I thank noble Lords for their contributions on this important set of amendments. I say at the outset that I note the various observations that are outside the Bill, as the noble Baroness, Lady Barker, pointed out, but I have noted them and I am sure we will discuss them on a number of occasions.

First, I turn to Amendments 46 and 47, tabled by the noble Lord, Lord Kamall, and the noble Earl, Lord Howe. I have heard how many noble Lords are in support not just of those two amendments but all the amendments in the group. I am sure noble Lords will not be surprised to know that I understand where people are coming from and I will be pleased to go through the response to them.

The noble Earl, Lord Howe, spoke about “troubling and sensitive matters” and about being inspired by testimonies that came through the charity Blooming Change—I express my thanks to that organisation for the work it does. Officials in the department have met the group and it made a very helpful contribution. Hearing from those with lived experience is crucial to making sure that this is the best Bill, and I know that many noble Lords have done that, so I thank the noble Earl for bringing that into these amendments.

Amendments 46 and 47 would change the definition of appropriate medical treatment to include treatment which

“seeks to minimise the patient’s distress and promote psychological wellbeing and recovery from any childhood trauma”.

Childhood trauma can of course have a devastating impact on psychological well-being. Effective and compassionate in-patient care must be informed, as I have said, in co-production with people with lived experience and be trauma informed. NHS England’s Culture of Care Standards for Mental Health Inpatient Services certainly underlines this.

The noble Earl, Lord Howe, and other noble Lords raised concerns around in-patient settings and how appropriate they are, which I understand. I hope it will be helpful to say in answer that the new definition of “appropriate medical treatment” introduces the requirement that treatment has to have a reasonable prospect of benefiting the patient. We would expect the setting in which someone is going to be detained to be considered as part of this. Of course, I am more than aware—without wanting to go into the generics in this group or any other group—that the place in which we start, in terms of the suitability and availability of the right settings, is not where I am sure any of us would want to be.

We also know that the sensory environments in settings can cause difficulties for people with sensory sensitivities. To support NHS services to address sensory aspects of the environment, which the noble Baroness, Lady Bennett, referred to, NHS England has published a sensory-friendly resource pack, which outlines 10 principles to improve the sensory environment and signposts other resources.

The Clause in the Bill that defines “appropriate medical treatment” already requires decision-makers to take into account the nature and degree of the disorder and all other circumstances, which could include childhood trauma, when considering whether medical treatment has a reasonable prospect of therapeutic benefit. The definition of medical treatment is unchanged and is indeed broad, including nursing care, psychological therapy and medication. All these interventions could include an overall aim to minimise distress and promote psychological well-being.

Amendments 50 and 51, tabled by the noble Baronesses, Lady Tyler and Lady Bennett, aim to ensure that the clinician considers non-drug-based interventions as part of the new “clinical checklist”. The checklist requires clinicians to identify and evaluate alternative forms of medical treatment when deciding whether to give a particular medical treatment to a patient. As I have already mentioned, the definition of medical treatment under the Act is broad. As well as non-drug-based interventions, it includes specialist mental health rehabilitation and care. On the point raised by the noble Baroness, Lady Bennett, which is an important one, it does include the therapeutic environment or setting. This requirement, as outlined, would apply to all patients falling under Part IV of the Act. It includes patients with a learning disability and autistic patients who are detained for assessment under Section 2 and patients detained for treatment under Part III.

With specific regard to those with a learning disability and autistic people, I recognise the concern that they are more likely to be prescribed an antipsychotic than the general population. I emphasise that psychotropic medication should only be given for the right reasons, in the lowest dose, for the shortest time. NHS England has a national programme of work to stop overmedication and the inappropriate prescribing of these medications, which is aimed in particular at people with a learning disability and autistic people. Noble Lords will be aware of the STOMP programme. Alongside it is a national supporting treatment and appropriate medication in paediatrics programme called STAMP—the two are not to be confused. These programmes work particularly closely with those with lived experience, families and carers organisations, and a wide range of health and social care professional bodies.

Amendment 53, in the names of the noble Earl, Lord Howe, and the noble Lord, Lord Kamall, would require the approved clinician to offer a patient any treatment that is appropriate, having applied the new clinical checklist. The reference to medical treatment in that checklist should already be read in accordance with Clause 8, which inserts a new definition of appropriate medical treatment to enact the principle of therapeutic benefit.

The clinician must also support the patient to participate in decision-making to make sure that they do not simply offer their preferred treatment to the patient, with no discussion or consideration of alternatives. The Bill also requires clinicians and, where relevant, the second opinion appointed doctor to provide a written record that the treatment being administered meets the definition of appropriate medical treatment. Therefore, it is felt that the Bill already meets the intention of this amendment. Furthermore, if the intention is to ensure that a range of treatments is being considered by the responsible clinician, I can reassure noble Lords that this is already the case, because, as I have said, the definition of medical treatment is broad.

Amendment 54, tabled by the noble Lord, Lord Kamall, and the noble Earl, Lord Howe, seeks to ensure that, where a patient has autism or a learning disability, the approved clinician, having applied the clinical checklist, must secure the agreement of two professional clinicians before any treatment could be given which departs from the patient’s preference, as expressed by either the patient’s nominated person or the patient’s advance choice document. While we recognise that this amendment may help ensure that preferences are more central to clinical decision-making, we do not feel that this additional safeguard is necessary on top of the protections already introduced by the Bill. For example, the clinical checklist and the new rules that limit the use of compulsory treatment and require the earlier involvement of a second opinion appointed doctor achieve a similar objective. Furthermore, sometimes a patient’s preferences, or those of their nominated person, may not be clinically appropriate or practically achievable. In that situation, the amendment would create a new burden on staff, with little benefit in return. Therefore, we feel it would be better to rely on the discretion of the treating clinician in this circumstance.

The noble Earl, Lord Howe, made an important point about the need for transparency and empowerment. We certainly agree with that aim and there are a number of measures in the Bill to make improvements: for example, the clinical checklist, the compelling reason criteria and the increased oversight by the second opinion appointed doctor. I hope that this will deal with the point about transparency and empowerment.

Amendments 54A and 54B, tabled by the noble Lord, Lord Scriven, relate to the Secretary of State’s power under Clause 18 to set out in regulations the circumstances under which the requirement for a second opinion appointed doctor’s certification of urgent and compulsory electroconvulsive therapy may be dispensed with and seek to limit those circumstances. We have received a recommendation from the Delegated Powers and Regulatory Reform Committee to limit the extent of the delegated power. I can assure the noble Lord that we are considering this recommendation carefully and will reflect closely on the views that he has brought before the Committee today. I aim to clarify the Government’s position on Report.

Amendment 95, in the name of the noble Earl, Lord Howe, and supported by the noble Lord, Lord Kamall, would require an independent mental health advocate to consult with people on their experience of in-patient hospital treatment after discharge and report this to the hospital managers, who must then publish a report each year on lessons learned and actions taken.

We feel that there are already mechanisms in legislation that serve a similar purpose, which I well understand. For example, under the CQC’s statutory duty to monitor the Mental Health Act, the CQC visits and interviews detained patients. Insights from these interviews inform the findings of the CQC’s annual monitoring of the Mental Health Act. The findings from this monitoring may also result in the CQC requiring action statements from providers on what they will do to improve services. Where providers do not take the necessary action, they may ultimately be subject to sanctions under the regulatory powers of the CQC.

The noble Earl, Lord Howe, raised concerns about the debriefing process after discharge from hospital. The code of practice provides guidance on the provision of information about the complaints process. The Bill will put this requirement on a statutory footing and place a duty on hospital managers to supply complaints information to detained patients, community patients and conditionally discharged patients, as well as their nominated person.

We have been clear that improvements are needed to make healthcare regulation and oversight more effective, and the CQC is already making improvements following independent reviews. Beyond legislation, it is the responsibility of trust boards to ensure that feedback is gathered to improve services. The patient and carer race equality framework, now part of the standard NHS contract, requires that visible and effective ways for patients and carers to feed back are established, as well as clear processes to act and report on that feedback.

Lastly on this amendment, while we are committed to expanding access to independent mental health advocacy, we are also mindful of not overburdening the workforce. This amendment is likely to be resource intensive, as well as resulting in a significant deviation from the IMHA’s current role: to support people to understand and access their rights when detained.