Mental Health Act 2025 — Impact Assessments: Impact Assessment from the Department of Health and Social Care

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TitleMental Health Bill
IA No: DHSCIA9587 (1)
RPC Reference No: RPC-DHSC-5184(2)
Lead department or agency: Department of Health & Social Care
Other departments or agencies: Ministry of Justice
Impact Assessment (IA)
Date: November 2024
Stage: Final Stage
Source of intervention: Domestic
Type of measure: Primary legislation
Contact for enquiries: MHBill@dhsc.gov.uk

SummaryIntervention and Options

RPC OpinionAwaiting Scrutiny
Cost of Preferred (or more likely) Option (2019/20 prices)
Total Net Present
Social Value
Business Net Present
Value
Net cost to business per
year Business Impact Target Status
Non qualifying provision
-£119.3m -£10.9m £0.7m
What is the problem under consideration? Why is government action or intervention necessary?
The Mental Health Act 1983 (MHA) provides a legal framework to authorise the detention and compulsory treatment of
people who have a mental health disorder and are considered at risk of harm to themselves or others. A 2018 Independent
Review of the MHA found that it was out of step with a modern-day mental health service: the patient’s voice lost within
processes that are out-of-date; an unacceptable overrepresentation of people from ethnic minorities amongst people
detained, especially black people; and people with a learning disability and autistic people also facing particular
disadvantage in their care and treatment. This Impact Assessment (IA) accompanies the Mental Health Bill which intends
to update legislation. This legislation is part of a suite of reforms informed by a public consultation and recommendations
of the Independent Review.

What are the policy objectives of the action or intervention and the intended effects?
The main policy objectives of the proposals are to:
• maintain the power to intervene and detain people under the Act when appropriate, to prevent harm to self or
others;
• modernise mental health legislation to give patients greater choice and autonomy over their care and treatment,
and access to enhanced rights and support under the MHA;
• ensure that the patient, their family and/or carer, and their Nominated Person are proactively supported to take
part in decision making around care, treatment, and planning.
• introduce new patient safeguards, such as granting informal patients access to an Independent Mental Health
Advocate (IMHA);
• improve existing patient safeguards, such as giving patients earlier access to the Mental Health Tribunal (MHT)
and to a Second Opinion Appointed Doctor (SOAD);
• reduce racial disparities under the MHA and promote equality;
• ensure that patients receive therapeutic benefit from detention and that they are treated with dignity and respect,
with a view to improving patient experience and limiting the length of their detention; and
• prevent longer term detentions for people with a learning disability and autistic people under the civil parts of the
Act where they do not have a co-occurring mental disorder that would warrant hospital treatment

What policy options have been considered, including any alternatives to regulation? Please justify preferred
option (further details in Evidence Base)
Option 1: Business as Usual (BAU) with no changes to the MHA.
Option 2: Implement the proposals outlined in the Government’s response to its consultation on the MHA reforms.
The IA’s main focus is on the reforms requiring legislation to improve safeguards, both in the health and social care
system and in the justice system. It does not include wider costs and benefits of investment and quality improvement
that are required to deliver the wider ambitions of the Bill in terms of patient experience and treatment outcomes,
which fall beyond the scope of the legislation an d therefore the IA. It is recognised that realising the ambitions of
the Independent Review and other commitments are also dependent on this wider activity.
Option 2 is the preferred option.
Is this measure likely to impact on international trade and investment? No

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Will the policy be reviewed? It will not be reviewed. If applicable, set review date: N/A
Are any of these organisations in scope? Micro
No
Small
No
Medium
No
Large
No
What is the CO2 equivalent change in greenhouse gas emissions?
(Million tonnes CO2 equivalent)
Traded:
N/A
Non-traded:
N/A
I have read the Impact Assessment and I am satisfied that (a) it represents a fair and reasonable view of the
expected costs, benefits and impact of the policy, and (b) that the benefits justify the costs.
Signed by the responsible Minister:

Date05/11/2024

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Summary: Analysis & Evidence Policy Option 1
Description:
FULL ECONOMIC ASSESSMENT
Price Base
Year 24/25
PV Base
Year 24/25
Time Period
Years 20
Net Benefit (Present Value (PV)) (£m)
Low: High: Best Estimate:

COSTS (£m) Total Transition
(Constant Price) Years

Average Annual
(excl. Transition) (Constant Price)
Total Cost
(Present Value)
Low

High
Best Estimate

Description and scale of key monetised costs by ‘main affected groups’
This option pertains to the counterfactual, that is, the status-quo with no new national policies implemented. Therefore,
we assume that there are no additional costs to the baseline associated with the Business as Usual option and impacts
are assessed as marginal changes against the Business as Usual baseline.
Other key non-monetised costs by ‘main affected groups’
N/A
BENEFITS (£m) Total Transition
(Constant Price) Years

Average Annual
(excl. Transition) (Constant Price)
Total Benefit
(Present Value)
Low

High
Best Estimate

Description and scale of key monetised benefits by ‘main affected groups’
This option pertains to the counterfactual, that is, the status -quo with no new national policies implemented.
Therefore, there are no additional benefits to the baseline associated with the Business as Usual option and impacts
are assessed as marginal changes against the Business as Usual baseline.

Other key non-monetised benefits by ‘main affected groups’
N/A
Key assumptions/sensitivities/risks Discount rate (%)

N/A

BUSINESS ASSESSMENT (Option 1)
Direct impact on business (Equivalent Annual) £m: Score for Business Impact Target (qualifying
provisions only) £m: Costs: Benefits: Net: 0

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Summary: Analysis & Evidence Policy Option 2
Description:
FULL ECONOMIC ASSESSMENT
Price Base
Year 24/25
PV Base
Year 24/25
Time Period
Years 20
Net Benefit (Present Value (PV)) (£m)
Low: -4,835 High: 3,876 Best Estimate: -169

COSTS (£m) Total Transition
(Constant Price) Years

Average Annual
(excl. Transition) (Constant Price)
Total Cost
(Present Value)
Low 19
2
141 2,016
High 19 468 6,623
Best Estimate

19 282 4,006
Description and scale of key monetised costs by ‘main affected groups’
The overall costs of the reforms are estimated at around £5.3 billion for housing, health and social care costs and
£313 million for costs to the justice system in England and Wales (in 2024/25 prices and constant value terms).

The below breakdowns have been provided for England. These will not sum to the total NPV above as these have
been uplifted to account for the cost of the reforms on Wales whilst the costs below are provided in constant value
terms.

In England, the net monetised costs relate to• £1.9 billion of costs for the NHS (excluding housing costs for reforms relating to people with a learning
disability or autistic people)
• £396 million of costs for Local Authorities (excluding reforms relating to people with a learning disability or
autistic people)
• £2.5 billion of housing -and care-related costs for reforms for people with a learning disability or autistic
people
• £78 million of costs for the Care Quality Commission (CQC)
• £287 million of costs for the Courts and Tribunals Service

In the latest annual data for 2023/24, there were 52,458 new detentions under the Mental Health Act and 5,618
uses of Community Treatment Orders (CTOs)1. The monetised costs associated with these reforms include:
• Transitional costs of around £19m for familiarisation of existing staff with MHA reforms – modelled to occur
over two years in 2025/26 and 2026/27.
• Around £1.3 billion of net process costs to health and social care. This includes:
o Additional process costs resulting from increased workload for the Mental Health Act workforce
as they are expected to support additional activities due to the reforms. For instance, these include
the costs associated with expanding eligibility of advocacy support to informal patients (expected
to add an additional 27,000 to the IMHA caseload per year once implemented) and the costs
associated with greater take-up of Advance Choice Documents (expected to be around 40,000
new ACDs drafted per year once fully implemented). Full breakdowns of cost by policy or process
can be found in the monetised cost section.
o Process cost savings , representing a reduction in the additional process costs above resulting
from fewer detentions and CTOs expected due to the reforms (estimated to be a reduction of
around 1,300 CTOs per year once fully implemented).
• Training costs of around £132 million for expanding the health and social care workforce to accommodate
additional demands of the reforms.
• Costs of around £99m for alternative community mental health care for people who are no longer admitted
to hospital, associated with an increase in the use of Advanced Choice Documents (expected volumes
listed against monetised benefits).
• Costs of around £3.4 billion for community services, care and housing for people with a learning disability
and autistic people who are no longer detained in hospital following reform (expected volumes listed
against monetised benefits).
• Costs of around £287 million for the proposals relating to the Mental Health Tribunal (MHT), including legal
aid. This mainly reflects the judicial costs of the additional sitting days needed and includes £219m for
automatic referrals, £56m for proposals relating to treatment choice, £14m for expanded powers of the
MHT, and cost savings of around £1m for reforms to detention criteria.

1 Mental Health Act Statistics, Annual Figures, 2023-24 - NHS England Digital

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Other key non-monetised costs by ‘main affected groups’
Key non-monetised costs for the health and social care system pertain to ensuring cultural change and familiarisation for
the reforms for workforce groups not modelled, monitoring duties for CQC, additional workload for MHA managers,
making ACDs available at the point of need, and other reforms such as prison transfers, section 117 aftercare,
supervised discharge, crown dependencies and improving discharge. For the justice system, the non-monetised costs
pertain to expanded tribunal powers and impacts on the court of protection.
BENEFITS (£m) Total Transition
(Constant Price) Years

Average Annual
(excl. Transition) (Constant Price)
Total Benefit
(Present Value)
Low 0
-
127 1,788
High 0 421 5,892
Best Estimate

0 274 3,836
Description and scale of key monetised benefits by ‘main affected groups’
We present quantified monetised benefits for reforms relating to Advanced Choice Documents (ACDs) and new detention
criteria for people with a learning disability and autistic people. These are based on estimates of the reduction in
admissions or patient numbers caused by the policies, combined with estimates of the total hospital costs per bed day for
mental health patients.
The monetised benefits for England and Wales (2024/25, constant prices) are estimated at:
• £400m of benefits from fewer overall admissions (either as an informal patient or detention) due to ACDs
(estimated to equate to a reduction in admissions in England by around 1,500 per year on average once
reforms are fully implemented).
• £5.1 billion of benefits from fewer detentions due to reforms for people with a learning disability and autistic people
(estimated to equate to a reduction in admissions in England by around 400 per year on average once
reforms are fully implemented)
These benefits should not be understood as cashable savings but will in practice lead to health benefits for other patients.
Other key non-monetised benefits by ‘main affected groups’
The key non-monetised benefits pertain to improved patient experience of the MHA due to improved safeguards and
increased patient empowerment, avoiding unnecessary or inappropriate detention and admission, a potential reduction
in length of detentions, benefits associated with timeliness of prison transfers and stopping prison being used as a place
of safety on the grounds of mental health, and health benefits to patients and associated wider economic benefits of
improved mental health.
The Independent Review of the MHA heard concerns around the disparity of access to, and experience of,
mental health services for different disadvantaged groups, including LGBTQ+, ethnic minority communities,
people with a learning disability or autistic people, and asylum seekers and refugees. This can influence the
likelihood of detention in the first place, given varying access to and success of alternatives, as well as
experiences when subject to the Act. Broadly, it is anticipated that improved involvement of patients in treatment
decisions (before or after the potential need for detention arises) could improve patient satisfaction and
adherence with treatment, and lead to improved health outcomes in the face of the specific needs for such
disadvantaged groups. We have further explored the differential impacts of the reforms in the distrib utional and
wider impacts section.
In the absence of quantitative evidence, we use a breakeven analysis to illustrate the benefits per patient detained
required to offset the cost of Option 2. For the total discounted costs of the policy to be offset by these benefits from
2025/26 we estimate that in the central scenario, it would require a 0.33 day reduction in length of stay per detention, a
patient health gain of 0.003 QALYs per detention (equivalent to helping someone live an extra 0.9 day in perfect health),
or a 0.01 point improvement in patient wellbeing on the self-reported life satisfaction scale.

Key assumptions/sensitivities/risk Discount rate
(%)

3.5%
Many impacts were not able to be monetised due to lack of data or research evidence, and furthermore given the 20-
year appraisal period, there is a likelihood that input assumptions/estimates may change over the period in ways it is not
possible to accurately predict now. Therefore, there is significant uncertainty around monetised estimates of costs and
benefits. This is reflected in sensitivity analysis which varies key assumptions, such as the impact of reforms on
workforce time requirements, community costs and baseline detention scenarios, to approximate low and high
estimates of the additional costs and benefits of Option 2. The estimated benefit presented here should not be
understood as cashable savings. Other risks have been considered including wider capacity and workforce constraints,
risks around provision of housing, duration of community care costs and possible unintended consequences.
BUSINESS ASSESSMENT (Option 2)
Direct impact on business (Equivalent Annual) £m: Score for Business Impact Target (qualifying
provisions only) £m:
Costs: 1.1 Benefits: 0.0 Net: 1.1

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Table of Contents
Policy Rationale
Policy background ................................ ................................ ................................ ............................ 8
Problem under consideration and rationale for intervention ................................ .............................. 9
Policy objective and options ................................ ................................ ................................ ............ 10
Cost Benefit Analysis
Summary and changes since the previous IA ................................ ................................ ................. 18
Rationale and evidence to justify the level of analysis used in the IA (proportionality approach) ..... 19
Option 1: Business as Usual ................................ ................................ ................................ ................... 19
Detentions and admissions baseline scenarios ................................ ................................ ............... 19
Community Treatment Order (CTO) baseline scenarios ................................ ................................ . 20
Mental Health Tribunal (MHT) receipts ................................ ................................ ........................... 20
Option 2: (Preferred option) Implementation of proposed reforms ................................ .......................... 20
Costs
Monetised Costs - Health and Social Care System ................................ ................................ ......... 25
Monetised Costs – Justice System ................................ ................................ ................................ . 42
Non-monetised Costs ................................ ................................ ................................ ............................. 48
Non-monetised Costs - Health and Social Care System ................................ ................................ . 48
Non-monetised Costs - Justice System ................................ ................................ .......................... 53
Benefits
Monetised benefits ................................ ................................ ................................ ................................ . 55
Benefits to the Health and Social Care system ................................ ................................ ............... 55
Non-monetised benefits ................................ ................................ ................................ .......................... 60
Breakeven analysis ................................ ................................ ................................ ................................ 67
Health benefits to patients ................................ ................................ ................................ .............. 68
Wellbeing benefits to patients ................................ ................................ ................................ ......... 69
Reduction in length of stay ................................ ................................ ................................ .............. 69
Risks and assumptions
Modelling uncertainties ................................ ................................ ................................ ................... 70
Wider capacity & workforce constraints ................................ ................................ .......................... 71
Possible unintended consequences ................................ ................................ ................................ 72
Housing risks ................................ ................................ ................................ ................................ .. 73
Sensitivity analysis ................................ ................................ ................................ ................................ . 74
Health System ................................ ................................ ................................ ................................ 74
Justice System ................................ ................................ ................................ ............................... 74
One-way Sensitivity Analysis ................................ ................................ ................................ .......... 75
Summary of Sensitivity Analysis ................................ ................................ ................................ ..... 79
Summary and Preferred Option ................................ ................................ ................................ ...... 80
Direct costs and benefits to business calculations .................................................................................... 81
Health and Social Care System ................................ ................................ ................................ ...... 81
Justice System ................................ ................................ ................................ ............................... 83
Impact on small and micro businesses ........................................................................................................ 83

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Independent health and social care providers ................................ ................................ ................. 83
Providers of advocacy services ................................ ................................ ................................ ....... 84
Distributional and Wider impacts
Racial disparities................................ ................................ ................................ ............................. 85
Age and gender ................................ ................................ ................................ .............................. 88
Learning disability and autism ................................ ................................ ................................ ......... 90
Religion or belief ................................ ................................ ................................ ............................. 91
Monitoring and Evaluation
Evaluation of implementation ................................ ................................ ................................ .......... 95
Monitoring outcome and process data ................................ ................................ ............................ 95
Evaluating impacts on patient and carer experience ................................ ................................ ....... 96
Annex
Annex A. List of acronyms ................................ ................................ ................................ ...................... 98
Annex B. Methodological summaries of forecasts used in baselines ................................ ...................... 99
B.I. Forecasting the baseline number of detentions and admissions under the Mental Health Act and
estimating their average cost ................................ ................................ ................................ .......... 99
B. II. Estimating the number of Community Treatment Orders (CTOs) ................................ .......... 102
Annex C. Methodological summaries of methods used in estimating costs and benefits of individual
policy changes concerning the Health and Social Care System ................................ ........................... 103
C.I. Estimating the impact of changes to Community Treatment Orders (CTOs) ........................... 103
C.II. Estimating the impact of Nominated Persons ................................ ................................ ........ 104
C.III. Estimating the costs of production of Advanced Choice Documents (ACDs) and their impacts
on admissions ................................ ................................ ................................ ............................... 105
C.IV. Estimating the impact of Opt-Out Advocacy ................................ ................................ ......... 109
C.V. Estimating the impact of Informal Advocacy ................................ ................................ .......... 110
C.VI. Estimating the impact of changes to SOADs ................................ ................................ ........ 111
C.VI. Estimating the impact of changes to Care and Treatment Plans (CTPs) .............................. 113
C.VII. Estimating the health and social care impacts of changes to tribunals ................................ 115
C.VIII. Estimating the impact of increased Section 3 Renewals ................................ .................... 115
C.IV. Estimating additional workforce training, familiarisation and backfill costs ............................ 116
Annex D. Methodologies for Learning Disability and Autism Reforms ................................ ................... 119
D.I. Estimating costs for changing the detention criteria for people with a learning disability and
autistic people ................................ ................................ ................................ ............................... 119
DII. Estimating the impact of putting Care (Education) Treatment Reviews on a statutory footing . 130
DIII: Estimating the impact of requiring ICBs to establish and monitor Dynamic Support Registers
(DSRs) ................................ ................................ ................................ ................................ .......... 133
Annex E. Estimation approach for Justice system impacts. ................................ ................................ .. 137
E.I Types of costs modelled. ................................ ................................ ................................ ......... 137
E.II. Justice system estimates for automatic referrals ................................ ................................ ... 138
E.III. Justice system cost estimates for treatment choice ................................ .............................. 140
E.IV. Justice system cost estimates for expanded powers ................................ ............................ 140
E.V. Justice system cost saving estimates for detention criteria ................................ .................... 141
Annex F. Methodology behind breakeven analysis for non-monetised benefits ................................ .... 142
Annex G – Estimation approach for Wales ................................ ................................ ........................... 144

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Policy Rationale
Policy background
1. The Mental Health Act 1983 (MHA)1, 2 is the main piece of legislation that covers the assessment,
treatment and rights of people with a mental health disorder. It provides a legal framework to
authorise the detention and compulsory treatment of people who have a mental health disorder
and are considered at risk of harm to themselves or others. Powers for compulsory admission
under the MHA are set out in Part II and Part III.
2. Part II of the MHA deals with patients who are detained in hospital and have no criminal proceedings
against them, or have criminal proceedings against them not related to their mental health. These
are generally referred to as civil patients.
3. Part III of the MHA is concerned with the care and treatment of offenders with severe mental health
needs who are involved in criminal proceedings or under sentence. There are two categories of
Part III patients – unrestricted or restricted:
• Unrestricted patients - are defendants or offenders without a restriction order who receive a
hospital order or transfer direction. This includes patients who were originally subject to
restrictions, but whose restrictions have since ended or been lifted. The Secretary of State for
Justice does not have involvement in these cases , unless the patient falls into their ambit in
another way, for example multi agency public protection cases.
• Restricted patients - are offenders with severe mental health needs who are detained under
Part III of the Act in hospital for treatment and who are subject to special controls by the
Secretary of State for Justice. Restrictions are imposed either by a Court or the Secretary of
State, for offenders who present a risk to the public. They can take the form of a restriction
order, limitation direction or a restriction direction, depending on the type and status of patient
within the criminal justice system. The aim of the restricted patient regime is to protect the public
from serious harm while at the same time recognising patients’ right to access treatment in an
appropriate setting.

4. The Independent Review3 conducted by Professor Sir Simon Wessely in 2018 identified that the
current MHA is out of step with a modern -day mental health service and is in significant need of
reform to make it work better for everyone. The reforms the Review recommended were driven by
the following problems : rising rates of detention; racial disparities in detentions and Community
Treatment Orders; poor patient experience; and the particular disadvantages felt by people with a
learning disability and autistic people. These are explained below.

1 A list of the acronyms used in this IA can be found in Annex A
2 Mental Health Act 1983 (legislation.gov.uk)
3 Department of Health and Social Care. (December 2018). Modernising the Mental Health Act - Increasing choice, reducing compulsion. Final
report of the Independent Review of the Mental Health Act 1983. Accessed at: Modernising the Mental Health Act – final report from the
independent review - GOV.UK (www.gov.uk)

9

5. Between 20064 and 20165, in the lead up to the Independent Review, the number of detentions
rose by over a third. According to the Care Quality Commission investigation monitoring the MHA
published in January 20186, this increase may have been due to a range of factors such as:
• the 2007 reform of the MHA, which widened the definition of mental disorder and of treatment;
• greater police awareness of mental health and more diversion from the Criminal Justice
System;
• changes in legal requirement for patients without capacity to consent to admission made it more
likely that these patients would be assessed for detention under the MHA than in the past;
• reduced availability of alternative community care;
• population growth, including among groups that are more at relatively high risk of detention (for
instance those experiencing social exclusion and untreated drug and alcohol misuse); and
• improvements in data quality, which also prevented double counting of detentions when
hospital transfers took place7.
6. Recent data from NHS England showed that the number of detentions continued to increase from
2016/17 up to 2020/21. However, there were decreases in the number of detentions for the next
two years up until 2022/23, before increasing again in 2023/24 8. (More detail is given in Annex
B.I.) The Review considered that improvements in community mental health services and crisis
care services could make a substantial contribution in tackling this increase.
Problem under consideration and rationale for intervention
7. The Independent Review recognised the continuing need for the Mental Health Act . As Sir Simon
Wessely notes in the Independent Review “I often heard from those who told me, looking back,
that they realise that compulsory treatment was necessary, even life -saving, but then went on to
say "why did it need to be given in the way it was?". And it was that last comment which has given
rise to the majority of our recommendations. ” The aim of these reforms is to improve patient
outcomes and experiences under the Act, whilst maintaining the appropriate powers to intervene
when appropriate to protect vulnerable people and the wider public.
8. In considering the need to improve patients ’ experiences of detention under the MHA, evidence
shows that patients’ involvement in care and treatment planning is patchy, and they are not always
aware of their rights under the MHA. The CQC’s ‘Monitoring the MHA in 2022/239 report suggests
that there are still examples of patients not being told their rights or not understanding them. In
2020/21, during the COVID -19 pandemic, patient involvement in care and access to advocacy
services was variable, with some good examples of good practice but with some services
continuing to fail to explain patients’ legal rights effectivel y10. In the 2022 /23 report, the CQC
reported that they are seeing many positive examples of good practice where patients have been
involved in decisions around their care and treatment plans but there is also evidence of patients
not being involved in their care amongst many providers. The Independent Review identified that

4 NHS Digital (14 October 2009). Inpatients Formally Detained in Hospitals Under the Mental Health Act, 1983 and Patients Subject to
Supervised Community Treatment - 1998-1999 to 2008-2009. Accessed at: Inpatients Formally Detained in Hospitals Under the Mental Health
Act, 1983 and Patients Subject to Supervised Community Treatment - 1998-1999 to 2008-2009 - NHS England Digital
5 NHS Digital (30 November 2016). Inpatients Formally Detained in Hospitals under the Mental Health Act 1983 and Patients Subject to
Supervised Community Treatment 2015/16, Annual Figures. Accessed at: [ARCHIVED CONTENT] Inpatients formally detained in hospitals
under the Mental Health Act 1983 and patients subject to Supervised Community Treatment: 2015/16, Annual figures - NHS Digital
(nationalarchives.gov.uk)
6 Care Quality Commission (January 2018). Mental Health Act – The rise in the use of the MHA to detain people in England. Accessed at:
Mental Health Act – The rise in the use of the MHA to detain people in England - Care Quality Commission (cqc.org.uk)
7 Data published prior to 2016/17 were collected using an aggregate data collection (KP90), which did not allow for identifying transfers to
another hospital and therefore, double counted some detentions; this is now recorded in the Mental Health Services Data Set (MHSDS), and so
can be identified and excluded from the total number of detentions in the year – estimated at 15% in 2016/17 (see Annexes B.I and H).
8 Mental Health Act Statistics, Annual Figures - NHS England Digital
9 Monitoring the Mental Health Act in 2022/23 - Care Quality Commission (cqc.org.uk)
10 Monitoring the Mental Health Act in 2022/23 - Care Quality Commission (cqc.org.uk)

10

more needed to be done to proactively support patients to take part in care and treatment decisions
and ensure their views were taken on board as far as possible.
9. Regarding ethnic disparities, Black or Black British people are disproportionately likely to be
detained under the MHA (three and a half times higher than that of the White ethnic group) or be
subject to community treatment orders (over seven times the rate for the White ethnic group); have
longer periods of detention and more repeated admissions, and are also more likely to be subject
to police holding powers under the MHA 11. The Independent Review was clear that the use of
coercion is far greater for the Black or Black British population, and that this at least in part stems
from “unconscious bias, structural and institutional racism” in the mental health system. It
recommended that the legal framework be reformed to increase patient agency and giv e more
opportunity to challenge inappropriate restriction, to protect against the disproportionate use of
coercion amongst racialised communities and other inequalities.
10. Regarding people with a learning disability and autistic people, we know there are cases of poor
care where a common theme was that detained inpatients were not receiving sufficiently
therapeutic or reasonably adjusted care. The use of the MHA to detain someone for treatment can
lead to perpetuated detention even when detention criteria are no longer satisfied and, while this
could be true of other people detained under the MHA, the sensory needs of autistic people and
people with a learning disability and reduced ability to self-advocate may exacerbate these risks12.

Policy objective and options
11. The main policy objectives of the proposals are to:
• maintain the power to intervene and detain people under the Act when appropriate, to
prevent harm to self or others;
• modernise mental health legislation to give patients greater choice and autonomy over
their care and treatment, and access to enhanced rights and support under the MHA;
• ensure that the patient, their family and/or carer, and their Nominated Person are
proactively supported to take part in decision making around care, treatment, and
planning.
• introduce new patient safeguards, such as granting informal patients access to
an Independent Mental Health Advocate (IMHA);
• improve existing patient safeguards, such as giving patients earlier access to the Mental
Health Tribunal (MHT) and to a Second Opinion Appointed Doctor (SOAD);
• reduce racial disparities under the MHA and promote equality;
• ensure that patients receive therapeutic benefit from detention and that they are treated
with dignity and respect, with a view to improving patient experience, improving
recovery and therefore reducing the length of their detention; and
• prevent longer term detentions for people with a learning disability and autistic people
under the civil parts of the Act where they do not have a co-occurring mental disorder
that would warrant hospital treatment.

12. As has been highlighted through the Independent Review, regular reports from the CQC as part
of their monitoring of the MHA and stakeholder feedback (including from people with lived
experience), there is significant variation in the experiences of people detained under the MHA
compared to the expectations for care and treatment outlined in national guidance, including the
statutory Code of Practice. Given the severity of the decision to remove someone’s liberty, and

11 Mental Health Act Statistics, Annual Figures, 2023-24 - NHS England Digital
12 Independent review of the Mental Health Act: interim report - GOV.UK (www.gov.uk)

11

treat them at times against their will, it is vital there are clear standards and expectations for all
patients, for their safety and protection and the protection of others , and also to ensure that
detention provides a therapeutic benefit, supports recovery and doesn’t only manage risk. The
current guidance, while in line with many of the changes being introduced in the Bill, clearly is not
sufficient to ensure that expected practice is followed. By placing requirements directly into
primary legislation, they must be followed, whereas the statutory guidance should be followed,
with clinicians deviating from the guidance if they think there is a rationale for doing so. While
some elements will appropriately remain in guidance to allow flexibility to respond to the very
different needs of particular groups of and individual patients, the provisions being taken forward
in the Bill are critical areas of the detention process where we wish to tighten requirements so
that all patients can expect the same processes to be followed and safeguards provided. As such,
other options for improving practice within the current legislative framework or reducing variability
have not been assessed in this Impact Assessment.

Non legislative reforms
13. A range of non -legislative actions will play a role in addressing the disparity in outcomes and
detentions, enhancing patient voice, increasing transparency and scrutiny of decisions, improving
patient's right to challenge and keeping people safe. Further reforms and guidance to tackle racial
inequalities will be included in the Mental Health Act Code of Practice, the statutory guidance that
will be drafted after Royal Assent to support the implementation and application of the new Act.
These actions are expected to happen in both the BAU and Option 2. Whilst not within the scope
of this IA’s analysis which focuses primarily on the legislative changes, further actions include:
• Filling evidence gaps, particularly on tackling racial disparities – the National Institute for Health
Research Policy Research Programme (NIHR PRP), on behalf of the Department of Health &
Social Care (DHSC), has now funded four new research projects on h ow to tackle the rising
rates of detention and understanding the experiences of people from minority ethnic
backgrounds and family and friends of people who have been detained13.
• Improvements in data collection – DHSC are working with NHSE to improve the validity and
completeness of existing data collections , such as the Mental Health Services Data Set
(MHSDS), which will support with measuring the use of mental health services and the Mental
Health Act, and monitoring patient outcomes against the policy objectives . NHS Executive in
Wales are also improving data to include patient level information and outcome/experience
measures.
• Culturally Appropriate Advocacy (CAA) – DHSC have commissioned pilots to develop models
for delivering CAA for people from ethnic minority backgrounds who access mental health
services. The first phase of piloting ran from November 2021 to June 2022 and tested various
models of C AA in three areas of England. An independent evaluation took place and
recommended further testing to develop understanding. Phase 2 of the pilots went live in
October 2023 and will run until March 2025. The final evaluation will inform the development of
a framework for commissioning and delivering CAA.
• Cultural change – legislation alone will not drive changes in the day -to-day experiences of
patients and staff. To achieve this, we need to bring about an overall culture change. This will
require a whole system response and strong leadership from clinicia ns and experts informed
by experience. To contribute to this, NHSE are delivering a Mental Health, Learning Disability
and Autism (MHLDA) Quality Transformation programme. All mental health, learning disability
and autism inpatient services for children and young people, adults and older adults are in
scope of this programme, including specialised inpatient services. The programme, which has

13 New research to improve experiences of people with serious mental health problems | NIHR

12

been co-produced with key stakeholders from across systems and especially people, families
and staff. The programme includes specific consideration of the cultural change required to
create and sustain an inpatient environment in which patients and staff c an flourish, such as
reducing restrictive practice and embedding therapeutic relationships. This programme
complements wider ongoing transformation of all -age mental health services – to ensure that
people can access the care they need when they need it, h elping people to live well in their
communities and reducing the need for use of the MHA.
• Another way we are achieving cultural change is via NHS England’s anti -racism framework,
the Patient and Carer Race Equality Framework (PCREF) 14 published in October 2023. The
framework was developed with a number of stakeholders including the support and ongoing
commitment from CQC. The PCREF is a mandatory framework to ensure mental health trusts
and mental health providers are responsible for co -producing and implementing concrete
actions to reduce racial inequality within their services and will become part of CQC’s and
EHRC's inspection processes.
• The national roll out will support mental health providers to improve access, experience and
outcomes and reduce disparities for people from ethnic minority groups which includes data
submission on the mental health act broken down by ethnicity. All mental health providers will
be required to report on the PCREF metrics set out in the framework by March 2025 as aligned
to the NHS Standards Contract 2024/25.
• DHSC and MoJ will continue to work with NHSE, and other partners, to look at further national
support requirements to drive change in the system including but not limited to: ensuring that
training is centred around supporting meaningful co -production with the patient; that we drive
up expert-by-experience leadership roles within providers and local systems.
Option 1: Business as Usual

14. The Business as Usual option (BAU) assumes that there are no changes to the MHA and that
none of the Government proposals are implemented. This is t he counterfactual used in this IA,
which reflects the status quo considering only current national policies in England and Wales.
Therefore, there are no additional costs and benefits to the baseline associated with the BAU
option.
15. To provide a counterfactual this ‘BAU’ option assumes no other legislative changes to mental
health (MH) services and performance over the 20-year appraisal period. In reality, even without
the proposed MHA reforms we might expect to see alternative changes to services which might
impact detentions and costs, but it is not possible to anticipate these with confidence. There is
currently a large amount of unmet need, therefore we expect to require ongoing reform and
investment in MH services to better meet existing demand.

Option 2(Preferred option) Implementation of the Bill
Summary of preferred option

16. The Bill includes the following measures:
• Detention criteria – Detention criteria are set out in the MHA to provide a threshold against
which decisions are made about whether to detain a person, and whether to keep that person
detained. It is important that this threshold balances the interests of public protection and risk,

14 NHS England » Advancing mental health equalities

13

with personal freedoms and autonomy. This Bill includes amendments to the MHA which aim
to ensure that, in order for a person to be detained, there must be a risk of serious harm and
that this harm is likely to occur. The Bill will also ensure that people are only detained if there
is a reasonable prospect of the patient receiving therapeutic benefit from detention. This is
achieved as the detention criteria require that there is appropriate medical treatment available
in order to detain . The Bill changes adds to this definition: ‘ has a reasonable prospect of
alleviating or preventing. The intention is that treatment outcomes such as a short -term
reduction in aggression or dangerousness will still be capable of satisfying the detention criteria
when someone is first detained. However, ‘appropriate medical treatment’ with a more
enduring therapeutic benefit should be considered when decisions are being made about
renewing a patient’s detention. the worsening of, the disorder or one or more of its symptoms
or manifestations’.
• Discharge protocol and managing patient safety – Although it is already established good
practice for clinicians to consult with the wider multi -disciplinary team, technically a clinician
can act independently to discharge patients under Part II or unrestricted Part III patients at any
time under the Act. Similarly, for Part II patients under guardianship, the local authority,
responsible clinician or nearest relative have the power to independently decide to discharge
a person from guardia nship. This is the same for guardianship patients under Part III o f the
Act, the only modification being that these patients cannot be discharged by their nearest
relative. The Bill includes amendments to the discharge protocol to put good practice into law
- requiring that the decision maker must consult with one or mor e professionals concerned
with the patient’s care who, where relevant, must be of a different profession to the
Responsible Clinician before making an order for discharge. For patients subject to a restriction
under Part III of the Act, the decision to discharge (either absolutely or conditionally) remains
for the Secretary of State for Justice and/or the Tribunal, though the Responsible Clinician will
be required to consult before making recommendations. In addition, as part of the patient’s
Statutory Care and Treatment Plan (see below), our intention is that the Responsible Clinician
should create a safety management plan for the patient (this is to be set out in secondary
legislation).
• Detention periods – The Bill will shorten the initial period that patients under certain sections
can be kept in detention for treatment. This change will mean that a patient’s initial detention
period will expire sooner and, if the patient’s detention is to continue, it must be reviewed and
renewed sooner. Currently the responsible clinician must renew the detention of a patient
subject to section 3 every six months in the first year of detention and every 12 months
thereafter; the Bill will shorten the initial period so a patient’s detention will be reviewed at three
months, then at six and 12 months from date of admission.
• Learning disability and autism – The Bill will further limit the extent to which Part II of the
MHA can be applied to people with a learning disability and autistic people, most notably by
removing the power to detain for treatment under Part II section 3 where the patient does not
have a co -occurring mental health condition that warrants hospital treatment. We do not
propose an equivalent change to the detention criteria for people with these conditions who
are sentenced to hospital stays by the court or those transferred from prison to hospital for
treatment under the MHA i.e., because they have been detained after a criminal offence.
• The Bill introduces a duty on the patient’s responsible commissioner to make arrangements to
ensure that care, (education) and treatment review meetings happen within a certain
timeframe for people with a learning disability and autistic people who are liable to be detained
under the Act. The patient’s responsible clinician, responsible commissioner, ICB and local
authority must have regard to the recommendations of the review meeting.

14

• The Bill also places a duty on ICBs to create a register of people with a learning disability and
autistic people who may be at risk of admission. ICBs and local authorities would be required
to have regard to the information on the register when exercising their commissioning and
market functions respectively. The Bill requires that both ICBs and local authorities seek to
ensure that the needs of people with a learning disability and autistic people can be met without
detaining them under Part II of the Act.
• Strengthening the rights of patients to express a treatment preference – Under the Bill
patients will have greater opportunity to inform clinical decision making through measures such
as a personal Advance Choice Document (ACD). Mental health service users can record their
wishes, feelings, beliefs and values, including advance decisions to refuse specific medication
in their ACD, such that these can inform clinical decision making when they are too unwell to
express these things at the time . Commissioning bodies will be under a duty to make
arrangements so that people who are at risk of detention are informed of their ability to make
an ACD and that those who wish to receive professional support to write an ACD, receive it.
• The Bill places a duty on c linicians to follow a ‘checklist’ to ensure that care and treatment
decisions are personalised to the patient’s individual needs. For example, the clinician must
support the patient to take part in decision making about their care, t hey must consider their
wishes and feelings (whether in an ACD or expressed at the time) and not make unjustified
assumptions about the patient that may unfairly bias their decision.   
• While the Bill does not remove the power to give compulsory treatment, it introduces new
safeguards that aim to strengthen patient autonomy and ensure that it is only used when strictly
necessary. For example, i f a patient is refusing non -urgent medical treatment ( through an
advance decision or at the time), the treatment can only be provided if there is a ‘compelling
reason’ i.e. the clinician can’t identify a clinically viable alternative medication or one that is
acceptable to the patient. This is to prevent compulsory treatment being administered without
any attempt by the clinician to find a more agreeable alternative medication. Where it is
deemed appropriate to treat a patient with medication for their mental health disorder without
their consent, the patient will benefit from much earlier access to a second opinion appointed
doctor (SOAD), appointed by the Care Quality Commission. Furthermore, patients who lack
capacity to consent to treatment (where treatment is not in conflict with an advance decision)
will also receive earlier access to a SOAD. Lastly, the Bill also introduces stronger safeguards
around when urgent compulsory treatment can be used (including in relation to electro-
convulsive therapy).
• Statutory Care and Treatment Plans – The Bill includes provisions to ensure that patients
under detention receive a Care and Treatment Plan as soon as possible, which will provide
details of how the patient will be supported towards recovery and discharge (where relevant).
The plan should be developed by the person in charge of the patient’s care in direct
collaboration with the patient and those close to them, so that it is tailored to the patient’s
individual needs and preferences. Staff will be required to review and revise plans on a regular
basis and plans will be subject to internal scrutiny, to ensure that they meet all statutory
requirements. It is our intention that they will also be shared with the Mental Health Tribunal
(MHT) to help inform decisions regarding the patient’s ongoing detention.
• Community Treatment Orders (CTOs) – CTOs were introduced in the 2007 revision of the
MHA and have been subject to high levels of criticism since. They mean that a person can still
be subject to conditions after they are discharged from hospital and be recalled if concerns
about their need for treatment develop. Stakeholders believe that in the last eight years they
are have been overused.15 with around 5,000 to 6,000 orders per year. The Government
proposes reforms to introduce greater scrutiny to CTOs and amend the CTO criteria in line

15 Mental Health Act Statistics, Annual Figures, 2023-24 - NHS England Digital Table 3a.

15

with the new detention criteria are expected to have the effect of reducing CTOs by ensuring
they are used in a more targeted way. They should only be used where there is a risk of serious
harm self or others and where the community clinician agrees that i t is necessary and
appropriate for the patient. Earlier automatic referrals to the tribunal should also see people
discharge from CTOs sooner. However, it is possible that clinicians may be more risk averse
in the public protection context and therefore more inclined to issue a CTO, which may negate
the degree to which use of CTO decreases overtime with our changes.
• Improving patient representation and support – The Bill will modernise the existing
arrangement under the MHA in which a family member is automatically appointed ‘nearest
relative’ and has powers to make decisions about a person’s care. Instead, the Bill will give
patients the freedom to choose their own ‘nominated person’ (NP), when they are well enough
and have the mental capacity to do so. The role of a NP will also include increased powers
within the legislation, for example, a NP will have a new right to be consulted on the patient’s
statutory care and treatment plan and the power to object to the use of a CTO (where the
Responsible Clinician doesn’t deem this a danger to the patient or others).
• Independent Mental Health Advocates - The Bill will make informal patients, those who have
agreed to come into hospital voluntarily, eligible to access an independent mental health
advocate (IMHA), to support patients to understand their rights and to participate in decisions
about their care and treatment. The Bill will also make changes to improve advocacy uptake
among formal patients.
• Places of safety –The Bill also includes legislative changes that will end the use of prison and
police cells as a place of safety under the MHA. For people in contact with the criminal justice
system t his will end the practice of courts diverting defendants requiring assessment and
treatment in an inpatient setting to prison when there is no hospital bed available.
• Removal of remand for own protection solely on mental health grounds - The Bill will
amend the Bail Act to end the use of remand for own protection where the court’s sole concern
is the defendant’s mental health. Instead, courts will be directed to bail the defendant and work
with local health services to put in place appropriate support and care to address risks to their
safety.
• The Mental Health Tribunal – The role of the MHT is to act as the ultimate safeguard for a
patient in detention. It forms part of HM Courts and Tribunals Service (HMCTS) and provides
judicial oversight of detentions made under the MHA. The MHT has the power to consider
whether the conditions for continuing treatment under compulsory powers are met and it may
authorise treatment orders that specify the detention of a patient in a specific hospital or to
reside at a specified place (when not able to reside at home). The Bill proposes increasing the
frequency with which patients can appeal their detention and will ensure that those who do not
appeal themselves will nevertheless have their case referred to the Tribunal for it to determine
whether they continue to meet the criteria for detention 16. The Tribunal will have a power to
recommend that community services are provided, where this could facilitate a fast/smoother
discharge, and they will also be able to inform the conditions that apply to a patient’s
Community Treatment Order. The Bill will also reduce the burden of hearings cancelled at the
last minute due to Section 3 patients no longer meeting the criteria.
• Supervised Discharge – The Bill includes a new power to allow for patients detained through
the courts, who are subject to special controls by the Secretary of State for Justice to protect
the public from serious harm, to be discharged into the community with conditions which
amount to a deprivation of liberty. This power will only be applicable when a patient is no longer

16 Hearing - The hearing is a meeting at which the tribunal panel considers evidence (either orally or paper based) and reaches a decision
(where the decision may be to adjourn or to agree a final outcome). Source: Guide to Tribunal Statistics Quarterly - GOV.UK (www.gov.uk)

16

therapeutically benefiting from hospital detention but continues to pose a level of risk which
needs supervision to be managed in the community.
• Transfers to hospital from prisons and other places of detention - The Bill introduces a
statutory time limit of 28 days for the transfer of patients who meet the threshold for detention
under the Mental Health Act from prisons, Immigration Removal Centres (IRCs) and other
places of detention to mental health hospitals for treatment. It aims to further embed the good
practice set out in NHS England’s guidance on transfers and remissions published in June
2021 and increase accountability among the agencies involved in the transfer process to meet
the deadline.
• Crown dependencies - The Bill will remove the exclusions that exist in sections 83 and 85 of
the MHA that prevent offenders remanded to hospital or made subject to interim hospital orders
from transferring between the Crown Dependencies and England and Wales. The exclusions
have had an effect of limiting the powers of courts in the Crown Dependencies from
appropriately dealing with offenders suffering from complex mental health needs. The Bill will
resolve this by providing that remand and interim patients can be transferred into England and
Wales from the Crown Dependencies for reports or treatment, whilst being appropriately
detained under domestic provision, and then returned for the continuation of their criminal
proceedings.
• Section 117 aftercare (“ordinary residence”) – The Bill applies the ‘deeming rules’ under
social care legislation to the determination of ordinary residence to identify which local authority
is responsible for arranging section 117 aftercare to an individual patient. Namely, in relation
to those aged under 18, section 105(6) of the Children Act 1989 (as modified) applies, and in
relation to adults , the deeming rules under the Care Act 2014 and the Social Services and
Well-being (Wales) Act 2014 apply for the purposes of determining ordinary residence.
• Principles - The Independent Review, working closely with service users, developed four
guiding principles to be considered when carrying out the functions and powers under the
Mental Health Act. These principles are Choice and Autonomy, Least Restriction, Therapeutic
Benefit and The Person as an Individual. The principles have had strong support since the
review, and stakeholders and PLS have sought their inclusion in the Bill. In response, we are
amending Section 118, which imposes statutory requirements in relation to the content of the
Code of Practice, the statutory guidance which sits alongside the Act, to include the wording of
the Review’s principles. Secretary of State will be required to include the four principles in the
statement of principles in the Code of Practice, and those subject to the Code should have
regard for these principles when performing functions under the Act.
Description of implementation plan
17. The Bill will extend and apply to England and Wales. The proposed reforms concern health,
which is primarily a devolved matter in Wales, and the criminal justice system, which is reserved
for England and Wales. Where legislating for devolved areas, we will seek a Legislative Consent
Motion (LCM) from the Welsh Government. The Welsh Government has expressed support for
the reforms as they apply to Wales and will confirm this following the Bill’s Introduction . In this
document, we have modelled the impacts on Wales for the majority of the reforms, excluding
advocacy and Statutory CTPs, C(E)TRs and DSRs, as these policies either apply to England only
or are already in place in Wales17.
18. The commencement dates referenced in this impact assessment are provided for
illustrative purposes only and cost and benefit estimates and should not be interpreted as
fixed timelines or commitments. Actual commencement dates may vary depending on the
progression of relevant processes, legislative actions, or unforeseen circumstances .

17 Annex A page 53 Draft Mental Health Bill: explanatory notes (publishing.service.gov.uk)

17

Table 1, for illustrative purposes, sets out start dates for various reforms, for the purpose of
modelling costs and savings.
19. Expected timelines for implementation of the reforms are set out in Table 1 . Departments are
developing a cross-agency workplan to ensure that clear pathways are in place to safely enact
our proposed reforms which will take into consideration both judicial and clinical resourcing.
Table 1. Estimated commencement dates for specific MHA reforms
2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32
New detention
criteria, including
for people with a
learning disability
and autistic
people *
Implementation
starts

C(E)TRs made
statutory
Implementation
starts
All ICBs required
to establish &
monitor DSRs
Implementation
starts

Nominated
Person

Implementation
starts
Auto referral of
formal patients to
IMHA services

Implementation
starts

Expansion of
IMHAs to informal
patients
Implementation
starts

Advance Choice
Documents Implementation
starts
Changes to
SOAD role**

Implementation
starts

Changes to
SOAD visits -
Urgent ECTs

Implementation
starts
Changes to
CTOs Implementation
starts
Compulsory
CTPs

Implementation
starts
Increased S3
Renewals Implementation
starts

Changed
frequency of
tribunals
Implementation
starts

Supervised
Discharge
Implementation
starts

Transfers to
hospital from
prisons and other
places of
detention
Implementation
starts

Remand for Own
Protection

Departments are working together to ensure there are clear pathways and provision in place to safely enact these
reforms and the timeline for implementation will depend on the conclusion of this work.
Prison as a place
of safety

Crown
Dependencies

*This timeline is highly indicative as an illustration for modelling purposes. This reform will commence once systems
are able to demonstrate sufficient levels of community support for people with a learning disability and autistic people
as an alternative to hospital-based care.
**Includes costs for other professional groups such as clinical staff, who have a role in the interaction with the SOAD.
20. As the policy implementation is staggered over time, with the latest powers (for increased
frequency of tribunals) potentially turned on in 2031/32, the economic appraisal period will cover
20 years of impacts of Option 2 (implementation of the Mental Health Bill).
21. Estimates developed for this Impact Assessment are economic estimates developed for the
purpose of economic options appraisal, where the options being considered are either (1)
maintaining the status quo and current legislation, or (2) proceeding to make the legislative
changes set out in the Bill. They are not financial projections and shouldn’t be viewed as su ch,
nor should they represent a full implementation and workforce plan which will be developed

18

alongside the Code of Practice. Cost estimates are partial in nature and don’t reflect, for instance,
cost pressures or efficiencies that would occur in both Option 1 and Option 2 scenarios. More
information on the approach economic appraisal used in Impact Assessments can be found in
the HMT Green Book18.
Cost Benefit Analysis
Summary and changes since the previous IA
22. This Impact Assessment (IA) focusses on analysing the costs and benefits associated with
proposed legislative changes in the Mental Health Bill , particularly on improving safeguards in
both the Health and Social Care system and in the Justice system. It accompanies the Bill and
updates the previous IA (published alongside the draft MHA Bill in 2022 for Pre-legislative scrutiny
(PLS)19).20
23. This Final Stage IA updates the estimates for costs and benefits in response to further updates
of methodologies and development of policies, including: detentions and patient number
projections; the scope, expectations and impacts of Advanced Choice Documents (ACDs); the
delivery of Care and Treatment Plans (CTPs); changes to the rules of around urgent use of
electroconvulsive therapy (ECT); the implementation of Nominated Persons; changes to
Community Treatment Order (CTO) processes and use; the benefits and costs from reduced
hospital admissions and detentions, and the incorporation of impacts for reforms applying in
Wales. It also covers, in quantitative or qualitative terms, the impacts of the following policies
which were not included in the previous IA:
• Discharge protocol and managing patient safety
• ACD duty to signpost and support
• Dynamic Support Registers (DSRs)
• Care, Education, Treatment Reviews (C(E)TRs)
24. It is important that Government proposals relating to access to the MHT are not seen in isolation
from clinical care. The MHA operates in a complex and dynamic system, where changes to the
balance of safeguards can have profound impacts on patient care. We have tried to account for
this interaction when feasible e.g., MHT hearing volumes generated from a model estimating the
impact of the Justice System proposals inform another which estimates the impacts on clinical
staff and estimates of potential reductions in the number of detentions caused by policy changes
effect estimates of the costs of changing patients’ experience of detention.
25. In this Impact Assessment, we have modelled the impacts for the majority of the reforms on
Wales, excluding advocacy , Statutory CTPs, C(E)TRs and DSRs. These reforms have been
excluded when modelling the impacts on Wales as the policies either apply to England only or
are already in place in Wales. To account for the impact of the reforms on Wales, we have used
a scaling approach where costs and benefits have initially been estimated for England only.
Impacts have then been weighted by scaling up impacts de pending on the processes that the
reforms are linked to. See further detail in Annex G.

18 The Green Book (2022) - GOV.UK (www.gov.uk)
19 PLS allows for the detailed examination of a draft Bill by either the relevant Commons Departmental select committee, or an ad hoc joint
committee of both Houses (House of Commons and House of Lords). It seeks to improve legislation by allowing thorough consultation and
scrutiny of legislation while it is in a more easily amendable form and makes it easier to ensure that potential parliamentary objections and
stakeholder view are elicited. This ultimately helps to smooth the Bill’s passage in Parliament by reducing the need for amendments.
20 Mental Health Act Draft Bill: impact assessment (publishing.service.gov.uk)

19

Rationale and evidence to justify the level of analysis used in the IA (proportionality approach)
26. This impact assessment presents our best estimates of costs and benefits of the options
considered based on available data and evidence.
27. We present the modelling assumptions and estimated costs throughout the following section and
annexes, highlighting uncertainties and associated risks. The assumptions for the models were
discussed with NHSE, CQC and also other stakeholders (e.g., MHT judi ciary and HMCTs
operational colleagues, providers of services, professional associations) and drawn from data or
research whenever possible.
28. For some policies, their timing of introduction and impact depend on wider policy changes,
funding, and secondary legislation. This means it is currently less clear what the potential costs
and benefits will be, or how far they should be attributed to this legislative change , and this is
also discussed. We have included sensitivity analysis to capture this uncertainty and demonstrate
changes to the costs and benefits when key assumptions are varied.
29. In some cases, further changes to practice and/or investment will be needed to achieve the aims
of the reforms. Costs and benefits associated with these are not captured in the IA as they are
not directly implied by the legislative changes in the Bill but will be important to consider for future
policy.
Option 1: Business as Usual
Detentions and admissions baseline scenarios
30. The number of Business as Usual (BAU) detentions and admissions under Option 1 informs
estimates for the Health and Social Care workforce requirements for the additional recommended
safeguards and for the volume of MHT activity.
31. The BAU approach for detentions under the MHA assumes that:
• In the central scenario, d etention rates for different age groups remain constant in the
future, at the same level as the rates observed in the 2023/24 published data. These rates
are applied to ONS population forecasts to produce projections for the number of detentions
in each group.
32. The BAU approach for admissions assumes that:
• In the central scenario, admission rates for different age groups remain constant in the
future, at the same level as the rates observed in the 2023/24 published data. These rates
are applied to ONS population forecasts to produce projections for the number of detentions
in each group. The number of informal admissions is then calculated by subtracting the
projected number of detentions from the projected number of admissions.
33. The BAU approach for people with a learning disability and autistic people is nearly identical, but
instead of holding figures constant at the same level as the rates observed in the 2023/24
published data, we ignore the latest 8 months of data, and calculate an average from the 12
months of timeseries data preceding this point (December 2022 – November 2023). This is due
to known late reporting, partly due to diagnosis of patients as having a learning disability or as
autistic after admission to hospital.
34. There are known limitations in the data quality for the number of detentions recorded under the
Mental Health Act, with not all providers submitting data, and some submitting incomplete data.
Therefore, we consider low and high scenarios in the sensitivity analysis section.

20

Community Treatment Order (CTO) baseline scenarios
35. The number of BAU CTOs under Option 1 informs estimates for the Health and Social Care
workforce requirements for the additional recommended safeguards and for the volume of MHT
activity.
36. The BAU approach for CTOs assumes that:
• The number of CTOs as a proportion of the average total detentions (estimated over eight
years from 201 6/17 to 202 3/24) stays stable in BA U and hence will grow in line with
weighted demographic changes from annual detention forecasts.
• There have previously been some concerns about data quality issues with the CTO data
as well as wider factors. Therefore, we consider low and high scenarios in the sensitivity
analysis section.
37. As with detentions, we also consider a high and low scenario in the sensitivity analysis section.
Mental Health Tribunal (MHT) receipts
38. We assume that the volume of MHT receipts21 will follow the same trend as the projected number
of detentions. From the latest 2023/24 figure, the trajectory is applied to future years. Further
information is provided in Annex E.
Option 2: (Preferred option) Implementation of proposed reforms
Costs
39. The monetised costs of the reforms include:
• Costs to the Health and Social Care (H&SC) system. We present additional costs in two
ways:
o Impacts disaggregated by the specific policies that cause them; and
o Impacts disaggregated, where possible, by the relevant professional groups in the
NHS and Local Authorities in England.
• Costs to the justice system. We present additional costs for the proposed changes to the
MHT, disaggregated by the specific policy area s of automatic referrals, expanded powers
and treatment choice, changes to the detention criteria, and legal aid impacts.

40. The monetised cost estimates include the ‘process costs’ introduced by the reforms , which
mostly relate to additional workload for the MHA workforce . Some reforms are anticipated to
reduce the number of patients voluntarily admitted to hospital, detained or put onto CTOs. This
will have the effect of reducing some of the additional process costs described above . The
reduction in process costs have been presented in the costs section, to better represent the
overall impact on these processes and workload. Additional costs also arise from the transfer of
activity from hospital into community care associated with these reductions in admissions and
detentions.
41. The cost tables are set out in 2024/25 prices using the GDP deflator as set out in the June 2024
Quarterly National Accounts from ONS22. Figures in tables are rounded to the nearest million and
may not sum exactly due to this rounding. Due to rounding, some figures may appear as zero but

21 Receipt - Volumetric term covering the acceptance of a case by a HMCTS Tribunal. Source: Guide to Tribunal Statistics Quarterly - GOV.UK
(www.gov.uk)
22 Office for National Statistics (ONS), released 30 September 2024, ONS website, statistical bulletin,
https://www.ons.gov.uk/economy/grossdomesticproductgdp/bulletins/quarterlynationalaccounts/apriltojune2024

21

still have a net impact e.g. , C(E)TRs. All monetary values exclude VAT. All costs are
undiscounted unless otherwise specified.
42. Costs for Wales have been estimated by applying an uplift to costs for England. Further detail is
provided in Annex G.
43. There are expected to be a range of costs which have not been able to be monetised. These are
additionally discussed in the non-monetised section and split into costs to the Health and Social
Care system and Justice system.
Summary of monetised costs
44. Overall costs of the reforms are estimated at £5.7 billion over the 20 -year appraisal period for
England and Wales. Due to the phased implementation nature of the proposals, these costs are
not evenly split over the 20 years starting from when the necessary legislation is assumed to be
in place. Costs are estimated to average around £294 million per year over the implementation
period from 2031/32 (undiscounted real 2024/25 prices).

Table 2. Summary of health, housing and social care costs and costs to the justice system,
England and Wales (£millions, 2024/25 prices, undiscounted) – Central Estimate

2024/25
*
2025/26
*
2026/27
*
2027/28
*
2028/29
*
2029/30
*
2030/31
*
2031/32
*
2032/33
*
2033/34
*
Additional
costs 0 4 466 360 203 232 291 307 317 317

Of which
health,
housing,
and social
care
0 4 466 360 203 232 260 283 290 291
Of which
justice 0 0 0 0 0 0 30 24 27 26
Process
cost
savings
0 0 1 1 1 2 5 6 7 9

Of which
health,
housing,
and social
care
0 0 0 1 1 2 1 2 3 4

Of which
justice 0 0 0 0 0 0 4 4 5 5

Total costs 0 4 465 359 203 230 285 300 310 308

Of which
health,
housing,
and social
care
0 4 465 359 203 230 259 281 288 287

Of which
justice 0 0 0 0 0 0 26 19 22 21

2034/35
*
2035/36
*
2036/37
*
2037/38
*
2038/39
*
2039/40
*
2040/41
*
2041/42
*
2042/43
*
2043/44
* Total
Additional
costs 326 320 327 327 330 332 335 337 340 342 5,811
Of which
health,
housing,
and social
care
296 294 298 299 301 304 306 308 310 313 5,417
Of which
justice 30 26 29 28 28 29 29 29 29 30 394
Process
cost
savings
10 12 12 12 12 13 13 13 13 13 156

22

Of which
health,
housing,
and social
care
5 6 6 6 6 6 6 6 7 7 75
Of which
justice 6 6 6 6 6 6 6 6 7 7 81
Total costs 316 308 315 315 318 320 322 324 327 329 5,656
Of which
health,
housing,
and social
care
291 288 292 293 295 297 299 302 304 306 5,342
Of which
justice 25 20 23 22 22 22 22 23 23 23 313
*Timeline and cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.

Summary of costs by public service sector
45. The estimated monetised costs of the policy interventions under Option 2 in England have been
disaggregated into costs relating to the NHS (excluding housing costs for people with a learning
disability and autistic people) , Local Authorities (excluding reforms relating to people with a
learning disability and autistic people), Housing and Care costs (reforms relating to people with
a learning disability and autistic people ), Care Quality Commission ( CQC), and the Justice
System.
46. Over the 20-year appraisal period, in England, there are an estimated £1.9 billion of costs for the
NHS (excluding housing costs for people with a learning disability and autistic people) , £396
million of costs for Local Authorities (excluding reforms related to people with a learning disability
and autistic people ), £2.5 billion for housing and care costs (reforms relating to people with a
learning disability and autistic people, NHS/LA/DWP), £78 million of costs for the CQC, and £287
million of costs for the Justice system.
47. These costs include process cost savings, which represent reductions in the additional process
costs due to the reforms, such as those relating to a reduction in the use of CTOs. It has not been
possible to disaggregate the costs by public service sector in Wales.
Table 3. Additional costs by public body, England only (£millions, 2024/25 prices, undiscounted) -
Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
NHS (excl. housing
costs for people with
a learning disability
and autistic people)
0 4 215 110 38 62 84 100 107 106
Local Authority (excl.
additional community
care costs for
reforms relating to
people with a
learning disability
and autistic people)
0 0 2 15 18 21 20 26 26 26
Housing and care
costs (reforms
relating to people
with a learning
disability and autistic
people), (NHS, LA,
DWP)
0 0 202 201 129 129 130 130 131 132
CQC 0 0 0 0 0 0 5 5 5 5
Justice System 0 0 0 0 0 0 28 22 24 24

23

Total 0 4 419 326 185 213 267 283 293 293

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
NHS (excl.
housing costs
for people with
a learning
disability and
autistic people)
109 107 109 110 111 112 113 114 115 116 1,941
Local Authority
(excl.
additional
community
care costs for
reforms
relating to
people with a
learning
disability and
autistic people)
27 27 27 28 28 29 30 30 31 31 441
Housing and
care costs
(reforms
relating to
people with a
learning
disability and
autistic people)
(NHS, LA,
DWP)
132 133 133 134 134 135 135 136 137 137 2530
CQC 5 6 6 6 6 6 6 6 6 6 78
Justice System 28 24 27 26 26 26 26 27 27 27 362
Total 302 296 302 303 305 308 310 312 315 317 5,352
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.

Table 4. Process cost savings by public body, England only (£millions, 2024/25 prices,
undiscounted) - Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
NHS (excl. housing
costs for people with
a learning disability
and autistic people)
0 0 0 1 1 2 1 1 1 1
Local Authority (excl.
additional community
care costs for
reforms relating to
people with a
learning disability
and autistic people)
0 0 0 0 0 0 0 1 2 2
Housing and care
costs (reforms
relating to people
with a learning
disability and autistic
people) (NHS, LA,
DWP)
0 0 0 0 0 0 0 0 0 0
CQC 0 0 0 0 0 0 0 0 0 0
Justice System 0 0 0 0 0 0 4 4 4 5
Total 0 0 0 1 1 2 5 6 7 8

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total

24

NHS (excluding
housing costs for
people with a
learning disability
and autistic
people)
2 2 2 2 2 2 2 2 2 2 28
Local Authority
(excl. additional
community care
costs for reforms
relating to people
with a learning
disability and
autistic people)
3 4 4 4 4 4 4 4 4 4 44
Housing and care
costs (reforms
relating to people
with a learning
disability and
autistic people)
(NHS, LA, DWP)
0 0 0 0 0 0 0 0 0 0 0
CQC 0 0 0 0 0 0 0 0 0 0 0
Justice System 5 6 6 6 6 6 6 6 6 6 74
Total 10 11 11 11 12 12 12 12 12 13 147
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.

Table 5. Total costs by public body, England only (£millions, 2024/25 prices, undiscounted) -
Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
NHS (excluding
housing costs for
people with a
learning disability
and autistic people)
0 4 215 109 38 61 83 99 106 105
Local Authority (excl.
additional community
care costs for
reforms relating to
people with a
learning disability
and autistic people)
0 0 2 14 18 21 20 24 24 24
Housing and care
costs (reforms
relating to people
with a learning
disability and autistic
people) (NHS, LA,
DWP)
0 0 202 201 129 129 130 130 131 132
CQC 0 0 0 0 0 0 5 5 5 5
Justice System 0 0 0 0 0 0 24 18 20 19
Total 0 4 419 325 184 210 262 277 286 285

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
NHS (excluding
housing costs for
people with a
learning disability
and autistic
people)
108 105 107 108 109 110 110 111 113 114 1,913
Local Authority
(excl. reforms
relating to people
24 23 24 24 25 25 26 26 26 27 396

25

with a learning
disability and
autistic people)
Housing and care
costs (reforms
relating to people
with a learning
disability and
autistic people)
(NHS, LA, DWP)
132 133 133 134 134 135 135 136 137 137 2,530
CQC 5 6 6 6 6 6 6 6 6 6 78
Justice System 23 18 21 20 20 21 21 21 21 21 287
Total 292 285 291 292 294 296 298 300 302 304 5,205
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.
Monetised Costs - Health and Social Care System
Costs by process/policy
48. The estimated additional costs for the main health and social care policies for each policy change
or process have been monetised and are presented in Table 7 for England only. The majority of
these costs relate to additional process costs due extra workload. Some of the reforms are
expected to reduce the volume of detentions, admissions , and CTOs, which will reduce these
process costs. We refer to these as process cost savings in Table 8. The total estimated costs of
these reforms are shown in Table 9. Some associated costs have not been monetised, which are
discussed in the non-monetised section. Detail of the analytical assumptions used to monetise
these costs can be found in Annex C.
49. Costs for Wales have been estimated based on applying an uplift factor to costs for England.
Further detail and costs for Wales are presented in Annex G.
50. The details of the health and social care policies are presented below:
• Nominated person (NP) - This includes administrative costs for activities such as recording
the NP, and any associated changes, in the patient’s record, providing information to the NP
(e.g. on the CTP) and consulting with them where necessary. This also covers costs associated
with additional meetings required between AMHPs and Nominated Person before a CTO can
be finalised, and costs to nurses relating to CTP liaison.
• Opt-Out Advocacy - This covers costs to IMHAs for providing advocacy support for formal
patients which equates to between 46,000 and 48,000 detentions each year post
implementation.
• Informal advocacy - This covers costs to IMHAs for providing advocacy support for informal
patients which equates to around an additional 27,000 admissions each year post
implementation.
• Advance Choice Documents (ACDs) – This covers the costs associated with the additional
workload for staff who may be involved with signposting and supporting people identified as
being at high risk of admission under the MHA to draft an ACD. The modelling assumed to
include costs for the NHS staff (key worker/care coordinators and ACD facilitators,
psychiatrists, administrative staff) and local authority staff (social workers). In practice, a wider
range of workforce groups may be involved, and the extent of support is dependent on what is
best for individuals. For example, this may include VCSE staff, may not always require clinical
involvement, or may any form of professional support at all, where the person wishes to write
the ACD alone or with their family or carer. This also includes process cost savings resulting
from a reduction in overall admissions (driven by a reduction in detentions) . Full assumptions
used to monetise these impacts can be found in Annex C.III.

26

• Changes to SOAD visits – This covers costs to SOADs relating to additional visits from
around 15,000 per year to 28,000 per year post implementation. It also covers costs for Section
61 reviews, and their new role in deciding urgent ECTs . This also includes process costs to
Approved Clinicians and Nurses relating to additional contact with SOADs.
• Changes to CTOs – The reforms introduce greater scrutiny to CTOs and amend the CTO
criteria in line with the new detention criteria are expected to have the effect of reducing CTOs
by ensuring they are used in a more targeted way. They should only be used where there is a
risk of serious harm self or others and where the community clinician agrees that it is necessary
and appropriate for the patient. Earlier automatic referrals to the tribunal should also see people
discharge from CTOs sooner. However, it i s possible that clinicians may be more risk averse
in the public protection context and therefore more inclined to issue a CTO, which may negate
the degree to which use of CTO decreases overtime with our changes.
• This costs for this policy therefore includes additional process costs for community supervising
clinicians relating to additional involvement in CTO assessments and renewals . This also
includes process costs savings due to a reduction in the use of CTOs , which is expected
following changes in the CTO criteria and greater scrutiny applied to CTOs.
o In the central scenario, we assume that CTOs will decrease gradually over a five-year
period from 2031/31, reaching a total 20% reduction relative to the baseline. Table 6
shows this reduction in CTOs, which is inclusive of reductions due to the impact of
reforms for people with a learning disability and autistic people and ACDs. Further
information can be found in Annex C.I.
Table 6. Estimated Reduction in CTOs (based on central detention scenario)
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Central Scenario - (gradual reduction in CTOs reaching 20% reduction in 2031/32)
Reduction in
CTOs 0 0 20 40 40 130 170 400 630 850
2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Reduction
in CTOs
1,070 1,290 1,290 1,300 1,300 1,310 1,310 1,320 1,320 1,330 15,100
*Profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: These numbers have been modelled using data from England only. Numbers are rounded to nearest 10.
• Statutory Care and Treatment Plans (CTPs) – This includes costs to Approved Clinicians for
setting up CTPs, costs to nurses for CTP updates, costs to administrative staff for setting up
an automated system and for CTP audits, and costs to IMHAs for preparation, meeting and
travel.
• Additional tribunals – This covers support for more frequent tribunal for patients detained
under the MHA and CTOs, which corresponds to additional costs for clinicians, nurses and key
workers/care coordinators (relating to certification, travel and report writing), and costs to
administrative staff for setting up tribunals.
• Increased S3 renewals – This includes costs related to additional workload for Approved
Clinicians.
• C(E)TRs - This includes workforce costs for staff conducting the C(E)TR, including a
chairperson, a clinical expert, an expert by experience, clinical staff involved in delivering an
individual’s everyday care, education representatives if the CETR is for a CYP, and an
administrator.
• DSRs - This includes workforce costs for staff conducting the DSR care plan review, including
a commissioning manager, a learning disability and autism senior officer, a social care services

27

manager, an administrator, and the following additional staff if the review is for a CYP: a senior
EHCP coordinator and keyworker support.
• Change in detention criteria for people with a learning disability and autistic people -
This includes costs of community care e.g. housing capital and revenue costs, care and support
packages. This also includes estimates for community infrastructure costs which cover a range
of support services including intensive support teams, community fore nsic teams, and
keyworker services. See Annex D for more details on associated cost modelling.
• Familiarisation and backfill costs – This includes costs for one-off familiarisation training and
backfill pay for Approved Clinicians, Section 12 doctors, MHA managers, SOADs, AMHPs and
IMHAs, and costs to establish an NHS online learning hub.
• Training costs – This includes t raining costs for all modelled staff groups , assuming an
expansion in workforce to accommodate additional workload of the reforms.

Table 7. Additional costs for the Health and Social Care system by policy or process, England
only (£millions, 2024/25 prices, undiscounted) – Central Estimate

2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Nominated
Persons 0 0 0 2 2 2 2 3 3 3
Opt-Out Advocacy 0 0 0 10 10 10 10 10 10 10
Informal Advocacy 0 0 0 0 5 5 6 6 6 6
ACDs 0 0 0 0 0 22 16 16 16 16
Changes to SOAD
visits 0 0 0 0 0 0 9 10 10 10
Changes to CTOs 0 0 0 0 0 0 0 0 3 3
Statutory CTPs 0 0 0 2 2 2 2 22 23 23
Additional
Tribunals 0 0 0 0 0 0 10 6 7 6
Increased S3
Renewals 0 0 0 0 0 0 6 7 7 7
C(E)TRs – see
Annex DXI for
costs
0 0 0 0 0 0 0 0 0 0
DSRs 0 3 3 3 3 3 3 3 3 3
Familiarisation &
Backfill Costs 0 0 9 9 0 0 0 0 0 0
Training Costs 0 0 0 1 0 3 7 10 11 10
NHS Community
Care Services
(transfer of
activity) (excl.
people with a
learning disability
and autistic
people)
0 0 0 0 0 3 5 5 6 6
NHS Community
Care Services
(transfer of
activity) (people
with a learning
disability and
autistic people) -
excl. Housing
Costs
0 0 343 130 0 0 0 0 0 0
Social Care
Services (transfer
of activity) (people
with a learning
disability and
autistic people)
0 0 0 44 44 44 44 44 44 45

28

Housing capital
cost 0 0 12 58 58 58 58 59 59 59
Housing revenue
cost 0 0 19 35 27 27 27 28 28 28
Community
Infrastructure cost 0 0 33 33 33 33 33 33 33 33
Total 0 4 419 326 185 213 239 262 269 269

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Nominated
Persons 3 3 3 3 4 4 4 4 4 4 55
Opt-Out
Advocacy 10 11 11 11 11 11 12 12 12 12 181
Informal
Advocacy 6 6 6 6 6 7 7 7 7 7 99
ACDs 16 17 17 17 18 18 18 18 19 19 263
Changes to
SOAD visits 10 10 11 11 11 11 11 11 11 12 149
Changes to CTOs 3 2 2 2 2 2 3 3 3 3 31
Statutory CTPs 23 24 24 25 25 26 26 26 27 27 329
Additional
Tribunals 9 6 8 7 7 8 8 8 8 8 105
Increased S3
Renewals 7 7 7 7 7 8 8 8 8 8 102
C(E)TRs – see
Annex DXI for
costs
0 0 0 0 0 0 0 0 0 0 4
DSRs 3 3 3 3 3 3 3 3 3 3 53
Familiarisation &
Backfill Costs 0 0 0 0 0 0 0 0 0 0 18
Training Costs 10 9 10 9 9 9 9 9 8 8 133
NHS Community
Care Services
(transfer of
activity) (excl.
people with a
learning disability
and autistic
people)
7 7 7 7 7 8 8 8 8 8 99
NHS Community
Care Services
(transfer of
activity) (people
with a learning
disability and
autistic people) -
excl. Housing
Costs
0 0 0 0 0 0 0 0 0 0 472
Social Care
Services (transfer
of activity)
(people with a
learning disability
and autistic
people)
45 45 45 45 46 46 46 46 46 47 766
Housing capital
cost 59 60 60 60 60 60 61 61 61 61 1,023
Housing revenue
cost 28 28 28 28 29 29 29 29 29 29 505
Community
Infrastructure cost 33 33 33 33 33 33 33 33 33 33 603
Total 274 272 276 277 279 281 283 285 288 290 4,990
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding. This may make some non-zero figures appear as “0”,
for example, C(E)TRs. Due to the interaction between different policies and processes related to detention volumes, the impacts
listed for each policy include not only the impacts of the policy change, but also impacts affecting the process cost item most
relevant to the policy. This means that some impacts may occur before a specific policy change has been implemented.

29

Table 8. Process cost savings for the Health and Social Care System by policy or process,
England only (£millions, 2024/25 prices, undiscounted) – Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Nominated Persons 0 0 0 0 0 0 0 0 0 0
Opt-Out Advocacy 0 0 0 0 0 0 0 0 0 0
Informal Advocacy 0 0 0 0 0 0 0 0 0 0
ACDs 0 0 0 0 0 0 0 0 0 0
Changes to SOAD
visits 0 0 0 0 0 0 0 0 0 0
Changes to CTOs 0 0 0 0 0 1 1 2 3 4
Statutory CTPs 0 0 0 0 0 0 0 0 0 0
Additional Tribunals 0 0 0 0 0 1 0 0 0 0
Increased S3
Renewals 0 0 0 0 0 0 0 0 0 0
C(E)TRs 0 0 0 0 0 0 0 0 0 0
DSRs 0 0 0 0 0 0 0 0 0 0
Familiarisation &
Backfill Costs 0 0 0 0 0 0 0 0 0 0
Training Costs 0 0 0 0 0 0 0 0 0 0
NHS Community
Care Services
(transfer of activity)
(excl. people with a
learning disability and
autistic people)
0 0 0 0 0 0 0 0 0 0
NHS Community
Care Services
(transfer of activity)
(people with a
learning disability and
autistic people) -
excl. Housing Costs
0 0 0 0 0 0 0 0 0 0
Social Care Services
(transfer of activity)
(people with a
learning disability and
autistic people)
0 0 0 0 0 0 0 0 0 0
Housing capital cost 0 0 0 0 0 0 0 0 0 0
Housing revenue
cost 0 0 0 0 0 0 0 0 0 0
Community
Infrastructure cost 0 0 0 0 0 0 0 0 0 0
Total 0 0 0 1 1 2 1 2 3 4

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Nominated Persons 0 0 0 0 0 0 0 0 0 0 0
Opt-Out Advocacy 0 0 0 0 0 0 0 0 0 0 0
Informal Advocacy 0 0 0 0 0 0 0 0 0 0 0
ACDs 0 0 0 0 0 0 0 0 0 0 0
Changes to SOAD
visits 0 0 0 0 0 0 0 0 0 0 0
Changes to CTOs 5 6 6 6 6 6 6 6 6 7 69
Statutory CTPs 0 0 0 0 0 0 0 0 0 0 1
Additional Tribunals 0 0 0 0 0 0 0 0 0 0 2
Increased S3
Renewals 0 0 0 0 0 0 0 0 0 0 0
C(E)TRs 0 0 0 0 0 0 0 0 0 0 0
DSRs 0 0 0 0 0 0 0 0 0 0 0
Familiarisation &
Backfill Costs 0 0 0 0 0 0 0 0 0 0 0
Training Costs 0 0 0 0 0 0 0 0 0 0 1
NHS Community
Care Services
(transfer of activity)
(excl. people with a
learning disability
and autistic people)
0 0 0 0 0 0 0 0 0 0 0
NHS Community
Care Services
(transfer of activity)
(people with a
learning disability
0 0 0 0 0 0 0 0 0 0 0

30

and autistic people) -
excl. Housing Costs
Social Care Services
(transfer of activity)
(people with a
learning disability
and autistic people)
0 0 0 0 0 0 0 0 0 0 0
Housing capital cost 0 0 0 0 0 0 0 0 0 0 0
Housing revenue
cost 0 0 0 0 0 0 0 0 0 0 0
Community
Infrastructure cost 0 0 0 0 0 0 0 0 0 0 0
Total 5 6 6 6 6 6 6 6 6 7 73
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding. Due to the interaction between different policies and
processes related to detention volumes, the impacts listed for each policy include not only the impacts of the policy change, but
also impacts affecting the process cost item most relevant to the policy. This means that some impacts may occur before a specific
policy change has been implemented.
Table 9. Total costs for the Health and Social Care System by policy or process, England only
(£millions, 2024/25 prices, undiscounted) – Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Nominated Persons 0 0 0 2 2 2 2 3 3 3
Opt-Out Advocacy 0 0 0 10 10 10 10 10 10 10
Informal Advocacy 0 0 0 0 5 5 6 6 6 6
ACDs 0 0 0 0 0 22 16 16 16 16
Changes to SOAD
visits 0 0 0 0 0 0 9 10 10 10
Changes to CTOs 0 0 0 0 0 -1 -1 -2 1 -1
Statutory CTPs 0 0 0 2 2 2 1 22 23 23
Additional Tribunals 0 0 0 0 0 -1 10 6 7 6
Increased S3
Renewals 0 0 0 0 0 0 6 7 7 7
C(E)TRs – see
Annex DXI for costs 0 0 0 0 0 0 0 0 0 0
DSRs 0 3 3 3 3 3 3 3 3 3
Familiarisation &
Backfill Costs 0 0 9 9 0 0 0 0 0 0
Training Costs 0 0 0 1 0 3 7 10 11 10
NHS Community
Care Services
(transfer of activity)
(excl. people a with
learning disability and
autistic people)
0 0 0 0 0 3 5 5 6 6
NHS Community
Care Services
(transfer of activity)
(people with a
learning disability and
autistic people) -
excl. Housing Costs
0 0 343 130 0 0 0 0 0 0
Social Care Services
(transfer of activity)
(people with a
learning disability and
autistic people)
0 0 0 44 44 44 44 44 44 45
Housing capital cost 0 0 12 58 58 58 58 59 59 59
Housing revenue
cost 0 0 19 35 27 27 27 28 28 28
Community
Infrastructure cost 0 0 33 33 33 33 33 33 33 33
Total 0 4 419 325 184 211 238 260 266 266

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Nominated
Persons 3 3 3 3 4 4 4 4 4 4 55
Opt-Out Advocacy 10 11 11 11 11 11 12 12 12 12 180
Informal Advocacy 6 6 6 6 6 7 7 7 7 7 99
ACDs 16 17 17 17 18 18 18 18 19 19 263
Changes to SOAD
visits 10 10 11 11 11 11 11 11 11 12 149
Changes to CTOs -2 -3 -3 -3 -4 -4 -4 -4 -4 -4 -38

31

Statutory CTPs 23 24 24 25 25 26 26 26 27 27 328
Additional
Tribunals 9 6 8 7 7 8 8 8 8 8 103
Increased S3
Renewals 7 7 7 7 7 8 8 8 8 8 102
C(E)TRs – see
Annex DXI for
costs
0 0 0 0 0 0 0 0 0 0 4
DSRs 3 3 3 3 3 3 3 3 3 3 53
Familiarisation &
Backfill Costs 0 0 0 0 0 0 0 0 0 0 18
Training Costs 10 9 10 9 9 9 9 9 8 8 132
NHS Community
Care Services
(transfer of activity)
(excl. people with a
learning disability
and autistic people)
7 7 7 7 7 8 8 8 8 8 99
NHS Community
Care Services
(transfer of activity)
(people with a
learning disability
and autistic people)
- excl. Housing
Costs
0 0 0 0 0 0 0 0 0 0 472
Social Care
Services (transfer
of activity) (people
with a learning
disability and
autistic people)
45 45 45 45 46 46 46 46 46 47 766
Housing capital
cost 59 60 60 60 60 60 61 61 61 61 1,023
Housing revenue
cost 28 28 28 28 29 29 29 29 29 29 505
Community
Infrastructure cost 33 33 33 33 33 33 33 33 33 33 603
Total 269 266 270 271 273 275 277 279 281 283 4,917
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding. This may make some non-zero figures appear as “0”,
for example, C(E)TRs. Due to the interaction between different policies and processes related to detention volumes, the impacts
listed for each policy include not only the impacts of the policy change, but also impacts affecting the process cost item most
relevant to the policy. This means that some impacts may occur before a specific policy change has been implemented.
Costs by professional group
51. Below presents a summary of the approach for monetising process costs due to changes in MHA
activities, disaggregated by workforce group where this has been possible in England. This has
not been the case for all impacts considered, so the following results should not be taken as
comprehensive of all the impacts on affected workforces, with some additional effects detailed
under ‘Non-monetised costs’.
52. Presented below are our best estimate of the process cost impacts , mostly valued using
information on salaries and on -costs applied to staff time estimates , with more methodological
detail provided in annexes for different policy changes. In some cases, these estimates represent
a simpli fication, with some costs estimated using assumptions that all relevant tasks are
conducted by certain types of staff when in practice some other professionals may undertak e
these duties instead in some cases.
53. These cost estimates disaggregated by staff group do not sum to the total costs of the policies,
because they exclude the impact of changes to detention criteria for people with a learning
disability and autistic people, presented separately, or the wider cost impacts (which go beyond
MHA process costs) of diverting other patients away from hospital care. They also only consider
the costs in England, as it has not been possible to disaggregate by workforce group in Wales.
54. The assumptions around additional FTE needed (which underpin the cost estimates ) can also
be found below, disaggregated by workforce group. This only shows a partial picture of workforce
impacts for the same reasons above. We also do not include the benefits (time saved) for

32

workforce resulting from diverting people away from admission in these FTE estimates, as these
were modelled using a ‘top down’ approach using total bed day costs rather than by costs for
each workforce group. These estimates represent the additional workforce time in equivalent FTE
to indicate the scale of additional pressure on the system. They do not represent headcount
estimates or imply a workforce implementation plan.
Costs by professional group – Independent Mental Health Advocates (IMHAs)
55. An IMHA is an independent advocate who is trained to work within the framework of the MHA to
support people understanding their rights under the Act and participating in decisions about their
care and treatment. IMHAs are not employed by the NHS or any private healthcare provider; they
are commissioned via local authorities in England23.
56. Under Option 1 (BAU), IMHAs are assumed to be involved in the following activities:
• Providing independent mental health advocacy to formal patients
• Providing advocacy for Care and Treatment Plans (CTPs)
• Providing support for Mental Health Tribunals (MHT)
• Providing support at CTO assessments
57. Under Option 2, the IMHA is expected to have additional workload resulting from the following
policy changes:
• The Government proposes that all formal patients (excluding those under short term
sections, like Section 4) receive a timely plan on their care and treatment and how they will
be progressed towards discharge. This is expected to increase the uptake of CTPs which
will require more support from IMHAs.
• The Government proposes to increase access to and frequency of MHTs. proposals
relating to MHTs. This is expected to increase the support required from IMHAs.
• The Government proposes to increase the uptake of independent advocates among formal
patients. The statutory right to an IMHA will also extend to all mental health patients,
including informal/voluntary patients . This will result in additional people requiring IMHA
advocacy and support.

58. Under Option 2, the IMHA is expected to have a reduced workload resulting from the following
policy change:
• The Government proposes to introduce greater scrutiny and ensure that a CTO is only
used when appropriate. This is expected to reduce the use of CTOs.

59. In both Options 1 and 2, annual costs associated with IMHAs cover estimated salary, oncosts ,
overheads, and capital costs. Costs were calculated by multiplying the estimated FTEs in each
year by the estimated annual cost per AMHP in Option 1 (BAU) and Option 2. The total additional
cost is the difference between Option 1 and Option 2. Further detail of the assumptions used to
estimate the impact of policy changes on this workforce group can be found in Annex C.

60. Table 10 illustrates the additional process costs and saving s over the twenty-year appraisal
period from 2024/25 to 2043/44, giving a total cost for IMHAs of £382 million.

Table 10. Process costs and additional FTE for Independent Mental Health Advocates, England
only (£millions, 2024/25 prices, undiscounted) - Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*

23 POhWER. Independent Mental Health Advocacy (IMHA). Accessed at: Independent Mental Health Advocacy (IMHA) | POhWER

33

Additional process
costs 0 0 0 12 17 17 17 22 23 23
Process cost
savings 0 0 0 0 0 0 0 0 0 0
Total process
costs 0 0 0 12 17 17 17 22 22 23
Total additional
FTE (in year) 0 0 -1 227 333 326 323 415 416 417

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional
process costs 23 24 24 25 25 26 26 27 27 28 386
Process cost
savings 0 0 0 0 0 0 0 0 0 0 4
Total process
costs 23 24 24 25 25 25 26 26 27 27 382
Total additional
FTE (in year) 419 420 421 423 424 426 427 428 430 431
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.
Costs by professional group – Approved Mental Health Professionals (AMHPs)
61. Approved Mental Health Professionals (AMHPs), who are mostly commissioned by local
authorities, are responsible for organising and undertaking assessments under the MHA and,
where statutory criteria are met, authorising detention under the Act. Their work covers a wide
range of activities, including, but not limited to, ensuring service users are int erviewed in an
appropriate manner, that they know what their rights are if they are detained, and that detainees
are treated in a human and dignified way24.
62. Under Option 1 (BAU), AMHPs are assumed to be present at assessment and at renewals of
Community Treatment Orders (CTOs).
63. Under Option 2, the AMHP is expected to have additional workload resulting from the following
policy change:
• The Government proposal to introduce greater scrutiny and ensure that a CTO is only
used when appropriate will require an AMHP to attend an additional meeting with the
Nominated Person for a CTO assessment.

64. Under Option 2, the AMHP is expected to have a reduced workload resulting from the following
policy change:
• The Government proposal to introduce greater scrutiny and ensure that a CTO is only
used when appropriate is expected to reduce the use of CTOs.

65. In both Options 1 and 2, annual costs associated with AMHPs cover estimated salary, oncosts,
overheads, and capital costs. Costs were calculated by multiplying the estimated FTEs in each
year by the estimated annual cost per AMHP in Option 1 (BAU) and Option 2. The total additional
cost is the difference between Option 1 and Option 2. Further detail of the assumptions used to
estimate the impact of policy changes on this workforce group can be found in Annex C.
66. Table 11 illustrates the additional process costs and process cost savings over the twenty-year
appraisal period. As AMHPs are involved with CTO activity, which is forecast to reduce due to
the reforms, there is estimated to be an overall saving for AMHPs of £31 million.

24 Lancashire Care NHS Foundation Trust (2018). What is an Approved Mental Health Professional. Accessed at (12/09/19):
https://www.lancashirecare.nhs.uk/Approved-Mental-Health-Professional

34

Table 11. Process costs and additional FTE for Approved Mental Health Professionals, England
only (£millions, 2024/25 prices, undiscounted) - Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional process
costs 0 0 0 1 1 1 1 1 1 1
Process cost
savings 0 0 0 0 0 0 0 1 2 2
Total process
costs 0 0 0 1 1 0 0 0 -1 -2
Total additional
FTE (in year) 0 0 -1 6 6 4 2 -4 -10 -16

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional
process costs 1 1 1 1 1 1 1 1 1 1 10
Process cost
savings 3 3 3 3 4 4 4 4 4 4 41
Total process
costs -2 -3 -3 -3 -3 -3 -3 -3 -3 -3 -31
Total additional
FTE (in year) -22 -29 -29 -29 -29 -29 -29 -29 -29 -29
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes

NoteTotals may not equal the sum of the annual figures due to rounding.
Costs by professional group – Social Workers
67. Under Option 2, we expect that local authority staff will have additional workload resulting from
the following policy change:
• Commissioning bodies will be under a duty to make arrangements so that people who are
at risk of detention are informed of their ability to make an ACD and that those who wish
to receive professional support to write an ACD, receive it.

68. Local authority staff may be involved with supporting people to draft an ACD. We have proxied
local authority costs using mental health social worker salaries. We have used evidence from the
Personal Social Services Research Unit (PSSRU) at the University of Kent 25 to estimate annual
costs to employ social workers. Costs include salaries, oncosts (such as National Insurance) and
overheads as well as accommodating for annual leave and sick leave.
69. It is assumed that local authority staff may be involved with supporting drafting of ACDs in 50%
of cases. Assumptions around staff time for ACDs can be found in Annex C.III. This is estimated
to cost £35 million over the 20-year appraisal period as seen in Table 12.

Table 12. Process costs and additional FTE for Social Workers, England only (£millions, 2024/25
prices, undiscounted) - Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional process
costs 0 0 0 0 0 3 2 2 2 2
Process cost
savings 0 0 0 0 0 0 0 0 0 0
Total process
costs 0 0 0 0 0 3 2 2 2 2
Total additional
FTE 0 0 0 0 0 35 26 25 25 25

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total

25 Personal Social Services Research Unit: p75, The unit costs of health and social care_Final3.pdf (kent.ac.uk)

35

Additional
process costs 2 2 2 2 2 2 2 2 3 3 35
Process cost
savings 0 0 0 0 0 0 0 0 0 0 0
Total process
costs 2 2 2 2 2 2 2 2 3 3 35
Total additional
FTE (in year) 25 25 25 25 25 25 25 25 25 25
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes

NoteTotals may not equal the sum of the annual figures due to rounding.
Costs by professional group – Second Opinion Appointed Doctors (SOADs)
70. The Second O pinion Appointed Doctor (SOAD) service is managed by the Care Quality
Commission (CQC) and safeguards the rights of patients detained under the MHA who either
refuse the treatment prescribed to them or are deemed incapable of consenting. The role of the
SOAD is to decide whether the treatment, determined by the patient’s clinical team, is
appropriate. As part of this assessment, the SOAD should assess if due consideration has been
given to the views and rights of the patient.
71. Under Option 1 (BAU), certain cohorts of patients are eligible for the SOAD service. Under this
option, the SOAD service is also responsible to review Section 61 reports, which are reports
made by the Clinician and sent to CQC when patients are not consenting to treatment.
72. Under Option 2, the SOAD is expected to have additional workload resulting from the following
policy changes:
• The cohort eligible to be in scope for a SOAD visit is widened.
• The SOAD will also be able to request Section 61 reports for consenting patients and will
also be required to certify urgent Electro-Convulsive Therapy (ECTs) for patients who are
not consenting (either refusing via an advance choice document (ACD) or lacking capacity
to consent at the time).
73. This will result in additional demand for SOADs, with more requirements placed on individual
SOADs and more SOADs being needed than are currently in place. Further information is
provided in Annex C.VI. In both options, annual costs associated with SOADs cover unit costs
per SOAD visit as well as other oncosts like travel and subsistence.
74. Table 13 illustrates the additional process costs and process cost savings over the twenty-year
period from 2024/25 to 2043/44, showing an overall net cost of £77 million.
Table 13. Process costs and additional headcount for Second Opinion Appointed Doctors
(SOADs), England only (£millions, 2024/25 prices, undiscounted) - Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional process
costs 0 0 0 0 0 0 5 5 5 5
Process cost
savings 0 0 0 0 0 0 0 0 0 0
Total process
costs 0 0 0 0 0 0 5 5 5 5
Total additional
headcount (in
year)**
0 0 0 0 0 -1 274 385 396 404

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional
process costs 5 6 6 6 6 6 6 6 6 6 77
Process cost
savings 0 0 0 0 0 0 0 0 0 0 0

36

Total process
costs 5 6 6 6 6 6 6 6 6 6 77
Total additional
headcount (in
year)**
410 414 419 421 422 423 425 426 428 429
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
** The additional headcount was modelled by using number of visits and so FTE was not appropriate

NoteTotals may not equal the sum of the annual figures due to rounding. Costs in the table above exclude training costs.
Costs by professional group – Clinical teams
75. Clinical teams in inpatient and community settings are formed of multiple disciplines, including
psychiatrists, nurses, occupational therapists, social workers, psychologists, support workers and
healthcare assistants.
76. Under Option 1 (BAU ), members of multi -disciplinary teams may be involved in the following
activities:
• Set up of Care and Treatment Plans (CTPs)
• Attending and follow up of Mental Health Tribunals (MHTs), including providing certification.
• Assessment and renewals of Community Treatment Orders (CTOs)
• Contact with SOAD visits.
• Section 3 detention renewals

77. Under Option 2, clinical teams will have additional workload resulting from:
• increased number and reviews of CTPs
• increased number and frequency of MHTs
• increased frequency of Section 3 renewals
• increased SOAD visits
78. In addition, given a new duty placed on ICBs to provide make people aware of ACDs and provide
support to people to develop ACDs, these professionals (particularly those working in the
community) will likely play a new role in supporting patients to prepare their Advanced Choice
Documents (ACDs). More details can be founded in Annex C.III.
79. However, there will be process cost savings resulting from fewer CTOs under Option 2 on this
professional group.
80. For both options, we calculated the additional costs to the healthcare system by multiplying the
number of extra staff required for each profession by estimated staff costs. ACD annual costs
were assessed separately for each healthcare profession for Option 2 with assumptions about
additional workload discussed and agreed with NHS England.
81. NHS staff costs have been estimated using data from the PSSRU where total annual costs are
provided per staff group. Annual costs include Salary costs, oncosts and overheads and account
for annual/sick leave.
82. Over the twenty-year period from 2024/25 to 2043/44, additional process costs were estimated
at £761 million and process cost savings of £28 million, showing an overall process cost of £734
million as shown in Table 14.
Table 14. Process costs and additional FTE for clinical teams, England only (£millions, 2024/25
prices, undiscounted) - Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional process
costs 0 0 0 1 1 19 34 46 51 51
Process cost
savings 0 0 0 0 0 1 1 1 1 1

37

Total process
costs 0 0 0 0 0 17 34 45 50 50
Total additional
FTE (in year) 0 0 -1 6 6 175 263 308 327 320

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional
process costs 54 51 54 54 55 56 57 58 59 60 761
Process cost
savings 2 2 2 2 2 2 2 2 2 2 28
Total process
costs 52 49 52 52 53 54 55 56 57 58 734
Total additional
FTE (in year) 333 313 323 321 321 322 323 324 325 326
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes

NoteTotals may not equal the sum of the annual figures due to rounding.
Costs by professional group – Administrative staff in healthcare providers
83. Policies that are expected to bring additional costs for administrative staff under Option 2 are:
• The development of ACDs
• Increased number of tribunals
• Extra workload from the reform of Nearest Relative to Nominated Person as a patient may be
able to update this multiple times per detention.
• Additional responsibilities for the Mental Health Act Managers
84. To estimate these additional tasks for administrative staff costs, we used assumptions on extra
time required for the additional tasks and multiplied the number of these by the average staff
costs associated with each 26. More information can be found in Annex C under each policy
description.
85. The estimated additional process costs are estimated at £43 million over the twenty-year
appraisal period from 2024/25 to 2043/44, as shown in Table 15.
Table 15. Process costs and additional FTE for administrative staff in healthcare providers,
England only (£millions, 2024/25 prices, undiscounted) - Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional process
costs 0 0 0 1 1 2 2 3 3 3
Process cost
savings 0 0 0 0 0 0 0 0 0 0
Total process
costs 0 0 0 1 1 2 2 3 3 3
Total additional
FTE (in year) 0 0 0 17 17 26 28 43 43 42

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional
process costs 3 3 3 3 3 3 3 3 3 3 43
Process cost
savings 0 0 0 0 0 0 0 0 0 0 0
Total process
costs 3 3 3 3 3 3 3 3 3 3 43
Total additional
FTE (in year) 43 42 43 43 43 43 43 43 43 44
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes

NoteTotals may not equal the sum of the annual figures due to rounding.

26 It is quite uncertain how the NP changes will be in practice and how much more additional administrative they would require. Due to this
uncertainty, agreement on illustrative scenarios was more difficult and they would need to be refined.

38

Familiarisation training & associated backfill costs
86. It is expected that there will be transitional costs to services associated with reforming the MHA,
as several organisations, such as local authorities, commissioners, and providers will have to
update policies, procedures, and documentation. It is likely that extra training would be needed
to prepare those organisations whose roles will directly change because of the reforms. Since it
is not clear at this stage to what extent some of Government’s proposals already represent best
practice in some organisati ons, and what will be taken forward as part of routine updates to
clinical practice, it is not possible to obtain a clear estimate of costs.
87. To help facilitate the planned changes, we have considered that existing staff may need
familiarisation training to bring them up to a working knowledge of the reforms. We have modelled
familiarisation costs based on data available to us on the size of the existing MHA workforce and
additional training that may be required for the reforms. In this IA, we have monetised
familiarisation costs for existing staff for the following workforce groups: NHS staff ( Approved
Clinicians27, Section 12 doctors, MHA managers), Local Authority Staff (AMHPs and IMHAs), and
SOADs. We expect that these are the groups that will require the most significant amount of
training because of the reforms. See Annex C.X where further detail on familiarisation and backfill
cost assumptions has been provided.
88. Familiarisation training is likely to occur in a staggered way in line with the implementation plan
as reforms are ‘switched on’ . H owever, given the uncertainty around actual commencement
dates and difficulty in estimating the size of the affected workforce in each stage of the
familiarisation programme, we have modelled this familiarisation training as occurring for half of
the total existing workforce in 2026/27 and half in 2027/28, as a simplification. We would expect
that ongoing training beyond this initial familiarisation would become part of their normal refresher
training and absorbed into baselines.
89. Familiarisation costs for other existing staff groups could not be monetised due to a lack of
available data on the number of existing staff working on the MHA; we expect many mental health
staff will need to understand what these reforms mean for patients and their work, though these
groups are expected to require less intensive training . We have additionally included a cost of
£350k (2024/25 prices) to establish an online MHA training hub which will capture some of the
cost of delivering familiarisation training to other existing NHS staff, which has been estimated
using stakeholder advice. This cost is expected to occur in 2026/27.
90. A full scoping is required before training can be properly costed . H owever this is currently
estimated at £18 million over the appraisal period, as shown in Table 16.
Table 16. Familiarisation & backfill costs by staff group, England (£million, 2024/25 prices,
undiscounted) - Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
AMHPs 0.0 0.0 1.5 1.5 0.0 0.0 0.0 0.0 0.0 0.0
IMHAs 0.0 0.0 0.3 0.3 0.0 0.0 0.0 0.0 0.0 0.0
Approved Clinicians 0.0 0.0 4.8 4.8 0.0 0.0 0.0 0.0 0.0 0.0
S12 doctors 0.0 0.0 1.9 1.9 0.0 0.0 0.0 0.0 0.0 0.0
MHA managers 0.0 0.0 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.0
SOADs 0.0 0.0 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.0
NHS online learning
hub 0.0 0.0 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Total 0.0 0.0 9.2 8.8 0.0 0.0 0.0 0.0 0.0 0.0

27 The British Psychological Society. Approved Clinician frequently asked questions. (2017). Accessed at: Mental Health Act Advisory Group |
BPS

39

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
AMHPs 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3.0
IMHAs 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.6
Approved
Clinicians 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 9.6
S12 doctors 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3.7
MHA
managers 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.4
SOADs 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3
NHS online
learning hub 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3
Total 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 18.0
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes

NoteTotals may not equal the sum of the annual figures due to rounding.
Training costs of expanding the workforce
91. There will be a range of training requirements for clinical staff that will need consideration,
including operational training on implementing the changes to the MHA and training aimed at
embedding the cultural change the Government wants to achieve as part of the reform agenda –
for example, ensuring that the patient has a greater say and control over their care and treatment.
It is still not defined how this training will be designed, so these costs have not been monetised
yet.
92. DHSC is working with system partners to understand the workforce requirements of the Mental
Health Act Reforms, which will provide the foundation for planning the phased approach to
implementation of the reforms. Monetised staff costs in this IA are based on providing greater
capacity due to additional workload require ments which will likely be satisfied by existing and
newly recruited staff. As ongoing staff training costs are not directly impacted by the reforms and
would be incurred under Option 1, they have not been monetised in the IA.
93. In t his IA , the training costs for staff groups have been modelled where we have quantified
estimates of additional resource requirements, were the workforce to be expanded to
accommodate the additional demands modelled for each staff group.
• NHS Workforce ( Clinicians, Nurses, Other Clinical Staff, Key Workers, Community
Supervising Clinicians): To estimate the costs of training new NHS staff due to additional
workforce being required, we have used evidence from the Personal Social Services Research
Unit (PSSRU) at the University of Kent28 to inform staff unit qualification costs. These represent
the total training cost for a member of staff apportioned across their whole health service career.
The number of additional FTEs estimated to be required to deal with additional MHA process
costs annually is converted to headcount equivalents using data on average workforce contract
hours and multiplied by the se unit costs. Reflecting that many staff will spend the majority of
their time on other tasks beyond those assessed in this IA and may work well beyond the time
horizon assessed here (generating patient benefits not captured), this approach ensures that
only the marginal impact on training costs of the additional workforce demands of the reforms
are included, for a fair comparison with benefits, but means that the estimates are smaller and
not as front-loaded as might be necessary to deliver the necessary capacity in the shorter term.
They do not correspond precisely with the financial costs of a workforce recruitment plan that
considered these reforms along with other staffing requirements.

• Training costs incurred have been estimated using proxies where appropriate, i.e. using Nurses
training costs as a proxy for key workers whilst ‘Other Clinical Staff’ could include psychologists,

28 Personal Social Services Research Unit: p106, The unit costs of health and social care_Final3.pdf (kent.ac.uk)

40

occupational health therapist or healthcare assistants an d have been cost ed using Band 5
nurses as a proxy, so may overstate those for some named workforces whilst omitting others
that will in practice work for the similar organisations and play relevant roles. For the purposes
of this IA, we only include training costs that occur over the appraisal period and are adjusted
for inflation over time. PSSRU estimates of training costs include tuition costs, living expenses
and clinical placements. For doctors, placement fees and salaries are also included.

• AMHPs and IMHAs: the year-on-year difference in additional staff required across the period
has been used to estimate training costs in a simpler way, given training courses for
AMHPs/IMHAs are relatively short compared to clinicians who will incur larger training costs
over a longer period of time . Note, the modelling does not factor in the training pipelines and
the supply routes that will need to be used to increase the supply of staff to support the
expansion of the MHA workforce.
94. Ongoing training costs for existing staff have not been modelled on top of familiarisation costs,
as it is expected that the reforms will form part of refresher training as BAU. See Annex C.X
where further detail on training costs has been provided.
95. The estimates do not include the potential impact of offsetting savings arising from reduced
hospitalisation of patients, which were modelled using sector -level unit costs rather than a
bottom-up assessment for specific staff groups. The refore, they may overstate additional
demands and are not a definitive forecast of the exact workforce numbers that are required or
when it would be optimal to bring additional staff in.
96. Training costs are estimated at £133 million over the appraisal period, as shown in Table 17.
Table 17. Additional training costs by staff group, England only (£million, 2024/25 prices,
undiscounted) - Central Estimate
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
AMHPs 0 0 0 0 0 0 0 0 0 0
IMHAs 0 0 0 1 0 0 0 0 0 0
Social Workers 0 0 0 0 0 0 0 0 0 0
Approved Clinicians 0 0 0 0 0 1 5 8 8 7
Nurses 0 0 0 0 0 0 0 1 1 1
Key Worker/ Care
coordinators 0 0 0 0 0 2 1 1 1 1
Other Clinical Staff 0 0 0 0 0 0 0 0 0 0
Community Supervising
Clinician 0 0 0 0 0 0 0 0 1 1
SOADs 0 0 0 0 0 0 0 0 0 0
Total 0 0 0 1 0 3 7 10 11 10

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
AMHPs 0 0 0 0 0 0 0 0 0 0 0
IMHAs 0 0 0 0 0 0 0 0 0 0 1
Social Workers 0 0 0 0 0 0 0 0 0 0 5
Approved Clinicians 7 7 7 7 6 6 6 6 6 6 92
Nurses 1 1 1 1 1 1 1 1 1 0 8
Key Workers / Care
coordinators 1 1 1 1 1 1 1 1 1 1 18
Other Clinical Staff 0 0 0 0 0 0 0 0 0 0 2
Community
Supervising Clinician 1 1 1 1 1 1 1 1 0 0 7
SOADs 0 0 0 0 0 0 0 0 0 0 0
Total 10 9 10 9 9 9 9 9 8 8 133
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes

NoteTotals may not equal the sum of the annual figures due to rounding.

41

Opportunity costs
97. The measurement and valuation of direct health benefits/costs from a policy intervention is
typically performed by estimating the number of Quality adjusted life years (QALYs) generated.
QALYs account for impacts on length of life (longevity) and health-related quality of life (QoL). It
assumes that a year of life lived in perfect health is worth 1 QALY (1 year of life x 1 utility = 1
QALY) and that a year of life lived in a state of less than perfect health is worth less than 1. For
example, half a year lived in perfect health is equivalent to 0.5 QALYs (0.5 years x 1 utility), the
same as 1 year of life lived in a situation with a utility 0.5 (e.g. bedridden) (1 year x 0.5 utility).
98. We estimate the opportunity costs that would arise if health and social care spending was funding
from existing budgets, in terms of the QALY gains forfeited.
NHS resources opportunity cost
99. In DHSC, it is considered that an additional QALY (valued by society at £ 70,000) can be
purchased for £15,000. Where proposed health spending redirects resources from alternative
use in the NHS, the opportunity cost of spending is around 4.7 times the financial cost (£70,000
divided by £15,000 ≈ 4.7).
100. If funding for these policies were met from within existing NHS resources rather than provided
for separately, this would create an opportunity cost of around £4.7 for every £1 of diverted
resources. To estimate the impact were this to be the case, in the table below we have uplifted
estimated total net costs for NHS to account for the lost social value . These healthcare
opportunity costs were not applied in cost estimates presented above and are not included in the
NPV reported on the summary sheets of this IA.
101. The total cost to the NHS is estimated to be £1.9m (excluding housing costs relating to reforms
on people with a learning disability and autistic people) . This equates to a potential opportunity
cost of £8.9m as shown in Table 18.

Table 18. Summary of total NHS costs with and without opportunity costs – England only
(£millions, 2024/25 prices, undiscounted)
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
NHS (without
opportunity costs) 0 4 215 109 38 61 83 99 106 105
NHS (with
opportunity costs) 0 18 1003 511 176 284 387 464 493 490

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
NHS (without
opportunity costs) 108 105 107 108 109 110 110 111 113 114 1,913
NHS (with opportunity
costs) 503 488 500 502 507 511 516 520 525 530 8,928

*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes

NoteTotals may not equal the sum of the annual figures due to rounding.
Social care resources opportunity cost
102. Forder et al. (2018)29 analysed the impact of social care services on the quality of life of service
users. The estimates they produced indicate that the marginal cost of generating one additional
QALY in social care was approximately £20,000. This implies an opportunity cost of £3.5 for
every £1 of diverted resources. To estimate the impact were this to be the case, we have uplifted

29 Forder (2018) ‘The impact and cost of adult social care: marginal effects of changes in funding’ QORU Discussion Paper,
https://www.pssru.ac.uk/pub/5425.pdf

42

the total Local Authority and Housing care costs by a factor of 3.5 to account for the lost social
value.
103. The total net Housing and Care cost is £2.9m (including reforms for people with a learning
disability and autistic people). This equates to a potential opportunity cost of £10.2m as shown in
Table 1 9. These opportunity costs were similarly not included in the NPV reported on the
summary sheets of this IA.

Table 19. Summary of total housing and care costs with and without opportunity costs – England
only (£millions, 2024/25 prices, undiscounted)
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Housing and care
costs (without
opportunity costs)
0 0 204 215 147 150 150 155 155 155
Housing and care
costs (with
opportunity costs)
0 0 713 753 513 525 524 542 543 544

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Housing and care
costs (without
opportunity costs)
156 156 157 158 159 160 161 162 163 164 2,926
Housing and care
costs (with opportunity
costs)
545 546 550 553 557 560 563 567 570 574 10,242

*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes

NoteTotals may not equal the sum of the annual figures due to rounding
Monetised Costs – Justice System
104. The Government aims to enhance the rights and freedoms of people using mental health
services. As a result, there will be an increased role for the Mental Health Tribunal (MHT), which
handles legal matters related to mental health care. The costs associated with this expansion of
the MHT’s role will impact the justice system.
105. These costs have been divided into two main areas: the MHT itself and legal aid expenses.
More details on how these estimates were made can be found in Annex E.
106. Since this kind of analysis involves many uncertainties, a sensitivity analysis was done to test
various assumptions . Below is the central estimate, with additional details in the sensitivity
analysis section.
Table 20. Costs for the Mental Health Tribunal, including legal aid, England only (£millions,
2024/25 prices, undiscounted) - Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional costs 0 0 0 0 0 0 28 22 24 24
Process cost
savings 0 0 0 0 0 0 4 4 4 5
Total costs 0 0 0 0 0 0 24 18 20 19

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional costs 28 24 26 26 26 26 26 27 27 27 361
Process cost
savings 5 6 6 6 6 6 6 6 6 6 74
Total costs 23 18 21 20 20 20 21 21 21 21 287
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes

43

NoteTotals may not equal the sum of the annual figures due to rounding.

107. Note that the above table presents costs for England only. Applying a scaling approach based
on the number of tribunal hearings in England and Wales (see Annex G for details), we estimate
the total costs for England and Wales to be £313m, compared with £287m for England only.

108. The main additional costs for the justice system, including legal aid, relate to the following
proposals:

• Automatic referrals to the MHT: Patients detained or receiving treatment under the
MHA who haven't applied to the MHT will be automatically referred at specific intervals.
• Treatment choices: This proposal involves considering a patient's statutory Care and
Treatment Plan (CTP) during an MHT hearing.
• Expanded powers of the MHT: The MHT would gain new powers to discharge patients
and review Community Treatment Orders (CTOs).
• Detention criteria: Before a Tribunal hearing for a section 3 detention, the Responsible
Clinician and Approved Mental Health Professional (AMHP) must confirm 10 days in
advance that the patient still meets the criteria for detention.

109. The estimated monetised costs of the policy interventions under Option 2 in England have been
disaggregated into costs relating to these 4 areas as shown in Table 21.

Table 21. Total costs for the Mental Health Tribunal, including legal aid, by proposal type,
England only (£millions, 2024/25 prices, undiscounted) - Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Automatic Referrals 0 0 0 0 0 0 20 14 16 14
Treatment choice 0 0 0 0 0 0 4 3 4 4
Expanded Powers 0 0 0 0 0 0 1 1 1 1
Detention criteria 0 0 0 0 0 0 0 0 0 0
Total 0 0 0 0 0 0 24 18 20 19

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Automatic
Referrals 18 14 16 15 15 15 15 15 16 16 219
Treatment choice 4 4 4 4 4 4 4 4 4 4 56
Expanded
Powers 1 1 1 1 1 1 1 1 1 1 14
Detention criteria 0 0 0 0 0 0 0 0 0 0 -1
Total 23 18 21 20 20 20 21 21 21 21 287
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.
Automatic referrals
110. Under Option 1 , p atients must wait longer for reviews of their detention due to the current
automatic referral system. Some patients, such as those conditionally discharged in the
community, may not be automatically referred even if they could qualify for an absolute discharge,
leaving them under unnecessary restrictions.

111. Under Option 2, patients detained or receiving treatment under the Mental Health Act (MHA)
who haven't applied to the Mental Health Tribunal (MHT) will be automatically referred at specific

44

intervals. The automatic referral proposals impact different patient groups (e.g., some proposals
only affect Part III patients).

112. The Government plans to implement the following under Option 2:
• For patients detained under Section 3: Automatic referral to the MHT at 3 months, 12
months, and then annually after detention begins. This works alongside a proposal to
shorten the initial detention periods for Part II patients (three periods: two of 3 months,
then one of 6 months).
• For Part III patients: Automatic referral to the MHT every 12 months.
• For conditionally discharged patients: Automatic referral after 24 months, and then every
4 years if they haven't applied directly.

113. Additionally, under Option 2:
• For patients on a Community Treatment Order (CTO): Automatic referrals after two
consecutive 6-month periods, followed by a 12 -month period. Even though this could
lead to more referrals, the overall number of CTOs is expected to decrease, reducing
the total number of MHT referrals.

114. To estimate the cost impact, an assumption of 20% decrease in annual CTOs is expected by
2035/36, with a gradual decline over 5 years (see Annex E for details).

115. Key cost drivers of the proposed reforms include (all costs are presented in 24/25 prices and
undiscounted):

• Automatic referrals are expected to add £219 million in net costs to the justice system
over 14 years.
• The cost of automatic referrals at 3 months, 12 months, and annually for Section 3
patients is estimated at £29 million, assuming a 100% increase in yearly referrals.
• Reducing the maximum detention period under Section 3 is expected to add £81 million
due to a 37% rise in MHT applications.
• Automatic referrals for Part III patients have the highest additional cost at £140 million,
based on a projected 390% increase in receipts.
• Proposals relating to CTOs could save an estimated £72 million over 14 years.
• Automatic referrals for conditionally discharged patients are expected to add £41 million
in costs over the same period.

Table 22. Costs, including legal aid, from implementing the automatic referrals, England only
(£millions, 2024/25 prices, undiscounted) - Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional costs 0 0 0 0 0 0 23 18 20 19
Process cost
savings 0 0 0 0 0 0 4 4 4 5
Total costs 0 0 0 0 0 0 20 14 16 15

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional costs 23 19 22 21 21 21 21 21 21 22 292
Process cost
savings 5 5 5 6 6 6 6 6 6 6 73
Total costs 18 14 16 15 15 15 15 16 16 16 219
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.
Detention Criteria

45

116. Under Option 1, no changes are proposed, and the system continues as it currently operates.
117. Under Option 2, the Government proposes that patients detained under Section 3 of the Mental
Health Act should be certified as still meeting the criteria for detention 10 days before their hearing
at the Mental Health Tribunal (MHT). This change is aimed at reducing the nu mber of MHT
hearings cancelled within 48 hours.
118. Before considering how this change affects cancellation fees (fees incurred for assembling a
panel that doesn’t end up holding a hearing), it's important to note that:
119. The cost of this policy change is estimated by:
• First, predicting the number of Section 3-related cancellations in the future, based on
current cancellation rates and future detention trends
• Assuming that 50% of these cancellations can be avoided with the proposed change.
• Then, multiplying the number of avoided cancellations by the sitting fees of tribunal staff
to estimate the savings. More details can be found in Annex E.

Table 23. Costs of new detention criteria on the Mental Health Tribunal, England only (£millions,
2024/25 prices, undiscounted) - Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional costs 0 0 0 0 0 0 0 0 0 0
Process cost
savings 0 0 0 0 0 0 0 0 0 0
Total costs 0 0 0 0 0 0 0 0 0 0

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional costs 0 0 0 0 0 0 0 0 0 0 0
Process cost
savings 0 0 0 0 0 0 0 0 0 0 1
Total costs 0 0 0 0 0 0 0 0 0 0 -1
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.
Treatment Choice
120. Under Option 1, the MHT does not consider the patient's Care and Treatment Plan (CTP),
where concerns have been expressed.
121. Under Option 2, the Government proposes to have the MHT consider as part of the papers to
the Tribunal the patient’s CTP , where concerns have been expressed. CTPs would become
statutory for most patients detained under the MHA, including Section 2 patients .30 For these
patients we do not expect that this would affect the length of MHT hearing s, as existing patient
plans already include reports to MHTs. Costs have therefore not been estimated for this subset
of hearings.
122. The cost of this policy is calculated by assuming reviewing the CTP takes 40 minutes as a
central scenario. This is used to calculate the new length of hearings and therefore the reduced
number of hearings which can be unde rtaken in one sitting day. The number of hearings which
are applications for discharge (excluding section 2) are then summed up and used to calculate
the number of new sitting days required which can be converted to a cost. Further details of this
can be found in annex E.

30 This excludes patients detained under ”short-term” sections detention in a place of safety under emergency powers in sections 135 or 136 of
the MHA, or where there is a direction for Part III patients under section 35 subsection (4), 36 subsection (3), 37 subsection (4), 38 subsection
(4) or 45A subsection (5), as these patients are not detained long enough to obtain a benefit from a plan.

46

123. The estimated additional costs associated with the proposed legal changes are presented in
the table below. The estimated additional cost of the proposed changes , to have the MHT
consider a patient’s CTP, over the period is £56 million as shown in Table 24.

Table 24. Costs of increased treatment choice on the Mental Health Tribunal England only
(£millions, 2024/25 prices, undiscounted) - Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional costs 0 0 0 0 0 0 4 3 4 4
Process cost
savings 0 0 0 0 0 0 0 0 0 0
Total costs 0 0 0 0 0 0 4 3 4 4

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional costs 4 4 4 4 4 4 4 4 4 4 56
Process cost
savings 0 0 0 0 0 0 0 0 0 0 0
Total costs 4 4 4 4 4 4 4 4 4 4 56
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.
Expanded Powers
124. Under Option 1 (BAU), the current scope of tribunal powers mean that certain patients face
difficulties in being conditionally discharged into the community when they are well enough to
leave hospital, as the tribunal lacks a power to discharge patients with conditions that restrict
their freedom in the community. This means they will continue to occupy bed space and obstruct
transferring other people in from prison.
125. Under Option 2, t he Government proposes to expand the powers of the MHT through three
reforms for which costs have been estimated. This will give the MHT the power, during an
application for discharge, to grant leave from hospital and transfer to a different hospital (currently
it has the power to make recommendations) and extend the MHT’s power to direct the provision
of aftercare services.
126. The total estimated additional cost including legal aid of these policies over the period is £14m
as shown in Table 25.
Table 25. Costs of expanded powers on the Mental Health Tribunal, including Legal Aid –
England only (£millions, 2024/25 prices, undiscounted) – Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional costs 0 0 0 0 0 0 1 1 1 1
Process cost
savings 0 0 0 0 0 0 0 0 0 0
Total costs 0 0 0 0 0 0 1 1 1 1

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional costs 1 1 1 1 1 1 1 1 1 1 14
Process cost
savings 0 0 0 0 0 0 0 0 0 0 0
Total costs 1 1 1 1 1 1 1 1 1 1 14
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.

Application for discharge

47

127. Under Option 2, during an application for discharge of non-restricted patients, the MHT should
have the power to recommend that the relevant aftercare bodies make plans for the provision of
aftercare services for the patient, where this is necessary to facilitate discharge at a future date.
By conferring this power on to the MHT, it is considered that this will strengthen the MHT’s role
in reviewing a patient’s detention and, where necessary, ensure earlier consideration is given to
what services could be put in place for the patient.
128. The costs associated with this policy relate to the extra 2 hours of hearing time per case which
would be required. Assuming that there are 10 cases which would be heard per year, this would
require an additional four sitting days per year for the MHT. The additional estimated cost for
these 4 days a year is around £0.2m over the appraisal period.
129. The Government additionally proposes that the MHT should have the power to review the
conditions attached to the CTO when dealing with an application or reference by or on behalf of
a community patient. It is also proposed that the MHT be able to recommend that the Clinician
reconsider the conditions specified in a CTO in line with Section 17B(2) criteria. The Government
proposes that the power to recommend should apply to all CTO conditions. This will again result
in an estimate of additional judicial time of one hour per case for an additional 753 hearings,
resulting in 151 extra sitting days for the MHT per year, assuming there are 5 hours per sitting
day. This corresponds to an additional cost estimated at around £9.9 million over the appraisal
period.
130. For a very distinct group of restricted patients the Government proposes that the MHT should
have the power to discharge with conditions that restrict their freedom in the community, with a
new set of safeguards. This reform would be those for whom the MHA is no longer providing
therapeutic benefit by detention in hospital, but who pose such a significant risk to others they
would need continuous supervision to be managed safely in the community. Costs arise from
MHT reviews of these conditions.
Reviews

131. Under Option 2, a MHT should take place at 12 months after discharge, and then every two
years. The patient can apply to the MHT between 6 -12 months following discharge. In addition,
the Secretary of State for Justice also holds a discretionary power to refer a patient to the MHT
for review at any time.
132. The result is that there will be a stock of patients reviewed by the MHT after 12 months and
then every 2 years, as well as small numbers of new patients each year. Data on this cohort are
extremely limited, although the size is expected to be small. The modelling has used an indicative
estimate of an initial stock of 220 individuals with an extra 10 per year; only half of stock patients
will be reviewed in 2031/32 and half in the following year.
133. This results in extra sitting days per year for the MHT, meaning extra costs are incurred. It is
estimated that these are minimal compared to the total additional costs for the Justice system.
The estimated additional cost is therefore around £6 million (undiscounted), with an additional £2
million in estimated additional Legal Aid costs (undiscounted).
Legal Aid
134. Legal aid impacts have been provisionally estimated for all of the Government proposals, where
possible. If a proposal results in a higher or lower MHT workload than would otherwise be the
case, then legal aid expenditure will change in the same direction.
135. Most of the preparation work for an MHT hearing, for which providers can claim a preparation
level fee, will be done more than 10 days in advance of the hearing date. Therefore, we do not
expect the proposal which aims to reduce the burden of MHT cancelled at the last minute, to
have much impact on the legal aid claim total. Regarding the proposal that would allow the MHT

48

to review the patients CTP, there is no expected impact on receipt volumes, so it has not been
possible to estimate the potential legal aid costs associated with this recommendation. However,
it is possible that it could increase the proportion of cases th at escape the fixed fee scheme,
which is the set fee legal aid providers can claim for the majority of their MHT work.
136. Most recommendations which alter either the volume of receipts for hearings at the MHT or the
time required for hearing preparation, will likely have a legal aid cost impact. Therefore, where
possible, the cost impact of legal aid has been individually calculated. For more detail, see Annex
E.
137. The table below shows the total estimated cost for legal aid that can be claimed by providers
as a result of potentially increased receipts in the MHT. It is important to note that the estimated
costs shown are based on the indicative workload expected to start in each year of
implementation. The legal aid claim total for each year is likely to differ as providers will usually
submit a final bill after all work on a case has been completed, resulting in a lag between the
hearing date and the legal aid claim. Over the 14-year implementation period it is estimated that
the proposals could result in an additional legal aid cost of £73m as shown in Table 26.

Table 26. Costs for legal aid from increased receipts and hearings in the Mental Health Tribunal
system (£millions, 2024/25 prices, undiscounted) - Central Scenario
2024/25* 2025/26* 2026/27* 2027/28* 2028/29* 2029/30* 2030/31* 2031/32* 2032/33* 2033/34*
Additional costs 0 0 0 0 0 0 7 5 6 5
Process cost
savings 0 0 0 0 0 0 0 0 0 0
Total costs 0 0 0 0 0 0 7 5 6 5

2034/35* 2035/36* 2036/37* 2037/38* 2038/39* 2039/40* 2040/41* 2041/42* 2042/43* 2043/44* Total
Additional costs 6 5 5 5 5 5 5 5 5 4 74
Process cost
savings 0 0 0 0 0 0 0 0 0 0 0
Total costs 6 5 5 5 5 5 5 5 5 4 73
*Cost profile is indicative - assumed commencement of policies is illustrative for modelling purposes
Note: Totals may not equal the sum of the annual figures due to rounding.
Non-monetised Costs
Non-monetised Costs - Health and Social Care System
Change to detention criteria
138. We have not modelled additional costs as a direct result of the changes to detention criteria for
mental health patients which makes it clear that people will only be detained if they pose a risk
of serious harm to themselves and/or others, and if they will benefit from the proposed treatment.

139. This is because the changes clarify the criteria and reflect existing guidance and so we do not
expect to see a significant change in detention practice nationally. There may be individual cases
where decision to detain or not is different due to the change in legislation, but we do not have
relevant data, and assess the scale of these impacts to be limited. There may be some costs
associated with ensuring the change to criteria works well and safely but these have not been
monetised due to lack of data.

140. We have similarly not factored any impact of these changes to detention criteria into the
modelling of reduction in detentions due to the reforms.

49

Improving discharge
141. Given the changes to the discharge protocol, to consult another professional, largely formalises
best practice, we do not anticipate there to be substantial additional costs associated with this
policy change.

142. However, there may be some increased process costs where the change improves adherence
to good practice, which we think are likely to be modest overall. Costs relating to the patient’s
safety plan, which should be conducted as part of the patient’s statutory Care and Treatment
Plan (to be set out in secondary legislation), are already accounted for within the costs on Care
and Treatment Plans. Again, safety management plans are already best practice for many Trusts.

Familiarisation training

143. There will be transitional costs to services associated with reforming the MHA with
organisations having to update policies, procedures, and documentation. We expect there to be
costs for familiarisation training for other staff groups beyond those which were modelled ,
including the wider local authority mental health workforce and healthcare staff in prisons.
144. CQC workforce groups will require training on the revisions to the Act and the new Code of
Practice, as well as training in revised ways of working to deliver their statutory MHA duties and
regulatory functions. The CQC MHA Operations team will need ongoing training throughout the
whole implementation period, and training will also need to be provided to teams such as Senior
Specialists and Inspectors as well as policy and strategy teams, the national contact centre team
and other workforce groups who help deliver CQC’s wider regulatory role. These costs have not
been monetised due to a lack of data.
145. Familiarisation costs for these staff groups could not be monetised due to a lack of available
data on the number of existing staff working on the MHA , however, it is expected that these
groups will require less intensive training. There will also be costs associated with developing the
training for the reforms, which have not been monetised due to lack of data.

Activity to drive culture change
146. Beyond costs of training for familiarisation with legislative changes, there will be costs
associated with wider training/initiatives for the existing workforce to enable a change in culture
and practice to accompany and support legislative changes.

147. Costs associated with cultural change activity have not been monetised as a) they go beyond
the direct content of the legislation and b) we do not have data on the extent current practice
already aligns with best practice.

Costs to Care Quality Commission (CQC) monitoring duties

148. CQC has a duty under section 120 of the MHA to monitor how services exercise their powers
and discharge their duties under the Act, in addition to delivering statutory second opinions
delivered by SOADs. These monitoring duties extend to three key areas: responding to
complaints; regularly visiting places of detention to conduct interviews and review patient records;
and reporting on providers’ use of the Act and implementation of the Code of Practice. The CQC
also monitors wider use of MHA powers outside o f hospital settings, such as those relating to
CTOs.

50

149. These duties require specialist MHA monitoring and operational teams. Under the reforms,
these teams will need appropriate training and will incur implementation costs to deliver CQC’s
monitoring and regulatory functions.
150. In addition, under the reforms it is expected there will be costs for CQC in resourcing the
increase in MHA complaints that are expected to occur from the hospital managers having a
statutory duty to inform, on a more regular basis, patients of their right to complain.
151. In addition, CQC will be required to update their digital systems for data collection and reporting
and support adequate oversight of services which carry out duties under the MHA. CQC will also
have additional costs for their wider regulatory teams and the impacts of these reforms on their
work, such as their inspection and policy teams.
152. These costs have not been monetised in this IA due to a lack of cost data for these teams and
assumptions surrounding the expected increase in complaints.
153. In addition to the costs associated with monitoring duties, CQC expect there will be in increase
in travel and subsistence costs as remote SOAD assessments will only be permitted for urgent
ECT requests. These have not been monetised due to a lack of data to model the costs.
Learning Disability and Autism
154. The introduction of the C(E)TR and DSR reforms may lead to additional one-off costs (and
potentially ongoing maintenance/monitoring costs) to support the increased use of C(E)TRs &
DSRs. F or example, this could be in the form of IT support to upgrade existing DSRs , and
additional administrative support to assist with an anticipated increase in paperwork generated
following the increased volume of C(E)TRs carried out. However, we do not include these costs
in our estimates because they are highly uncertain and likely to vary significantly between ICBs.
155. In assessing the costs of the change in detention criteria for people with a learning disability
and autistic people, we have assumed that some people who are discharged from inpatient
settings, will need a new home to live in. However, we assume that people who avoid admission
in future years ( people who are no longer eligible for detention ), who are already living in the
community, instead only require housing adaptations to their existing home. This may be an
underestimate of the actual need for new hous ing who are at risk of admission due to the
consequences of living in unsuitable accommodation. Anecdotal evidence suggests that it is not
uncommon for unsuitable housing to contribute to the crisis which would have in a baseline
scenario precipitated an admission to hospital. We do not include these costs in our estimates
due to uncertainties in understanding the scale of how many people are currently in unsuitable
housing.
156. In addition, when costing community costs relating to housing, we have included a housing
revenue line. We understand that in addition to this there may be specific “support” funding from
local authorities provided. Our understanding is that provision of this varies by local authority and
due to these uncertainties, this is not included in cost estimates.
157. The proposed reforms to the detention criteria for people with a learning disability and autistic
people envisage more people receiving care and treatment in the community, rather than in
hospital. To ensure that these individuals receive the right care and support, the Bill introduces
new duties on ICBs to hold a register of those at risk of admission and for ICBs and local
authorities to use this information when exercising their commissioning and market fu nctions.
Under the proposals, both ICBs and local authorities must seek to ensure that the needs of people
with a learning disability and autistic people can be met without admission to hospital . In
implementing these reforms, we will monitor the impact of the proposed detention criteria
changes to ensure that they are having this intended effect and seek to mitigate any unintended
consequences, such as increased use of the Mental Capacity Act as a means to detain a person
in hospital.

51

Removal of police cells as a place of safety
158. The Bill will remove police stations as ‘places of safety’ under the MHA to ensure people
experiencing mental health crisis or with severe mental health needs are not held in police cells
but in a health-based place of safety.

159. Data suggests that the number of people in scope of this policy is small, and numbers are
declining over time due to this already reflecting current policy . In 2022/23, 297 people were
taken to a police cell as a place of safety in England31. We have therefore not monetised the
potential health and justice system costs of this policy on the basis that costs are likely to be
limited.
Removal of prisons as a place of safety
160. Similar to police cells, the Bill will remove prisons as ‘places of safety’. We do not have reliable
data on the number of people in prison as a place of safety . We have therefore not monetised
the potential health system costs of this policy . We believe given the scale of the potential
population in scope, the health and justice system costs of this change are likely to be limited.
Section 117 Aftercare
161. This policy clarifies which local authority is responsible for providing S117 aftercare, for example
where ordinary residence, detention and discharge locations vary. It further requires that written
notice if provided to the individual in receipt of aftercare when the decision to stop aftercare has
been made.

162. As this policy is not expected to change entitlement to aftercare, we expect that there to be
minimal impacts. Any impact on costs is likely to reflect a transfer between local authorities,
therefore these have not been monetised.
Mental Health Act Managers
163. MHA managers are responsible for making sure the hospital and staff meet their duties under
the MHA. Under the reforms MHA will have additional responsibilities including: the responsibility
to provide patients and their Nominated Person with complaints information; the duty to refer all
qualifying patients to advocacy (which is a wider group under the reforms); and ensure that Care
and Treatment Plans meet the statutory requirements. These will likely include both one-off and
ongoing costs.
164. Some costs for CTP requirements have been costed (see Annex C.VI) but for others it has not
been determined how this would look in implementation and will depend on what systems a
provider already has in place. Therefore, these costs have not been monetised.

Advance Choice Documents (ACDs)
165. There are expected to be costs associated with ensuring that ACDs can be stored securely and
easily accessed by service users and staff (including community clinicians, AMHPs and
healthcare staff working in prisons when required. This will involve setting up systems for storing
ACDs in a place that is accessible in electronic records systems, as well as staff familiarisation,
which together are likely to generate additional costs. There is ongoing work to digitise the mental
health act , which may reduce the costs associated with thi s, but this impact has not been
modelled as is expected to happen in the BAU scenario as well as Option 2.
166. There are expected to be costs to AMHPs associated with having to locate and use ACDs at
the point of MHA assessment. Once a system is up and running to make ACDs available, we

31 Other PACE powers, year ending March 2023 (second edition) - GOV.UK (www.gov.uk)

52

would expect these costs to be offset to some extent by other potential benefits of ACDs for
AMHP time, such as the ability to more quickly indicate key information like who the Nominated
Person is. An AMHP may also spend time with service users developing an ACD and conducting
preventative work to reduce future admissions.
167. These costs have not been monetised due to uncertainty around the exact processes and lack
of data to be able to estimate.

Transfers to hospital from prisons and other places of detention
168. This reform introduces a statutory time limit target of 28 days for the transfer of patients who
meet the threshold for detention under the Mental Health Act from prisons, Immigration Removal
Centres (IRCs) and other places of detention to mental health hospitals for treatment. It aims to
further embed the good practice set out in NHS England’s guidance on transfers and remissions
published in June 2021 32 and increase accountability for the agencies involved in the transfer
process to meet the deadline.

169. Costs for the measure have not been monetised because they are principally driven by wider
systematic changes which are supported by the legislation , such as improved partnership
working, as well as ensuring resources are available to achieve transfers within the time limit in
a greater proportion of cases.
Supervised Discharge
170. The Bill includes a new power to allow for patients detained through the courts, who are subject
to special controls by the Secretary of State for Justice to protect the public from serious harm,
to be discharged into the community with conditions which amount to a deprivation of liberty .
There will be no immediate ‘new’ patient intake related to supervised discharge as the patients
that will be subject to these conditions are already being managed as restricted patients using
long term escorted s17 leave.

171. Published statistics on the total number of restricted patients do not show a significant change
in trend33 meaning that the same numbers of patients will be subject to special controls by the
Justice Secretary. Therefore, we do not expect to see a significant impact of the introduction of
supervised discharge, so these costs have not been monetised.

Removal of remand for ‘own protection’ solely on mental health grounds
172. The Bill amends the Bail Act to prevent the remand of a defendant on own protection or welfare
grounds where the sole concern is their mental health. Instead, courts will be directed to bail the
defendant and work with local health services to put in place appropriate support and care to
address risks to their safety.

173. We expect the number of people on remand solely for mental health reasons to be low and
therefore health and justice costs relating to this change are likely to be negligible, and therefore
have not been monetised.
Crown dependencies
174. The Bill includes reforms to improve the process of transferring people to and from hospital
between the Crown Dependencies and England to ensure mentally unwell prisoners can access
treatment in the most appropriate setting.

32NHS (June 2021), The transfer and remission of adult prisoners under the Mental Health Act 1983. Report template - NHSI website
(england.nhs.uk)
33 Restricted Patients Statistics, England and Wales - GOV.UK (www.gov.uk)

53

175. Data suggest the number of people detained under Part III in the Crown Dependencies is small,
therefore we have not monetised the costs on the basis that these are expected to be limited.
Non-monetised Costs - Justice System
Recruitment campaign costs
176. The expected increase in hearings in the MHT will required additional judges and other
judicial employees. It will therefore be necessary to conduct recruitment campaigns to ensure
sufficient judicial resources are available in the Tribunal to meet the increased demand. The
costs of these recruitment campaigns have not been modelled for this IA as it is unclear how
much additional recruitment activity will be required over and above that which normally occurs.
Familiarisation costs
177. We expect that there may be costs for justice staff to familiarise themselves with the MHA
reforms. These costs are expected to occur in the first years after Bill introduction but have not
been modelled due to lack of data . We expect that t he reforms should form part of the normal
refresher training justice staff must undertake in Business as Usual.
Expanded MHT Powers
178. Several Government proposals would expand the powers of the MHT, to empower it to make
decisions beyond determining an appeal for discharge. These proposals are discussed in the
following three areas.
Displacement and overruling a Nearest Relative (Nominated Person)
179. The Government has considered whether the County Court’s power to displace a NR should
be replaced by an MHT power to overrule or displace a NP on the grounds that the MHT is better
placed to make this decision. Considering the wider reforms and impacts on the MHT, we propose
that the power to fully displace a NP should remain in the County Court. In addition, we propose
that the Responsible Clinician (RC) should have the power to temporarily ‘block’ the NP (through
a barring order) if the NP appeals Section 3 admission, or objects to a CTO or ordering a patients
discharge, but the patient is considered dangerous to themselves or others. This is in -keeping
with the existing approach set out in Section 25 of the Act, which enables the RC to bar the use
of the NR’s power to discharge the patient.
180. The MHT will only be involved if the NP is barred, and they later decide to use their right to
apply to the tribunal (as is the case where the NR receives a barring order). In this way, the NP
will still be able to retain their position and inform the patient’s care and treatment, except for in
the most e xtreme or serious circumstances e.g. where they pose a safeguarding risk to the
patient, in which case the application can be made to the County Court to displace the NP. The
cost would come from a potential small increase in applications to the MHT by the NP, we do not
expect this number to be significant. We require further data to form appropriate assumptions
and costs.
Additional training for panel members
181. The Government agreed in principle in its White Paper that training should be developed for
MHT panel members in specialisms including children and young people, forensic psychiatry,
learning disability, autism, and older people.
182. The Government agrees that the individual needs of the patient should be recognised.
However, the judiciary, through the Judicial College, are responsible for setting and developing
the training for MHT panel members. There could be a potential cost associated with this training,
however, this is expected to be negligible so have not been monetised.

54

Length of detention
183. The Government proposed that where a person has been subject to detention under Section 3
within the last twelve months, an application for detention under Section 2 should only be made
where there has been a material change in the person’s circumstances. In addition, the
Government proposed that the Code of Practice should make it clear that Section 3, rather than
a Section 2, should be used when a person has been already subject to Section 2 within the last
twelve months. Finally, the Government has propo sed that the detention stages and timelines
should be reformed so that they are less restrictive through extending the right of appeal for
Section 2 beyond the first 14 days. These proposals have not been modelled in this iteration of
the IA as there is currently insufficient data to inform estimates of the impact on the tribunal.
Impacts on the Court of Protection
184. It is possible that the proposed reforms to the detention criteria, , the new treatment safeguards
and Nominated Person proposed in the Bill could result in new burdens on the Court of Protection,
which is responsible for deciding whether a person has the mental capacity to make a particular
decision for themselves under the Mental Capacity Act (MCA) , and for adjudicating on whether
a particular decision made on their behalf is in their best interests.
185. Appointment of a Nominated Person is contingent on the person’s capacity to make the
appointment at the time, and many of the new treatment safeguards are contingent on an
advance decision to refuse treatment or decisions by a done appointed under a lasting power of
attorney or a deputy appointed by the Court of Protection. While there is limited evidence upon
which to base an assessment of the size of the impact it is expected that many of these changes
pose a minimal risk of increased demand on the Court of Protection. These impacts have
therefore not been monetised but are discussed further in the Risks section.
186. The proposed changes to the detention criteria will mean that civil patients with a learning
disability and autistic patients can only be detained for treatment under sect ion 3 if they have a
co-occurring mental disorder that warrants hospital treatmen t. Some stakeholders have raised
concern that alternative legislative routes could be used to detain people in hospital when section
3 is no longer an option. This includes use of the Mental Capacity Act, which would have impacts
on the Court of Protection. We have not monetised these potential impacts due to lack of data.
Benefits
187. In terms of the benefits of the proposals, and using the work done by the Independent Review,
we would expect that “patients and service users should experience improved choice, less
coercion and restriction of their liberties, care that is more consistently respectful, and meets their
individual needs” (p. 228). That is, patients should feel supported to share their wishes and
preferences, that they have more control over their care and treatment, and that compulsory
medical treatment is only used as a last resort when there is no alternative. These outcomes are
difficult to monetise, but evidence indicates that they a re highly valued by patients, improving
health outcomes and quality of life, and that they are associated with the delivery of more
appropriate and cost-effective services, including reducing length of inpatient stay.
188. Since improved patient experience due to increased participation in decisions regarding care
and being treated with dignity and respect is not easily monetised, they should also be understood
in qualitative terms. These have been investigated by the Independent Review and we use their
words to summarise this point:

“We believe that improving patients’ and service users’ ability to make decisions about
their own care and treatment is essential to upholding dignity. This theme runs
throughout the report from start to finish. It underlies our recommendations, for

55

example, on the importance of advance choices, and how these can become more
common and more powerful. It is part of our recommendations on the right to
advocacy, for those who find it difficult to make their wishes and preferences known
and how these are particularly relevant for those at greater risk of discrimination, such
as those from a minority ethnicity background. (…)
These recommendations are essential if we are to achieve a real shift in the balance
of power between the patient and the professional, and make it easier for patients and
service users to participate in decisions about their care. (…). Much of this merely
reflects current best practice but, sadly, we are in little doubt that this is far from
standard, and that without our recommendations bad practice will continue.” (pp 18-
19)

189. It is also likely that the impact of the reforms will be affected by other changes in service
provision which could, for example, provide more opportunities for the sort of therapeutic care
which patients may have preferences for, or enhance community ment al health provision as an
alternative to hospital admission.
190. In our approach to estimating benefits, we distinguish between:
• Monetised benefits to the Health & Social Care system, arising from a reduction in the
number of inappropriate detentions and overall admissions due to the impacts of the
reforms;
• Non-monetised benefits to the Health & Social Care and Justice systems;
• Non-monetised benefits to patients, including improved health outcomes and a better
and more dignified experience of treatment under the MHA, for patients and carers –
the primary aim of the proposals.
Monetised benefits
Benefits to the Health and Social Care system
191. Whilst some measures are expected to result in process cost savings which will partially offset
the additional costs estimated, the monetised benefits presented in this IA reflect the impacts of
avoiding inappropriate or unnecessary admissions and detentions in hospital. Here, a prudent
approach has been taken: t he only policy measures assumed to directly reduce admissions or
detentions are changes to the ability to detain people with learning disabilities or autistic people
without co-occurring mental health conditions, and the uptake of ACDs , reflecting the strongest
logic or research evidence for a likely effect.

192. We have not modelled impacts on detentions due to the changes to the detention criteria
beyond those particularly relevant to people with a learning disability and autistic people. The
new provisions set out two new tests that must be met to fulfil the criteria for detention: firstly that
“serious harm may be caused to the health or safety of the patient or of another person” and
secondly that the decision maker must consider “the nature, degree and likelihood of the harm”.
Further guidance on this, including defining serious harm, will be provided in the Code of Practice.
The current Code of Practice already guides clinicians to consider the ‘nature’ ‘likelihood’ and
‘severity’ of harm as well as the benefits of treatment to the patient. The new criteria will formalise
these considerations, putting them into a clear and consistent legal footing to enable clinicians to
determine when detention is appropriate. We do not expect to see an increase or decrease in
detentions as a result of the revised criteria in these respects.

193. There are currently significant constraints on bed occupancy and health care resources, with a
significant treatment gap for mental health patients, bed occupancy at over 90%, significant waits

56

in Emergency Departments and the community for bed s, and out of area placements still used .
This means that any reduction in admissions or lengths of stay for patients affected directly by
these reforms would likely lead to releasing clinicians’ time and hospital capacity to care for others
who are waiting for a bed. This would represent an indirect health benefit from treat ing other
people, and how these benefits will be realised will vary by area.

194. The monetised benefits are presented in Table 27 below for England and Wales, and England
only. These are based on estimates of the reduction in admissions or patient numbers caused by
the policies, combined with estimates of the total hospital costs per bed day for mental health
patients – see Annexes CIII and D for more detail on methodology. These benefits should not all
be understood as cashable savings but will in practice lead to health benefits. These values will
require further investigation.

195. Many of the changes in the Bill are principally intended to improve patient experience and
therapeutic outcomes, which should have health and wellbeing benefits. It has not been possible
to quantify or monetise these effects, and they are described in the ‘Non -monetised benefits’
section.

Table 27. Summary of benefits, England and Wales (£millions, 2024/25 prices, undiscounted) –
Central Estimate
2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 2032/33 2033/34
Benefits from
fewer admissions
due to ACDs
0 0 0 0 0 12 19 22 24 25

Benefits from
fewer detentions
due to reforms for
people with a
learning disability
and autistic
people
0 0 269 271 273 274 276 277 279 280

Total benefits 0 0 269 271 273 286 294 299 303 306

2034/35 2035/36 2036/37 2037/38 2038/39 2039/40 2040/41 2041/42 2042/43 2043/44 Total
Benefits from
fewer admissions
due to ACDs
27 28 29 29 30 30 31 31 32 33 400
Benefits from
fewer detentions
due to reforms for
people with a
learning disability
and autistic
people
282 283 284 286 287 288 290 291 292 293 5,075
Total benefits 308 311 313 315 317 319 320 322 324 326 5,475

Table 28. Summary of benefits, England only (£millions, 2024/25 prices, undiscounted) – Central
Estimate
2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 2032/33 2033/34
Benefits from
fewer admissions
due to ACDs 0 0 0 0 0 11 18 21 23 24
Benefits from
fewer detentions
due to reforms for
people with a
learning disability
and autistic
people
0 0 242 243 245 246 248 249 251 252

Total benefits 0 0 242 243 245 258 266 270 273 276

2034/35 2035/36 2036/37 2037/38 2038/39 2039/40 2040/41 2041/42 2042/43 2043/44 Total

57

Benefits from
fewer admissions
due to ACDs 26 27 28 28 29 29 30 30 31 31 384
Benefits from
fewer detentions
due to reforms for
people with a
learning disability
and autistic
people 253 254 256 257 258 259 260 261 262 263 4,560
Total benefits 279 281 283 285 287 288 290 291 293 295 4,945
Impact of Advanced Choice Documents on hospital admissions
196. Research evidence on interventions that focus on involving service users in defining
preferences and planning for their care in the event of a future mental health crisis, including
ACDs, have been found to sometimes reduce the risk of hospital admissions34. It is assumed in
a central scenario that 12.5% of those who would have been detained and would have already
written an ACD at that point (following prior admission) under Option 1 35, would now not be
detained. This calculation then informs the number of patients to which the wider ‘process costs’
of MH Act reform (which mainly affect detained patients specifically) are applied, reducing the
estimated cost impacts.
197. Research suggests many patients who might avoid detention due to a crisis-planning initiative
will be voluntarily admitted instead, and that other admissions besides detentions might be
prevented. Therefore, a separate calculation assumes that 5% of baseline admissions (voluntarily
or under detention) under Option 1for those estimated to have already written an ACD would now
not be admitted at all. For these patients, benefits are estimated using an assumption that they
would have spent 26 days in hospital (based on the median for detentions under Part II of the
MHA in recent years) and information on the average costs per NHS mental health inpatient bed-
day which include all hospital running costs, not just the minority associated with MHA processes.
198. For these patients it is assumed that they instead receive other forms of mental health care
whilst in the community, including crisis -related services such as Crisis Resolution Home
Treatment Teams 36. For modelling purposes, it is assumed that this has costs equivalent to
receiving daily mental health care contacts over a 2-week period whilst living at home, which
offsets some of the benefits. These costs of community care have been presented in the
monetised costs section.
199. It is likely that for some patients now receiving treatment/support at home rather than in hospital,
there will be increased demands of social care and Voluntary, Community and Social Enterprise
(VCSE) services. It has not been possible to model those here. It has not been possible to
apportion the benefits and community provision costs from this transfer of activity out of hospitals
across different workforce groups . The benefits are highly uncertain and depend on the
availability of suitable mental health crisis provision.
200. More detail around the assumptions used in this modelling can be found in Annex C.III. We
have captured uncertainty around the reduction in admissions using a range of estimates, which
is discussed in the sensitivity analysis section.

34 Molyneaux, E., Turner, A., Candy, B., Landau, S., Johnson, S. & Lloyd-Evans, B. (2019). Crisis-planning interventions for people with
psychotic illness or bipolar disorder: systematic review and meta-analyses. BJPsych Open. 2019 June; 5(4): e53; published online 2019 Jun 13.
doi: 10.1192/bjo.2019.28
35 Estimates of MH patients with a learning disability and autism are removed from this BAU scenario for calculations of the impact of ACDs on
admissions, because for many the change in detention criteria will have a more immediate impact on admissions.
36 Rojas-García A, Dalton-Locke C, Sheridan Rains L, Dare C, Ginestet C, Foye U, Kelly K, Landau S, Lynch C, McCrone P, Nairi S,
Newbigging K, Nyikavaranda P, Osborn D, Persaud K, Sevdalis N, Stefan M, Stuart R, Simpson A, Johnson S, Lloyd-Evans B. (2023),
‘Investigating the association between characteristics of local crisis care systems and service use in an English national survey’. BJPsych Open.
2023 Nov 3;9(6):e209. doi: 10.1192/bjo.2023.595..

58

Table 29. Estimated reduction in flow of admissions following Advance Choice Documents
(ACDs) (based on central detention scenario)
2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 2032/33 2033/34
Central Scenario - (5% overall admission prevention and 12.5% detention prevention rate)
Reduction in
admissions 0 0 0 0 0 710 1,110 1,280 1,380 1,450
Of which
detentions 0 0 0 0 0 910 1,420 1,630 1,770 1,860
Of which informal
patients 0 0 0 0 0 -200 -310 -360 -390 -410

2034/35 2035/36 2036/37 2037/38 2038/39 2039/40 2040/41 2041/42 2042/43 2043/44 Total
Reduction in
admissions 1,500 1,550 1,580 1,590 1,590 1,600 1,600 1,610 1,610 1,620 21,760
Of which
detentions 1,930 1,980 2,030 2,040 2,040 2,050 2,060 2,060 2,070 2,080 27,910
Of which
informal
patients
-420 -440 -450 -450 -450 -450 -460 -460 -460 -460 -6,150
Note: These numbers have been modelled using data from England only. Numbers are rounded to nearest 10.

Reducing detention of people with a learning disability and autistic people
201. We expect that the change in detention criteria for people with a learning disability and autistic
people will lead to a reduction in the number of detentions in this population. To model this, we
have considered NHSE-provided monthly timeseries data for the number of admissions of people
with a learning disability and autistic people, split into those with a Severe Mental Illness (SMI)
flagged or not flagged within the data, as a proxy37.
202. Under Option 1, we assume for modelling purposes that admissions of people with a learning
disability and autistic people remain constant into the future (at a per capita rate) at an annual
average figure for total Part II Section 3 admissions. This does not take into account ongoing
policy and work to reduce inpatient numbers. We assume admissions remain constant due to
high proportions of suppression within the available rounded data from NHSE (to minimise risk
of disclosure), meaning more accurate trends and forecasts for future admission figures cannot
be estimated within our analysis.
203. Under Option 2, we assume implementation occurs in 2026/27 – this is an arbitrary date chosen
for modelling purposes only. It should not necessarily be seen as a target or as a likely timeframe
for the change in detention criteria change. U pon implementation, only people with a learning
disability and autistic people with a co-occurring mental health condition, meeting the detention
criteria, should be admitted and detained under Part II Section 3. For modelling purposes, w e
assume future admissions under Option 2 remain constant into the future (at a per capita rate) at
an annual average figure for Part II Section 3 admissions of people with a learning disability and
autistic people with SMI flagged (used as a proxy) . This leads to an estimated reduction in the
number of admissions of people with a learning disability and autistic people of 7,030 over the
appraisal period.
204. To note, our analysis on the cost impacts of the change in detention criteria for people with a
learning disability and autistic people uses estimated projections on the change in total number
of inpatients with a learning disabil ity and autistic inpatients, rather than the change in
admissions. This is because the reform may result in some immediate discharges when it is
switched on (as some inpatients may now no longer be eligible for detention and therefore be
discharged). Therefore, looking at admissions alone would miss the increase in discharges when

37 NHSE unpublished internal analysis

59

the reform is switched on. Given this, we use total change in inpatients per year (i.e. a “stock”
figure, rather than “flow” figures of admissions/discharges) to understand the overall impact of
the reform. See Annex D for further methodological details on modelling inpatients with a learning
disability and autistic inpatients and our resulting community cost estimates.
205. Within our analysis we have not produced high and low scenario estimates for the change in
admissions of people with a learning disability and autistic people under Option 2 compared to
Option 1 because NHSE data provides a fairly consistent view of the percentage of inpatients
with a learning disability and autistic inpatients with an SMI flagged over time which is being used
as a proxy for modelling purposes. Furthermore, our understanding of the reform on the change
in detention criteria is that those wi thout a SMI will no longer be detained following reform. We
have however undertaken sensitivity testing in how we apply the inpatient volume estimates over
time, to costs. Therefore, final cost figures have been through sensitivity testing and a range is
provided.
Table 30. Estimated Reduction in number of admissions of people with a learning disability and
autistic people (based on central detention scenario, compared to Option 1)
2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 2032/33 2033/34
Central Scenario
Reduction in
admissions of
people with a
learning disability
and autistic
people
0 0 220 390 390 390 390 390 400 400

2034/35 2035/36 2036/37 2037/38 2038/39 2039/40 2040/41 2041/42 2042/43 2043/44 Total
Central Scenario
Reduction in
admissions of
people with a
learning
disability and
autistic people
400 400 400 400 410 410 410 410 410 410 7,030
Note: These numbers have been modelled using data from England only. Numbers are rounded to nearest 10.
Indirect health benefits
206. The monetised benefits above have been estimated as a direct benefit to the health and social
care system based on a reduction in bed day costs but may in practice lead to health benefits for
other patients due to high demand. These indirect health benefits have been estimated using a
multiplier of around 4.7, which represents the marginal gain in social value for each NHS benefit
(as is similarly applied to opportunity costs in the monetised costs section).

Table 31. Summary of total NHS benefits with and without health benefits – England only
(£millions, 2024/25 prices, undiscounted)
2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 2032/33 2033/34
NHS benefits
(without health
benefit)
0 0 242 243 245 258 266 270 273 276
NHS benefits (with
health benefit) 0 0 1,128 1,136 1,143 1,202 1,240 1,260 1,276 1,289

2034/35 2035/36 2036/37 2037/38 2038/39 2039/40 2040/41 2041/42 2042/43 2043/44 Total
NHS benefits (without
health benefit) 279 281 283 285 287 288 290 291 293 295 4,945
NHS benefits (with
health benefit) 1,301 1,311 1,322 1,329 1,337 1,345 1,353 1,360 1,368 1,376 23,075
Note: Totals may not equal the sum of the annual figures due to rounding.

60

Non-monetised benefits
207. In addition to the monetised benefits, there are expected to be benefits associated with Option
2 that have not been able to be monetised due to lack of available data and uncertainty around
the expected impacts.
208. To give an indication of the benefits required to offset the costs of the policy in each year, we
have undertaken breakeven analysis. These includes the potential benefits to the individual (in
terms of health and wellbeing improvements) and potential benefits to the health system (in terms
of reduced length of stay in hospital).
Benefits of improved patient experience
209. The main policy objectives of the reforms are to:
• maintain the power to intervene and detain people under the Act when appropriate, to
prevent harm to self or others;
• modernise mental health legislation to give patients greater choice and autonomy over their
care and treatment, and access to enhanced rights and support under the MHA;
• ensure that the patient, their family and/or carer, and their Nominated Person are proactively
supported to take part in decision making around care, treatment, and planning.
• introduce new patient safeguards, such as granting informal patients access to
an Independent Mental Health Advocate (IMHA);
• improve existing patient safeguards, such as giving patients earlier access to the Mental
Health Tribunal (MHT) and to a Second Opinion Appointed Doctor (SOAD);
• reduce racial disparities under the MHA and promote equality;
• ensure that patients receive therapeutic benefit from detention and that they are treated with
dignity and respect, with a view to improving patient experience , improving recovery and
therefore reducing the length of their detention; and
• prevent longer term detentions for people with a learning disability and autistic people under
the civil parts of the Act where they do not have a co-occurring mental disorder that would
warrant hospital treatment.
210. While the patient benefits aren’t monetised due to a lack of quantitative evidence, the benefits
to patient experience form the principal rationale for the policy and are therefore important to
consider and understand.
211. Qualitative evidence on patient experience under the MHA can provide an understanding of the
gap for potential patient improvements and benefits of the MHA reform. The Independent Review
describes the very negative patient experience associated with being detained for many
patients.38 A systematic review of patients' experiences of assessment and detention under
mental health legislation found themes of fear and distress during detention. 39 Synthesis of
evidence found often negative, traumatic impacts on emotional well-being and self-worth.40 The
research carried out by the Independent Review found that services are experienced as overly
coercive, as not treating people with dignity, and as uncommunicative.41
212. Evidence on the link between patient experience and outcomes can illustrate the potential
patient benefits from the reform. A study in England on 1,570 involuntary admitted patients follows
interviews within the first week of admission and 1 year after.42 The evidence shows that involving

38 Modernising the Mental Health Act – final report from the independent review - GOV.UK (www.gov.uk)
39 Akther SF, Molyneaux E, Stuart R, Johnson S, Simpson A, Oram S. Patients’ experiences of assessment and detention under mental
health legislation: systematic review and qualitative meta-synthesis. BJPsych Open. 2019;5(3):e37. doi:10.1192/bjo.2019.19
40 A qualitative meta-synthesis of service users’ and carers’ experiences of assessment and involuntary hospital admissions under mental
health legislations: a five-year update | BMC Psychiatry | Full Text (biomedcentral.com)
41 Reforming the Mental Health Act - Centre for Mental Health
42 Priebe S, Katsakou C, Amos T, et al. Patients’ views and readmissions 1 year after involuntary hospitalisation. British Journal of Psychiatry.
2009;194(1):49-54. doi:10.1192/bjp.bp.108.052266

61

patients in decisions about their treatment under involuntary mental health treatment is
associated with improved outcomes such as a lower likelihood of readmission, and that providing
information, respect, empathy, and engaging patients in treatment plann ing and including their
preferences in treatment decisions can improve treatment satisfaction. The main findings of the
results are that patients who expressed a lower satisfaction with hospital care within the first week
of involuntary admission are more likely to be involuntarily readmitted within 1 year. Overall, these
findings suggest that involving patients in their treatment decisions could potentially improve
patient satisfaction and adherence with treatment and lead to improved health outcomes, thereby
reducing the likelihood of readmission.
213. The proposed changes to the MHA aim at improving patient’s voice and experience and it is
expected that these will bring beneficial impacts on wellbeing and health for patients who are
detained under the MHA. For example, if patients draft an ACD, have increased access to IMHAs
and SOADs, are automatically referred to the MHT on a more regular basis, then they will have
more opportunities to voice any concerns and have their detention reviewed by the relevant
professionals. Health impacts may be realised in the form of improvements to the patient’s
original condition as a result of more personalised and targeted treatments , or they could be
gained through a reduction in the stress or anxiety that patients may face during detentions after
the safeguards implemented by the policy improve the overall patient experience. As mentioned
above, there is evidence that improvements in patient experience and patient engagement, both
of which are aims of this policy intervention in their own right , are associated with in creased
adherence to treatment and have a beneficial impact on health outcomes. Strengthening patient
involvement in their own care and treatment is intended to improve experiences of the MHA ,
improve autonomy, and provide dignity to those detained under the MHA. These are important
outcomes, but they are not easily monetised. The extent to which the changes outlined
throughout this IA will affect patient dignity is uncertain, and the value attributed to it is subjective
and likely variable across patients.
214. If a patient refuses the chosen medical treatment, while it will be harder for the clinician to simply
overrule the patient, it may still result in treatment being administered. The responsible clinician
will be required to demonstrate that either there is no other alternative available, or that they have
considered alternatives with the patient and/or those close to the patient, but the patient has not
consented to them. However, before treatment can be administered against a patient’s consent,
a SOAD will be required to approve the necessary treatment and to ensure the clinician has taken
all the necessary steps. Therefore, while patient engagement with treatment planning may not
always align with preferences, it is the greater transparency in the overall dec ision-making
process and the stricter criteria for actioning against preferences, which we think will contribute
towards increased patient satisfaction. To support greater dignity and respect of patients, any
reasons for deviating from their stated preferences will be explained by the clinical team. These
improved outcomes would be expected to have some direct health and wellbeing benefits to
patients. However, due to the wide range of the conditions and circumstances experienced by
patients detained under the MHA, it has not been possible to quantify these benefits in terms of
QALY or WELLBY gains . A breakeven analysis has been provided to illustrate the scale of
benefits required to offset the costs of the policy, discussed in greater detail below.
Avoiding unnecessary or inappropriate admissions and restriction
215. In terms of impacts on the number of patients admitted and detained to start with, we have
modelled the potential effects of ACD and CTO reforms and impacts to people with a learning
disability and autistic people of changing detention criteria. As well as creating the impacts
described in the ‘Monetised Benefits’ section, where detention or admission would have been
inappropriate, the associated reduction in restriction to pa tients can be expected to improve
patient and carer welfare.

62

216. Both the Independent Review43 and the CQC annual reports on their monitoring of the uses of
the MHA44 have found that many patients are still not involved in the decisions involving their
care, are not treated with dignity and respect, and are detained in low quality physical spaces.
Many have spoken about their concerns or complaints, and about the traum a detention and
treatment has caused them. The Independent Review concluded that often it is crisis rather than
need that opens the door to services for patients. It report ed that opportunities for early
intervention are missed too often, which leads to a person confronting crisis unsupported, and a
further consequence of that is that increasingly the first contact is with the police rather than with
healthcare.
217. An evaluation conducted in one inner London NHS Trust45 found assessments were less likely
to result in detention when professionals other than the assessing team were in attendance
(although this association weakened after adjusting for potential confounders ). This concludes
that local assessment processes could contribute to minimising detention rates, such as
community team participation in assessments, although challenges are posed by limited
resources.
218. One study by Camden and Islington NHS Foundation Trust aimed to demonstrate an alternative
model of psychiatric care found that a 4-week trial of embedded mental health and physical health
care for admission avoidance in the elderly was well received by staff and meant that three people
who would otherwise have had potentially long and deleterious mental health admissions to
inpatient care were cared for successfully at home with a cost savin g. The trial displayed that
through integration of care between community, secondary care and mental health services we
can achieve better outcomes at lower cost for the patient group.
219. It is possible that some reforms, including shortening initial detention periods; increasing
application opportunities and automatic referrals to the MHT ; and supporting patients to
understand and exercise their rights via increased use of advocacy , will lead to some patients
being discha rged sooner . Such impacts have not been quantified due to a lack of relevant
research evidence and significant uncertainty over the effects, but this would likely bring
additional benefits to patients who have been detained under the Act.
Impact of Advanced Choice Documents on hospital admissions and patient outcomes
220. The monetised benefits section described the approach to estimating the impact of Advanced
Choice Documents on admissions and estimated in a central scenario that 12.5% of those who
would have been detained and would have already written an ACD at that point (following prior
admission) under Option 1 would now not be detained, but might still be informally admitted. This
calculation then informs the number of patients to which the wider ‘process costs’ of MH Act
reform (which affect detained patients specifically) are applied, r educing the estimated cost
impacts.
221. The estimated reduction in admissions following ACDs (based on central detention scenario) is
a total of 22,000 reduction in admissions and 28,000 reductions of detentions over the appraisal
period. For example, in year 2033/34 an estimated reduction in admissions of 1,500 , 1,900 of
which are a reduction in detentions (the difference being an increase in informal patients).
222. Aside from the impact on hospital admissions, ACDs can provide qualitative benefits identified
for patients from ACDs for crisis planning, which are separate from the wider benefits for inpatient
experience mentioned in above section. Benefits of ACDs will vary for individuals, the principle

43 Department of Health and Social Care. (December 2018). Modernising the Mental Health Act - Increasing choice, reducing compulsion. Final
report of the Independent Review of the Mental Health Act 1983. Accessed at: https://www.gov.uk/government/publications/modernising-the-
mental-health-act-final-report-from-the-independent-review
44 Monitoring the Mental Health Act - Care Quality Commission (cqc.org.uk)
45 Mental Health Act Assessment Process and Risk Factors for Compulsory Admission to Psychiatric Hospital: A Mixed Methods Study | The
British Journal of Social Work | Oxford Academic (oup.com)

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is to think about which elements of past illness experiences they consider having been most
harmful to them and how ACDs can be used to minimise these harms in future.
223. International and national evidence46 suggests that most people with severe mental illness are
in favour of advance decision making, and research suggests people who have ACDs express
feelings of self-determination, autonomy and empowerment47. It can give people who have ACDs
a degree of independence when thinking about their care.48 For some people, this may be about
harnessing earlier intervention and mechanisms that helped, which could potentially prevent
spiralling or reduce severity and/ or duration of an episode. It has been noted as helping to “take
control” during situations of illness48
224. For others, this could be about using ACDs to ensure that treatment is accessed when unwell,
even if individual knows from past experience that they may be unwilling 49. This might not
necessarily mean detention or inpatient treatment – it could be that simply having an ACD in
place means that the individual will be more inclined to accept treatment. For example, there may
treatments with the same outcomes but varied side effects, a particular individual may be less
affected in term s of side effects by one treatment and therefore prefer to use this treatment. 48
This can lead to ensuring treatment is better targeted for the individual, which hopefully leads to
better interventions and more well managed periods of illness.
225. ACDs also give the chance for individuals to give instructions about practical aspects of their
life, such as domestic, financial,50 caring and responsibilities (such as children or pets)48,which
aids them to be looked after when unwell and aim to ease additional anxieties. They can also
improve therapeutic relationships and trust in mental health professionals – there is evidence
suggesting that ACDs may reduce negative coercive treatment experiences, which reduce
willingness to interact with mental health services 51. The collaborative approach of ACDs
stimulate communication between health professionals and service users, which may aid in
improving therapeutic relationships52.
226. A case study of anecdotal evidence53 from patients displayed filling out an ACD is therapeutic
and that having an ACD can be a comfort for patients. Carer case study evidence filling out an
ACD is helpful to do together so that the carer can better understand needs and instructions, as
well as helping to spot signs that a psychotic episode might be imminent.
Reducing detentions of people with a learning disability and autistic people
227. Under Option 2, upon implementation, only people with a learning disability and autistic people
with a co-occurring mental health condition should be admitted and detained under Part II Section
3. This is expected to lead to an estimated reduction in admissions of people with a learning
disability and autistic people of 7,030, over the appraisal period used for the purposes of this IA.
228. Some people with a learning disability and autistic people detained under the Act may have
experienced inappropriate care, a lack of specialised services tailored to their needs, overuse of

46 G.S. Owen, T. Gergel, L.A. Stephenson, O. Hussain, L. Rifkin, A. Ruck Keene (2019). Advance decision-making in mental health –
Suggestions for legal reform in England and Wales. International Journal of Law and Psychiatry. 2019; 64:162-177.
doi:10.1016/j.ijlp.2019.02.002
47 Zelle, H., Kemp, K. and Bonnie, R.J. (2015). Advance directives in mental health care: evidence, challenges and promise. World Psychiatry,
14: 278-280. doi:10.1002/wps.20268
48 How can they help? — Advance Choice Documents
49 Self-Binding Directives — Advance Choice Documents
50 Money and Mental Health - a charity founded by Martin Lewis
51 Zelle, H., Kemp, K. and Bonnie, R.J. (2015). Advance directives in mental health care: evidence, challenges and promise. World Psychiatry,
14: 278-280. doi:10.1002/wps.20268
52 Jankovic, J., Richards, F., & Priebe, S. (2010). Advance statements in adult mental health. Advances in Psychiatric Treatment, 16(6), 448-
455. doi:10.1192/apt.bp.109.006932
53 https://www.advancechoice.org/

64

restraints, over-medication, and extended periods of detention54. The MHA reforms are intended
to address this.
229. The MHA Code of Practice states that hospital detention is “rarely likely to be helpful” for an
autistic person, and that for people with a learning disability, “evidence -based good practice is
that most of their needs can best be met at home or in communi ty settings”55. A Care Quality
Commission (CQC) review of 43 specialist autism and learning disability hospital wards in 2020
concluded that most were not therapeutic environments56. In 2023, 31% of NHS trusts and 47%
of private providers of learning disability and autism services received a “requires improvement”
or “inadequate” safety rating.
230. Therefore, in addition to the benefits to the Health system associated from a reduction in
admissions, there are expected to be significant additional benefits for people with a learning
disability and autistic people in improvements in treatment, care and outcomes, which we have
not been able to monetise.
231. In assessing the costs of the change in detention criteria for people with a learning disability
and autistic people, some benefits arising from there being fewer people in inpatient settings have
been monetised. However, the analysis includes only benefits per inpatient bed, and we
understand there may be additional costs whilst an individual is in hospital as they may receive
an Enhanced Care. Enhanced Care is put into place for patients who, without additional
supervised observation, may be at risk of ha rm from e.g. falls, deterioration or isolation.
Therefore, the monetised inpatient benefits may underrepresent the true inpatient benefits
anticipated from this reform.
232. Putting C(E)TRs and DSRs on a statutory footing is expected to lead to an increase in the
number of C(E)TRs being carried out, and an increase in the use of DSRs. Given that both
C(E)TRs and DSRs aim to reduce the number of people in inpatient settings , there may be
reductions in inpatients which are not captured in monetised cost estimates . We do not include
these numbers in cost estimates because the impact is highly uncertain and we lack evidence to
make assumptions on the scale of inpatient reduction, following the reforms.
Reducing the use of Community Treatment Orders
233. The use of CTOs is expected to reduce as a result of changes in the CTO criteria. In the central
scenario, we assume that CTOs will decrease gradually to a total 20% reduction over a five-year
period from 2031/32 relative to the baseline. This leads to an estimated reduction in CTOs of
around 15,000 over the appraisal period.
234. It is expected that t he reforms will help to address the well documented racial disparity in the
use of CTOs. The standardised rate of Community Treatment Orders per 100,00 population is 7
times higher for Black or Black British ( 48.8 per 100,000 population) than for White or White
British people (6.9 per 100,000 population)57. To some extent this reflects higher overall detention
rates, but the number of CTOs as a proportion of overall detention numbers is higher for Mixed
(14%), Asian or Asian British (1 3%), Black or Black British (2 0%), and Other Ethnicity (1 3%)
people compared with White people (10%)58.
235. Patients on CTOs are likely to have their liberty restricted for significantly longer periods of
time59. Therefore, aside from the process costs savings associated from a reduction in the volume

54 POST-PN-0722.pdf (parliament.uk)
55 (2015). Mental Health Act 1983: Code of Practice for England
56 Care Quality Commission (2020). Out of sight – who cares?: Restraint, segregation and seclusion review
57 NHS Digital Mental Health Act Statistics, Annual Figures 2023/24: Table 3c
58 NHS Digital Mental Health Act Statistics, Annual Figures 2023/24: Table 1c, Table 3c. To give CTO: overall detention ratios, crude CTO rates
per 100,000 population from Table 3c are divided by crude detention rates (which include CTOs) per 100,000 from Table 1c.
59 Effectiveness of Community Treatment Orders: The International Evidence - PMC (nih.gov)

65

of CTOs, there may be additional non -monetised benefits for patients. Overall, although some
stakeholder views are positive, there is currently no robust evidence about either the positive or
negative effects of CTOs on key outcomes, including hospital readmission, length of hospital
stay, improved medication compliance, or patients’ quality of life 6061. Therefore, these benefits
have not been monetised.
Benefits for the Health and Social Care System
236. Benefits associated with improving health outcomes covered above will also have an impact on
the health & social care system. The proposals may help patients who previously were subjected
to long-term detentions but would now have better access to appeals and more effective care
treatment plans, potentially bringing a higher chance of earlier discharge. There is also evidence
(from a systematic literature review of 55 studies) that improvements in patient experience are
associated with reduced use of primary and secondary care resource s (such as fewer
hospitalisations, readmissions and primary care visits).62
237. Recent systematic reviews of qualitative evidence of patients' experiences of detention under
mental health legislation and of interventions for involuntary patients using randomised controlled
trials (RCTs) suggest that care planning interventions centred on the patient and increasing their
involvement in decision-making, which are areas covered by the MHA proposed reforms (e.g.,
CTPs, ACDs), could improve patient outcomes, including reducing the likelihood of these patients
relapsing and being involuntarily readmitted6364.
238. Once the improved safeguards that allow patients to be more involved in the decision-making
process are introduced, alongside more opportunities to review and challenge the detention and
the replacement of the nearest relative with a NP, there is the potential for some detentions to be
reduced in length. Since longer detentions have a direct cos t pressure on NHS budgets, there
could potentially significant benefits realised if the improved safeguards were to result in a
reduction in the average length of a detention. This would mean a cost saving for the NHS which
could then be put to use elsewhere in the Healthcare system and generate further direct health
benefits in the form of QALYs elsewhere. This benefit has not been monetised due to the lack of
clear evidence on exactly whether or how much length of stays are likely to be reduced by
following the introduction of the policy changes outlined in this IA. As an illustration, the breakeven
analysis section explores further the degree to which detention lengths would need to fall by for
the costs of the policy to be offset by this benefit alone.
Benefits For the Justice System
239. It is known that for some mental health problems the earlier an individual receives mental health
treatment the more effective it can be. This is because, if left untreated, especially in the wrong
environment, the problem can worsen and become harder to eventually treat and take more time
and resource to resolve for health providers. For example, lengthy delays in prisoner transfer to
secure hospitals can lead to mental health conditions deteriorating and becoming more
established. We anticipate that ensur ing individuals are able to access appropriate care faster

60 International experiences of using community treatment orders (psychrights.org)
61 Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental
illness: a systematic review and meta-analysis - PubMed (nih.gov)
62 Doyle, C., Lennox, L., & Bell, D. (2012) A systematic review of evidence on the links between patient experience and clinical safety and
effectiveness. BMJ Open. 2013; 3(1). Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3549241/
63 Giacco, D., Conneely, M., Masoud, T., Burn, E., & Priebe, S. (2018). Interventions for involuntary psychiatric inpatients: A systematic review.
European Psychiatry, 54, 41-50. doi:10.1016/j.eurpsy.2018.07.005. Also accessed at: Interventions for involuntary psychiatric inpatients: A
systematic review | European Psychiatry | Cambridge Core
64 Akther, S., Molyneaux, E., Stuart, R., Johnson, S., Simpson, A., & Oram, S. (2019). Patients' experiences of assessment and detention under
mental health legislation: Systematic review and qualitative meta-synthesis. BJPsych Open, 5(3), E37. doi:10.1192/bjo.2019.19. Also accessed
at: Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis |
BJPsych Open | Cambridge Core

66

will therefore lead to improved health outcomes, both short and long term, and help ensure
treatment is more cost effective.
240. It is anticipated that commitments to ensure that those in the Criminal Justice system are able
to access care as quickly and early as possible (such as increasing the timeliness of transfers
and ending the use of prison as a place of safety) would also co ntribute to efficiency gains in
other parts of the Justice system of England and Wales. Due to a lack of data, it is not possible
to monetise the impact on justice system costs, or prisoner or His Majesty’s Prison and Probation
Services (HMPPS) staff health and welfare of these policies.
241. In terms of Justice system impacts, prisoners awaiting transfer to secure hospitals and those
remanded to prison with severe mental health needs can be highly demanding of prison staff time
as they often require intensive monitoring and individualised support. Tackling lengthy delays in
prison transfers and ending the use of prison as a place of safety on the grounds of mental health
could therefore alleviate pressure on staff time within HMPPS, which could be reallocated
towards other priorities. We do not have reliable data to model these impacts but expect that the
population affected is small, therefore in line with the decision to not estimate the health system
impacts, we have we have also not monetised any corresponding savings to the prison system
resulting from these changes due to these expecting to be limited.
242. The reforms to supervised discharge will provide a legal basis for the discharge of patients
detained through the courts, who are subject to special controls by the Secretary of State for
Justice to protect the public from serious harm, to be discharged in to the community with
conditions which amount to a deprivation of liberty. This will be clearer for the patient and Mental
Health Tribunal and more transparent than relying on workarounds. It also allows for greater
scrutiny of the number of people subject to such conditions and the reasons why they are
necessary. The reform also responds to a gap left by a Supreme Court decision in 2018, which
found that there was no route under the current Act to apply discharge conditions which amount
to a deprivation of liberty, even if a patient consents to these.
Benefits for People with Relevant Protected Characteristics
243. The Independent Review65 heard concerns around the disparity of access to, and experience
of, mental health services for different disadvantaged groups, including LGBTQ+, ethnic minority
communities, people with a learning disability or autistic people, and asylum seekers and
refugees. This can influence the likelihood of detention in the first place, given varying access to
and success of alternatives, as well as experiences when subject to the Act. NHS England’s
Mental Health Services Data Set 66 is the main source for information about uses of the Mental
Health Act in England. It collects data on detentions by age, gender and race but does not collect
data on other protected characteristics. These gaps in the evidence base limit our understanding
of how certain groups are affected by the Act.
244. Broadly, it is anticipated that improved involvement of patients in treatment decisions (before
or after the potential need for detention arises) could improve patient satisfaction and adherence
with treatment, and lead to improved health outcomes6768, in the face of the specific needs for
such disadvantaged groups. The reforms should also help ensure that people are aware of their
rights under the Act and are appropriately informed and can actively participate in decisions
around their care and treatment.

65 Modernising the Mental Health Act: Final Report of the Independent Review of the Mental Health Act 1983
66 Mental Health Act Statistics, Annual Figures, 2023-24 - NHS England Digital
67 Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient involvement in health care decision making: a review.
Iranian Red Crescent medical journal, 16(1), e12454. doi:10.5812/ircmj.12454 (also accessed at: https://pubmed.ncbi.nlm.nih.gov/24719703/)
68 Doyle, C., Lennox, L., & Bell, D. (2012) A systematic review of evidence on the links between patient experience and clinical safety and
effectiveness. BMJ Open. 2013; 3(1). Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3549241/

67

245. It is anticipated that the reforms will have differential impacts for distinct groups of people. There
are expected to be benefits for people with a learning disability or autistic people from reduced
inappropriate admissions after the reforms, discussed in more detail in the monetised benefits
section. Additionally, the reforms are expected to reduce the use of CTOs , which may help to
address the well -documented disparities in their use. We have further explored the differential
impacts of the reforms in the distributional and wider impacts section.
Wider economic benefits resulting from potential improvements in mental health outcomes
246. The Organisation for Economic Cooperation and Development (OECD) has published a series
of reports outlining the significant economic burden of mental illness through the reduction in
workforce participation through unemployment, sickness absence and lost productivity. People
with a mental health condition have employment rates almost half of the general population (44%
vs 80% in 2020 -21)69, with severe conditions cutting life expectancy by 15 -20 years 70. This
translates into lost human capital and productivity. Mental health-related sickness absence alone
costs the UK economy £9 billion per year71, while economic inactivity affects 660,000 people who
cite mental health as their main health condition72.
247. The economic burden of mental ill -health has been estimated to be around £150bn per year ,
which is largely driven by lost output due to not being in paid work. There is a significant cost to
the government, estimated at around £70bn each year from tax and national insurance forgone
from being out of the workforce, plus NHS costs and benefits payments 73. Mental health issues
also create significant indirect economic costs through their impact on families, employers, and
wider society. Individuals with mental health conditions, are more likely to experience
absenteeism or presenteeism, diminishing productiv ity, reducing overall wellbeing, and leading
to a greater incidence of anxiety and depression.
248. Under the proposed policy Option 2, these reforms are likely to support better mental health
outcomes in the long term which could create economic gains. These gains could be driven by
the improvement of human capital and increased labour market participation, reduce d
absenteeism, and the opportunity to explore volunteering and paid employment as part of
recovery journeys, which can contribute to increased productivity and economic growth. The
largest impacts will likely be for those of working-age (18 to 64), which accounted for 77% of all
detentions in 2023/2474.
249. However, gains are likely to be limited among patients with experience under the MHA, who
are more likely than the wider population to be distanced from the labou r market. Additionally,
family members and friends may be providing additional unpaid care in the community as a result
of the reforms , which could impact their labour market participation. These wider economic
benefits have therefore not been monetised, as the impact is expected to be limited.
Breakeven analysis
250. The breakeven analysis described below seeks to estimate the non -monetised benefits
required to offset the estimated net monetised impacts of the policy (which are negative in NPV
terms in the central scenario). We use three ways to illustrate this: i) improved quality of life; i i)
improved wellbeing; iii) reduction in the length of stay for detainees.

69 The economic and social costs of mental ill health, Centre for mental health, (2022)
70 Public Health England (2018). Severe mental illness (SMI) and physical health inequalities: briefing.
71 The economic and social costs of mental ill health, Centre for mental health, (2022)
72 Labour Force Survey data (Jul-Sep 2022)
73 The economic cost of ill health among the working-age population, Oxera(2023) CentreforMH_TheEconomicSocialCostsofMentalIllHealth-
1.pdf (centreformentalhealth.org.uk)
74 Mental Health Act Statistics, Annual Figures, 2023-24 - NHS England Digital

68

251. Breakeven calculations have been carried out using the central NPV estimate, as well as the
low NPV scenario estimated in sensitivity analysis. Breakeven analysis was not performed for
the high NPV scenario which is positive. Results are shown in Table 32. It is important to consider
that this breakeven analysis is illustrative only. Further detail on the calculations behind this can
be found in Annex F.
Health benefits to patients
252. Patient benefits may materialise through detained patients responding better to treatment (due
to more involvement in their care) or through patients experiencing less stress and anxiety
resulting from a poor experience whilst being detained. These patient benefits are non-monetised
but we can illustrate the improvement in patient health per detention needed to offset the negative
NPV in the central scenario.
253. The measurement and valuation of a health intervention is typically performed by estimating
the number of QALYs generated . The value society places on a QALY are estimated to be
£70,000.75
254. Based on the calculated NPV over the 20-year appraisal period for Option 2, we
estimate that the in-year patient health gains per detention projected across the period
would need to be equivalent to 0.003 QALYs in the ‘policy on’ scenario in order to
produce discounted benefits commensurate with the monetised NPV. This is equivalent
to a 0.04 point improvement in QALYs if delivered over a 26 day period (26 days being
the median detention length for Part II patients in 2023/24).
255. This QALY gain of 0.003 calculated in this breakeven analysis is equivalent to helping someone
live for an extra 0.9 days in perfect health (i.e. health-related quality of life (HRQoL) of 1), or, live
for an extra 1.9 days in a state of perfect health rather than in moderate health (if that were
equivalent to a HRQoL of 0.5).
256. One of the most widely used preference -based instruments for the assessment of Health -
Related Quality of Life (HRQoL) that can be used to generate QALYs is the EQ -5D. We can
illustrate using the EQ-5D-5L to measure the health state of a patient.
• For example, a health state of 23245 (slight mobility, moderate self-care, slight usual
activities, severe pain/ discomfort, extreme anxiety/ depression) is equivalent to an
EQ5D score of 0.247. If a patient moves to a slightly improved health state of 23234
(slight mobility, moderate self-care, slight usual activities, severe pain/ discomfort,
severe anxiety/ depression), with the difference being from extreme to severe
anxiety / depression, the EQ5D score equates to 0.251. 76 Therefore, over a year
this patient has gained the equivalent of 0.004 QALYs ((0.251-0.247) x 1 year). This
is a hypothetical example to show the extent of patients’ health gains which would
equate to similar (bigger) QALY impacts needed to offset the net monetised impacts
of the policy.
257. To contextualise, successful treatment through talking therapies is estimated to lead to QALY
gain of 0.11.77 ‘The Economic and Social Costs of Mental Illness’ published by the Sainsbury
Centre for Mental Health (SCMH), June 200378 calculated coefficients for severe mental health
and moderate mental health; severe mental health was 0.352 of a QALY, and moderate mental
health was 0.098 of a QALY.

75 Franklin150331Monetary-Valuation-of-a-QALY-2014-prices.pdf (dhsc.gov.uk); DH Title (dhsc.gov.uk)
76 Valuing health-related quality of life: An EQ-5D-5L value set for England (euroqol.org)
77 Microsoft Word - Talking therapies IA final.doc
78 CentreforMH_TheEconomicSocialCostsofMentalIllHealth.pdf

69

Wellbeing benefits to patients
258. Improving patient experience of the MHA is a key policy objective of the Bill. Wellbeing is about
how people feel. Patient experience, choice, and autonomy all feed into the wellbeing of the
patients. Wellbeing outcomes are captured for an individual dependent on wellbeing, health,
relationships, environment, living, finances, economy, governance, education, and work. Health
is a subset of what is captured within wellbeing.
259. The idea of a WELLBY is about length of life and quality of life. The quality ‘weight’ is how
satisfied people themselves say they are with their life. 1 WELLBY is one unit of life-satisfaction
on a 0-10 scale for one person for one year, further detail is in Annex F.
260. Therefore, we have used WELLBYs to quantify the wellbeing of patients. This patient wellbeing
is non -monetised (further detail in the non -monetised section) but we can illustrate the
improvement in patient wellbeing needed to offset the NPV of the policy.
261. The standard value of one wellbeing adjusted life year on a WELLBYs is estimated to be
£13,000.79
262. We estimate that in order to offset the NPV of the policy and ‘breakeven’, an improvement
in wellbeing of 0.012 points of life satisfaction (on a 0 -10 scale) is required per detained
patient over the appraisal period. This is equivalent to a 0.16 point (i.e. moving from 5.00
to 5.16 on a 1 to 10 scale) improvement in life satisfaction if delivered over a 26 day period
(26 days being the median detention length for Part II patients in 2023/24).
263. To contextualise, the effect of employment to unemployment is estimated as -0.46 WELLBYs
in the UK 80; improvement from moderate loneliness to mild loneliness is estimated as +0.7
WELLBYs8182. The WELLBY decrease (difference between having the condition and not having
the condition) in working age adults (20 -65) for the following conditions have been estimated:
OCD, 0.857; BPD, 1.21; eating disorders, 0.998; anxiety, 0.717; MDD, 0.968; S chizophrenia,
0.991; ADHD, 0.846.83
Reduction in length of stay
264. One of the potential benefits of the reforms may be a r eduction in the length of stay for
detainees. This may be from mechanisms including better access to reviews and appeals of
detentions and more effective care treatment plans, potentially bringing a higher chance of earlier
discharge. Here we consider only the health benefits of freeing up mental health beds (as
monetised for patients diverted from hospital altogether in ‘Monetised Benefits’) rather than other
impacts for the patients hypothetically experiencing shorter stays.
265. Focusing on the bed day costs associated with a period in detention from the NHS Cost
Collection (which constitute the majority of costs), we estimate that the proposals would
require a 0.33 day reduction in all detainees’ lengths of stay to breakeven. For reference,
the median length of a detention is estimated to be around 26 days (for part II patients)84.

79 Wellbeing_guidance_for_appraisal_-_supplementary_Green_Book_guidance.pdf (publishing.service.gov.uk)
80 Slides - Paul Frijters and Christian Krekel - Treasury Guest Lecture: Wellbeing Report seminar series: WELLBY cost-benefit analyses,
principles and examples - 9 June 2022
81 loneLINESS MONETISATION REPORT
82 from 3 - "occasionally" lonely - to 2 - "hardly ever" lonely - on a 1 to 5 self-reported scale,
83 CentreforMH_TheEconomicSocialCostsofMentalIllHealth.pdf
84 Mental Health Act Statistics, Annual Figures, 2023-24 - NHS England Digital Table 8a

70

Table 32. Summary of breakeven analysis with sensitivity analysis results incorporated for
England and Wales.
Non-monetised
benefit
Central
NPV
Low NPV scenario
from sensitivity
analysis
Unit / description
Reduction in the
length of stay for
detainees
0.334 8.929
Reduction in length of stay (days) for
detentions occurring from 2025/26 in
appraisal period to produce health benefits to
offset NPV of the policy
Increase in health
benefits: QALYs 0.003 0.068
Health gain (QALYs) for each detention
occurring from 2025/26 in appraisal period to
offset NPV of the policy
Increase in health
benefits:
WELLBYs
0.012 0.308
Wellbeing gain (WELLBYs) for each
detention occurring from 2025/26 in appraisal
period to offset NPV of the policy

Risks and assumptions
Modelling uncertainties
266. The impacts which have been monetised in this IA consider the change in activities directly
related to the reforms. Many impacts were not able to be monetised due to lack of data or
research evidence, and furthermore given the 20-year appraisal period, there is a likelihood that
input assumptions/estimates may change over the period in ways it is now possible to accurately
predict now. Therefore, there is significant uncertainty around estimates of costs and benefits, as
reflected in sensitivity analysis. Some key areas of uncertainty include:
• CQC fees: For instance, costs to CQC have been based on current SOAD fee rates . Any
future fee increases would increase costs.
• Use of CTOs: The proposed reforms to the Bill aim to ensure that the MHA continues to get
the right balance between patient and individual rights, and public and patient safety. Reforms
to introduce greater scrutiny to CTOs and amend the CTO criteria in line with the new
detention criteria are expected to have the effect of reducing CTOs by ensuring they are used
in a more targeted way where someone is a risk to others rather than to their self. However,
there is a risk that clinicians may be more risk aver se in the public protection context and
therefore more inclined to issue a CTO, which may negate the degree to which use of CTO
decreases. Alternatively, it may make sure they are used in a more targeted way where
someone is a risk to others rather than to their self.
• Duration of community care: the analysis on the change in detention criteria for people with
a learning disability and autistic people assumes that the duration of community care required
for an individual who avoids admission is equal to how long they would have stayed in hospital.
This is a simplifying assumption made for modelling purposes, due to lack of evidence of what
their expected duration of stay in community care would look like in practice following reform.
As explained below, we have conducted sensitivity analysis on the community costs figures
which present a wide range, reflecting the uncertainty.
267. As noted in the annexes, a large range of assumptions have had to be made in the absence
of direct evidence – regarding patient uptake, staff time requirements for tasks, and which staff
members may be involved in different processes – to estimate monetised impacts. It is also not
certain how far some of the proposals already represent best practice in delivery organisations.

71

As such, sensitivity analysis has been conducted with respect to the proposed MHA reforms in
the draft Bill, which varies the key assumptions used to monetise impacts in order the
demonstrate the potential impacts on results.
268. The results of this sensitivity analysis and discussion of other risks are set out below.
Wider capacity & workforce constraints
269. The impacts discussed in this IA are dependent on wider system capacity and workforce
constraints being addressed. For instance, realising the health service and patient benefits from
diverting patients from hospital admission and detention will depend on the capacity in the system
to safely shift people away from inpatient settings to the community, which is dependent on the
investment and services costed in this IA being implemented. Similarly, depending on delivery
models deployed, difficulties in building or securing appropriate housing, either associated with
the planning and construction process or funding issues, would mean that the benefits from
reducing detentions of people with a learning disability and autistic people may either not be fully
realised, realised later than anticipated, or result in greater than expected costs.
270. For some workforce groups in particular the reforms are expected to lead to an increase in
MHA-associated activity that is significant as a proportion of current levels, such as SOAD and
advocacy activity. As such the need to increase capacity and risk of that meeting workforce
supply constraints may be higher for these workforces than for other areas.
271. As stated in the 'Monetised costs section' the IA does not constitute a fully developed workforce
implementation plan This IA has not set out a detailed workforce implementation plan but has, in
approximate terms, estimated some of the marginal costs associated with an expansion in
workforce (for example, training), in addition to ongoing resource costs, to accommodate th e
additional workload generated by the reforms. Regardless of whether budgets are available to
pay staff, realising this expansion and the se costs will require attracting sufficient new trainees
or recruits to various roles in the health, courts, social work, wider local authority and VCSE
sectors, and ensuring retention does not deteriorate. The reforms are not the only source of future
demand that may require an expansion of the relevant workforces, but if workforce numbers are
not sufficient to accommodate additional demands, then either the benefits of the proposals
would not be achieved in full, or they may result in negative impacts whe re professionals must
divert time away from other tasks.
272. Implementation timelines set out in this IA are indicative and actual commencement dates will
depend on the progression of relevant processes, legislative and non-legislative actions, capacity
in the system, or unforeseen circumstances. In some cases, certain reforms will not be
commenced until we are satisfied that clear pathways are in place to safely enact the proposed
reforms. This may mean that the profile of costs and benefits set out in this IA may vary in
practice, or occur later than modelled here, but this flexibility provides a mitigation to the risks
discussed above.
273. Increased demand on services as a result of the reforms may contribute to wider system
pressures and delays, such as delays in people receiving a SOAD who can certify their treatment
or delays in MHT proceedings.
274. The reforms to the MHT are expected to increase demand, potentially straining resources and
leading to delays in proceedings. To manage this, the government plans to delay tribunal-related
reforms until 2030/31, providing time to recruit and train personnel, upscale capacity, and address
resource implications. This phased approach aims to ensure that the tribunals can meet
increased demand without compromising decision -making quality or exacerbating system
pressures.

72

Possible unintended consequences
275. Mental Capacity Act and Court of Protection: It is possible that the proposed reforms to the
detention criteria, treatment safeguards for people with a learning disability and autistic people,
the new treatment safeguards and Nominated Person proposed in the Bill could pose a small risk
of increased demand on the Court of Protection, which is responsible for deciding whether a
person has the mental capacity to make a particular decision for th emselves under the Mental
Capacity Act (MCA), and for adjudicating on whether a particular decision made on their behalf
is in their best interests.
276. For instance, the proposed changes to the detention criteria will mean that civil patients with a
learning disability and autistic patients can only be detained for treatment under section 3 if they
have a co-occurring mental disorder that warrants hospita l treatment. Some stakeholders have
raised concern that alternative legislative routes could be used to detain people when section 3
is no longer an option, especially where adequate community care is not available. This includes
use of the Mental Capacity Act, which would have impacts on the Court of Protection, or detention
under Part III.
277. It is expected that the proposed reforms to the detention criteria should result in more people
receiving care and treatment in the community rather than being detained in hospital through
alternative routes. To ensure that these individuals receive the ri ght care and support, the Bill
introduces new duties on ICBs to hold a register of those at risk of admission and for ICBs and
local authorities to use this information when exercising their commissioning and market
functions. Under the proposals, both ICB s and local authorities must seek to ensure that the
needs of people with a learning disability and autistic people can be met without admission to
hospital. The proposed changes to the detention criteria for people with a learning disability and
autistic people will only be switched on when systems are able to demonstrate sufficient level of
community support to safely move inpatients from hospital back into t heir community. We will
monitor the impact of the proposed reforms to ensure that they are having their intended effects
and seek to mitigate any consequences, such as impacts on the Court of Protection and those
associated with increased use of the Mental Capacity Act.
278. Nominated Persons: There is a risk that the Nominated Person policy leads to an increase in
challenges against the suitability of the Nominated Person chosen by the patient, given that
competence for under 16s can be difficult to judge. However, this is mitigated by a robust
nomination process and the processes put in place to overrule or displace the Nominated Person
where appropriate. A health or social care professional or advocate must witness the nomination
and sign a statement to say that they have no reason to think that i) the patient lacks capacity (or
competence if under 16) to make a nomination, ii) any fraud or undue pressure has been used
to induce the patient to make the appointment, iii) the Nominated Person is unsuitable to act as
an Nominated Person. Decisions made by Nominated Person can be overruled by Responsible
Clinicians or AMHPs if they are likely to cause danger to the patient or others, and the Nominated
Person can also be displaced by the courts if they meet criteria deeming them to be unsuitable.

279. Timeliness of mental health treatment: New treatment safeguards and measures such as
ACDs are likely to require increased clinical input to support the patient to share their wishes and
feelings, to engage with the wishes shared at the time or in advance, and/or to consult with those
close to the patient to come to a decision on what may be best for the patient. There is a risk that
in some cases this could delay the administration of treatment to the patient. However, we
anticipate that as a result of thes e reforms, the final outcome of any clinical decision is likely to
be more in line with the patient’s wishes and preferences and therefore conducive to a more
positive clinician-patient relationship and improve the patient’s recovery. The reforms also do not
prevent a clinician providing treatment when immediately necessary for the range of reasons
covered in the urgent treatment criteria.

73

Housing risks
280. Developing housing, and in particular specialised supported housing where location and design
is crucial, depends on several factors such as planning, infrastructure, the viability of the scheme
and local authority backing. The successful delivery of compl ex supported housing schemes
requires all the critical factors to be met at the right time.
281. The delivery of supported housing also works best when local services work together alongside
providers. The Government will shortly implement the duty set out in the Supported Housing
(Regulatory Oversight) Act 2023 requiring local housing authorities and social services authorities
to formulate a supported housing strategy for the district. The strategies will enable developers
to make informed decisions about where new supported housing schemes are most needed and
for which groups, including people with a learning disability, autistic people and those with
enduring mental ill health.
282. Risks to delivering the right accommodation in the right place can be mitigated by local
partnership working, and at national level through joint boards such as the Supported Housing
Programme Board which includes the Ministry of Housing, Communities and Local Government,
the Department for Health and Social Care and the Department for Work and Pensions.
283. Other key risks to housing include:
• Capital Investment: Securing capital funding is often a significant barrier, especially where
public finances are limited. The cost and availability of land, construction materials, and labour
all contribute to a high initial outlay, making it challenging to build new properties to the design
standards and at the scale required.
• Planning Permission: Obtaining planning permission can be lengthy and complex, with extra
hurdles for securing permission for specialist accommodation. There are often delays due to
local objections or changes in planning policies, which can significantly extend timelines.
• Feasibility in Practice: Even with capital and planning approval, the actual construction
process can be delay ed due to factors like supply chain disruptions, contractor availability,
and regulatory compliance. This can impact delivery timelines and increase costs.
• Gaps and Lead Times: There is a high likelihood of gaps between the demand for housing
and the delivery of new builds. Lead times for specialist accommodation can be particularly
long due to the bespoke nature of the designs, which need to accommodate specific needs,
such as accessibility features or sensory-friendly environments.
• Responsiveness to Demand: Public house building often struggles to keep pace with changes
in demand, particularly in areas where housing shortages are already acute. This can be
exacerbated by fluctuations in policy or funding priorities, leading to a misalignment between
what is built and what is needed.
284. Given these potential issues associated with building new homes, we recognise there is a risk
that the housing rent costs required to provide accommodation for people with a learning disability
and autistic people who are no longer eligible for detention and are discharged from hospital, are
higher with higher private sector housing revenue costs instead, because the building or
purchase and retrofit of the homes will need to be funded via private lending (with the additional
costs of borrowing built into t he ongoing housing revenue costs, i.e. into the rents paid to the
landlord). The private housing revenue costs are likely to be ~£16k (or more) higher (per person,
per year, in 24/25 prices) than the social rents that would’ve been incurred, had the homes been
funded via public sector capital investment. Therefore, there is a risk that if it is not feasible to
build new homes or purchase and adapt existing homes via public sector capital funding (e.g. via
the Affordable Homes Programme), then overall costs to the public purse could be higher than
stated.

74

Sensitivity analysis
285. This section explores how sensitive the estimated net discounted costs over the appraisal
period (i.e. the Net Present Value, NPV) are to potential variations in key input variables or
assumptions.
Health System
286. There are the following main groups of uncertainties for the impacts to the Health and Social
Care system:
• The magnitude of the future number of people admitted to hospital, detained or under CTOs,
either in response to wider trends, or the impact of the proposed reforms;
• How much additional time from the health and social care workforce will be required to deliver
the additional safeguards and how much current work will be re -adjusted or in line with the
reforms;
• Counterfactual costs used for ACD diverted admissions are based on an assumption around
a greater number of community mental health contacts for these people. This does not
include the possible costs for social workers and VCSE staff, who may be additionally
providing care, and therefore our cost saving/ benefit estimates may be an overestimate. We
have accounted for the risk by including a scenario in which there are no cost savings
associated with the policy.
Justice System
287. Some of the principal assumptions, and the associated ranges are set out below. Additional
details can be found in Annex E:
• Detention periods: expected increase in Section 3 applications of between 25% and 49%, the
central scenario employs the midpoint of 37%.
• Automatic referrals for Part III patients: expected increase in Section 71(2) referrals of
between 355% and 420% due to varying estimation methodologies; the central scenario
employs the midpoint of a 390% increase.
• Automatic referrals for people on conditional discharge: the annual volumes of referrals vary
depending on the success rate of achieving absolute discharge (i.e., no conditions attached
because the criteria for detention are no longer met) for the cohort o f patients being
automatically referred in previous years. These success rates differ depending on the
duration spent on conditional discharge at the time of the tribunal hearing. At the 2 year point
the success rate varies between 3% and 7%; the central s cenario employs the midpoint of
5%. At the 6 year point the success rate varies between 30% and 36%, and the central
scenario employs the midpoint of 33%.
• On certifying 10 days in advance of a tribunal hearing that a Section 3 patient continues to
meet the criteria for detention: the estimated benefits are dependent on the assumption that,
across all scenarios, MHT panel members can be reallocated in 50% of cancellations, which
would mean that there are no cancellation fees to be claimed in these instances.
• CTP treatment choice: the additional costs are generated by the expected increase in hearing
times from considering the statutory CTP. The extra time is put at 20 minutes in the low-cost
scenario, 40 minutes in the central cost scenarios and 60 minutes in the high-cost scenario,
as advised by HMCTS operational experts.

75

One-way Sensitivity Analysis
288. We present in the table below the key assumptions in each model for the central scenario and
for alternative scenarios.
289. Due to the complexity of the modelling, we have limited this section to the important and
uncertain assumptions – see Table 33 below. We then present the impact the NPV when each
key assumption varies and all the other remain constant under a central scenario. This is followed
by a summary section covering two scenarios (low cost and high cost) where we vary the key
listed assumptions simultaneously and assess the impact on estimated NPV.

Table 33. Summary of key assumptions and sensitivities
Assumption Central
scenario
Low NPV scenario High NPV scenario
Volumes
Baseline
projections for
detention
volumes
Growth factor applied
based on previous
trends
Increase in
line with
population
changes
Increase by
average
(population-
adjusted) pre-
pandemic growth
rate in detentions
(1.16%, observed
from 2016/17 to
2019/20) until
2033/34, then
increase in line with
population changes
thereafter

Increase by
average
(population-
adjusted) growth
rate (-0.87%,
observed from
2016/17 to 2023/24)
until 2033/34, then
increase in line with
population changes
thereafter
Baseline
projections for
admission
volumes
Growth factor applied
based on previous
trends
Increase in
line with
population
changes
Increase by average
(population-
adjusted) pre-
pandemic growth
rate in admissions
(0.57%, observed
from 2016/17 to
2019/20) until
2033/34, then
increase in line with
population changes
thereafter

Increase by
average
(population-
adjusted) growth
rate in admissions
(-2.64%, observed
from 2016/17 to
2023/24) until
2033/34, then
increase in line with
population changes
thereafter

Policy impact
ACD uptake and
impact
ACD uptake 45%

60%
(ACD uptake was
modelled to range
between 30-60%).
However, when the
impact of ACDs on
detentions and
admissions is low,
60%
(ACD uptake was
modelled to range
between 30-60%).
However, when the
impact of ACDs on
detentions and
admissions is high,

76

the lowest NPV is
achieved when
uptake is highest,
when coupled with a
low impact scenario
on admissions)
the highest NPV is
achieved when
uptake is highest
when coupled with
a high impact
scenario on
admissions)

Proportion of ACDs
re-written after
discharge where
relevant

60% 80% 40%
Impact of ACD on
overall admissions

5% 0% 10%
Impact of ACD on
detention

12.5% 0% 25%
Policy impact on
CTOs
Reduction in CTOs
as a result of policy
(assumed to occur
gradually over 5
years from 2031/32)
20% 0% 40%
Uptake of
advocacy
Proportion of
detained and
informal patients
using IMHAs.
Detained
patients: 85%
Informal
patients: 50%
Detained patients:
90%
Informal patients:
60%
Detained patients:
70%
Informal patients:
40%
MoJ
assumptions
Assumptions
used for MoJ
modelling [see
above section]
(excluding inputs
from DHSC
model that are
varied in above
scenarios)
See Justice System
section above
(paragraph 288) for
details
Central MOJ
input
assumptions
MoJ inputs which
result in highest
justice system costs
MoJ inputs which
result in lowest
justice system costs
Costs
Additional
workload
Additional workforce
times a result of
reforms to AMHPs,
IMHAs, Approved
clinicians, Nurses,
Key Workers, Social
workers, community
clinician, other
clinician staff,
SOADs Admin
teams.
- +20% -20%

77

Community costs
and inpatient
benefits from
changing the
detention criteria
for people with a
learning disability
and autistic
people
Community costs
estimates comprise
various elements,
including: housing
capital costs, housing
revenue costs,
community care and
support package
costs for people
discharged from
inpatient settings and
community
infrastructure costs.

Inpatient benefits
relate to the change
in inpatient costs
arising from fewer
people with a
learning disability
and autistic people
being in hospital.

In the sensitivity
analysis, we have
produced high and
low costs and
benefits figures.
See Annex
D.X.
Exact change in
costs/benefits varies
by area. See Annex
D.X for further detail
on assumptions
made.

The Low NPV
scenario compares
a high-cost
scenario, with a low
benefits scenario.

Exact change in
costs/benefits
varies by area. See
Annex D.X for
further detail on
assumptions made.

The High NPV
scenario compares
a low-cost scenario,
with a high benefits
scenario.

290. Using the scenarios presented above, the impact of varying our key assumptions on the central
net present value estimate are summarised in the table below. Process cost savings and
monetised benefits depend on the assumed impact of reforms of the number of admissions,
detentions, CTOs and tribunals.

Table 34. Impact of varying assumptions on the Net Present Value (NPV) in relation to the central
scenario (2024/25 prices, discounted)
Assumption Scenario Modelled total NPV Impact on NPV
Central NPV
Baseline detentions Central scenario -£169m
Low scenario -£240m -£71m
High scenario -£98m +£72m
Baseline admissions Central scenario -£169m
Low scenario -£175m -£6m
High scenario -£137m +£32m
Policy impact on CTOs Central scenario -£169m
Low scenario -£222m -£53m
High scenario -£117m +£53m
Policy impact on
admissions (ACDs)
Central scenario -£169m

78

Low scenario -£500m -£331m
High scenario +£200m +£370m
Additional workload Central scenario -£169m
Low scenario -£229m -£60m
High scenario +£49m +£218m
Uptake of advocacy Central scenario -£169m
Low scenario -£207m -£38m
High scenario -£82m +£87m
MoJ assumptions Central scenario -£169m
Low scenario -£235m -£66m
High scenario -£22m +£147m
Community costs and
inpatient benefits relating to
people with a learning
disability and autistic people
Central scenario -£169m
Low scenario -£4,001m -£3,832m
High scenario +3,119m +£3,288m

Figure 1. Impact of varying assumptions on the Net Present Value (NPV) in relation to the central
scenario for England and Wales (2024/25 prices, discounted)
291. Uncertainty in community costs for people with a learning disability and autistic people has by
far the most significant impact on the overall Net Present Value . However, there is also
uncertainty related to other assumptions – the below chart excludes variation due to uncertainty
in community costs to more clearly demonstrate the relative impacts of other assumptions on the
overall Net Present Value.

79

Figure 2. Impact of varying assumptions (excluding those regarding community costs for people
with a learning disability and autism) on the Net Present Value (NPV) in relation to the central
scenario for England and Wales (2024/25 prices, discounted)

Summary of Sensitivity Analysis
292. Using the estimated high and low costs and benefits described above for the proposed policies,
we have combined these to provide low and high estimates of the NPV for both England and
Wales.
293. To estimate the overall low NPV, we assume that all inputs are simultaneously set to the low
NPV scenario (see Table 35). To estimate the overall high NPV, we assume all inputs are set to
the high NPV scenario.
294. The analysis suggests that all the pessimistic assumptions (low costs plus high savings) could
cause the total estimated net present value of Option 2 to fall by £4,666m (NPV=-£4,835m). The
optimistic assumptions (low savings plus high costs) could cause the NPV to rise by £4,045m
(NPV=£3,876m). In all cases, these NPVs do not include benefits for health and experience of
the MHA patients.

Table 35. Summary of NPV for England and Wales (£millions, 2024/25 prices, discounted)
2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 2031/32 2032/33 2033/34
Central £0 -£4 -£183 -£79 £61 £47 £7 -£1 -£5 -£2
Low £0 -£7 -£532 -£398 -£191 -£206 -£269 -£280 -£283 -£275
High £0 -£1 £149 £202 £277 £278 £247 £241 £233 £231

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2034/35 2035/36 2036/37 2037/38 2038/39 2039/40 2040/41 2041/42 2042/43 2043/44 Total
Central -£5 £2 -£1 -£0 -£0 -£1 -£1 -£1 -£1 -£1 -£169
Low -£273 -£260 -£256 -£248 -£241 -£235 -£229 -£223 -£217 -£211 -£4,835
High £223 £225 £216 £211 £205 £199 £193 £188 £182 £177 £3,876

Figure 3. Summary of NPV for England and Wales (£millions, 2024/25 prices, undiscounted)
Summary and Preferred Option
295. Overall, Option 2 is the preferred option as the implementation of the Government proposals is
expected to modernise the MHA and make it fit for purpose. In particular, the proposals are
expected to bring significant benefits to patients interacting with the MHA through increasing
patient choice and autonomy over their treatment, ensuring they are treated with dignity and
respect, increasing scrutiny of detention , and promoting equality throughout the process. This
also aligns with the general view from the responses to the public consultation85 which took place
in 2021, which overall supports the policy objectives that the reforms aim to achieve.
296. Over the 20 -year time horizon, the estimated net benefit is estimated to be -£169 million in
2024/25 prices and in Present Value terms . The summary tables for all monetised costs and
benefits have been discounted using a discount rate of 3.5% for all costs (see HM Treasury
Green Book86).
297. This pertains to additional costs (excluding opportunity costs) estimated at £4,006 million and
monetised benefits (excluding health benefits) estimated at £3,836 million, in present value terms
for England and Wales. Whilst only a narrow range of cost savings have been monetised in this

85 Reforming the Mental Health Act - GOV.UK
86 HM Treasury (2022). The Green Book: appraisal and evaluation in central government. The Green Book: appraisal and evaluation in central
government - GOV.UK (www.gov.uk)fisand