Key takeaways
Advance choice documents strengthen patient autonomy
Commissioners must support individuals in recording treatment preferences.
New statutory duties for health commissioners
Systems, training, and compliance monitoring will be essential.
Guidance will define who receives ACD support
Commissioners should prepare pathways for high-risk cohorts.
The Mental Health Bill currently passing through Parliament has implications for a number of different health and social care providers. Here, we look at the implications for commissioners of mental health care.
The Bill introduces Advance Choice Documents (ACDs) as a statutory mechanism to enhance patient autonomy and improve care planning for individuals with mental health conditions.
ACDs allow individuals to record their:
preferences,
decisions,
wishes and
feelings.
An ACD can relate to:
any relevant matter that may arise at a future point when a person may be detained under the Mental Health Act (MHA) 1983 for assessment or treatment, or
consideration is being given to their detention, and they lack the mental capacity to make the relevant decisions.
Legal and policy
Under the Mental Capacity Act 2005, advance decisions about physical health treatments are legally binding (if meeting the statutory requirements when made). Similar decisions for mental health treatment have lacked statutory force for those subject to the MHA 1983.
Clause 44 of the Bill places new duties on health commissioners, including Integrated Care Boards and NHS England, to:
Proactively inform individuals about ACDs.
Provide support through suitably qualified professionals (e.g. advocates, peer support workers).
Encourage creation of ACDs within 12 months of discharge from mental health services.
Impact on commissioners
These reforms represent a new duty in commissioning responsibilities. Commissioners will be required to:
Develop systems and pathways to identify eligible individuals (e.g. recently discharged patients).
Ensure resource allocation for training staff and delivering ACD support.
Monitor compliance and effectiveness, including uptake rates and integration into care planning.
It is not defined who will fall into the group that commissioners will be required to provide this to. The new Code of Practice that will be developed following the Bill being made law will give further guidance on this.
In terms of providing support, we understand the focus will be on those who are at known risk of further detention under the MHA 1983. Guidance is expected to define expectations to help commissioners determine how they will ensure provision of information, and how to determine who should receive support and from whom. Commissioners will need to establish pathways with mental health providers to identify individuals who will fall into this cohort.
Challenges and opportunities
Whilst ACDs are expected to improve patient satisfaction, commissioners face challenges such as:
Operational complexity in ensuring information and support reaches people to make ACDs across diverse services.
Ensuring clinical buy-in and consistency in respecting ACDs and understanding the legal requirements where some aspects of an ACD may be legally binding but others not, though all must be given due regard.
Addressing public concerns around potential treatment refusal and safety.
The reforms also offer opportunities to:
Promote least restrictive practices and patient autonomy.
Enhance continuity of care across settings.
Foster collaborative decision-making and trust between services and service users
Conclusion
ACDs mark a significant step toward person-centred mental health care. For commissioners, the Bill introduces both a duty and an opportunity to reshape service delivery around patient choice, autonomy, and recovery-focused care. The Code of Practice will provide important guidance for commissioners.
