Debate on Amendment 43 resumed.

My Lords, I will speak to my Amendment 44 in this group. Having listened at Second Reading, I was minded to table this amendment based on my noble friend Lady Parminter’s speech giving her real-life experience of the need for community treatment orders. Both the amendments and the Second Reading debate show the wide range of views on community treatment orders, ranging from some who feel they are not needed to those who feel that they are needed and those who feel a review is needed. However, something in the present system is not quite right, so, again, this is a probing amendment to try to understand where the Government’s thinking is.

Given that, even if a review were to take place, CTOs would still exist, my amendment would in principle provide an initial 12-month period for a community treatment order with some very clear provisions. If we are going to have these provisions, they need to be on the face of the Bill rather than in the code of practice—even if they are not the provisions in my amendment. I suggest that the initial order is for 12 months and that, before the order is made, the patient has to be consulted, as well as

“the patient’s nominated persons, and any relevant mental health care professional involved in the patient’s treatment or care planning”.

Importantly, the CTO has to be in line with the necessity for therapeutic benefit, and it has to involve consulting a second medical professional. I understand that the wording of the amendment may not be correct, because a particular type of medical professional, a psychiatrist, would need to be consulted with regards to the community treatment order and whether it will have therapeutic benefit.

I suggest that, at the end of the 12 months, if the clinician feels that an extension is needed, a review takes place, which goes through the process that I have just outlined—to ensure that there is therapeutic benefit, and a second medical practitioner is consulted—and that it is then reviewed after a maximum of six months. That is absolutely right in terms of trying to ensure that the therapeutic benefit is central and a second medical opinion is provided, particularly at the review stage, to ensure that there is a need for the CTO. The reason for this is the wide range of views on CTOs but also the statistics regarding the racial discrimination that there appears to be around their use, which is well documented and well evidenced.

I look forward to the Minister trying to explain the Government’s thinking on community treatment orders and how they need to change. Clearly, something is not quite right in the implementation, the length of time that people are on CTOs and whether CTOs have therapeutic benefit for many of those who are on them.

My Lords, I will speak to my Amendments 67 and 86. I think that this is the right place—I apologise for my earlier confusion; I had a problem with the list.

I will start with Amendment 86 because it follows on from the very important contribution from the noble Lord, Lord Scriven. I should preface this by saying that I cannot claim that what I will say originates from me; it is based on the Law Society briefing, which many noble Lords will have received. I saw that nobody else had picked up this amendment, but I thought that it was so important that it should be picked up. As the explanatory statement says:

“The amendment would keep the safeguard of an automatic referral to the tribunal when a patient’s Community Treatment Order is revoked which results in them being detained in a mental health hospital”.

As the noble Lord, Lord Scriven, said, a range of views on CTOs has been expressed in these debates, but the general direction of travel is certainly not to remove safeguards and we should be keeping the safeguards that already apply. I will not claim great expertise on this, but it seemed to me that this is an important issue that we need to discuss in Committee.

Amendment 67 is somewhat different but really important. Later on, we will discuss very important issues, which I have signed amendments about, concerning minoritised communities being potentially overtargeted or subjected more to mental health provisions. This amendment picks up something that no one else has picked up, which is economic and social disparities relating to community treatment orders. I went looking for some statistics on CTOs in disadvantaged communities, but I was not able to split them out; perhaps the Minister has them. However, the charity Rethink Mental Illness talks about the burning injustice of how Mental Health Act detention rates are three and a half times higher in the most deprived areas of England compared with the least deprived. Looking at those figures, I can only see that CTOs must be something very similar to that.

We need to ask a question here, and we need the stats and that is why we should have the reporting. It is probably unclear whether we have a psychiatrisation of poverty, so that when people are living in conditions of poverty, that is seen as some form of mental illness in itself, or a discriminatory application of the law against people living in conditions of poverty. The third possibility is that poverty is making people ill. Either way, we should know about these facts. They should be regularly reported, and we should be able to examine them and check on them.

I was just looking at an issue that will be raised later about debt and mental health, on which I will point noble Lords who have not seen it to a really interesting POSTnote that the Parliamentary Office of Science and Technology produced on that subject last year. It suggests a two-way relationship between financial and mental well-being. People with mental health issues are three or more times more likely to have problem debt.

Some interesting recent research in a study published in Public Health indicates how social conditions are related to mental health. “Sandwich carers” in the UK —the 1.3 million people who have responsibility for caring for children and older parents—have experienced a significant decline in mental health.

These issues around social and economic disparities and the use of community treatment orders are embedded in the community, and it is crucial to see what is happening. Amendment 67 aims to ensure that we get regular reports relating to community treatment orders.

My Lords, I wanted to speak to this group because I made some harsh criticisms, on principle, of community treatment orders at Second Reading concerning their coercive and intrusive nature. Since then, perhaps similarly to the noble Lord, Lord Scriven, I have had cause to think again, not least after speaking to a number of working psychiatrists and taking on board the comments of the noble Baroness, Lady Parminter, at Second Reading, which really had an impact on me. It is quite unusual to change one’s mind in this place—maybe it is just me—so I wanted to note that.

I was reminded of this issue by practitioners—I was once one of those—when they said, “We worry about how many idealistic discussions about mental illness just do not take into account the reality of chronic mental illness”; I thought that was a fair reprimand. There are a group of people who are chronically symptomatic, perhaps some of them may never be well, and CTOs are a way to allow people to leave hospital who otherwise clinicians might worry would be too risky to release.

I have been thinking about this issue and in that sense was happy to see and support Amendment 44 in the name of the noble Lord, Lord Scriven, which sets out time limits. It is useful to think about probing time limits, renewal safeguards and so on, because one does not want automatic continuation and therefore indefinite CTOs on the books, which is what people are concerned about.

I would have been more enthusiastic about Amendment 66, put forward by the noble Lord, Lord Kamall, and the noble Earl, Lord Howe, which calls for a statutory review of CTO use, but the wording implies that CTOs are problematic per se. Perhaps we need a more open-ended review, because one of the reasons why CTOs are so contentious for so many people is their spiralling and increasing use, and we need to understand why that is.

One worry I have about the Bill in general, and not just this group of amendments, is that, because the drivers of the legislation are concerns about inappropriate hospital admissions and wanting to ensure that we have proportionate detention powers which are used only as a last resort, we need to be wary of demonising hospital care and recognise how much good can be done for mentally distressed patients in hospitals, particularly if they are given time and resources and the right kind of medical Intervention. But, as with all hospital matters, that is not necessarily what is happening. Many psychiatric wards are under pressure to get people out into the community as soon as possible—in the sense not of them being well, but of freeing up hospital beds. One might wonder whether the CTOs are a mechanism for effectively turfing patients out before they are ready or well enough.

It also seems that CTOs are necessary when community care is under huge strain, because the idea of voluntarily accessing a wide variety of support in the community is a myth in today’s circumstances. All the briefings we have been sent draw attention to this. A range of groups and people have argued—and a number of noble Lords have said this today—that we need more resources, money and staff for appropriate care in the community to really work. That sounds reasonable, but I am concerned that this will miss the target. I want to reiterate the elephant in the room that I mentioned at Second Reading, which I have not changed my mind about: culturally, we are seeing the medicalisation of more and more problems of the human condition. This encourages ever greater numbers of people to view social, economic, educational and personal difficulties through the prism of mental health.

The problem the Bill will have if we do not tackle the new culture that is eroding the distinction between those who require expert intervention and those simply experiencing normal, if unpleasant, emotions or experiences, is that this is reducing time and resources for those who clinically require external help. That cultural climate is sadly leading to a diagnostic free-for-all, an issue I will return to later in Committee. That in turn is stretching community resources so thinly that CTOs become, in some instances, the only guarantee that those who have been ill enough to be hospitalised can access proper community help.

We cannot just propose throwing resources at the problem. We need to know that those resources will be accessed by those who need them, not just those who have acquired a “mental health” label. More and more people are saying this. Noble Lords will have noticed that Tony Blair said something on the issue. It has been commented on recently in terms of the number of people on sickness benefits, the impact on productivity and the mental health crisis. An article in the British Medical Journal made the case against this therapeutic imperative very well, and it is important that we bear this in mind, or the Bill will not succeed in doing what it needs to do:

“There is a down-side to viewing emotional distress in terms of mental disorder. It expands the potential demand for services such as counselling and mental health services at a time when demand seems already to exceed supply. We may be raising expectations that cannot be met. In addition, the belief that one is in some sense mentally disordered might lead to the assumption that some form of expert help is required, and hence undermine the roles of active coping and non-professional support.”

I hope that, as we move forward, we can also tackle the problem of an overinflated sense of the mental health crisis leading to the danger of neglecting the real mental health crisis.

My Lords, I support Amendments 44 and 66. The Joint Committee on which I serve recommended that community treatment orders be abolished for Part II patients. That recommendation is supported by organisations such as Mind. That is partly due to the awful racial disparity statistics—you are up to 11 times more likely to be under a CTO if you are from a black or Caribbean background—combined with a lack of evidence that CTOs reduce hospital admissions. It took a brave gulp, even as the Joint Committee, to recommend that. The independent review had not gone as far as that, but it was in the report of the Joint Committee.

I, too, like the noble Baroness, Lady Fox, recognise the powerful speech of the noble Baroness, Lady Parminter, at Second Reading. I remember that, because of the extremely tight timetable the Joint Committee was given, it did not have time to consider in detail eating disorders or personality disorders, which was regrettable.

I can see from the reasons the noble Baroness outlined that there may be a case for retaining CTOs, perhaps even just for eating disorders. To quote her words from Second Reading, a CTO

“puts a boundary around the eating disorder … that a voluntary agreement could not, in that it makes it clear what will be the result

The Bill outlines protocols for specific treatments, such as ECT, so it seems possible in principle to have the law apply to specific disorders.

Most reluctantly, I have not made an Amendment in Committee in support of the Joint Committee’s recommendation. But the independent review stated that “action is required”. We must not lose sight of that urgency. There are significant problems with CTOs. The argument that is proffered—that they help and are the least restrictive measure for a very small number of patients—is not a good basis for retaining them, bearing in mind the enormous harm they are doing on the other side. I ask the Minister to look for another way, going forward, to help this small group, and not to ask racialised communities to, once again, pay such a high cost for such a small group of patients.

In the Joint Committee’s report, it seemed that the group of patients we were talking about were unrestricted patients under Part III of the Act. Bearing in mind that 79% of CTOs are under Part II, which is for civilian patients, can we look in detail at the evidence to find out which small group of patients we are talking about? There are particular issues, according to our report, if a restraint or restriction is being used on people when the small group of patients seems to be within the forensic context rather than under Part II.

I ask the Minister to put CTOs where they need to be, as a result of these amendments. The independent review said that they should be in the last chance saloon. We must be careful not to lose the urgency that the independent review gave to these issues. Although I support Amendment 66, tabled by my noble friends, it is the very least we can do. The restrictions outlined in Amendment 44 are about ending them after a certain period, because part of the problem is that they go on and on, rolling over for years and years. That coercive effect on certain communities seems to remain, as the path of least resistance.

My Lords, I want to say a few things about a couple of the amendments. I thank noble Lords for listening and for recognising the situation. It was powerful to hear that, and I am sure that many in the eating disorder community will be delighted to hear it.

I will not repeat what I said at Second Reading, as there seems no need, but in mentioning that, I want to support the Amendment tabled by the noble Baroness, Lady Browning, which picks out the focus on community care and the need for more psychiatrists. I and others have made the case for why CTOs can be valuable for people with eating disorders—and for forensic patients, I understand. The value of the CTO is that the individual is helped to engage in the community with their mental health team. It is a multidisciplinary team, but the anchor is the psychiatrist. The noble Baroness was not sure if this was the right place to put her amendment because it has wider ramifications, but it certainly has value in this debate. CTOs, which I believe should be retained, can work only if there are proper multi-disciplinary teams anchored by a psychiatrist in the community, so that those individuals can be kept out of detained settings and engaged in the community. I thank her for bringing that forward, and I support it.

With regard to Amendment 44, I do not support a maximum duration for a community treatment order, because this is about the individual and what they decide, with their multidisciplinary team. What I like about the amendment tabled by the noble Lord, Lord Scriven, is that it rightly says that we have to review community treatment orders. People’s mental health situations change, and it is important to have step points at which people know they will be reviewed. I do not support a maximum time limit but the break points, which his probing amendment talks about, are worthy of further debate and discussion. I am grateful to him for bringing that forward.

I say with regret that I do not agree so much with the support of the noble Baroness, Lady Bennett, for retaining the automatic referral to a tribunal of any CTO that is lifted. Again, that goes against my sense that CTOs are about what is right for the individual. With eating disorders, there will be cases of CTOs being lifted because the person is no longer able to engage with the community team because the eating order has gone beyond the bounds of the CTO and is compromising their health and putting them, bluntly, at risk of death. I do not see why, in those circumstances, there needs to be an automatic referral to a tribunal. Strengthening people’s rights to go to a tribunal where there is a case for that is right and proper, but, because of my view about personalised care—especially for eating disorders, but this has wider ramifications—I do not support the case for automatic referral.

I know that there are people around the Committee who understand the concerns far better than me, particularly about the high preponderance of people in the black community who are on CTOs. I understand and hear that concern. I tried to get to the bottom of the figures, like the noble Baroness, Lady Bennett, to find out how many forensic patients were on CTOs. Given that you are four times more likely to be in prison if you are a black person than a white person, I tried to work out what the figures were to get the correlation to say whether it is because there are more people in prison that CTOs are preponderantly in the black community. I could not work that out. Equally, I could not work out how many people with eating disorders were on CTOs. I got the Library to try to help me, and it said that the figures are not cut that way and do not work that way. It seems to me that there is an issue about the data that we, and the Minister, are working with to make informed decisions.

I am not sure about the exact terms and conditions of the review that has been proposed by the noble Lord, Lord Kamall, and which in a later group is proposed by the noble Baroness, Lady Tyler, but I think there is an issue about the data out there. It is not helping us, or anyone else, make CTOs work for those where they can work, are working and should work in the future, and is clearly causing a problem. We need to get to the bottom of that.

My Lords, I thank all noble Lords who have spoken on this group. I will speak to Amendment 66 in my name and that of my noble friend Lord Howe. One of the motivations when we were considering amendments from our Benches was not only to respond to concerns raised by stakeholders but to probe the Government on why they did not accept some of the recommendations of the pre-legislative Joint Committee. That is the nature of these amendments. To the noble Baroness, Lady Fox, I say that the amendment is meant as a probing amendment to ask the Government why they have not adopted all the recommendations of the Joint Committee.

One of the things that drives many of us—I feel particularly strongly about this, given my background—is why so many people of an Afro-Caribbean background are being detained or are subject to CTOs. The noble Baroness, Lady Parminter, made a valuable point. One of the reasons I have tabled other amendments along those lines, which will be discussed in later groups, is that, after all these years of saying that too many people from the black community are being detained, if we want to do something about it, we need data, and we need to understand why they are being detained. Without the data, it is left to rumour or speculation, or people make up reasons. Everything needs to be driven by the data if we are to address the fact that a disproportionate number of black people are detained.

We tabled Amendment 66 because the pre-legislative committee recommended that community treatment orders be abolished for Part II patients, those not in the criminal justice system, and wanted a statutory process and timeline to be put in place for the review and potential abolition—I say those words from the Joint Committee’s recommendation very carefully—for Part III patients, those involved with the criminal justice system.

Many noble Lords came to the Second Reading debate wanting to see an end to community treatment orders, and many noble Lords have spoken tonight about this. We were all struck by the words of the noble Baroness, Lady Parminter, and of the noble Baroness, Lady Barker, who very honestly said that, having listened to patients and families, she knows that there is a small group of people for whom CTOs work, are the least restrictive option and are beneficial, and we should therefore keep them. I was particularly struck by that. The noble Baroness, Lady Fox, said that people do not change their mind very often, but the views that we brought to the debate in the first place have been challenged.

The noble Baroness, Lady Barker, made the important point that, while she is reluctant to admit it, she believes that there should be a change in the process around CTOs. That is important. This is why this probing amendment is asking for a comprehensive review of CTOs. We have listed a number of criteria that should be in that review, but I know that many noble Lords have concerns over CTOs.

I have since spoken to other noble Lords and corresponded with charities asking whether there is a way to ensure that CTOs are used for, and targeted at, only that small group of people for whom they work. I understand that many feel that this may be a loophole for CTOs to be used in inappropriate circumstances or lead to their disproportionate use. One charity wrote back to me to say that, while it understood the view of those who point to the evidence that CTOs are effective for a small group of people, it pushed back and said that it believed that that was

“outweighed by the overwhelming evidence for most people of their coercive nature, their ineffectiveness in preventing readmission and, above all, the huge racial disparities in their use”.

It added that it therefore still believed that

“CTOs should be abolished for all patients.”

For this reason, and given the variety of views, if we are going to do the right thing, we need a comprehensive review. First, we need to understand what the Government understand about CTOs—typically, you do your secondary research and identify your gaps, and that gives you the primary research. Therefore, what I am really asking the Minister is: what do the Government understand about the effectiveness of CTOs? What do they understand about each of the questions that we list in Amendment 66? I know that I am asking quite a lot of homework of the Minister and her team of officials, but I really want to understand what the Government understand about CTOs. That will help us make decisions about how effective or ineffective they are.

I know that some noble Lords might say that there has already been a review of CTOs, namely the Wessely review, which examined at length the impact of CTOs. It made recommendations which have found their way into this Bill, but it did not recommend that they be scrapped. The review also said that there had been three randomised controlled trials that looked at CTOs, but it believed that they provided limited evidence of their success. The Wessely report also noted that the “generalisability” of the randomised trials was limited, because

“some of the most unwell patients were excluded”.

For those reasons—it is why we tabled Amendment 66 —we want to see a statutory review make use of further, more rigorous and more reliable randomised controlled trials, as well as qualitative and user-led studies, to build a more holistic and accurate picture of the functioning of CTOs, as was recommended by the Wessely review. That is not to say that the review did not do an excellent job in examining their use, but since the scope of the review was significantly wider, looking at the functioning of the Mental Health Act as a whole, we may be able to gain a better insight into the effectiveness of CTOs than is currently available.

In many ways, we have asked the question: is it possible to find a way to scrap CTOs for the Majority of those for whom they are ineffective, while finding a way to continue their use for that small group of people who may still benefit? I hope that this review would answer that question and perhaps other relevant questions, but also allow us to follow a path that would deliver therapeutic benefit while at the same time align with the principle of least restriction.

Perhaps I may briefly address Amendment 43 in the name of my noble friend Lady Browning, on ensuring that treatment is delivered in a patient’s local community. That is one of the major efforts that can be undertaken. Many noble Lords have spoken tonight about how important it is that we have community-based treatment. It is a matter that my noble friend Lord Howe will try to address in some of our later amendments regarding the placement of children outside their local area. In this case, however, it is important to ensure that any community treatment orders include access to local prescribing psychiatrists.

In that vein, can the Minister tell us whether the Government’s concern might be about resources? If so, we understand that; the Minister was very open at Second Reading in saying that the Government would not be able to deliver everything immediately—it would be over 10 years—and that reforms would be delivered at different stages, depending on spending reviews and resources. However, there is a point about prescribing by mental health nurses. Mental health nurses have been prescribing treatment for mental health conditions since 2001 and in some ways have been able to alleviate some of the pressures on psychiatrists by acting as supplementary prescribers. I wonder whether the Government have given any thought to that as a way of doing things more cost effectively, or is there a concern? We heard the debate a few weeks ago about physician associates and anaesthesia associates and the concerns around that. Will the Minister tell us whether the Government will consider the use of mental health nurses, perhaps as a method of introducing more locally available psychiatric prescribing services, or are there too many concerns?

Can the Minister assure the Committee that the Government have a real understanding of the effectiveness of CTOs, or just say, “This is what we understand about CTOs, and this is what we need to do more research on to understand them more”? If so, many noble Lords might feel a bit more reassured. I look forward to the Minister’s response.

My Lords, I am most grateful to noble Lords for their contributions in this important and interesting area. There have been, and to some degree still are, many different opinions across the Committee. This has been one of those rare occasions when parliamentarians may say that they have changed their minds having listened to the debate and looked into things further; that has added to the richness of what we have before us.

Amendment 43 tabled by the noble Baroness, Lady Browning, would require clinicians to ensure that patients had access to a local prescribing psychiatrist when deciding on a community treatment order. I heard the noble Baroness’s comments about the word “local”; I appreciate her drawing the attention of the Committee to that. I particularly heard the support given by the noble Baroness, Lady Parminter.

In the Bill, to put someone on a community treatment order, it must be necessary for the patient to receive medical treatment, which can be provided without detention in a hospital. I think I heard the noble Baroness, Lady Fox, say—I hope she will forgive me for not quoting her directly—that we should not demonise hospitals. She is nodding; I thank her for that. I can assure her that there is no intention to do that; it is about getting a better balance in the interests of getting the right care for individuals. The responsible clinician must consider whether appropriate medical treatment is available. That would, by necessary implication, include access to a local prescribing psychiatrist if it is what the patient needed.

For a CTO to be made, our reforms also require a community clinician with oversight of the patient’s treatment in the community to agree. The Bill therefore already means that, when deciding whether a CTO is appropriate, access to a prescribing psychiatrist will be fully and properly considered if access to medication is required.

I recall that the noble Baroness, Lady Browning, raised an important point about the shortage of prescribing psychiatrists in some areas and the impact that this could have. We intend that the measures in the Bill in relation to dynamic support registers will improve the monitoring of the needs of, and support for, people who may be at risk of going into crisis and being detained under the Act. ICBs and local authorities will be required to have regard to information on the register when exercising their commissioning and—we have discussed this before—market-shaping functions respectively.

I mentioned earlier the requirements in respect of learning disability and autism training, and autism training for psychiatrists. I hope that will help to reassure the noble Baroness.

Amendment 44, tabled by the noble Lord, Lord Scriven, and spoken to by a number of noble Lords, including the noble Baronesses, Lady Berridge, Lady Parminter and Lady Fox, and the noble Lord, Lord Kamall, relates to the review into the extension of CTOs. I completely understand why the noble Lord was inspired to come forward with this, having been inspired, as the noble Lord and the noble Baroness, Lady Berridge, said, by the words of the noble Baroness, Lady Parminter, at Second Reading and the way in which she relayed her personal experience. That kind of contribution and the impact that it has is exactly what we welcome, and I am glad she is pleased that people listened— indeed we did.

The amendment would ensure that CTOs aligned with the statement of principles in the code of practice and could be extended beyond 12 months only under certain conditions, with a review of the ongoing necessity and the therapeutic benefit of the CTO. I strongly agree with the intention behind the noble Lord’s amendment but it is fully supported by existing provisions in the Bill. Alignment with the code and the four principles is already achieved by new Section 118(2D), which requires clinicians before placing someone on a CTO to have regard to the statement of principles in the code. Under Clause 6, the patient can be put on a CTO only if there is a reasonable prospect of it having therapeutic benefit for the patient, and the Bill will mean that a responsible clinician cannot extend a CTO beyond six months unless the conditions, including therapeutic benefit, continue to be met.

The current code of practice states that, before renewal, the responsible clinician should consult the multidisciplinary team, the patient, the nearest relative—or, in future, the nominated person—and an advocate. The Bill adds that the patient’s community clinician must be consulted before renewal. We are therefore increasing the frequency of automatic referrals to the tribunal to ensure that patients can come off CTOs when they are no longer benefiting. Under the new system, a CTO cannot be extended past the 12-month point without a referral to the tribunal. In the current system, the patient can go for three years before a further referral is required.

That is pleasing to hear from the Minister. So what would stop that going in the Bill?

As we have discussed before, it is about ensuring that we are able to update in line with good practice, and that can be nimbly—if I may use that word—outlined if it is not in the Bill. We are trying to future-proof it, as the noble Lord is aware, and to ensure that our reviews of our practice and so on are continually updated. That is how I would put it to the noble Lord.

Would the Minister reflect on this? CTOs were brought in under the 2007 Act. The then Labour Government went shopping around the world for various different models of CTOs and cherry-picked bits and pieces out of the ones that they liked to come up with the model that they did. CTOs were brought before the House, and we were assured that they would be used sparingly and we would not run into all the problems that people then foresaw about them being used disproportionately against some minoritised communities.

This is the first opportunity we have had to go back to CTOs. In the 20 years since, absolutely nothing has changed in practice. Twenty years on, there is no indication—even though there must be ample evidence, not just in this country but around the world—about how they work in practice and the fact that they have not worked in the way they were meant to when they were introduced. Does the Minister understand why those of us who have been here so often before are reluctant to accept the argument that is trotted out time after time, that Governments need to be flexible and make change, when within 20 years there has been no change in the face of overwhelming evidence that the law is not working in the way that was intended?

I can understand the frustration that the noble Baroness outlines. It is hard for me to comment on a number of those 20 years. My feeling is that that is why we are here today updating the Bill. Indeed, at the risk of repeating myself—I will try not to—I take the point that she is making, yet I feel there is a need, under the updated Bill, which I hope will become an Act, to review the overall impact of the new provisions. I understand that we cannot be on a hope and a wing and a prayer. That is not the intention. We will keep CTOs under review as we implement changes. I certainly want to keep a very close eye on their impact, as I know your Lordships’ House will. I know that noble Lords will not be shy to raise any concerns that they have.

Amendment 66, in the name of the noble Lord, Lord Kamall, and supported by the noble Earl, Lord Howe, would require the use of community treatment orders to be reviewed within two years of the Act being passed. As a number of noble Lords have said, we believe that CTOs can be valuable for certain patients—indeed, as we have referred to, the noble Baroness, Lady Parminter, spoke about their benefit for eating disorder patients, as she did at Second Reading—but reform is needed so that they are used only when appropriate and for the shortest possible time.

The noble Lord, Lord Kamall, made a couple of points, which I am happy to write to him about, about concerns about resources. He asked about the role of mental health nurses—an important point—and the effectiveness of CTOs. I will write further on those points.

If the Minister and the officials look at Amendment 66, they will see it asks four specific questions. It could include more, but I wonder whether we can understand what the Government understand about each of those four things, including the impact of community treatment orders on people from different ethnic minorities and the effectiveness of the continued use of community treatment orders. I think it would be interesting for noble Lords to understand what the Government currently understand, if that makes sense.

Yes, it does. I thank the noble Lord for the clarification. I will come to some of those points, particularly on racial disparity, but I just wanted to ensure that I did not miss the points that he made.

The noble Baroness, Lady Parminter, raised how people with eating disorders will be supported on CTOs. To elaborate a bit on what I said previously, for some people CTOs allow them to be cared for in the community with the least restriction, but with the safeguard that they can be recalled for treatment if necessary. That is a very necessary aspect.

I hope noble Lords are aware that I certainly would agree about the importance of the right data being used to inform decisions, trends and reviews. Data on community treatment orders are published as part of the annual Mental Health Act statistics. My officials are working with NHS England and others to understand what additional data should be collected to understand the impact of the reforms—this relates to the points made by the noble Lord, Lord Kamall.

I know that noble Lords more than understand that gathering new data takes time. Therefore, it is felt that a review after two years would be somewhat premature, as it would be based on data from before the reforms were commenced. So, rather than committing to a review in legislation at a fixed date, the Government are committed to ongoing monitoring of CTOs as we implement the changes. This will form part of our overall commitment to evaluate the impact of reform and to consider next steps. I am sure that your Lordships’ House would wish to continue to be involved in this.

I turn to Amendment 67, tabled by the noble Baroness, Lady Bennett, requiring a review of economic and social disparities in relation to CTOs. I agree, as I have many times, that there are significant disparities in the use of community treatment orders, particularly between different minority ethnic groups. This was spoken to by not just the noble Baroness, Lady Bennett, but the noble Baroness, Lady Berridge, and the noble Lord, Lord Scriven. I will make a few points about this. Those who are black are currently seven times more likely to be detained on a CTO—we have discussed this in your Lordships’ House a number of times, and rightly so, in my view. For CTOs, we are strengthening decision-making in three ways: first, by requiring that an individual must be at risk of serious harm to be made subject to a CTO; secondly, by requiring that the community clinician be involved in all community treatment order decisions; and, thirdly, by increasing the frequency of automatic reviews of patient cases by the tribunal. We will work closely to ensure that the Bill’s provisions are effectively implemented, because a main plank of this legislation is to reduce racial disparities in decision-making under the Act. I am sure we will return to this point many times, and rightly so.

I have two questions about data, and I entirely understand if this could perhaps be included in a letter. The racial disparities are well known and well canvassed, but I am wondering about disparities of people living in relatively deprived communities—those that used to be described as “left behind”. There seems to be some evidence of disparity between people in those poorer communities and wealthier communities. Also, on individuals living in poverty versus individuals not living in poverty, what difference is there in CTOs—and more broadly, but CTOs might be a particular area of concern? I am interested in what information the Minister can give—not necessarily now—because we need to focus on that as well.

The noble Baroness makes a fair point. We will certainly cover CTOs in the planned evaluation of the reforms, including consideration of economic and social disparities. I hope that reassures her.

I turn to the noble Baroness’s Amendment 86. The intended effect given in the explanatory statement provided by the noble Baroness is to retain the requirement for

“an automatic referral to the tribunal when a patient’s Community Treatment Order is revoked”.

The amendment as drafted does not achieve this because it amends a different part of Clause 30—

I tried.

Indeed the noble Baroness did try, and I have therefore taken its intention at face value.

The Bill removes the requirement for an automatic referral following the revocation of a CTO. This was a recommendation of the independent review which found that, in practice, the automatic referral was an ineffective safeguard, as often the patient is back in the community or back in hospital as a Section 3 patient before the tribunal has had the opportunity to review their case. Therefore, the current process creates a burden on tribunals but does not protect the patient. The Bill improves other safeguards for patients on a CTO, including increased access to tribunals. For these reasons, I hope that the noble Baroness feels able to withdraw her Amendment.

My Lords, I am grateful to everybody who has contributed on this group of amendments. Everybody has bought something different to the table. There have been some good things. I think we are all grateful to the noble Baroness, Lady Parminter, who led us at Second Reading to have a better understanding of how CTOs can help with eating disorders. I just think back to 2006 and the pre-legislative scrutiny committee of the previous Amendment of the 1983 Act. I think there are three of us in the Chamber tonight who were part of that pre-legislative scrutiny. I think that the noble Baronesses, Lady Murphy and Lady Barker, and I were members and I recall the debate on community treatment orders at that time, 20 years ago, when we had quite a lot of strong reservations about how they would work in practice.

Despite some of the good things we heard tonight on this group, I still sense that reservation. I think that if what we had before us was 20 years of lived experience—practical examples of where CTOs have been good, where they have been bad, where they needed to be amended and where they have been amended—we would feel a lot more confident. Too many parts of this jigsaw still seem to be missing to make what I feel is a substantial change to the 1983 Act 20 years later and know that we have got it right. I always think that when we are in doubt about legislation, there is that old, hackneyed thing: “Suppose this was something in a court. What would they say about this? What was Parliament’s intention at the time?” Can I actually define Parliament’s intention at the time? I am not sure that I can define it in as much detail as I would like, in order to feel we are doing the right thing as far as this legislation is concerned.

I thank the Minister. She has, as always, been as helpful and courteous as she can be with this very difficult issue, but I do not quite feel that we have got there yet. I beg leave to withdraw the amendment.

Amendment 43 withdrawn.