Mental Health Bill [ Lords ] (Fourth sitting)

Anna Dixon Excerpts

Committee stage
Thursday 12th June 2025 Public Bill Committees

[Anna Dixon (Shipley) (Lab)]

It is a pleasure to serve under your chairship, Mr Vickers. I will speak in support of the clause and Government amendment 30, and I may touch on the amendment moved by the Liberal Democrats.

As we all know, community treatment orders were introduced in 2007 under previous legislation, with good intent at the time. There was too often a problem with revolving doors into in-patient settings, in particular for patients with psychosis and schizophrenia. The intent behind the introduction of CTOs was to allow patients to be discharged into the community as long as they followed certain conditions, to provide ongoing contact with mental health services, and to provide support and help to prevent relapse. Under certain conditions, patients subject to CTOs could be recalled to a hospital under the Act. The provisions in the Bill are still in line with those underlying principles about the restrictions and the person as an individual.

The clause will amend the previous legislation, in particular to align the new risk criteria for detention, which we discussed in some detail under clause 5. It is important that there is consistency in the criteria for detention under a community treatment order, or indeed under detention in an in-patient setting. Again, that supports the need to use the orders only where serious harm may be caused to the health and safety of the patients or the person—the negative likelihood of harm, as we discussed with regard to similar amendments to a previous clause. There is wide support for the use of the criteria for detention as an in-patient as well as under the CTOs.

One of the concerns, as the hon. Member for Hinckley and Bosworth has discussed, is possible overuse and, in particular, disproportionate use in relation to race and ethnicity. Black people are seven times more likely to be placed on a community treatment order compared with white people. The Committee has received extensive evidence highlighting those racial disparities and the injustice not only in the application of CTOs, as the hon. Member pointed out—we will come to racial disparities in due course—but in the disproportionate use of CTOs to provide supervision in the community.

The evidence from the Centre for Mental Health concerned the interprofessional variation among psychiatrists. Practice can vary even within the same area, so it is not just inter-area variation. That suggests a potential lack of a standardised application of the use of CTOs in some cases, which is perhaps slightly more subjective. The use of the clear criteria, therefore, along with the code of practice, will, I hope, certainly help to address the racial disparity as well as the unwarranted interprofessional variation in the use of CTOs that we see in practice.

It is important that we consider the fact that people may be on a CTO longer than necessary, from the point of view of therapeutic benefit or, indeed, of the risk criteria. I commend the intent behind the amendment that was made in the other place, but there is a clear challenge in putting statutory limitations on the use of CTOs. We should allow clinical best practice, treat the person as an individual and apply the updated criteria in the Bill, recognising those individual cases.

[Dr Evans]

The hon. Lady is making an excellent speech and an excellent observation, and she clearly understands the rationale for the amendment. I just wonder, given that the use of a CTO is currently a clinical decision, why we find ourselves facing this problem in the first place. Ensuring a review and putting it on a statutory footing would hopefully stop that, because despite clinicians’ best intentions, more of these have been rolled on. This provision is simply a mechanism to try to stop that. What are her thoughts about how to make sure that that is the case?

[Anna Dixon]

There is a big difference, because when we address clinical variation we usually do so through clinical guidelines, clinical best practice, training and many other non-statutory levers, which are much more effective at driving out unwarranted variation. They also include feeding back data; the hon. Gentleman talked about data and encouraging NHS trusts and organisations to ensure transparency about which psychiatrists are overusing CTOs. That feeding back of data can be much more effective at driving out unwarranted variation, although that is not to say that we accept that there are people who are potentially on long CTOs that go through renewal.

The other point is that there are other mechanisms, as the hon. Gentleman acknowledged, such as the tribunals. Those review points need to be as effective as possible at ensuring that people are not unnecessarily being kept under community supervision when that is no longer necessary.

I will be seeking assurances from the Minister about what will be in the code of practice to ensure that any statutory time limit is really just a backstop that maximises the ability of clinicians to have some discretion, while using these other methods to ensure good practice, consistency in decision making and reductions, certainly in racial disparities, and as an urgent matter, but also in some of the intra-professional variation that is not necessarily connected with racial discrimination. In that sense, I will support Government amendment 30 as long as the Minister gives a reassurance that we do not accept either the racial disparities in use or some of the lengthy uses, and that he is confident that the provisions in the code of practice will start moving us away from the current situation with the use of CTOs.

The hon. Member for Hinckley and Bosworth made some interesting points about research and evaluation. Having been the chief analyst in the Department of Health and Social Care, I am well versed in this. Obviously we have a generous settlement for all the research and innovation. The National Institute for Health and Care Research is world-renowned for the research that it commissions. There is clearly quite a disparity in the views that this Committee has heard, with the likes of Mind perhaps at one end in saying that the only solution is to get rid of CTOs. I think the majority of us here see a role for them, but only if used in the right way.

In addition to the ongoing data collection and feedback to clinicians, which it was suggested the Minister might want to take away and consider with the NHS, the Department and NHS England—while perhaps also talking to NIHR about the research and evaluation in this area, as well as the research gaps that could inform future implementation of CTOs and help to underpin best practice—we might consider looking into such matters as what is driving the racial inequalities and interprofessional variation, so that we can ensure that future policymakers and legislators like ourselves are better informed and can make more evidence-based policy decisions.

I am close to concluding, but I would like to touch briefly on Liberal Democrat amendment 11. Mental health advocacy is clearly critical, particularly for those who lack capacity as well as those who are compulsorily detained in an in-patient setting. I hope and expect that with the use of CTOs as a method of discharge, the relationship with advocacy they may have accessed in the in-patient setting would continue in the community. I acknowledge the spirit behind the amendment and hope to hear the Minister respond on how we will ensure that all those with complex mental health issues—particularly those who lack capacity and are detained in an in-patient setting—will have access to appropriate advocacy.

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

I rise briefly to dilate on clause 6, on Liberal Democrat amendment 11 and on Government amendment 30. Those of us on the Health and Social Care Committee recently had a fascinating panel about the disparities for black and minority ethnic groups in maternity, and it does not end there, as we can see from the evidence raised by my hon. Friend the Member for Hinckley and Bosworth and by the hon. Member for Shipley.

When CTOs were introduced—for good reasons—the elements of controversy that hon. Members have raised were not predicted. The overuse of CTOs, especially among black and minority ethnic patients, should give us all concern, although I have to say that there is some limited evidence of effectiveness in reducing relapse or readmission. Will the Minister give us the Government’s view on that and how they might seek improvement going forward?

What we are trying to achieve in the clause is to bring legislation in line with the 2018 independent review of the Mental Health Act, which recommended tightening the use of CTOs, or indeed abolishing them altogether for some groups. I support the clause because it brings in stronger safeguards, a clearer commitment and time limits to reduce the risk of indefinite or inappropriate use. It also improves patient involvement, because it requires a consultation and review, promoting shared decision-making, and increases accountability because it aligns with the code of practice and introduces external oversight. It focuses on the reality, ensuring that CTOs are used only where truly needed.

I am slightly concerned about Government amendment 30, which will remove the detailed provision that would have introduced new statutory limits and review procedures for community treatment orders, specifically under subsection (3), and inserted new subsections (8) to (11) into section 17B of the Mental Health Act. The implication of removing subsection (3) is that essentially we will maintain the current legal framework, which does not impose a fixed maximum duration or the same level of structured review currently written into the clause. I am afraid that that would not bring in the safeguards and oversight mechanisms that would, at least to some degree, start to tackle the problems that hon. Members on both sides of the Committee have been talking about. It may be seen as taking a step back from what campaigners and professionals who are advocating for stronger patient rights and accountability on the use of CTOs would like to see.

I ask the Minister for the same reassurances that the hon. Member for Shipley asked for in this area. If the Government are to move Government amendment 30 successfully, we will need to see how they intend to deal with these issues going forward.

Liberal Democrat amendment 11 would ensure that people subject to a CTO receive information about their right to advocacy. That is an entirely laudable aim, but I ask Liberal Democrat Members to answer a few questions. First, how do they see the administrative burden on clinicians to ensure that both oral and written communications are documented? Secondly, what additional training do they think those professionals might need to ensure that the information is both consistent and correct? Thirdly, might there be delays in issuing a CTO if, for some reason, advocacy information is not immediately available?

[The Minister for Care (Stephen Kinnock)]

It is a pleasure to serve under your chairship, Mr Vickers.

I turn to amendment 11, tabled by the hon. Member for Winchester. Under the Bill, English qualifying patients subject to the Mental Health Act 1983, including those on a community treatment order, will be covered by a new opt-out approach to advocacy. That means that the relevant hospital manager must provide the advocacy provider with information about the patient so that they can arrange for an advocate to interview them to determine whether they wish to use advocacy services. Requiring oral and written information about their right to an advocate would therefore be unnecessary. I hope that that is satisfactory, and I encourage the hon. Member for Guildford to withdraw the amendment.

Government amendment 30 would remove clause 6(3) from the Bill on the basis that it is unnecessary. The requirement in section 118(2D) of the Mental Health Act for decision makers to have regard to the code of practice already ensures that they must take it into account when making decisions in relation to community treatment orders. Imposing a maximum duration of 12 months on community treatment orders, with the option to renew them after a review every six months, is also unnecessary. That is because the Bill already requires community treatment orders to be reviewed before renewal after the initial six months, again after the next six months and then yearly. The responsible clinician can renew the CTO only if there is a risk of serious harm without it and a reasonable prospect of it having therapeutic benefit for the patient.

The Bill increases professional oversight by requiring the community clinician to be involved in all decision making relating to CTOs. That aligns with Lord Scriven’s amendment, but, rather than that person being a General Medical Council-registered psychiatrist, it is more appropriate that they be an approved clinician, meaning that they have specific training regarding the Mental Health Act and approval to make decisions under the Act.

We have also increased the frequency of tribunal reviews so that they will happen automatically at renewal periods following the initial six-month period, after a further six months and after any subsequent 12-month periods. We are already providing a new power for the tribunal to recommend that the responsible clinician reconsider whether a CTO condition is necessary. Clause 6(3) would duplicate that.

[Anna Dixon]

I am grateful to the Minister for outlining so clearly what safeguards will be in place to ensure that there are no unnecessary extensions to CTOs beyond the period during which the patient is benefiting therapeutically or meets the detention criteria, which are being updated by the Bill. The answers that the Minister has given assure me that there will be significant review points. Does he, like me, think that these provisions will, in time, reduce some of the unwarranted variation and some of the excessive lengths? As the Bill is implemented in practice, we will see changes in the pattern of use of CTOs.

[Stephen Kinnock]

I pay tribute to my hon. Friend for her expertise and am pleased to hear that she feels reassured by my remarks. It is absolutely the Government’s ambition to bring more consistency and clarity to this area. A number of hon. Members have raised issues around racial disparities; I plan to come on to that. That is a specific focus, I know, for her and other colleagues. More broadly, this is about ensuring that the CTO system is proportionate, well regulated and managed on the basis of a patient-centric system.

We therefore wish to remove clause 6(3), as we do not think that it is necessary. It duplicates some provisions in the Bill or, in the case of the review periods, conflicts with existing renewal periods, and under the current drafting it is not clear how the two would interact. Where there are differences, the current provisions are more appropriate, for example in requiring a community clinician to be involved in all decision making.

Let me move on to clause 6 in its entirety. CTOs allow individuals detained under the Mental Health Act to be discharged into the community, under specific conditions, to ensure continued treatment. CTOs aim to maintain contact with mental health services to provide support and prevent relapse. Patients on CTOs can be recalled to hospital under that Act in certain circumstances. The main purpose of introducing CTOs was to improve care for higher-risk patients and to enhance public safety. We believe that community treatment orders remain necessary in a small number of cases to ensure continued treatment and to protect both patients and the public.

However, the independent review rightly noted that considerably more people than expected were being put on a community treatment order—about 5,500 people a year—and that there were racial disparities in the use of CTOs. Clause 6 therefore amends the community treatment order risk criteria in line with the new detention criteria set out in clause 5. It is now the case that, to be put on a community treatment order, the patient must be at risk of serious harm and there must be a reasonable prospect of therapeutic benefit for the patient.

--- Later in debate ---

[Jen Craft]

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

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

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

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

[Anna Dixon]

I commend my hon. Friend for her honest account of her personal experiences and thank her for bringing that experience into our discussion of the Bill. It is absolutely right that the welfare and wellbeing of individuals who are living their lives, at such distressing times as when they need mental health support, should be at the heart of the Bill. I want to acknowledge her contribution to the debate.

[Jen Craft]

I thank my hon. Friend for her kind words.

That concludes what I was trying to get at: the importance of a clause in the Bill that is focused on patient experience. Understanding and acknowledging the sheer importance of that person’s experiences, and the value that brings to their care plan, cannot be overestimated. I hope that members of the Committee will support the clause, because it represents quite a sea change in how people subject to treatment under the Mental Health Act are treated.

--- Later in debate ---

[Zöe Franklin]

I thank the hon. Gentleman for that interjection, and I thank the Committee for considering these amendments. I hope the Government will either consider agreeing to them or give me an overview of how they will already be addressed in the detail of the Bill.

[Anna Dixon]

It is an honour to speak again in the Committee’s debates on the Bill. I really welcome clause 21, in that it introduces care and treatment plans, as well as a statutory requirement that all those patients formerly detained under the Act should have such a plan, apart from those who were only on short detention. It also brings England in line with Wales.

The clause fits with the fundamental purpose of the NHS. One of the founding principles in the NHS constitution is:

“The patient will be at the heart of everything”.

The constitution states:

“NHS services must reflect, and should be co-ordinated around and tailored to, the needs and preferences of patients, their families and their carers.”

It goes on to say:

“Patients, with their families and carers, where appropriate, will be involved in and consulted on all decisions about their care and treatment.”

Even though freedoms have, in a way, been taken from people through detention under the Act, it is so important that such detention should not remove all their choice, autonomy and ability to express preferences, whether that is simply over things in daily life, such as when they wake up, get up or go to bed. It is about making it really clear that patients can continue to express preferences and make choices over things that may give them a better quality of life, even while they are detained.

[Dr Evans]

The hon. Lady makes an excellent point. This is especially relevant when capacity fluctuates in some patients, which we expect to see more often with the kind of dementia that will potentially come forward —for example, some of the new illicit drugs that are available can cause significant problems. Does she agree that having that flexibility is key? That is why the clause will help to ensure that the patient is empowered at all those different moments, and that there is a robust statutory framework to hold them to account. We do not want them to slip through the net, because if they do, by definition, not having these treatment plans up to date and in place may lead them to other parts of the Act, and we are trying to avoid that in the first place. That is the problem with having CTOs, or the concern that she mentioned in our sitting this morning, which has also been raised by charities. Does she agree?

[Anna Dixon]

I agree that it is really important to put it on a statutory footing. Obviously, other provisions such as subsection (5) of proposed new section 130ZA will ensure that it is regularly reviewed. There is no point in having such a plan if it is not regularly updated to ensure that it reflects trigger points, which the hon. Member for Guildford raised. When circumstances change for the patient, that is obviously an important point at which to reconsider their care and treatment.

I want to go back to the Wessely review. The clause is such a fundamental part of realising all four of its principles. If I may, I will briefly read from the review:

“We must improve choice and decision making, both prior to and within a setting of compulsion…We believe that improving patients’ and service users’ ability to make decisions about their own care and treatment is essential to upholding dignity.”

The report recommended that where a patient has capacity, the care and treatment plan should record their wishes and preferences, whether expressed at the time or in an advance choice document.