the Government consider a limited override provision in extreme cases where the risk is immediate, catastrophic and the capacity assessment is finely balanced? We will see more of these kinds of cases as we go forward, with more and more people living with the likes of dementia or acquired brain injuries.

If the Government do not support the amendment as drafted, might they consider refining the code of practice to provide clear guidance on how capacity, autonomy and right to self are waived? The amendment presents a thoughtful and principled intervention. It is not perfect in my eyes, but it challenges us, rightly, to consider whether our mental health laws strike the right balance between protection and personal freedom.

Amendment 53, like its partner on section 2, reflects a growing consensus that the law should better respect the autonomy of people with mental health conditions, especially when they have the capacity to make informed decisions. In introducing a necessary distinction, if someone can truly understand the consequences of refusing treatment and they pose no risk to others, should the state override their decision on their own behalf? The amendment would add a capacity-based distinction into section 3, mirroring the earlier amendment on section 2. Specifically, if a patient lacks capacity to consent to a medical treatment, they may be detained if there is risk of serious harm to themselves or others. If a person has capacity, they may be detained only if there is risk to others. In short, if a person is mentally unwell but understands the consequences of refusing treatment in this case and only poses a risk to themselves, they would not be eligible for detention under this amendment.

Imagine a woman with anorexia nervosa who is dangerously underweight, has a good understanding of her condition and the risk, and refuses in-patient treatment. Under the Bill as it stands she can be detained, but under the amendment if she is judged to have capacity and only poses a risk to herself, she could not be detained under section 3. Therefore, there are huge and far-reaching consequences to the amendment. The wider science is moving towards capacity, but it needs to answer some of these questions. Some are even being grappled with now—take the Terminally Ill Adults (End of Life) Bill. This truly cuts to the heart of humanity and I am sure there are varying views not only across the Committee, but across society. Similar questions will arise when it comes to capacity.

To that end, the question posed is not simple. In some cases, such as severe anorexia or chronic suicidal tendencies, capacity may be technically present but clinically contested. The stakes could not be higher. The amendment challenges us, and therefore the Government—and rightly so—to ask: are we doing enough to balance liberty and care? Do we have the right clinical tools, legal thresholds and ethical safeguards in place?

New clause 24 is on a different but related subject. This Back-Bench amendment relates to the application for admission in respect of patients who are already on hospital grounds but have not yet been formally admitted. This is really important, because it comes down to the ability. As my hon. Friend the Member for Solihull West and Shirley said, when it comes to the mechanism this is the day-to-day reality. Someone, just because they turn up in A&E, is not under the care of A&E per se until they are admitted. That is when the clinicians will take control. If they just give their name, at what point do we have that grey area? That is the matter of contention in day-to-day working.

Currently, under section 5(1) of the Mental Health Act, applications for detention or admission can be made only in relation to patients who are already admitted to hospital—that is the key part. This leaves a grey area for people who come to hospital voluntarily, perhaps by walking into A&E and seeking help or being brought by an ambulance or the police, but have not yet been formally admitted. The amendment would explicitly allow applications for admission to be made as soon as someone attends or is brought into hospital to seek help, even before formal admission.

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[Gregory Stafford]

Just in case my hon. Friend the Member for Runnymede and Weybridge is not following this Bill in Hansard, I will pass on the hon. Lady’s compliments to him. Like her, I have great respect for him; I am not trying to denigrate his great work on the amendments and the new clause. All I am suggesting is that, from a layperson’s perspective, there are some elements that need tightening up, if not changing altogether. I take the hon. Lady’s point about pre-legislative scrutiny, but obviously these amendments and the new clause were not part of that because they have only just been tabled. I therefore think it is entirely appropriate to be debating them now.

[Dr Evans]

I have spoken to my hon. Friend the Member for Runnymede and Weybridge and looked into this issue a bit further. Psychiatry is already looking towards future capacity and trying to bring the two pieces of legislation together. I believe that Scotland has already moved in that direction. We are therefore into the cycle of chasing legislation for something behind us. I appreciate the concerns, but that is why the Government need to be alive to these situations. At the end of the day, the nub of the issue is patients getting caught up between capacity and safety under the Mental Health Act. Does my hon. Friend agree?

[Gregory Stafford]

I thank my hon. Friend for his extraordinarily helpful intervention. I was not aware of the changes, and I certainly had not heard of fusion before, or about what is going on in Scotland. Of course, if the new clause had already been enacted in another part of the United Kingdom in some form, I would be much more comfortable with it. But, as I said in relation amendments 52 and 53, if the new clause is to pass in its current form in this Bill or in some future form in another Bill, there has to be a focus on proper training and guidance. Because there is potentially such a legal quagmire, we must ensure that people understand the legal framework within which they can do this.

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We have committed to continue to explore the issue. We will engage with stakeholders to understand how the current legal framework is applied and identify solutions to the problems raised. We will also provide further guidance on the existing legal framework, including the handover process from police to health, in the next revision of the code of practice.

[Dr Evans]

I am grateful to the Minister for how seriously he is taking this issue, and I agree that there is not necessarily a consensus even within the Opposition. Having the debate is therefore really important. It may be useful to collect data on the number of incidents and where these handovers are. Would the Government commit to that? We would be better able to have this debate, and to decide how much of a problem this is and to work out what the solutions are. Again, I struggle to find data that indicates where this is an issue, but I have spoken to clinicians who I know and colleagues who I have worked with when I have seen it. It happens enough that I was aware of it as a bog-standard GP who has worked in A&E, but it is clearly not rampant and we are not seeing it every single day. Would the Government commit to collecting data on it? If so, in what format would it come?

[Stephen Kinnock]

I ask the hon. Gentleman to clarify his question about data collection. Is he looking for clarity on the number of people who are judged to have mental capacity but who trigger the deprivation of liberty condition because they are seen to be either of severe risk of harm to themselves or to society?

[Dr Evans]

That would be a very useful piece of data, but I was in fact talking about new clause 24 and the grey area of hospital detentions. That data is probably easier to collect. I specifically ask the Minister to keep in mind the collection of data on those who turn up to A&E but end up having to be taken out of the hospital to be sectioned, for example. That is the nub of the issue and the practicality of what is going on. In a number of incidents, although the law is set in a way that is supposed to be helpful, the interface unfortunately becomes very difficult.

The Minister has rightly pointed out that there are different ways to deal with this. The new clause is one such potentially heavy-handed way of dealing with it. At the same time, it comes from the good place of trying to address what clinicians deal with in A&E day in, day out. However, we need some data and some teeth behind that to understand and appreciate how much of a problem it is and to then come up with a solution. I hope that clarifies my question.

[Stephen Kinnock]

That does clarify it. I will absolutely discuss that with officials. It is clear that we need a complete picture of the prevalence of people reporting to emergency departments and then having to be extracted from them and put into other facilities. That is an important point. We clearly need to think more about this issue and consult further. Obviously, understanding the data is a very important part of that. I cannot give the hon. Gentleman a nailed-on commitment to do that, but I give him a nailed-on commitment to discuss it with officials. It is possible that the data is already out there. We need to find that out.

We have heard concerns that there is a lack of clarity about what legal powers are available to health professionals to hold someone in emergency departments until they can be assessed. However, it is a complex issue that requires extreme care and caution. We have committed to continue to explore the issue. We will engage with stakeholders to understand how the current legal framework is applied, and identify solutions to the problems raised. We will provide further guidance on the existing legal framework, including the handover process from police to health, in the next revision of the code of practice. We are also taking steps to address current operational pressures. NHS operational and planning guidance for this year tasks local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in emergency departments.