Mental Health Bill [ Lords ] (Fifth sitting)

The Committee consisted of the following Members:

Chairs: Gill Furniss, Carolyn Harris, † Sir Desmond Swayne, Martin Vickers

† Bloore, Chris (Redditch) (Lab)

† Brandreth, Aphra (Chester South and Eddisbury) (Con)

† Burton-Sampson, David (Southend West and Leigh) (Lab)

† Chambers, Dr Danny (Winchester) (LD)

† Craft, Jen (Thurrock) (Lab)

† Dean, Josh (Hertford and Stortford) (Lab)

† Dixon, Anna (Shipley) (Lab)

† Evans, Dr Luke (Hinckley and Bosworth) (Con)

Franklin, Zöe (Guildford) (LD)

† Irons, Natasha (Croydon East) (Lab)

† Joseph, Sojan (Ashford) (Lab)

† Kinnock, Stephen (Minister for Care)

† Morris, Joe (Hexham) (Lab)

† Owatemi, Taiwo (Lord Commissioner of His Majesty’s Treasury)

† Shastri-Hurst, Dr Neil (Solihull West and Shirley) (Con)

† Stafford, Gregory (Farnham and Bordon) (Con)

† Wrighting, Rosie (Kettering) (Lab)

Claire Cozens, Harriet Deane, Committee Clerks

† attended the Committee

Public Bill Committee

[Sir Desmond Swayne in the Chair]

Mental Health Bill [Lords]

09:25:00

Please ensure that mobile phones are turned to silent mode. If hon. Members and officials wish to remove their jackets, they have leave to do so. Clause 22 Consultation of the community clinician Question proposed, That the clause stand part of the Bill.

With this it will be convenient to discuss the following: Clause 23 stand part. New clause 4—General duty to secure sufficient resources for services in the community— “(1) It is the general duty of integrated care boards to ensure, insofar as is reasonably practical, that services in the community responsible for delivering care, treatment, or detention provisions under the Mental Health Act 1983 and this Act have the necessary resources, including financial support, to meet service demands. (2) Additional forms of resource may be determined by integrated care boards in consultation with relevant local authorities or health care service providers and may include— (a) sufficient numbers of trained medical professionals; (b) purpose-built facilities for patient care; (c) community services responsible for out-patient care. (3) Each Integrated Care Board must conduct an assessment of its resources every two years to evaluate its ability to deliver services in the community effectively. (4) Each Integrated Care Board must publish a report outlining its findings upon completing the assessment in subsection (3). The first reports must be published within one year of the passage of this Act.” This new clause places a general duty on integrated care boards to ensure that services in the community have the necessary level of resource to meet demand on services to ensure that the provisions of the Bill function as intended and to assess and report on this every 2 years.

It is a pleasure to serve under your chairmanship, Sir Desmond. I will discuss a number of issues concerning community treatment orders and ensuring sufficient resources for community-based care. Clause 22 will add the community clinician as a third key decision maker for community treatment orders, alongside the responsible clinician and approved mental health professional, ensuring additional professional oversight. Involving the community clinician in the initial request for a community treatment order will improve the planning and implementation of community treatment orders by ensuring good communication between ward and community doctors, aiding continuity of care. It should also help to prevent the inappropriate use of community treatment orders, for instance to free up beds where there are pressures on acute wards. Making sure that only those who need to be on a community treatment order will be put on one supports the principles behind the reform of the Mental Health Act 1983, including the principles of least restriction, of therapeutic benefit and of treating the person as an individual. It should also positively impact the racial disparities that have been seen in the use of community treatment orders. The community clinician’s opinion is important when a patient is under a CTO, because the clinician may have a better understanding of the patient’s progress, including how well the patient is engaging with their treatment while in the community. Their insights are valuable in deciding whether the patient should be discharged to a community treatment order or recalled to the hospital if their symptoms worsen. Those who are supporting the patient in the community should be a part of the decision of whether the restrictions of the CTO are still required. I turn to clause 23. In addition to reducing the number of people placed on CTOs, as has been referred to in relation to clauses 6 and 22, we aim to provide greater protection to those subject to them. CTOs extend the coercive powers of the Mental Health Act into people’s lives beyond hospital. CTOs should be used only when necessary, with conditions tailored to the individual rather than applying blanket restrictions. Currently, some CTO conditions display an overreach of power, such as requiring abstinence from alcohol even if this is unrelated to the person’s mental health condition. The clause will remove the ability of the responsible clinician to apply conditions to a person’s community treatment order which are appropriate but not necessary, giving a higher threshold for conditions to be set. The clause will allow the mental health tribunal to recommend that the responsible clinician reconsider the necessity of conditions specified in a CTO if the tribunal determines that the patient is not yet suitable for discharge. For example, while not set out in the Bill, the tribunal may use this power if it finds the conditions imposed in a CTO to be possibly disproportionate, overly restrictive, lacking clinical benefit or not treating the person as an individual. New clause 4 would place a general duty on integrated care boards in England to ensure that community services have the necessary resources to meet demand, and to report on this every two years. This duty to commission local services based on local need is already placed upon integrated care boards by the National Health Service Act 2006, as amended by the Health and Care Act 2022. An integrated care board must arrange for the provision of services as it considers necessary to meet the reasonable requirements of the people for whom it is responsible. Integrated care boards and their mental health trusts are required to prepare a joint forward plan that describes how the ICB will arrange for NHS services to meet their population’s physical and mental health needs. For that reason, we do not think the new clause is necessary, and it could place a disproportionate burden on ICBs and mental health providers. I therefore hope that the hon. Member for Winchester will be satisfied not to press it. I commend clauses 22 and 23 to the Committee.

It is a pleasure to serve under your leadership, Sir Desmond, especially on such a warm day. I hope that there is not too much hot air in the Committee to keep us even warmer. Clause 22 will introduce a series of important amendments to the operation of community treatment orders under the Mental Health Act 1983. The clause has the stated aim of strengthening clinical safeguards and ensuring continuity of care between hospital and community settings. The Opposition support these goals in principle. Let me set out the current legal position. At present, decisions to place a person on a CTO require two professional inputs: the patient’s responsible clinician and an approved mental health professional. The responsible clinician can vary, suspend, recall or revoke the order, often with no statutory obligation to consult the clinician who will be managing the patient’s care in the community.  Clause 22 will change that. It introduces the new role of the community clinician—defined as the approved clinician who will oversee the patient’s care in the community—and requires their involvement at key decision points in the life of a CTO. Specifically, it requires a written statement from the community clinician that the CTO criteria are met, where they are not the responsible clinician. It obliges the responsible clinician to consult the community clinician before varying conditions, recalling or revoking a CTO, unless such consultation would cause unreasonable delay. It also includes the community clinician in the process of renewing a CTO, again via a written statement.  These are not insignificant changes. They mark a shift towards multidisciplinary accountability and a greater emphasis on the continuity of care between in-patient and community settings. The Opposition strongly support both principles. However, there are several points that I would like to probe constructively, and I hope the Minister will respond in the spirit of improving what is clearly a well-intentioned clause.  First, the term “unreasonable delay” appears multiple times in the clause as an exception to the duty to consult the community clinician, but I cannot see it defined in the Bill or in the explanatory notes. Could the Minister clarify what constitutes “unreasonable delay” in practice? Will guidance be issued to ensure consistency across trusts and clinicians? We must ensure that this exception does not swallow the rule or become a loophole in time-sensitive situations. Secondly, what happens when clinicians disagree? The clause requires the agreement of the community clinician in writing before a CTO can be made, but it is silent on what happens when there is disagreement between the responsible clinician and the community clinician. This is not a hypothetical concern; differing clinical views are common and can be a healthy part of multidisciplinary practice. Could the Minister confirm whether there is a proposed resolution mechanism where clinicians differ? Would the decision default to a tribunal or a second opinion, or is the CTO simply not made? Thirdly, as the Minister has mentioned, on the operational readiness to implement this clause, the new duties on community clinicians are not trivial. They are being asked to produce written statements, engage in formal consultations and be available to advise on time-sensitive decisions such as recalls and condition changes. Can the Minister reassure the Committee that a workforce impact assessment has been or will be conducted? Will there be investment in community mental health staffing and digital infrastructure to ensure that this duty is workable? Fourthly, I want to raise the issue of handover and role clarity. The clause will introduce a new statutory role—the community clinician—but patients often transition rapidly between settings. There may be uncertainty about who holds that responsibility at a given time. Will guidance ensure that community clinicians are formally designated and that responsibilities are clearly recorded at the point of discharge? I want to end on a constructive note. Clause 22 is a step in the right direction. It reflects many of the recommendations of the independent review of the Mental Health Act, including the emphasis on least restriction and on therapeutic benefit. I encourage the Government to consider defining or clarifying unreasonable delay in regulations or guidance, introducing a clear process for resolving professional disagreement, and committing to publish a plan detailing workforce support, guidance and digital infrastructure to ensure that this takes place. Clause 23, which is linked to clause 22, will introduce two important amendments to the operation of community treatment orders under the Mental Health Act 1983. As things stand, section 17B(2) allows a responsible clinician to attach conditions to a CTO if they are necessary or appropriate, to ensure the patient receives treatment, to prevent risk to health or safety or to ensure engagement with services. Such conditions can include where the person lives, their attendance at appointments and even lifestyle restrictions such as abstaining from alcohol or drugs. However, we know that these conditions can be seen as coercive. Patients often feel that breaching them means automatic recall to hospital. In practice, some CTO conditions may drift toward overreach rather than clinical necessity. The clause responds to these concerns in two ways. Subsection (1) will remove the words “or appropriate” from section 17B(2), meaning that CTO conditions must now be strictly necessary, not just advisable or convenient. The Opposition support this narrowing of the threshold. It sends a clear message that CTO conditions must be clinically justified, proportionate and tailored to the individual’s needs. However, I ask the Minister how clinicians will be guided in applying the new “necessary” test. Will the code of practice be updated with examples and scenarios? Crucially, what measures will be taken to ensure that patients are clearly informed that a breach of a CTO condition, in itself, is not automatic grounds for recall?

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

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

Order. I am afraid we have to suspend the sitting, as the sound is unworkable. I am assured that a sound engineer is on the way. 9.37 am Sitting suspended.

09:45:00

Brevity is an important skill that you have exemplified in this House for many years, Sir Desmond, so I will not subject the Committee again to matters that I have already covered. I ask again the question that I posed just before the suspension: how will clinicians be guided in applying the new “necessary” test? Will the code of practice be updated with examples and scenarios? Crucially, what measures will be taken to ensure that patients are clearly informed that a breach of CTO conditions is not, in itself, an automatic ground for recall? That concern has come across in evidence and is a long-standing source of misunderstanding and mistrust, as has been highlighted in cases and in the Wessely report. Clause 23(2) will insert new subsection (3B) into section 72 of the Mental Health Act, giving mental health tribunals the power to recommend that the responsible clinician reconsider whether a CTO condition is necessary, even when they do not discharge the patient. That is a welcome enhancement of patient rights. Currently, if a tribunal decides not to discharge a patient, it has no power to challenge potentially excessive conditions. The clause strikes a useful middle ground, offering oversight without overturning clinical decisions. Having said that, will there be any requirement for the responsible clinician to formally respond to the tribunal’s recommendations? Without such a duty, there is a risk that recommendations may be quietly disregarded and the benefit of the provision may be undermined. Clause 23 is a positive and proportionate reform, but to strengthen its practical impact I suggest that the Government consider updating the code of practice to clarify what constitutes a “necessary” condition under section 17B of the Mental Health Act; introducing a duty to respond to tribunal recommendations under proposed new section 72(3B), with a short time limit and a written explanation if the recommendation is rejected; and providing clear information to patients. New clause 4, tabled by the Liberal Democrats, seeks to place a general duty on ICBs to ensure that sufficient resources are available for community-based mental health services, particularly in the context of implementing provisions under the Mental Health Act. It speaks to a concern that many Committee members will have heard time and again from patients, practitioners and families alike: that the success of any reform to the Mental Health Act will ultimately rest on the capacity of community services to deliver. We know the reality: patients can be discharged to under-resourced settings or subject to CTOs that depend on clinicians who may be overstretched or unavailable. Clause 22 will rightly expand the role of community clinicians in CTO decisions, but that works only if they exist, are available and have the time and tools to engage meaningfully. I acknowledge that new clause 4 identifies a genuine structural risk in the way in which we approach reform, and I commend colleagues for raising it, but should it sit in primary legislation? I am not so sure. I have some questions for the hon. Member for Winchester not about the intention of the new clause, but about the appropriateness and practicality of placing such a duty in primary legislation. Primary legislation is best used where duties are clear, enforceable and universal. The duty proposed in the new clause, although admirable, is qualified by the words “insofar as is reasonably practical”, which reflects the reality that integrated care boards do not control all the levers of workforce, capital investment or even, in many cases, service design. With that in mind, I ask the hon. Member the following questions. What mechanism would be used to enforce the duty? If an ICB fails to meet the duty, what would the consequences be? Would the duty not create legal ambiguity or even the potential for judicial review where service users feel that resources are inadequate, or even where the ICB has acted reasonably in difficult circumstances? Furthermore, how would the duty interact with the existing statutory duties on ICBs under the Health and Care Act 2022, including the duties around health inequalities and integration? A stronger element of the new clause, which merits closer consideration, is the assessment and publication of findings on local community mental health capacity. This kind of transparent, data-led accountability could be an effective tool not only for Parliament and regulators, but for local patients and advocacy groups. Perhaps that element could be taken forward in secondary legislation as part of the updated NHS England commissioning guidance. The Minister will forgive me, but I am not sure whether such a tool already exists, so perhaps he will address that point. Does the Department plan to require ICBs to assess and report on community mental health capacity in the light of the new duties being created by the Bill? Could there be scope for a reporting duty to be included in regulations or guidance, even if a general resourcing duty is not placed in primary legislation? The Bill refers to commissioning, and under earlier clauses we have talked about dynamic registers. Will the Minister set out whether the issue is covered here or in another way? We cannot ignore the resource dimension, so I am grateful to colleagues for pressing the Committee to address it. However, we must be careful about the tools we use, what we write into law, and what we deliver through planning, commissioning and political will. I look forward to hearing from the hon. Member for Winchester and the Minister in response to my questions.

It is a pleasure to serve under your chairmanship, Sir Desmond. I welcome the changes proposed in clauses 22 and 23. Clause 22 seeks to amend the Mental Health Act to require the community clinician responsible for overseeing the patient’s care as a community patient to be involved in decisions regarding the use and operation of community treatment orders. While I was practising as a mental health professional, I was personally involved in many community treatment orders and in recalling patients to hospital. Although I acknowledge the concerns raised by various charities and members of the Committee about the overuse of community treatment orders and restrictions on patients, such orders have many benefits. As the Minister has highlighted, they help to release the pressure on in-patient settings. They also help patients to live in a home environment: without such provision, some patients would have to stay in hospitals for longer, which can be more restrictive than being in the community. The Committee needs to understand the kinds of patient who are often considered for community treatment orders. These patients are already well known to mental health services. They may have a long-term serious mental illness and may have to take medication continuously. More often, they are on regular injections of what is called depot medication; mental health professionals administer such medication either once a month or once every three months. Community treatment orders enable clinicians to make sure that patients receive the medication they need, so that they do not relapse and so they can have a good quality of life. By introducing an additional professional check on whether the patient really needs the support of a community treatment order, and by requiring more evidence that the patient needs the support of the community treatment order to get better, clause 22 will adopt two of the four principles of treatment proposed in Sir Simon Wessely’s independent review, namely the principle of least restriction and the principle of therapeutic benefit.

The Committee is very lucky to have the experience and expertise of someone who has used community treatment orders in the field. Will the hon. Member address my point about clinical conflict? We are introducing two new people: a community clinician and a responsible clinician. Has he seen any difficulties in practice with a difference of opinion between clinicians? How were they resolved? Does he see any way in which the clause could create or resolve a problem? My worry is that there is no clear resolution that would deal with discrepancies. I would love to know what is happening at the moment, as the law stands, in the hon. Member’s clinical experience.

I thank the hon. Member for that important intervention. Healthy conflicts between professionals can be useful and can be used as a reassurance to people who are concerned about the overuse of CTOs. However, capacity can sometimes be an issue, especially in community settings, an issue that new clause 4 addresses. It is also important to understand that mental health services have changed over the years. The consultant who treats the patient in hospital may not know much about them or how they are in the community. In the past, all those patients were followed by a care co-ordinator—not necessarily a mental health psychiatrist, but a mental health nurse or social worker who followed the patient throughout their journey and kept an eye on them. We do not have enough capacity these days, so nobody is following the patient. A community treatment order helps them to have at least minimum contact when they have to go and see a patient to administer medication. I support that conflict—sometimes it can be very healthy—but I also acknowledge that we need more capacity in the community. Clause 22 makes a new distinction between a patient’s responsible clinician with overall responsibility for them, including in hospital, and a community clinician with the responsibility for the patient in the community. It will impose specific duties on the community clinician where they are not the responsible clinician. For example, subsection (2) will amend section 17A(4) of the Mental Health Act to require that where the responsible clinician is not the clinician who will have care for the patient in the community after their discharge, that community clinician must also agree in writing that the community treatment order criteria are met. That will ensure continuity of care of the patient from the hospital into the community, and it will have the added benefit of additional professional oversight in respect of the need for a community treatment order. That is to be warmly welcomed. I also highlight subsection (4), on the power to recall a community patient to hospital. That will mean that if the community clinician is not the responsible clinician, the community clinician will still need to be consulted before a patient can be recalled under the community treatment order, unless such a consultation would lead to an unreasonable delay. That seems an entirely welcome and sensible reform. In some cases, an unreasonable delay may not be helpful, because some patients need to have their medication at regular intervals. For example, a patient on clozapine who misses their medication for three or four days in a row may have to restart their whole treatment regime, which will mean an even longer in-patient admission process. Subsection (6) will require a community clinician to make a statement in writing, if they are not the responsible clinician, in support of the renewal of a patient’s community treatment order, if that is the conclusion of the responsible clinician. Getting written confirmation from the community clinician who is intimately involved in the patient’s care that a renewal of the community treatment order is both necessary and appropriate and is the correct thing to do. Once again, it is about ensuring that a further professional opinion is considered; it is also about checking whether the patient still needs the support of a community treatment order. Clause 23 will make changes in relation to the conditions that a person subject to a community treatment order may be required to follow. It will amend section 17B of the Mental Health Act so that conditions can be imposed only if they are “necessary”. This is a simple and welcome update from the current wording, “necessary or appropriate”. Clause 23’s second modernisation is to give the tribunal a new power to “recommend that the responsible clinician reconsider whether a condition…in the community treatment order is necessary”. This would apply when the tribunal has decided not to discharge a patient completely from a community treatment order, but has come to the conclusion that not all its conditions are required. Once again, this is a welcome reform and is in line with the principle of therapeutic benefit. Some conditions put on patients can be seen as restrictive: for example, if a condition states that patient cannot use alcohol or illicit drugs, the clinicians will be looking at whether the patient’s use of alcohol or illicit drugs has an impact on their mental state or on their non-compliance with treatment. That is very important. I welcome the changes in clause 23.

10:00:00

It is an honour to serve under your chairship, Sir Desmond. I thank the Minister and the hon. Member for Hinckley and Bosworth for their comments on Liberal Democrat new clause 4. This is another good example of how, although we are aware that it has laudable aims, the Bill will fail without the supporting infrastructure. As everyone will be aware, community mental health services are among the issues that generate the most emails and correspondence—certainly in Winchester, where young people especially are struggling to access mental health care. In that context, we are alarmed that mental health spending has fallen as a share of overall health spending in the last financial year. That has been coupled with the decision to drop a number of mental health targets, including targets for the number of people receiving mental health interventions such as talking therapy, and the target to ensure that 75% of people with a severe mental health illness receive an annual physical check. Priority has not been given to the services necessary to deliver better mental health care. For the Bill to make a meaningful difference, the Government must ensure that community mental health care services receive the investment that they need to fulfil their obligations under the Bill—I know that that is a bit of a circular argument—and reduce the overwhelming pressure on in-patient services. There is also the impact on schools, police services and families. When I went out with the police in Winchester not long ago, they told me that between 40% and 50% of their time is spent dealing with people who have a mental health issue in some capacity. The lack of community mental health care is not just a resource burden on the health service; a lot of our other services are also affected.

The hon. Member rightly talks about resources and about the cuts as a proportion—although small, it is a cut in NHS spending. The last Conservative Government brought in the mental health investment standard to try to ensure parity between physical health and mental health in investment so that, regardless of how big the pot was, mental health was prioritised. Does the hon. Member agree that there is a concern that that could be slipping under this Government? Does he agree that that needs to be addressed in the context of the community provision that we are discussing?

Where is the evidence for that?

Would the Minister like to intervene?

No, thank you. I am chuntering from a sedentary position.

I broadly agree. We were really heartened that in the King’s Speech, the Government said that mental health needs to be treated as seriously as physical health. There are many reasons to join a political party but, given my long history of working in mental health charities, one major reason for joining the Lib Dems was that they had been saying that for years. I was pleased to hear that in the King’s Speech too, but we have to ensure that the percentage of spend on mental health does not slip in proportion to other very important resources.

I think we are all agreed that, in order to implement the changes to the Bill, we need investment in mental health services, particularly community mental health services, but does the hon. Gentleman recognise that the Labour Government have kept the mental health investment standard, ensuring that there is sufficient and increasing investment in mental health in this country?

I hope that that is the case. I know that is the aim, but I suppose we will see in four, five or six years’ time what the mental health resources are. No one aims to underfund these services, but the demand on them changes and they need to be resilient. Darzi said that in April 2024 there were 1 million people on mental health waiting lists, and we know that some children wait 15 months, so we must not just maintain the current investment standard, but try to catch up on the huge backlog, which will not change unless we reform the system or invest in more staff and resources.

The hon. Gentleman makes a good point—mental health services are in a very bad place—but does he agree that the Government have already announced investment in mental health specialists in all schools, and in mental health crisis centres? I have no doubt that once the 10-year plan for the NHS comes out, there will be an even clearer path for how we tackle mental health issues.

I am really looking forward to the 10-year plan and reading about how it will improve mental health. We shared Labour’s manifesto commitments to mental health practitioners in each school and mental health hubs, so we certainly support that. The hon. Member for Hinckley and Bosworth made some very good points and said that this proposal should possibly not be in primary legislation. I accept that integrated care boards do not have control over how every part of the service is delivered, so I am happy not to press the new clause to a vote, but I think the second part, which says that integrated care boards should have a duty to assess and report on the resource needed to meet the demands on services every two years, is important.

I rise to speak to clauses 22 and 23 and to Liberal Democrat new clause 4. As my hon. Friend the Member for Hinckley and Bosworth said, the Opposition support clauses 22 and 23 generally. Clause 22 addresses the concern that community clinicians—essentially, those responsible for overseeing a patient’s care outside hospital—have historically had limited formal input into decisions about community treatment orders, even though they are central to the patient’s ongoing care. It ensures that community clinicians not only are consulted but, in some cases, must provide written agreement before key decisions are made. It aims to improve continuity of care, ensure decisions reflect the realities of community-based treatment, and reduce inappropriate and poorly co-ordinated use of CTOs. The benefits of the clause are obvious, but they are worth restating. Clearly, it improves the continuity of care and ensures that clinicians with direct knowledge of the patient’s community care are involved in those key decisions. It enhances safeguards, adding an additional layer of professional oversight before coercive measures are imposed or suggested. It promotes collaboration by encouraging joint decision making between the hospital-based and community-based clinicians, and it reduces the risk of inappropriate CTOs by ensuring they are used only when genuinely appropriate and supported by those delivering care. However, I ask the Minister to touch on three points. First, requiring a written agreement or consultation could delay urgent decisions if not managed efficiently, so will he explain how, under the clause, any potential delay—a disagreement or just administrative inertia—can be removed to ensure treatment is not delayed? That moves me on to the administrative burden. Clearly, the clause adds a level of complexity and requires more documentation and co-ordination. Although I understand that that is a necessary outcome, I would again be grateful for the Minister’s thoughts on how to ensure effective and speedy implementation. As my hon. Friend the Member for Hinckley and Bosworth said, the ambiguity in the roles of the two clinicians may create confusion or disputes over responsibilities if they are not clearly defined or agreed. My reading of the clause is that there is no such clear definition; will the Minister look to provide one through other agencies, or will he put something into the clause in Committee or later in the Bill’s proceedings? Clause 23, on the conditions of community treatment orders, addresses the concerns that the threshold for imposing conditions on community treatment orders has been too low, allowing conditions that may be clinically unnecessary or overly restrictive. By removing the “appropriate” test, the clause will tighten the legal standard to ensure that only necessary conditions are imposed. Additionally, the clause will empower tribunals to play a more active role in scrutinising CTO conditions by allowing them to recommend that clinicians review specific conditions, even if the patient is not discharged. This reflects the Bill’s broader aim of enhancing patient rights and removing unnecessary restrictions. The clause is a welcome addition. It will ensure that CTO conditions are imposed only when strictly necessary, meaning that there are stronger safeguards, and it will enhance the role of tribunals in protecting patient rights without requiring full discharge. It will reduce clinical overreach by preventing the use of overly broad or vague conditions that may not be clinically justified. However, as with the previous clause, I have some questions. First, the tribunal power is limited in that it can only recommend, not require, the reconsideration of conditions. Is that the intention, or will the Minister strengthen the clause at some point to ensure that the tribunal can require a reconsideration of conditions? If he will not, what issues does he see arising from there not being a reconsideration? Secondly, as I mentioned in my intervention on my hon. Friend the Member for Hinckley and Bosworth, I have a concern about the potential ambiguity in the shift from “appropriate” to “necessary” leading to uncertainty or dispute over interpretation. As we touched on in relation to other clauses, clinicians will need additional guidance or training to apply the revised standard consistently. Where will that revised training and guidance be located, and what is the timeframe for its implementation? We need to ensure that all clinicians are fully trained and ready to use this new power. I will briefly touch on new clause 4, tabled by the Liberal Democrats, because although I understand that the hon. Member for Winchester may not press it, somebody else might. It would place a general duty on integrated care boards to ensure that services in the community have the necessary level of resource to meet demand such that the provisions of the Bill function as intended, and to assess and report on this every two years. As my hon. Friend the Member for Hinckley and Bosworth mentioned, the Opposition generally support the overall aims of the new clause, but as ever, there are some issues with the detail, so I have five questions for the hon. Member for Winchester if he responds, or for the Minister to answer in his summing up. First, if we imposed a statutory duty on ICBs to ensure sufficient resources for the CTOs, what mechanisms would there be to monitor and enforce compliance? Secondly, what would be the consequences if an ICB failed to meet this duty? Would there be formal accountability or a sanction process? Thirdly, how would the duty interact with existing NHS budgetary constraints and competing priorities? Would it become a statutory obligation with no clear means of redress if unmet? Fourthly, could the duty set a precedent whereby Parliament mandates resource guarantees without providing additional central funding? Finally, what constitutes “sufficient” resources in the context of the CTOs? Who defines that standard, and it is defined locally or nationally?

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

10:15:00

I am grateful for the clarification. Does it mean that, in essence, there will be a hierarchy, so the responsible clinician is above the community clinician and trumps them? If a community treatment order cannot be signed off, it does not exist. I want to explore that angle; is that what the Minister is suggesting?

Yes, the responsible clinician has primacy. On the workforce impact, our impact assessment, which was published alongside the Bill, sets out the additional hours of required clinician activity. We will invest in implementing these reforms. On the meaning of the word “necessary”, we will provide further guidance in the code of practice to provide for a range of scenarios to help to clarify necessary conditions, as well as to clarify that failure to meet those conditions should not always result in recall to hospital. On the requirement for a responsible clinician to respond to recommendations, we considered giving the tribunal the power to change or remove conditions on a person’s community treatment order. However, the outcome of our stakeholder engagement was that tribunal colleagues did not consider that it was appropriate for them to make clinical judgments, for example whether a condition is of clinical benefit. Providing the power to recommend that the responsible clinician reconsiders the conditions allows the tribunal to provide additional scrutiny but also allows for clinical discretion in decision making. The hon. Member for Farnham and Bordon asked about training. The training plan will be in the first written ministerial statement. On where the terms are defined, clause 10 defines responsible clinician and clause 22 defines community clinician. We will define the distinction between the roles in the code of practice. Question put and agreed to. Clause 22 accordingly ordered to stand part of the Bill. Clause 23 ordered to stand part of the Bill. Clause 24 Nominated person Question proposed, That the clause stand part of the Bill.

With this it will be convenient to discuss the following: Amendment 54 to schedule 2, page 77, line 21, at end insert— “(3) Where the patient has not attained the age of 16 years, a nominated person must have parental responsibility for the patient.” This amendment would stipulate that the nominated person for a patient under 16 must have parental responsibility for the patient. Amendment 55 to schedule 2, page 80, line 13, after “2(2))” insert “, has parental responsibility for the patient (see paragraph 2(3))”. This amendment would stipulate that the nominated person for a patient under 16 must have parental responsibility for the patient. Government amendments 40 and 41. Schedule 2. Clauses 25 to 28 stand part.

I will discuss a number of issues concerning the topic of the nominated person, one of the Bill’s key reforms. I will first address clause 24 and schedule 2, which seek to replace the current nearest relative provisions with the nominated person, chosen by the patient, who can protect their rights when they are detained. The independent review found the nearest relative provision to be outdated and inappropriate. It allocates someone based on a hierarchical list, which does not reflect modern families and could result in someone unfamiliar or potentially risky to the patient being given the role.  We have ensured that appropriate safeguards are in place to protect patients as well as to enable choice. A health or social care professional or an advocate must witness the nomination and confirm in writing that the nominee meets the criteria and that no undue pressure has been put on the patient. Children and young people with the relevant capacity or competence can choose their own nominated person. We expect this will be their parent or guardian, but sometimes a step-parent or other relative over 18, without parental responsibility, may be more suitable to protect a patient’s rights. Safeguards will be put in place to support children in making this choice. If a patient of any age lacks capacity or competence to make a nomination, an approved mental health professional will appoint a nominated person on their behalf. For children under 16, this will be someone with parental responsibility, including the local authority if the child is subject to a care order. This appointment is temporary until the patient has capacity or competence to make their own appointment. For all patients, the responsible clinician or approved mental health professional can temporarily overrule the use of a particular nominated person’s power, for example to discharge the patient, if the patient is likely to act in a manner that is dangerous to themselves or others. A nominated person can be removed by the county court if deemed unsuitable—for example, if they misuse their powers or neglect the patient’s welfare or the public interest. Anyone with an interest in the patient’s welfare, such as their parents, can apply to the court. The Bill extends the nominated person safeguard to some restricted part III patients, but their nominated person’s powers will be limited, as appropriate, in the interests of public safety and criminal justice. Amendments 54 and 55 would require nominated persons for patients under 16 to have parental responsibility for the child, whether chosen by the child or appointed for them. The Bill currently requires this if the child lacks competence to appoint their own nominated person. However, where a child has competence to decide, we think it is right that they can choose the person to represent their interests. That view was supported by the majority of respondents to the White Paper consultation on reform of the Mental Health Act, and it is in keeping with the principles of choice, autonomy and treating the person as an individual. Like the current “nearest relative” provision, which the nominated person will replace, the amendments do not take into account the greater diversity of modern family structures—for example, where a step-parent may play a vital role in a young person’s life but does not have formal parental responsibility. Our engagement with children and young people during the development of the Bill suggests that the vast majority will appoint a parent as their nominated person. However, we think having choice is important to prevent children from having to have a nominated person who may not engage with the role or act in accordance with their best interests, just because they have formal parental responsibility. Where children have competence to choose their own nominated person, a health or social care professional, or advocate, will be required to witness the nomination and confirm in writing that the nominated person is over 18 and suitable to take up the position. Regardless of nominated person status, parents should be involved in a child’s care and treatment, and they will retain their legal rights under parental responsibility. Safeguards are in place to allow for the overruling and displacement of the nominated person if they are behaving in a way that is not in the child or young person’s best interests. Government amendments 40 and 41 will remove paragraph 11(3) to 11(5) of schedule 2 from the Bill, as it is unnecessary to specify in legislation which person with parental responsibility the approved mental health professional must appoint as nominated person for an under 16-year-old. A prescriptive list of who an approved mental health professional must appoint for a child under 16 may prevent a more suitable adult from being chosen as the nominated person. The Bill states that for under-16-year-olds lacking competence, an approved mental health professional must appoint a parent, or whoever has parental responsibility, to be the child’s nominated person. This would include consideration of special guardians and child arrangement orders. The Government do not agree that a person with residual parental responsibility should always be blocked from being a nominated person, as the child arrangement order or special guardianship may be in place for reasons other than the parent being a risk to the child. For example, the parent might struggle with their own health issues, but that does not necessarily mean that they would not be an effective nominated person. The situation is different in the case of a care order because the local authority is being given lead parental responsibility. We have engaged with the Children’s Commissioner on that point. If there is no suitable person with parental responsibility willing to act, the approved mental health professional must take into account the patient’s past and present wishes and feelings, so far as reasonably ascertainable, when deciding who to appoint. We will establish an expert taskforce to support the development of the statutory code of practice to provide clear guidance for professionals involved in the nominated person appointment process for children and young people. Clause 25 will require the approved mental health professional to consult the nominated person before they make an application for admission for treatment or guardianship. This is an existing right for the nearest relative. However, currently if the nearest relative exercises one of their powers, such as the ability to block admission, but the professional believes their objection is unreasonable, the only means of overruling them is to remove or displace them as the nearest relative. This can leave patients without someone to represent their interests during detention. Clause 25 will allow the approved mental health professional to make use of the existing barring order to temporarily overrule the nominated person, if the patient would be likely to act in a manner dangerous to other persons or themselves if their admission was blocked. This is a well-established process. Although the nominated person can continue to represent the patient in other ways, they can still be displaced by the court from the role entirely if their actions indicate they are unsuitable for the role—for example, if they are repeatedly objecting to admission without considering the welfare of the patient or the interests of the public. Approved mental health professionals can continue to use that process. Clause 26 will transfer the nearest relative provisions relating to the power to order discharge of a patient to the new nominated person role. The power can be temporarily overruled by a responsible clinician if they think that the patient’s discharge would result in danger to themselves or others. It is a well-established process that allows for clinical discretion, but means that the nominated person can continue to represent the patient’s rights in other ways. Clause 26 also reduces from six months to three months the time period during which the nominated person cannot make another order for discharge. That reflects the changes in detention periods under clause 29. Clause 27 will give the nominated person a new power to object to the use of a community treatment order. We also recognise, however, the importance of protecting patients and the public, so if the responsible clinician is concerned that without a community treatment order, there would be a risk of danger to the patient or others, they can overrule the nominated person’s objection. Those changes will help both to reduce the number of inappropriate community treatment orders and to ensure that safeguards are in place for patient safety and public protection. Finally, clause 28 provides that before deciding to transfer a patient, the person responsible for taking that decision must consult the patient’s nominated person, unless consultation is not reasonably practicable or would involve unreasonable delay. The nominated person will not be able to object to a transfer, because there may be good reasons for transferring a patient—for example, if a different trust can provide better care, such as a specialist eating disorder unit. Consulting the nominated person, however, means that they are aware of the reasons for transfer and how it will benefit the patient. That will help the nominated person to remain actively involved in protecting patients’ rights and kept informed about a patient’s care and treatment.

I welcome the chance to contribute to the debate on clauses 24 to 28. I will then turn to Government amendments 40 and 41 and to amendments 54 and 55, tabled by my hon. Friend the Member for Runnymede and Weybridge (Dr Spencer). Clauses 24 to 28 represent a significant reform to the Mental Health Act 1983. They seek a shift from the traditional concept of a nearest relative to giving patients more control by allowing them to nominate a person to act on their behalf. Clause 24 is the cornerstone of the reform, establishing the role of a nominated person as the patient’s chosen individual to take over certain rights and responsibilities previously held by the nearest relative. It represents a fundamental change from a fixed family-based system to one centred on patient choice and autonomy. Currently, the nearest relative, often by blood relation, holds a range of statutory powers under the Mental Health Act, regardless of the quality of their relationship with the patient. The clause will enable patients, especially adults, to nominate a trusted person—a family member, friend or advocate—who can act in their best interests. That is a progressive and patient-focused change relating to modern social realities, where family ties are complex and a biological relative is not always the best supporter. Empowering patients to select their nominated person can enhance trust, improve communication and ultimately lead to better care outcomes. It does, however, raise pressing questions. For children and young people, particularly those aged 16 and 17, who gain legal capacity to nominate, what safeguards ensure that parental concerns and children’s welfare remain adequately considered? How will disputes between nominated persons and relatives, or between the nominated person and clinicians, be resolved? Part of that might be addressed in Government amendments 40 and 41, but I am keen to understand a little more. What training and oversight will ensure that nominated persons understand their duties and, importantly, their boundaries? Finally, for a patient who does not or cannot nominate someone, will the nearest relative still have a role, and how will that be managed? Clause 25, on applications for admission or guardianship, builds on clause 24. It will require the approved mental health professional to consult the nominated person before making applications for admission or guardianship, except where consultation is not reasonably practicable or would cause unreasonable delay. It will also allow the nominated person to object to such applications, requiring a barring report from the approved mental health professional if an objection is made. The clause will formalise the nominated person’s involvement at a critically early stage of the intervention, ensuring that their voice can influence decisions that deeply affect the patient. The power to object introduces an important check, though it is balanced by the professional’s ability to override objections on the grounds of safety. The Opposition agree with that, but there are still some questions. How will professionals navigate conflicts between their clinical judgment and objections by the nominated person? Will there be clear guidance to avoid delays that could jeopardise patients or public safety?

10:30:00

Clause 26 will replace references to the “nearest relative” with “nominated person” in discharge decisions and shorten the time interval before another discharge application can be made from six months to three. That reflects the updated detention periods and reinforces the nominated person’s role in advocating for timely discharge. Although this change could accelerate patient recovery and reduce unnecessary detention, it also necessitates careful monitoring to ensure that short intervals do not result in rushed or unsafe discharges—I flag that point to the Minister. However, we broadly support clause 26.

Currently, the nearest relative must be informed but has no formal role in the CTO decisions. Clause 27 will rectify that by requiring consultation with the nominated person before a CTO is made and granting them a right to object. That enhances oversight of CTOs, which are often controversial due to their coercive nature. None the less, the power remains ultimately with the responsible clinician to override objections if they feel that the patient poses a danger without the CTO. That raises a question for the Minister: how will transparency and accountability be maintained in these potentially high-stakes overrides?

Clause 28 will require consultation with the nominated person before transferring the patient between hospitals, expanding their involvement in care decisions that affect the patient, as well as wellbeing and continuity of support. Again, exemptions exist where consultation is impractical or will cause unreasonable delays. Clarity is again needed on how those exemptions will be applied, particularly in emergencies.

As an overall reflection, taking them all together, these clauses will modernise the Mental Health Act by embedding patient choice and strengthening nominated persons’ roles. However, there are questions about these clauses. The ability of a patient aged 16 or over to choose their nominated person could cause conflicts with parents or guardians. What protections exist to ensure that young patients are not pressured or isolated from family support when it might be needed? When it comes to professional discretion and safeguards, the repeated provision allowing professionals to override nominated persons’ objections if a patient poses danger concentrates significant power. What mechanisms will ensure oversight and fairness and prevent misuse?

When it comes to definition and monitoring, “not reasonably practicable” and “unreasonable delay” are subjective terms that could limit meaningful consultations. The Minister hinted in the debate on the previous clause that this will be set out in the code. I assume that is the case, but will he clarify? On supporting patients without nominated persons, how will the system protect those who have no one to nominate or whose nominated person is unavailable or unwilling? Ultimately, the success of these reforms will depend on clear guidance, robust safeguards, staff training and ongoing evaluation.

Schedule 2, which does the heavy lifting in the legislation, introduces the concept of the nominated persons within the framework of the Bill alongside the related clauses 24 to 28. That is a significant development in ensuring that patients have a meaningful voice. There is clear intent behind schedule 2 to empower patients by enabling them to appoint a nominated person—a trusted individual who can support them during the treatment journey.

The schedule offers a balanced framework for appointment, termination and resignation of nominated persons, with safeguards built in to protect patients from inappropriate appointments or actions that could harm their welfare. I appreciate the inclusion of the court oversight allowing for termination orders if a nominated person acts contrary to the patient’s best interest or public safety. The schedule also sets out the criteria for eligibility, age requirements and procedural safeguards, such as the need for written instruments witnessed by professionals, and offers appropriate safeguards, checks and balances.

However, as with any framework seeking to balance patients’ rights, professional oversight and public safety, there are challenges and potential areas for refinement. One concern I have is about ensuring that patients fully understand the role of and implications of appointing a nominated person. The schedule requires that the appointment is witnessed by health or care professionals, but we must also ensure that adequate information and support are provided to patients, so that the appointment is truly informed and, most importantly, voluntary. Clear guidance and training for both patients and professionals will be essential to avoid confusion or misuse.

Furthermore, the power of approved mental health professionals to appoint a nominated person where the patient lacks capacity, while necessary, must be exercised with transparency and in close consultation with family or carers whenever possible. That could be supported by robust review mechanisms to prevent any potential conflicts of interest or erosion of patient autonomy over time. Could the Government confirm that that will be the case?

Finally, the grounds for the termination of an appointment, including objections to applications for treatment or community treatment orders, are necessarily broad. While that protects patients and public safety, there is a risk that disputes over treatment decisions could lead to instability in the nominated person role, which may ultimately unsettle the patient’s support network. It will be important to monitor how these provisions are applied in practice, and to ensure that the process is not misused to remove legitimate advocates.

Government amendments 40 and 41, which would amend schedule 2, relate to the appointment of a nominated person for children and young people under the Bill. The amendments may appear technical on the surface, but they touch on something fundamental: how we recognise and uphold parental responsibility in the care and treatment of children detained under the Mental Health Act. The first amendment makes it clear that where no local authority holds parental responsibility and there are others who do—whether parents, guardians or specialist guardians—and who are willing to act, an approved mental health professional must appoint one of them as a nominated person. The second amendment is a consequential change to reflect the revised structure.

In effect, that removes any ambiguity around whether someone with parental responsibility can be passed over simply because a child arrangement order or special guardianship order is in place. It strengthens the voice of those who are legally, and often emotionally, central to the child’s life, and who in many cases will be best placed to advocate for their rights and best interests during a period of detention and treatment. I welcome the intention behind the amendment. It places proper weight on the legal significance of parental responsibility and avoids an overly discretionary or arbitrary approach to who gets appointed to this critical role.

I will be grateful if the Minister can clarify a point about the two amendments. Amendment 40 would narrow the discretion of the approved mental health professional—where multiple people have parental responsibility and are willing to act, one must be chosen—but in cases where there are safeguarding concerns, perhaps where family breakdown or allegations of harm are involved, what safeguards exist to ensure that the appointed person will act in the best interests of the child? We must, of course, protect children from being placed in the care of someone whose involvement might undermine their safety or wellbeing, even if that person holds responsibility in law. It would be helpful to hear whether the statutory guidance will support professionals in navigating such complexities. The success of this provision will rest not only on the strength of the law but on the clarity in practice.

Amendments 54 and 55, which also relate to the schedule, would require the nominated person for a patient under the age of 16 to have parental responsibility. The amendments aim to insert a clear statutory safeguard that only individuals who hold parental responsibility can be nominated to serve in the vital role for a child patient. This is a well-intentioned and important proposal and I want to engage with it in good faith, because it is not a trivial issue. It cuts to the heart of how we protect our children while also respecting their rights and agency, and diverse family situations.

The Bill already makes significant reforms to the nearest relative system, replacing it with a person-centred, flexible approach based on the idea of a nominated person chosen by a patient or appointed by an approved mental health professional. Under schedule 2, children under 16 can nominate a person to act on their behalf as long as that person is over 18. AMHPs may also appoint a nominated person when one is not nominated, using a hierarchy that considers parental responsibility but does not require it.

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

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

My hon. Friend has identified the nub of the issue, and his intervention leads me on to an example that demonstrates the problems that we are talking about. I have chosen to debate these provisions in the order shown on the selection list because I wish to understand whether the Minister believes that Government amendments 40 and 41 will deal some of the issues that I am about to raise. There clearly has to be flexibility in dealing with these situations, but it is worth exploring what could go wrong. The nub of the issue is that they may well go wrong. Let us take an example. Say that A is 16, and she is struggling with anxiety and behavioural issues. She has had serious suicidal episodes and previous drug use. She lives at home with her loving, supportive parents, who have always acted in her best interests and want to engage constructively with her care, but A is under pressure from a 19-year-old boyfriend. He is controlling, and discourages her from speaking to her parents or professionals. When asked to nominate a trusted adult, A names him. Under the Bill as drafted, the nominated person could be accepted, provided A is deemed to be competent. That would give her boyfriend access to her care decisions and significant legal standing. Under amendments 54 and 55, that would not be possible because he does not have parental responsibility, and therefore could not be appointed. That example illustrates why the amendments matter. Children, especially those in crisis, may be vulnerable to coercion, grooming, or misplaced trust. Loving parents, who have legal obligations to protect and care for their children in every other walk of life—as my hon. Friend the Member for Farnham and Bordon pointed out—could find themselves legally sidelined. Are there risks in amendments 54 and 55? We must consider the edge cases. Not all children under 16 live with those who are trusted and have parental responsibility. There are estranged families, kinship carers, informal fostering arrangements and situations of abuse. A strict parental responsibility requirement could exclude the very people relied on by a child. I ask the Minister whether there is flexibility in the amendments for exceptional cases in which someone without PR may be appropriate, with oversight. Do Government amendments 40 and 41 already address that point? Forgive me if I have misinterpreted, but they seem to be bridging amendments. Would guidance or a statutory code of practice provide a better mechanism to balance protection and flexibility? What assessment has been made of children in care or informal arrangements, where parental responsibility might technically lie with a local authority or estranged parent, especially under the changes proposed by Government amendments 40 and 41? There are potential routes forward. One option might be to require PR by default but allow exceptions if the child expresses a clear competence preference, the AMHP agrees that a person is suitable and poses no safeguard risks, and a senior commissioner or legal oversight has sign-off. That is a possible way of keeping amendments 54 and 55 alive, and it would keep within the spirit of the amendments by protecting children from harmful influence without removing their voice in complex or marginal cases. We could also explore adding an explicit safeguard power to override a child’s nomination where there is concern of coercion or abuse, regardless of parental responsibility status. Again, I think that may be what Government amendments 40 and 41 are trying to do, but I would be grateful to see whether that is the case.

10:45:00

This is a sensitive and difficult area, but it really matters. The proposed amendment raises a real and pressing concern that we must not let vulnerable children be led astray under the guise of autonomy. We must also ensure that we do not write out the agencies of those who have legitimate reasons not to trust those with responsibilities, so I look forward to hearing from the Minister.

Finally, and briefly, I would like to address Lib Dem amendment 49, which seeks to expand the duties of independent mental health advocates under section 130B of the Mental Health Act. This amendment would introduce two important additional responsibilities: to support the patient’s carer and family in preparing for discharge, and to support the patient in accessing help with social and financial stresses that might otherwise contribute to relapse or re-detention.

At its core, amendment 49 is clearly about prevention. We know that discharge is not an endpoint but a transition, and too often the transition is undermined by poverty, housing instability or overwhelmed family carers who receive little support. These added duties would help independent mental health advocates to bridge the gap between meeting clinical recovery and real-world stability. They also recognise that mental health is social, not just medical.

However, I invite the Lib Dem spokesperson, the hon. Member for Winchester, to answer some questions. First, will the role expansion be backed by additional resources or training for IMHAs, and if so, what is the proposed plan for that? Secondly, does this already cross the remits of, for example, care co-ordinators or social workers? How do we ensure clarity of roles in the multidisciplinary team? Could existing codes of practice simply be strengthened to reflect these aims without requiring legislative support? None the less, the Opposition are pleased to engage with the Government on this issue. We think that the clauses broadly go in the right direction in dealing with patient welfare. The question really revolves around ensuring that children are protected.

It is a pleasure to serve under your chairship, Sir Desmond. I rise to speak to clauses 24 to 28, and I will start by sharing the story of two of my constituents: Carol and her husband John. John had been an active member of the local community before he was sadly diagnosed with dementia. As his dementia progressed, John was settled into a good care home and Carol was happy with the care that he was receiving. Due to a change in his medication, Carol was told that John had become more agitated and aggressive than usual. She was asked whether she would agree to John being assessed. Although she did not really understand what that meant, she did not see any reason to refuse. From that point on, Carol says that she felt like she had lost control over her husband’s care. John was assessed by four strangers, and Carol was told that she could not be present. Following the assessment, Carol was told that John would need to be detained under the Mental Health Act within the next two weeks. Carol was very concerned to hear that John would be detained, but despite having power of attorney, she was not able to overrule that decision. She hoped that he would be able to get help with his medication and that he would be discharged. In the end, Carol had only half an hour’s notice that John was going to be detained. She rushed to the care home to see her husband, who had been sat in the garden having a cup of tea with some friends, being abruptly put into a van by two men and taken away. She was not allowed to come with him, and for the first time in her life, Carol had a panic attack. She could not imagine how traumatic it was for John, who was disorientated and confused because of his dementia, to be taken by people he did not know to a strange place. John was taken to a secure mental health ward that was very different from the familiar environment of his care home. Carol was told that she could not visit him, but she was insistent and turned up anyway. She was then allowed to meet his doctors on his first day and was reassured to hear that he would be detained for only two weeks while his medication was reviewed. In the end, John was detained for eight months. Carol continued to visit every day, spending as much time as possible with him. She had specially adapted her home to accommodate John’s needs, but she was not able to have him discharged to either his home or a care home. Precious time was taken up with the endless fight to get John into a more appropriate environment. Sadly, John’s health significantly declined while he was detained. He lost the ability to walk and speak, and Carol felt that, in his declining state, he could not pose any danger to himself or anyone else. However, it was only after he was admitted to hospital for a catheter fitting that Carol was able to get him discharged, thanks to a doctor telling her that she could use her power of attorney to take him home—something she was told she was unable to do in the mental health facility. She took him to a care home, where, sadly, he died two weeks later. John’s cause of death was listed as Parkinson’s, but Carol feels strongly that the anxiety and fear of his final months contributed to his death. Carol understood that her husband was dying; all she wanted was to be included in making decisions about his care. She knew very clearly what she wanted for him. She told me: “I wanted him to die in a bed with clean sheets, with a window open and with me by his side.” Those wishes were not taken into account. As John’s wife and carer, Carol spent every day with him, yet she felt excluded from the decision-making process for his care. She should have been able to focus on what was important: spending time with him. The changes in clauses 24 to 28 would have helped Carol to feel more involved in representing John during his time in care. Clearly, there were failures to allow Carol, as John’s nearest relative, the rights that she was entitled to in order to support him. With the move from “nearest relative” to “nominated person”, the new rights afforded by the Bill would have given Carol even greater engagement. Given that she had power of attorney, it is likely that she would have been appointed the nominated person by the AMHP. However, moving forward, it is important that those rights are properly afforded to the nominated person, so that we do not have another situation like John and Carol’s. Although I welcome and fully support the changes in clauses 24 to 28, I seek an assurance from the Minister that all efforts will be made to ensure that the rights of nominated persons are fully recognised and assigned, and that nominated persons will be made fully aware of their responsibilities and powers, allowing advocacy for the patient under care. I turn briefly to amendments 54 and 55 and Government amendments 40 and 41. I agree with the Government’s view that if a child has capacity, they should be able to have the choice to appoint their own nominated person. I appreciate the intent of the amendments from the hon. Member for Runnymede and Weybridge, but I think that the Government’s approach is more appropriate.

I appreciate that the hon. Gentleman sees the potential benefit in the amendments standing in the name of my hon. Friend the Member for Runnymede and Weybridge. However, my hon. Friend the Member for Hinckley and Bosworth gave an example, which I do not think is entirely distanced from reality or possibility, in which a person could well choose someone who is deeply inappropriate. In that situation, the person or people—that is, the parents—who had in every other part of life had responsibility for that child would now potentially not have responsibility for the child, in what is probably the most important part of that responsibility. Does the hon. Member for Southend West and Leigh really not have any concerns about that? If he does, does he not support at least the intentions behind those two amendments, if not the exact wording or drafting? If he does accept those intentions, would he like to see the Government table similar amendments, drafted in a way that he would find more appropriate?

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

Amendment 49 extends the support offered by mental health advocates to cover social and financial stresses and to family carers and other members of the household when the patient is discharged. Other hon. Members have today discussed how social and financial struggles can play a major role in someone’s mental ill health and in blocking their recovery, and how those are often the areas where someone can most benefit from advocacy and advice. As we are all aware, patients should not be viewed as a collection of symptoms, but within their whole context, including the situation they are living in. Addressing someone’s housing insecurity, debt or family breakdown should not be viewed as a separate consideration, but as a core part of supporting them to live happily, healthily and independently. Furthermore, family carers and the wider household are absolutely critical for people’s wellbeing and recovery, and should be properly equipped to prepare for their loved one returning from hospital. They, too, may need advocacy and may be missing out on support that they can and should receive. A good example comes from Winchester, where Winchester Citizens Advice has a member of staff—a former mental health nurse—based at Melbury Lodge in-patient mental health unit. Often, someone may be admitted for two, three or four months, and when they are discharged, they go home to all their life admin—there will be final demands for credit cards or requirements to repay personal independence payments and that type of thing. It is very overwhelming, particularly for those who already have fragile mental health, to have to sort out a whole backload of administration—especially financial and complicated administration. For two days a week, that staff member supports in-patients in sorting out all their administration from anything that needs to be done. What is interesting is that when these patients are discharged from Melbury Lodge in Winchester, if they have had that help, they end up being hospitalised and on medication for a shorter time. They are also more likely to engage with various support and community services once they have been discharged and are much less likely to be readmitted to hospital. For every £1 spent on that initiative, £14.08 is saved in cost avoidance. That initiative run by Melbury Lodge and Winchester Citizens Advice was up for an NHS award last year. It is a proven concept and something that should be done across the entire country. It has been running for two years and has proved how much money can be saved. Unfortunately, it was a pilot project and is struggling to secure money to continue indefinitely. I urge the Government to look at how that type of initiative could be rolled out around the whole country.

The hon. Member is making a very valid point that all patients need help with their finance and accommodation to keep them in the community and make discharge more appropriate. However, those provisions are already in place as part of the patient’s care plan. Different hospitals have different settings, such as a discharge or enablement team, or even the nurses on the ward itself can help and look into those provisions. Does the hon. Member think that that is the role for independent mental health advocates, who prioritise detention and the Mental Health Act, rather than the finance and accommodation issues, which need to be resolved by a different team?

I accept that point. It is a very sensible point. There has been a huge amount of discussion about what is in scope. Given that this is focused primarily on both current in-patients and preventing readmittance to an in-patient unit, I think it is within scope. I am aware that a lot of staff support patients, but it is not a core part of their role. It is something they squeeze in among all their other duties. When we have the expertise of someone at citizens advice, who knows how to navigate the huge complexity of various organisations and businesses that have to be dealt with, it is a lot more efficient. The figures speak for themselves.

11:00:00

I commend the team in Winchester and the citizens advice bureau for what they are doing, but the hon. Gentleman slightly undermines his case. He is arguing that, in legislation, we should expand the independent mental health advocates—

Order. We have strayed on to amendment 49, which is a separate debate. Can we come back to the amendments before us?

My apologies, Sir Desmond. I thought amendment 49 was included in the debate on clause 24.

I rise to speak to clauses 24 to 28 and the Government amendments to them. They cover an important and long overdue reform, which introduces a new statutory role: the nominated person, replacing the outdated concept of the nearest relative. I think, cross party, we all agree that this is about protecting some of the most vulnerable people in society and children. The clauses and amendments make important changes to the current Act, which too often forces an individual to rely on someone they may not trust or even have contact with, just because of their family relationship. As the Minister said, the White Paper found that the vast majority would choose their parents, but we must have legislation that reflects the diversity of society and families. Growing up in a single parent family, it would have been inappropriate for my other parent—who is one of my nearest relatives, but who I did not live with, know or particularly trust—to be my representative or make decisions on my treatment and care. In my upbringing, the people who knew me best were not always my closest blood relatives. The nominated person model gives individuals the right to decide who should speak for them when they are at their most vulnerable. That might seem like a small change, but it is a powerful one and aligns with the Bill’s overall goal of placing patient voices at the heart of mental healthcare. Having someone a person trusts—someone who knows them and can advocate for them—is vital. I was contacted by a constituent whose brother was sectioned and assessed at hospital as needing ongoing support in sheltered accommodation. His social worker challenged the decision and recommended private accommodation. That confusion, despite his sister continually challenging the recommendation, meant he was discharged, with nowhere to go, in the middle of the night. It is crucial that safeguards will remain. Where an individual cannot nominate someone themselves, a person can still be appointed on their behalf, but with far clearer guidelines and recourse if concerns arise. It is not about removing protection; it is about modernising it to reflect the society we represent. Mental health legislation must reflect the value and diversity of the society it serves, and the clauses and amendments before us bring us a step closer to that.

It is a pleasure to serve under your chairmanship, Sir Desmond. I rise to support amendments 54 and 55, tabled by my hon. Friend the Member for Runnymede and Weybridge, but I will first briefly speak to clause 24, which is an important and long-overdue step towards modernising the Mental Health Act 1983, crucially strengthening the rights, dignity and autonomy of individuals subject to it. The reform of the existing nearest relative provisions, replacing them with a new system that allows for the appointment of a nominated person, is an important part of ensuring that individuals get the right support, and modernises an outdated system. The current model is based on a rigid and outdated hierarchy in which the role of the “nearest relative” is determined by law, not by the wishes of the patient. This one-size-fits-all approach fails to account for the complexities and nuances of individual relationships. It can result in someone unsuitable, or even actively harmful, being placed in a central role in a person’s care and treatment journey. Indeed, the limitations of the system have been acknowledged by practitioners, patients and policymakers alike. It is too often disempowering, and the patient can lose agency at a time when they need to be empowered to feel in control of the situation as much as possible. As the shadow Minister says, clause 24 is the cornerstone of the reforms. It is an important change to the current legislation to reaffirm the commitment to patient-centred care, to dignity and to the principle that those receiving treatment under the Mental Health Act should have a voice in decisions about their support network. The aim of the clause—to put the patient first—is important. It acknowledges that the person best placed to advocate for the patient may not be their closest relative. In some cases, family dynamics are fraught. In others, the designated relative may hold views about treatment that conflict with the patient’s wishes or medical advice. We have seen real-world examples in which the imposition of the “nearest relative” role has led to tension, distress and, ultimately, a breakdown in trust. That is not the kind of environment in which recovery is fostered. Amendments 54 and 55 would address the specific issue of nominated persons and those with parental responsibility for children under the age of 16. It is important that we consider situations in which a young person may be in a vulnerable position and their decision on who their nominated person should be may not be in their best interests. We have a particular duty to ensure that children are safeguarded. Clause 24 as it stands will allow under-16s to choose someone who is not the parent to have significant power, including the ability to discharge the child from hospital. We must listen to and actively try to support any young person who needs that kind of intervention—it is not that their views should not be considered. However, there is a very real risk that a vulnerable child or teenager might be coerced by or under the control of an older partner, for example, as my hon. Friend the Member for Hinckley and Bosworth pointed out. Perhaps they might choose an older friend. We need to consider that a decision made by the nominated person, such as an older friend, may have implications for those with parental responsibility. For example, that older friend may decide to discharge a child from hospital and into the care of the parents, who would not provide advocacy or be part of that decision making. The Minister said that safeguards will be put in place, but can he expand on that? There are some real concerns here. Let us consider a situation in which there has been a decision by a court to determine which parent has responsibility for the child. If complex family issues have already been considered by the family court, it is right that the decision be followed. I respectfully ask the Minister to reconsider this point. We must respect the fact that parents of those under 16 are best placed to advocate for, support and act for their children. This is about capacity, consent and, ultimately, safeguarding.

My hon. Friend makes a powerful point. I remember the comments made by the hon. Member for Southend West and Leigh, who is chuntering from a sedentary position—I think he disagrees with my hon. Friend’s point. In his reply to my intervention, he made the point that there are situations in which things are the other way round, where those who have parental responsibility are not necessarily the appropriate persons. Does my hon. Friend agree that, on first principles, the parent should have parental responsibility in all areas of life, including the ones that she is talking about, unless there are specific reasons, such as the court decision to which she referred, that suggest that the parent is not the correct person to have responsibility? Surely, in the balance of danger or risk, there is a far greater risk if the nominated person is not a parent than if the nominated person is a parent.

My hon. Friend makes an important point. If parents are not acting in the best interests of their children, there is a wider safeguarding issue that needs to be considered. One would question why such parents had been left in a situation in which they have responsibility for their children and are potentially harming them. That leads me nicely to another point, which is that introducing the additional wording would bring mental health in line with physical health. For someone under the age of 16, it is their parents who have the responsibility to act in the best interests of their physical health; it seems to me that one would expect the same for mental health. I therefore urge the Committee to support amendments 54 and 55. Let me return briefly to the overarching aims of clause 24. I underscore the point that the wider principle at stake—patient autonomy—is one that I support. The ability to make informed choices about one’s care should be a central component of our care system. In mental health, where individuals can feel particularly vulnerable, that becomes even more essential. Granting patients the power to nominate someone who will advocate for them, advise them and represent their wishes is a powerful act of empowerment. Moreover, this change enhances safeguards for patients. It ensures that the person acting on their behalf is someone they have chosen and trust. It reduces the potential for conflict and opens the door to a more collaborative and compassionate model of care. If the Committee agrees to the amendments, which would provide the necessary safeguards for children, who I believe should be considered separately to adults, my overall view is that clause 24 represents a pragmatic, compassionate and patient-focused update to the Mental Health Act. It aligns with our modern understanding of mental healthcare and puts trust, respect and dignity at the heart of our legislative framework.

It is a pleasure to serve under your chairmanship, Sir Desmond. I am grateful for the opportunity to speak to amendments 54 and 55, which propose that where a nominated person is appointed to represent the interests of a patient under the age of 16, that individual must hold parental responsibility. At face value, that is a concise and apparently straightforward proposal. However, as with much in the Bill and in our mental health legislation more broadly, what appears simple can raise intricate legal and ethical questions. I therefore wish to probe both the merits and the challenges of these amendments. I do so not to come down firmly on one side of the argument or the other, but in the hope of assisting the Committee to think through the implications of the amendments. I hope to prompt the Minister to provide further clarification as our consideration of the Bill proceeds. I will start by setting out the case in favour of the amendments. There is an intuitive and, I would argue, legally grounded rationale behind amendment 54. It rests on the principle that serious decisions concerning a child’s mental health—decisions that might involve treatment without consent, or even deprivation of liberty—ought to be taken, or at least overseen, by somebody who already holds recognised legal responsibility for that child. Parental responsibility is not merely administrative. It carries statutory and common-law duties to protect, support and advocate for a child’s welfare. By requiring the nominated person to have such responsibilities, the amendment seeks to ensure a level of legal legitimacy and continuity. It would strengthen the position of those with a formal bond to the child and might help to guard against the risk of unsuitable or ill-informed individuals stepping in to play such a critical role. In that sense, amendment 54 reflects what many would see as good legal hygiene. It would bring new legislation into closer alignment with the Children Act 1989 and with broader child welfare practice. It would create a baseline expectation that only those with legal authority over a child should make, or help to make, decisions of such magnitude. It would also offer reassurances to families. For parents and guardians already concerned about the complex and sometimes opaque processes of mental health detention, the amendment offers a clear signal that their role cannot be set aside lightly. That reassurance may be particularly important when children are subject to long-term care or involuntary treatment. However, questions begin to surface at precisely that point, because although the principle appears sound, the practice is far from straightforward. It is therefore important that we probe both the advantages and disadvantages of the amendment.

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First, I ask the Minister how the Department envisages the requirement working in cases in which the child is not in the care of somebody with parental responsibility. That is not a hypothetical scenario. Many children, especially those receiving mental health treatment, are in informal care arrangements. Grandparents, older siblings or long-term foster carers may play a daily, dedicated role in the child’s life without holding formal parental status. Does the Minister consider that they would be automatically excluded under the amendment? If so, what provision would be made to prevent disruption to continuity of care, particularly where the child has built a strong relationship of trust with a non-parental caregiver?

Secondly, there are safeguarding contexts to consider. In some cases, the individual who holds parental responsibility may in fact be the person from whom the child needs protection. We know that mental health difficulties among children are disproportionately common among those who have suffered abuse or neglect. I ask the Minister whether the amendment would place an undue burden on professionals to override the default position in safeguarding cases. Would it potentially delay or complicate the appointment of a nominated person who is actually in the child’s best interests?

A third point concerns the voice of the child. Our legal system recognises, through the Gillick competence test, that some children under 16 have the capacity to make informed decisions about their care. In such cases, a child may express a clear preference for who should advocate on their behalf, and yet, under the amendment, that preference could be overridden—not because the individual is unsuitable necessarily, but because they lack legal parental status. I ask the Minister what assessment has been made as to how the amendment would interact with a Gillick competent child’s right to be heard. Would it remove a degree of autonomy from children who are, in law, capable of forming and expressing valid preferences?

Fourthly, there is the matter of delay. Parental responsibility is a formal legal status. Acquiring it where it does not already exist can take time, but the decisions covered by this legislation are often urgent. Would there be a mechanism to appoint an interim nominated person while legal responsibility is conferred, or would the process be held up in the meantime? From a service delivery point of view, that could introduce delay, confusion and fragmentation at precisely the moment when a child most needs stability and clarity.

Finally, there is the wider issue of proportionality. The amendment introduces a hard rule in an area that has previously been guided by principles and professional judgment. There is nothing inherently wrong with that. It provides statutory clarity, which has an important place, but it raises the question whether the amendment introduces rigidity where flexibility may be more appropriate.

I ask the Minister what assessment has been made of the number of cases in which this amendment would prevent the appointment of a trusted and competent adult without parental responsibility. Is there evidence that the existing framework has caused harm or confusion that justifies a statutory intervention? I pose none of these questions purely for the purposes of rhetoric. They are asked in good faith and in a spirit of constructive scrutiny, because the role of the nominated person is not a mere formality; it touches at the very heart of the legislation’s protective architecture.

If we get this right, we will strengthen the rights of the child, the role of families and the legitimacy of mental health interventions; if we get it wrong, we will risk introducing legal friction, professional uncertainty and, worse than that, barriers to the compassionate child-centred care that the Bill is supposed to guarantee. These amendments reflect an important concern to ensure that those representing children in mental health settings do so from a position of legal authority. That must be balanced against the diversity of family arrangements, the voice of the child and the need of practical workability.

I am minded to support the amendments, but I urge the Minister and all members of the Committee to reflect carefully on the questions that I have raised and consider whether the amendments, as currently framed, strike the right balance where legal formality and humane flexibility are required. If they do not, I encourage the Minister to set out how he can work with my hon. Friend the Member for Runnymede and Weybridge to ensure that the legislation reflects the complex issues he has raised.

We all want a robust system that protects children and supports those who care for them. The task before us is to ensure that the Bill advances those aims rather than inadvertently obstructing them. I make these remarks with the intention of being constructive. If the Government are minded not to support the amendments, I ask for some clarity on how they will work with my hon. Friend to reflect his genuine and heartfelt concerns.

Ordered, That the debate be now adjourned.—(Taiwo Owatemi.)

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