New legislative programme in King's Speech

In Lade’s July blog, she reflects on the contents of the King’s Speech, the implications for psychiatry, and the College’s response.

It’s been a busy past month. Since our International Congress in Edinburgh, we have a new Government and Cabinet. Congratulations to the new Prime Minister – Sir Keir Starmer.

But also, a new Secretary of State for Health and Social Care, Wes Streeting and a new Mental Health Minister, Baroness Gillian Merron, whom I’m pleased to say has already made time to speak with me.

Last week we heard the first King’s speech under a new Labour Government, within which a list of 40 key policy Bills set to become law, were announced, some of which will extend and apply UK wide, others will be applicable to England and Wales only.

The inclusion in the speech that the newly formed Government will update the Mental Health Act (MHA) in England and Wales, is long overdue. This follows efforts already underway in Wales to modernise the legislative framework through the Mental Health Standards of Care (Wales) Bill, which is set to be introduced into the Senedd later this year.

These reforms are taking place separately to reforms of mental health legislation in Scotland and Northern Ireland.

The previous Government already began work on this, publishing a Draft Mental Health Bill¹ for England and Wales in June 2022. A Joint Committee on the draft Bill was appointed and published its final report in January 2023, and before the general election in March this year the Conservative Government issued its response to this rigorous report².

There was disappointment that the Government response dismissed the vast majority of the Joint Committee’s thoughtful and constructive recommendations. There remain concerns that the proposed changes will mean people with a learning disability and/or autism can never be detained under Part II of the MHA (civil section), because this risks them being more likely to enter the Criminal Justice System. I was particularly dismayed that the last Government chose to dismiss the recommendation to legislate for Advance Choice Documents (ACD), the only intervention that is evidenced to reduce compulsory detention.

The new Government should not repeat this mistake and must look again more closely at the Joint Committee’s recommendations, as well as the expert findings of the Wessely Review so that the updating of the Mental Health Act is truly fit for the 21^st century - something that works for patients and for mental health staff.

Putting race equity at the heart of the updated Act is a priority, and it was one of the main reasons Theresa May commissioned the Wessely Review.

There is stark inequality in mental healthcare, particularly for those from minoritised ethnic populations. We know that Black people are three and a half times more likely than White people to be detained under the Mental Health Act, and when they are detained, 40% of Black people are admitted to hospital in crisis via Emergency Departments or the police, having been unwell for some time. Despite this, like South Asian people from Pakistani and Bangladeshi backgrounds, they are grossly under-represented in outpatient care, such as NHS Talking Therapies, and even psychological services for people with severe mental illness. Essentially, they are far less likely to access and receive care from mental health services at an earlier stage in their illness.

The Wessely Review recommendations suggest ways that this disparity can be addressed, for example using an equity delivery system such as the Patient and Carer Race Equality Framework (PCREF), which is currently being piloted in four sites across England.

As set out in the Joint Committee’s recommendations, all health organisations should be required to appoint a responsible person to collect and publish data on, and oversee policies to address, racial and ethnic inequalities. This is because the initial step in driving real, meaningful and long-lasting change, is to recognise that the disparity exists in the first place and then leaders taking accountability for it.

A statutory right to culturally appropriate advocacy may be useful in facilitating people’s access to care and treatment. Culturally appropriate advocacy pilots are currently underway, the new government must use the learning from these pilots and fund further development, if they are successful.

A new updated Mental Health Act has the potential to provide more choice and autonomy for patients, whilst increasing the opportunity for the development of therapeutic relationships, something the majority of clinicians have been calling for. Having a statutory right to make an ACD, covering care and treatment, introduces a framework which encourages clinicians to get to know their patients better and requires services to allow clinicians to do this. This is potentially one of the most impactful reforms as it is the only measure known to reduce detentions. In addition, it has been shown to be cost effective, particularly for Black people³.

Another key priority for the updated Mental Health Act should be the inclusion of a Mental Health Commissioner for England to help drive the ongoing process of reform. This will also ensure accountability for implementation – in particular a requirement of commissioners to commission services that facilitate the delivery of the new reforms.

Mental health services will need to be properly staffed and resourced if they are to implement these reforms quickly and effectively. Ultimately, the use of detention should always be a last resort and people with severe mental illness should be able to access support before they reach crisis.

Though I’m sure you’ll all agree that it would be good to see Government make reforming the Mental Health Act a priority, this should not be undertaken with undue haste, as this could result in unintended consequences and the waste of much of the great work done across the sector.

The new Government are keen to push ahead with the MHA legislation in England and Wales. However, a small period of reflection should be undertaken to see what further changes could be made to the Draft Bill to improve it – primarily based on the work led by our past President, Sir Simon Wessely, along with our members who were part of the Wessley Review and Joint Committee.

This is an historic time for mental health and an historic time for psychiatrists. However, there is little time, so this means we have much work to do to influence and shape the Bill so that it works for patients, works for clinicians and is fit for now and fit for the future.

References

1. Draft Mental Health Bill 2022 - GOV.UK
2. Government response to the Joint Committee on the draft Mental Health Bill - GOV.UK
3.  Barrett B, Waheed W, Farrelly S et al. Randomised controlled trial of joint crisis plans to reduce compulsory treatment for people with psychosis: economic outcomes. PloS One. 2013, 8(11), e74210